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The Impact of COVID-19 on Education: A Meta-Narrative Review

• Original Paper
• Published: 05 July 2022
• Volume 66 , pages 883–896, ( 2022 )

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• Aras Bozkurt   ORCID: orcid.org/0000-0002-4520-642X 1 , 2 , 3 ,
• Kadir Karakaya   ORCID: orcid.org/0000-0003-3375-1532 4 ,
• Murat Turk   ORCID: orcid.org/0000-0002-5105-2578 5 ,
• Özlem Karakaya   ORCID: orcid.org/0000-0002-9950-481X 6 &
• Daniela Castellanos-Reyes   ORCID: orcid.org/0000-0002-0183-1549 7  

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The rapid and unexpected onset of the COVID-19 global pandemic has generated a great degree of uncertainty about the future of education and has required teachers and students alike to adapt to a new normal to survive in the new educational ecology. Through this experience of the new educational ecology, educators have learned many lessons, including how to navigate through uncertainty by recognizing their strengths and vulnerabilities. In this context, the aim of this study is to conduct a bibliometric analysis of the publications covering COVID-19 and education to analyze the impact of the pandemic by applying the data mining and analytics techniques of social network analysis and text-mining. From the abstract, title, and keyword analysis of a total of 1150 publications, seven themes were identified: (1) the great reset, (2) shifting educational landscape and emerging educational roles (3) digital pedagogy, (4) emergency remote education, (5) pedagogy of care, (6) social equity, equality, and injustice, and (7) future of education. Moreover, from the citation analysis, two thematic clusters emerged: (1) educational response, emergency remote education affordances, and continuity of education, and (2) psychological impact of COVID-19. The overlap between themes and thematic clusters revealed researchers’ emphasis on guaranteeing continuity of education and supporting the socio-emotional needs of learners. From the results of the study, it is clear that there is a heightened need to develop effective strategies to ensure the continuity of education in the future, and that it is critical to proactively respond to such crises through resilience and flexibility.

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Introduction

The Coronavirus (COVID-19) pandemic has proven to be a massive challenge for the entire world, imposing a radical transformation in many areas of life, including education. It was rapid and unexpected; the world was unprepared and hit hard. The virus is highly contagious, having a pathogenic nature whose effects have not been limited to humans alone, but rather, includes every construct and domain of societies, including education. The education system, which has been affected at all levels, has been required to respond to the crisis, forced to transition into emergency modes, and adapt to the unprecedented impact of the global crisis. Although the beginning of 2021 will mark nearly a year of experience in living through the pandemic, the crisis remains a phenomenon with many unknowns. A deeper and more comprehensive understanding of the changes that have been made in response to the crisis is needed to survive in these hard times. Hence, this study aims to provide a better understanding by examining the scholarly publications on COVID-19 and education. In doing this, we can identify our weaknesses and vulnerabilities, be better prepared for the new normal, and be more fit to survive.

Related Literature

Though the COVID-19 pandemic is not the first major disruption to be experienced in the history of the world, it has been unique due to its scale and the requirements that have been imposed because of it (Guitton, 2020 ). The economies of many countries have greatly suffered from the lockdowns and other restrictive measurements, and people have had to adapt to a new lifestyle, where their primary concern is to survive by keeping themselves safe from contracting the deadly virus. The education system has not been exempt from this series of unfortunate events inflicted by COVID-19. Since brick-and-mortar schools had to be closed due to the pandemic, millions of students, from those in K-12 to those in higher education, were deprived of physical access to their classrooms, peers, and teachers (Bozkurt & Sharma, 2020a , b ). This extraordinary pandemic period has posed arguably the most challenging and complex problems ever for educators, students, schools, educational institutions, parents, governments, and all other educational stakeholders. The closing of brick-and-mortar schools and campuses rendered online teaching and learning the only viable solution to the problem of access-to-education during this emergency period (Hodges et al., 2020 ). Due to the urgency of this move, teachers and instructors were rushed to shift all their face-to-face instruction and instructional materials to online spaces, such as learning management systems or electronic platforms, in order to facilitate teaching virtually at a distance. As a result of this sudden migration to learning and instruction online, the key distinctions between online education and education delivered online during such crisis and emergency circumstances have been obfuscated (Hodges et al., 2020 ).

State of the Current Relevant Literature

Although the scale of the impact of the COVID-19 global pandemic on education overshadows previously experienced nationwide or global crises or disruptions, the phenomenon of schools and higher education institutions having to shift their instruction to online spaces is not totally new to the education community and academia (Johnson et al., 2020 ). Prior literature on this subject indicates that in the past, schools and institutions resorted to online or electronic delivery of instruction in times of serious crises and uncertainties, including but not limited to natural disasters such as floods or earthquakes (e.g., Ayebi-Arthur, 2017 ; Lorenzo, 2008 ; Tull et al., 2017 ), local disruptions such as civil wars and socio-economic events such as political upheavals, social turmoils or economic recessions (e.g., Czerniewicz et al., 2019 ). Nevertheless, the past attempts to move learning and teaching online do not compare to the current efforts that have been implemented during the global COVID-19 pandemic, insofar as the past crisis situations were sporadic events in specific territories, affecting a limited population for relatively short periods of time. In contrast, the COVID-19 pandemic has continued to pose a serious threat to the continuity of education around the globe (Johnson et al., 2020 ).

Considering the scale and severity of the global pandemic, the impacts it has had on education in general and higher education in particular need to be explored and studied empirically so that necessary plans and strategies aimed at reducing its devastating effects can be developed and implemented. Due to the rapid onset and spread of the global pandemic, the current literature on the impact of COVID-19 on education is still limited, including mostly non-academic editorials or non-empirical personal reflections, anecdotes, reports, and stories (e.g., Baker, 2020 ; DePietro, 2020 ). Yet, with that said, empirical research on the impact of the global pandemic on higher education is rapidly growing. For example, Johnson et al. ( 2020 ), in their empirical study, found that faculty members who were struggling with various challenges adopted new instructional methods and strategies and adjusted certain course components to foster emergency remote education (ERE). Unger and Meiran ( 2020 ) observed that the pandemic made students in the US feel anxious about completing online learning tasks. In contrast, Suleri ( 2020 ) reported that a large majority of European higher education students were satisfied with their virtual learning experiences during the pandemic, and that most were willing to continue virtual higher education even after the pandemic (Suleri, 2020 ). The limited empirical research also points to the need for systematically planning and designing online learning experiences in advance in preparation for future outbreaks of such global pandemics and other crises (e.g., Korkmaz & Toraman, 2020 ). Despite the growing literature, the studies provide only fragmentary evidence on the impact of the pandemic on online learning and teaching. For a more thorough understanding of the serious implications the pandemic has for higher education in relation to learning and teaching online, more empirical research is needed.

Unlike previously conducted bibliometric analysis studies on this subject, which have largely involved general analysis of research on health sciences and COVID-19, Aristovnik et al. ( 2020 ) performed an in-depth bibliometric analysis of various science and social science research disciplines by examining a comprehensive database of document and source information. By the final phase of their bibliometric analysis, the authors had analyzed 16,866 documents. They utilized a mix of innovative bibliometric approaches to capture the existing research and assess the state of COVID-19 research across different research landscapes (e.g., health sciences, life sciences, physical sciences, social sciences, and humanities). Their findings showed that most COVID-19 research has been performed in the field of health sciences, followed by life sciences, physical sciences, and social sciences and humanities. Results from the keyword co-occurrence analysis revealed that health sciences research on COVID-19 tended to focus on health consequences, whereas the life sciences research on the subject tended to focus on drug efficiency. Moreover, physical sciences research tended to focus on environmental consequences, and social sciences and humanities research was largely oriented towards socio-economic consequences.

Similarly, Rodrigues et al. ( 2020 ) carried out a bibliometric analysis of COVID-19 related studies from a management perspective in order to elucidate how scientific research and education arrive at solutions to the pandemic crisis and the post-COVID-19 era. In line with Aristovnik et al.’s ( 2020 ) findings, Rodrigues et al. ( 2020 ) reported that most of the published research on this subject has fallen under the field of health sciences, leaving education as an under-researched area of inquiry. The content analysis they performed in their study also found a special emphasis on qualitative research. The descriptive and content analysis yielded two major strands of studies: (1) online education and (2) COVID-19 and education, business, economics, and management. The online education strand focused on the issue of technological anxiety caused by online classes, the feeling of belonging to an academic community, and feedback.

Lastly, Bond ( 2020 ) conducted a rapid review of K-12 research undertaken in the first seven months of the COVID-19 pandemic to identify successes and challenges and to offer recommendations for the future. From a search of K-12 research on the Web of Science, Scopus, EBSCOHost, the Microsoft Academic, and the COVID-19 living systematic map, 90 studies were identified and analyzed. The findings revealed that the reviewed research has focused predominantly on the challenges to shifting to ERE, teacher digital competencies and digital infrastructure, teacher ICT skills, parent engagement in learning, and students’ health and well-being. The review highlighted the need for straightforward communication between schools and families to inform families about learning activities and to promote interactivity between students. Teachers were also encouraged to develop their professional networks to increase motivation and support amongst themselves and to include opportunities for both synchronous and asynchronous interaction for promoting student engagement when using technology. Bond ( 2020 ) reported that the reviewed studies called for providing teachers with opportunities to further develop their digital technical competencies and their distance and online learning pedagogies. In a recent study that examines the impact of COVID-19 at higher education (Bozkurt, 2022 ), three broad themes from the body of research on this subject: (1) educational crisis and higher education in the new normal: resilience, adaptability, and sustainability, (2) psychological pressures, social uncertainty, and mental well-being of learners, and (3) the rise of online distance education and blended-hybrid modes. The findings of this study are similar to Mishra et al. ( 2021 ) who examined the COVID-19 pandemic from the lens of online distance education and noted that technologies for teaching and learning and psychosocial issues were emerging issues.

The aforementioned studies indicate that a great majority of research on COVID-19 has been produced in the field of health sciences, as expected. These studies nonetheless note that there is a noticeable shortage of studies dealing with the effects of the pandemic in the fields of social sciences, humanities, and education. Given the profound impact of the pandemic on learning and teaching, as well as on the related stakeholders in education, now more than ever, a greater amount of research on COVID-19 needs to be conducted in the field of education. The bibliometric studies discussed above have analyzed COVID-19 research across various fields, yielding a comparative snapshot of the research undertaken so far in different research spheres. However, despite being comprehensive, these studies did not appear to have examined a specific discipline or area of research in depth. Therefore, this bibliometric study aims to provide a focused, in-depth analysis of the COVID-19-related research in the field of education. In this regard, the main purpose of this study is to identify research patterns and trends in the field of education by examining COVID-19-related research papers. The study sought to answer the following research questions:

What are the thematic patterns in the title, abstract, and keywords of the publications on COVID-19 and education?

What are the citation trends in the references of the sampled publications on COVID-19 and education?

Methodology

This study used data mining and analytic approaches (Fayyad et al., 2002 ) to examine bibliometric patterns and trends. More specifically, social network analysis (SNA) (Hansen et al., 2020 ) was applied to examine the keywords and references, while text-mining was applied (Aggarwal & Zhai, 2012 ) to examine the titles and abstracts of the research corpus. Keywords represent the essence of an article at a micro level and for the analysis of the keywords, SNA was used. SNA “provides powerful ways to summarize networks and identify key people, [entities], or other objects that occupy strategic locations and positions within a matrix of links” (Hansen et al., 2020 , p. 6). In this regard, the keywords were analyzed based on their co-occurrences and visualized on a network graph by identifying the significant keywords which were demonstrated as nodes and their relationships were demonstrated with ties. For text-mining of the titles and abstracts, the researchers performed a lexical analysis that employs “two stages of co-occurrence information extraction—semantic and relational—using a different algorithm for each stage” (Smith & Humphreys, 2006 , p. 262). Thus, text-mining analysis enabled researchers to identify the hidden patterns and visualize them on a thematic concept map. For the analysis of the references, the researchers further used SNA based on the arguments that “citing articles and cited articles are linked to each other through invisible ties, and they collaboratively and collectively build an intellectual community that can be referred to as a living network, structure, or an ecology” (Bozkurt, 2019 , p. 498). The analysis of the references enabled the researchers to identify pivotal scholarly contributions that guided and shaped the intellectual landscape. The use of multiple approaches enables the study to present a broader view, or a meta-narrative.

Sample and Inclusion Criteria

The publications included in this research met the following inclusion criteria: (1) indexed by the Scopus database, (2) written in English, and (3) had the search queries on their title (Table 1 ). The search query reflects the focus on the impact of COVID-19 on education by including common words in the field like learn , teach , or student . Truncation was also used in the search to capture all relevant literature. Narrowing down the search allowed us to exclude publications that were not education related. Scopus was selected because it is one of the largest scholarly databases, and only publications in English were selected to facilitate identification of meaningful lexical patterns through text-mining and provide a condensed view of the research. The search yielded a total of 1150 papers (articles = 887, editorials = 66, notes = 58, conference papers = 56, letters = 40, review studies = 30, book chapters = 9, short surveys = 3, books = 1).

Data Analysis and Research Procedures

This study has two phases of analysis. In the first phase, text mining was used to analyze titles and abstracts, and SNA was applied to analyze keywords. By using two different analytical approaches, the authors were able to triangulate the research findings (Thurmond, 2001 ). In this phase, using lexical algorithms, text mining analysis enabled visualizing the textual data on a thematic concept map according to semantic relationships and co-occurrences of the words (Fig.  1 ). Text mining generated a machine-based concept map by analyzing the co-occurrences and lexical relationships of textual data. Then, based on the co-occurrences and centrality metrics, SNA enabled visualizing keywords on a network graphic called sociogram (Fig.  2 ). SNA allowed researchers to visually identify the key terms on a connected network graph where keywords are represented as nodes and their relationships are represented as edges. In the first phase of the study, by synthesizing outputs of the data mining and analytic approaches, meaningful patterns of textual data were presented as seven main research themes.

Thematic concept mapping of COVID-19 and education-related papers

Social networks analysis of the keywords in COVID-19 and education-related papers

In the second phase of the study, through the examination of the references and citation patterns (e.g., citing and being cited) of the articles in the research corpus, the citation patterns were visualized on a network graphic by clusters (See Fig.  3 ) showing also chronical relationships which enabled to identify pivotal COVID-19 studies. In the second phase of the study, two new themes were identified which were in line with the themes that emerged in the first phase of the study.

Social networks analysis of the references in COVID-19 and education-related papers 2019–2020 (Only the first authors were labeled – See Appendix Fig. 4 for SNA of references covering pre-COVID-19 period)

Strengths and Limitations

This study is one of the first attempts to use bibliometric approaches benefiting from data mining and analysis techniques to better understand COVID-19 and its consequences on published educational research. By applying such an approach, a large volume of data is able to be visualized and reported. However, besides these strengths, the study also has certain limitations. First, the study uses the Scopus database, which, though being one of the largest databases, does not include all types of publications. Therefore, the publications selected for this study offer only a partial view, as there are many significant publications in gray literature (e.g., reports, briefs, blogs). Second, the study includes only publications written in English, however, with COVID-19 being a global crisis, publications in different languages would provide a complementary view and be helpful in understanding local reflections in the field of education.

Findings and Discussion

Sna and text-mining: thematic patterns in the title, abstract, and keywords of the publications.

This section reports the findings based on a thematic concept map and network graphic that were developed through text mining (Fig.  1 —Textual data composed of 186.234 words visualized according to lexical relationships and co-occurrences) and sociograms created using SNA (Fig.  2 —The top 200 keywords with highest betweenness centrality and 1577 connections among them mapped on a network graph) to visualize the data. Accordingly, seven major themes were identified by analyzing the data through text-mining and SNA: (1) the great reset, (2) digital pedagogy, (3) shifting educational landscape and emerging educational roles, (4) emergency remote education, (5) pedagogy of care, (6) social equity, equality, and injustice, and (7) future of education.

Theme 1: The Great Reset (See path Fig.  1 : lockdown  +  emergency  +  community  +  challenges  +  during  >  pandemic and impact  >  outbreak  >  coronavirus  >  pandemic and global  >  crisis  >  pandemic  >  world; See nodes on Fig.  2 : Covid19, pandemic, Coronavirus, lockdown, crisis ). The first theme in the thematic concept map and network graphic is the Great Reset. It has been relatively a short time since the World Health Organization (WHO) declared the COVID-19 a pandemic. Although vaccination had already started, the pandemic continued to have an adverse impact on the world. Ever since the start of the pandemic, people were discussing when there would be a return to normal (Bozkurt & Sharma, 2020a , b ; Xiao, 2021 ); however, as time goes by, this hope has faded, and returning to normal appears to be far into the future (Schwab & Malleret, 2020 ). The pandemic is seen as a major milestone, in the sense that a macro reset in economic, social, geopolitical, environmental, and technological fields will produce multi-faceted changes affecting almost all aspects of life (Schwab & Malleret, 2020 ). The cover of an issue of the international edition of Time Magazine reflected this idea of a great reset and presented the COVID-19 pandemic as an opportunity to transform the way we live and work (Time, 2020 ). It has been argued that the pandemic will generate the emergence of a new era, and that we will have to adapt to the changes it produces (Bozkurt & Sharma, 2020 ). For example, the industrial sector quickly embraced remote work despite its challenges, and it is possible that most industrial companies will not return to the on-site working model even after the pandemic ends (Hern, 2020 ). We can expect a high rate of similar responses in other fields, including education, where COVID-19 has already reshaped our educational systems, the way we deliver education, and pedagogical approaches.

Theme 2: Digital pedagogy (See path on Fig.  1 : distance learning  >  research  >  teacher  >  development  >  need  >  training  +  technology  +  virtual  >  digital  >  communication  >  support  >  process  >  teaching  >  online  >  learning  >  online learning  +  course  >  faculty  >  students  >  experience ; See nodes on Fig.  2 : online learning, distance learning, computer-based learning, elearning, online education, distance education, online teaching, multimedia-based learning, technology, blended learning, online, digital transformation, ICT, online classes, flexible learning, technology-enhanced learning, digitalization ). Owing to the rapid transition to online education as a result of COVID-19, digital pedagogy and teachers’ competencies in information and communication technology (ICT) integration have gained greater prominence with the unprecedented challenges teachers have faced to adapt to remote teaching and learning. The COVID-19 pandemic has unquestionably manifested the need to prepare teachers to teach online, as most of them have been forced to assume ERE roles with inadequate preparation. Studies involving the use of SNA indicate a correspondence between adapting to a digital pedagogy and the need to equip teachers with greater competency in technology and online teaching (e.g., Blume, 2020 ; König et al., 2020 ). König et al. ( 2020 ) conducted a survey-based study investigating how early career teachers have adapted to online teaching during COVID-19 school closures. Their study found that while all the teachers maintained communication with students and their parents, introduced new learning content, and provided feedback, they lacked the ability to respond to challenges requiring ICT integration, such as those related to providing quality online teaching and to conducting assessments. Likewise, Blume ( 2020 ) noted that most teachers need to acquire digital skills to implement digitally-mediated pedagogy and communication more effectively. Both study findings point to the need for building ICT-related teaching and learning competencies in initial teacher education and teacher professional development. The findings from the SNA conducted in the present study are in line with the aforementioned findings in terms of keyword analysis and overlapping themes and nodes.

Theme 3: Shifting educational landscape and emerging educational roles (See path on Fig.  1 : future > education > role > Covid19; See nodes on Fig.  2 : higher education, education, student, curriculum, university, teachers, learning, professional development, teacher education, knowledge, readiness ). The role of technology in education and human learning has been essential during the COVID-19 pandemic. Technology has become a prerequisite for learning and teaching during the pandemic and will likely continue to be so after it. In the rapid shift to an unprecedented mode of learning and teaching, stakeholders have had to assume different roles in the educational landscape of the new normal. For example, in a comprehensive study involving the participation of over 30 K higher education students from 62 countries conducted by Aristovnik et al. ( 2020 ), it was found that students with certain socio-demographic characteristics (male, lower living standard, from Africa or Asia) were significantly less satisfied with the changes to work/life balance created by the COVID-19 pandemic, and that female students who were facing financial problems were generally more affected by COVID-19 in their emotional life and personal circumstances. Despite the challenges posed by the pandemic, there is likely to be carry over in the post-pandemic era of some of the educational changes made during the COVID-19 times. For example, traditional lecture-based teacher-centered classes may be replaced by more student-centered online collaborative classes (Zhu & Liu, 2020 ). This may require the development and proliferation of open educational platforms that allow access to high-quality educational materials (Bozkurt et al., 2020 ) and the adoption of new roles to survive in the learning ecologies informed by digital learning pedagogies. In common with the present study, the aforementioned studies (e.g., Aristovnik et al., 2020 ; König et al., 2020 ) call for more deliberate actions to improve teacher education programs by offering training on various teaching approaches, such as blended, hybrid, flexible, and online learning, to better prepare educators for emerging roles in the post-pandemic era.

Theme 4: Emergency remote education (see path Fig.  1 : higher education  >  university  >  student  >  experience  >  remote; See nodes on Fig.  2 : Covid19, pandemic, Coronavirus, higher education, education, school closure, emergency remote teaching, emergency remote learning ). Educational institutions have undergone a rapid shift to ERE in the wake of COVID-19 (Bozkurt & Sharma, 2020a ; Bozkurt et al., 2020 ; Hodges et al., 2020 ). Although ERE is viewed as similar to distance education, they are essentially different. That is, ERE is a prompt response measure to an emergency situation or unusual circumstances, such as a global pandemic or a civil war, for a temporary period of time, whereas distance education is a planned and systematic approach to instructional design and development grounded in educational theory and practice (Bozkurt & Sharma, 2020b ). Due to the urgent nature of situations requiring ERE, it may fall short in embracing the solid pedagogical learning and teaching principles represented by distance education (Hodges et al., 2020 ). The early implementations of ERE primarily involved synchronous video-conferencing sessions that sought to imitate in-person classroom instruction. It is worth noting that educators may have heavily relied on synchronous communication to overcome certain challenges, such as the lack of available materials and planned activities for asynchronous communication. Lockdowns and school closures, which turned homes into compulsory learning environments, have posed major challenges for families and students, including scheduling, device sharing, and learner engagement in a socially distanced home learning environment (Bond, 2020 ). For example, Shim and Lee ( 2020 ) conducted a qualitative study exploring university students’ ERE experiences and reported that students complained about network instability, unilateral interactions, and reduced levels of concentration. The SNA findings clearly highlight that there has been a focus on ERE due to the school closures during the COVID-19 pandemic. It is key to adopt the best practices of ERE and to utilize them regularly in distance education (Bozkurt, 2022 ). Moreover, it is important to note that unless clear distinctions are drawn between these two different forms of distance education or virtual instruction, a series of unfortunate events in education during these COVID-19 times is very likely to take place and lead to fatal errors in instructional practices and to poor student learning outcomes.

Theme 5: Pedagogy of care (See path Fig.  1 : r ole  >  education  >  Covid19  >  care ; See nodes on Fig.  2 : Stress, anxiety, student wellbeing, coping, care, crisis management, depression ). The thematic concept map and network graphic show the psychological and emotional impact of the COVID-19 pandemic on various stakeholders, revealing that they have experienced anxiety, expressed the need for care, and sought coping strategies. A study by Baloran ( 2020 ), conducted in the southern part of the Philippines to examine college students’ knowledge, attitudes, anxiety, and personal coping strategies during the COVID-19 pandemic, found that the majority of the students experienced anxiety during the lockdown and worried about food security, financial resources, social contact, and large gatherings. It was reported that the students coped with this anxiety by following protective measures, chatting with family members and friends, and motivating themselves to have a positive attitude. In a similar study, Islam et al. ( 2020 ) conducted an investigation to determine whether Bangladeshi college students experienced anxiety and depression and the factors responsible for these emotional responses. Their cross-sectional survey-based study found that a large percentage of the participants had suffered from anxiety and depression during the pandemic. Academic and professional uncertainty, as well as financial insecurity, have been documented as factors contributing to the anxiety and depression among college students. Both studies point to the need for support mechanisms to be established by higher education institutions in order to ensure student wellbeing, provide them with care, and help them to cope with stress, anxiety, and depression. Talidong and Toquero ( 2020 ) reported that, in addition to students’ well-being and care, teachers’ perceptions and experiences of stress and anxiety during the quarantine period need to be taken into account. The authors found that teachers were worried about the safety of their loved ones and were susceptible to anxiety but tended to follow the preventive policies. A pedagogy of care has been presented as an approach that would effectively allow educators to plan more supportive teaching practices during the pandemic by fostering clear and prompt communication with students and their families and taking into consideration learner needs in lesson planning (e.g., Karakaya, 2021 ; Robinson et al., 2020 ). Here it is important to stress that a pedagogy of care is a multifaceted concept, one that involves the concepts of social equity, equality, and injustice.

Theme 6: Social equity, equality, and injustice (See path on Fig.  1 : Impact  >  outbreak  >  coronavirus  >  pandemic  >  social ; See nodes on Fig.  2 : Support, equity, social justice, digital divide, inequality, social support ). One of the more significant impacts of COVID-19 has been the deepening of the existing social injustices around the world (Oldekop et al., 2020 ; Williamson et al., 2020 ). Long-term school closures have deteriorated social bonds and adversely affected health issues, poverty, economy, food insecurity, and digital divide (Van Lancker & Parolin, 2020 ). Regarding the digital divide, there has been a major disparity in access to devices and data connectivity between high-income and low-income populations increasing the digital divide, social injustice, and inequality in the world (Bozkurt et al., 2020 ). In line with the SNA findings, the digital divide, manifesting itself most visibly in the inadequacy and insufficiency of digital devices and lack of high-speed Internet, can easily result in widespread inequalities. As such, the disparities between low and high socio-economic status families and school districts in terms of digital pedagogy inequality may deepen as teachers in affluent schools are more likely to offer a wide range of online learning activities and thereby secure better student engagement, participation, and interaction (Greenhow et al., 2020 ). These findings demonstrate that social inequities have been sharpened by the unfortunate disparities imposed by the COVID-19, thus requiring us to reimagine a future that mitigates such concerns.

Theme 7: Future of education (See word path on Fig.  1 : Future  >  education  >  Covid19  >  pandemic  >  changes and pandemic  >  coronavirus, outbreak, impact  >  world ; See nodes on Fig.  2 : Sustainability, resilience, uncertainty, sdg4). Most significantly, COVID-19 the pandemic has shown the entire world that teachers and schools are invaluable resources and execute critical roles in society. Beyond that, with the compulsory changes resulting from the pandemic, it is evident that teaching and learning environments are not exclusive to brick-and-mortar classrooms. Digital technologies, being at the center of teaching and learning during the pandemic period, have been viewed as a pivotal agent in leveraging how learning takes place beyond the classroom walls (Quilter-Pinner & Ambrose, 2020 ). COVID-19 has made some concerns more visible. For example, the well-being of students, teachers, and society at large has gained more importance in these times of crisis. Furthermore, the need for educational technology and digital devices has compounded and amplified social inequities (Pelletier et al., 2021 ; West & Allen, 2020 ). Despite its global challenges, the need for technology and digital devices has highlighted some advantages that are likely to shape the future of education, particularly those related to the benefits of educational technology. For example, online learning could provide a more flexible, informal, self-paced learning environment for students (Adedoyin & Soykan, 2020 ). However, it also bears the risk of minimizing social interaction, as working in shared office environments has shifted to working alone in home-office settings. In this respect, the transformation of online education must involve a particular emphasis on sustaining interactivity through technology (Dwivedi et al., 2020 ). In view of the findings of the aforementioned studies, our text-mining and SNA findings suggest that the COVID-19 impositions may strongly shape the future of education and how learning takes place.

In summary, these themes extracted from the text-mining and SNA point to a significant milestone in the history of humanity, a multi-faceted reset that will affect many fields of life, from education and economics to sociology and lifestyle. The resulting themes have revealed that our natural response to an emerging worldwide situation shifted the educational landscape. The early response of the educational system was emergency-based and emphasized the continuance of in-person instruction via synchronous learning technologies. The subsequent response foregrounded the significance of digitally mediated learning pedagogy, related teacher competencies, and professional development. As various stakeholders (e.g., students, teachers, parents) have experienced a heightened level of anxiety and stress, an emerging strand of research has highlighted the need for care-based and trauma-informed pedagogies as a response to the side effects of the pandemic. In addition, as the global pandemic has made systemic impairments, such as social injustice and inequity, more visible, an important line of research has emerged on how social justice can be ensured given the challenges caused by the pandemic. Lastly, a sizable amount of research indicates that although the COVID-19 pandemic has imposed unprecedented challenges to our personal, educational, and social lives, it has also taught us how to respond to future crises in a timely, technologically-ready, pedagogically appropriate, and inclusive manner.

SNA: Citation Trends in the References of the Sampled Publications

The trends identified through SNA in citation patterns indicate two lines of thematic clusters (see Fig.  3 -A network graph depicting the citing and being cited patterns in the research corpus. Node sizes were defined by their citation count and betweenness centrality.). These clusters align with the results of the analysis of the titles, abstracts, and keywords of the sampled publications and forge the earlier themes (Theme 4: Emergency remote education and Theme 5: Pedagogy of care).

Thematic Cluster 1: The first cluster centers on the abilities of educational response, emergency remote education affordances, and continuity of education (Bozkurt & Sharma, 2020a ; Crawford et al., 2020 ; Hodges et al., 2020 ) to mitigate the impact of COVID-19 on education, especially for more vulnerable and disadvantaged groups (UNESCO, 2020 ; Viner et al., 2020 ). The thematic cluster one agrees with the theme four emergency remote education . The first trend line (See red line in Fig.  3 ) shows that the education system is vulnerable to external threats. Considering that interruption of education is not exclusive to pandemics – for example, political crises have also caused disruptions (Rapp et al., 2016 ) – it is clear that coping mechanisms are needed to ensure the continuity of education under all conditions. In this case, we need to reimagine and recalibrate education to make it resilient, flexible, and adaptive, not only to ensure the continuity of education, but also to ensure social justice, equity, and equality. Given that online education has its own limitations (e.g., it is restricted to online tools and infrastructures), we need to identify alternative entry points for those who do not have digital devices or lack access to the internet.

Thematic Cluster 2: The second cluster centers on the psychological impact of COVID-19 on learners, who during these times suffered a sense of uncertainty (Bozkurt, & Sharma, 2021 ; Cao et al., 2020 ; Rose, 2020 ; Sahu, 2020 ) which suggest that learners are experiencing difficult times that can result in psychological and mental problems. The thematic cluster two agrees with theme five which is pedagogy of care . Therefore, it can be argued that learners' psychological and emotional states should be a top priority. Brooks et al. ( 2020 ) reported the potential of post-traumatic issues with long-lasting effects, on top of the trauma that has already been suffered during the COVID-19 pandemic. In other words, the effects of the COVID-19 crisis may prove to extend beyond their current state and add long-term challenges. Additionally, it has further been reported that the socio-economic effects of the pandemic (Nicola et al., 2020 ) may cause inequality and inequity in educational communities (Beaunoyer et al., 2020 ). The research also shows that learners’ achievement gaps are positively associated with psychological issues, while support and care are negatively associated with their traumatic states (Cao et al., 2020 ). In this context, the second thematic cluster reveals that researchers have seriously considered the psychological and emotional needs of learners in their publications. Care (Noddings, 1984 ) and that trauma-informed pedagogy (Imad, 2020 ) can be a guideline during and after the COVID-19 pandemic. It is quite clear that learners have experienced educational loss (e.g., drop-outs, achievement gaps, academic procrastination, etc.), as well as social and emotional impairments (e.g., fear, frustration, confusion, anxiety, sense of isolation, death of loved ones, etc.). Therefore, we need to critically approach the situation, focusing first on healing our social and emotional losses, and then, on the educational losses. As Bozkurt and Sharma ( 2020a ) put it:

“What we teach in these times can have secondary importance. We have to keep in mind that students will remember not the educational content delivered, but how they felt during these hard times. With an empathetic approach, the story will not center on how to successfully deliver educational content, but it will be on how learners narrate these times” (p. iv).

Conclusion and Suggestions

The results from this study indicate that quick adaptability and flexibility have been key to surviving the substantial challenges generated by COVID-19. However, extreme demands on flexibility have taken a toll on human well-being and have exacerbated systemic issues like inequity and inequality. Using data mining that involved network analysis and text mining as analytical tools, this research provides a panoramic picture of the COVID-19-related themes educational researchers have addressed in their work. A sample of 1150 references yielded seven themes, which served to provide a comprehensive meta-narrative about COVID-19 and its impact on education.

A portion of the sampled publications focused on what we refer to as the great reset , highlighting the challenges that the emergency lockdown brought to the world. A publication pattern centered around digital pedagogy posited distance and online learning as key components and identified the need for teacher training. Given the need for adaptability, a third theme revealed the demand for professional development in higher education and a future shift in educational roles. It can be recommended that future research investigate institutional policy changes and the adaptation to these changes in renewed educational roles. The ERE theme centered on the lack of preparation in instituting the forced changes brought about by the COVID-19 pandemic. The publications related to this theme revealed that the COVID-19 pandemic uncovered silent threads in educational environments, like depression, inequality, and injustice. A pedagogy of care has been developed with the aim of reducing anxiety and providing support through coping strategies. These research patterns indicate that the future of education demands sustainability and resilience in the face of uncertainty.

Results of the thematic analysis of citation patterns (Fig.  3 ) overlapped with two of the themes found in our thematic concept map (Fig.  1 ) and network graphic (Fig.  2 ). It was shown that researchers have emphasized the continuity of education and the psychological effects of the COVID-19 crisis on learners. Creating coping strategies to deal with global crises (e.g., pandemics, political upheavals, natural disasters) has been shown to be a priority for educational researchers. The pedagogy of resilience (Purdue University Innovative learning, n.d. ) provides governments, institutions, and instructors with an alternative tool to applying to their contexts in the face of hardship. Furthermore, prioritizing the psychological long-term effects of the crisis in learners could alleviate achievement gaps. We recommend that researchers support grieving learners through care (Noddings, 1984 ) and trauma-informed pedagogy (Imad, 2020 ). Our resilience and empathy will reflect our preparedness for impending crises. The thematic analysis of citation patterns (1: educational response, emergency remote education affordances, and continuity of education; 2: psychological impact of COVID-19) further indicates suggestions for future instructional/learning designers. Freire ( 1985 ) argues that to transform the world we need to humanize it. Supporting that argument, the need for human-centered pedagogical approaches (Robinson et al., 2020 ) by considering learning a multifaceted process (Hodges et al., 2021 ) for well-designed learning experiences (Moore et al., 2021 ) is a requirement and instructional/learning designers have an important responsibility not only to design courses but an entire learning ecosystem where diversity, sensitivity, and inclusivity are prioritized.

ERE is not a representative feature in the field of online education or distance education but rather, a forced reaction to extraordinary circumstances in education. The increasing confusion between the practice of ERE and online learning could have catastrophic consequences in learners' outcomes, teachers' instructional practices, and institutional policies. Researchers, educators, and policymakers must work cooperatively and be guided by sound work in the field of distance learning to design nourishing educational environments that serve students’ best interests.

In this study, text mining and social network analysis were demonstrated to be powerful tools for exploring and visualizing patterns in COVID-19-related educational research. However, a more in-depth examination is still needed to synthesize effective strategies that can be used to support us in future crises. Systematic reviews that use classical manual coding techniques may take more time but increase our understanding of a phenomenon and help us to develop specific action plans. Future systematic reviews can use the seven themes identified in this study to analyze primary studies and find strategies that counteract the survival of the fittest mindset to ensure that no student is left behind.

Data Availability

The dataset is available from the authors upon request.

Adedoyin, O. B., & Soykan, E. (2020). Covid-19 pandemic and online learning: The challenges and opportunities. Interactive Learning Environments . https://doi.org/10.1080/10494820.2020.1813180

Article   Google Scholar  

Aggarwal, C. C., & Zhai, C. (Eds.). (2012). Mining text data. Springer Science & Business Media. https://doi.org/10.1007/978-1-4614-3223 -4

Aristovnik, A., Keržič, D., Ravšelj, D., Tomaževič, N., & Umek, L. (2020). Impacts of the COVID-19 pandemic on life of higher education students: A global perspective. Sustainability, 12 (20), 8438. https://doi.org/10.3390/su12208438

Ayebi-Arthur, K. (2017). E-learning, resilience and change in higher education: Helping a university cope after a natural disaster. E-Learning and Digital Media, 14 (5), 259–274. https://doi.org/10.1177/2042753017751712

Baker, V. L. (2020, March 25). How colleges can better help faculty during the pandemic . Inside Higher Ed.  https://www.insidehighered.com/views/2020/03/25/recommendations-how-colleges-can-better-support-their-faculty-during-covid-19 . Accessed 15 Apr 2022

Baloran, E. T. (2020). Knowledge, attitudes, anxiety, and coping strategies of students during COVID-19 pandemic. Journal of Loss and Trauma, 25 (8), 635–642. https://doi.org/10.1080/15325024.2020.1769300

Beaunoyer, E., Dupéré, S., & Guitton, M. J. (2020). COVID-19 and digital inequalities: Reciprocal impacts and mitigation strategies. Computers in Human Behavior, 111 , 106424. https://doi.org/10.1016/j.chb.2020.106424

Blume, C. (2020). German Teachers’ Digital Habitus and Their Pandemic Pedagogy. Postdigital Science and Education, 2 (3), 879–905. https://doi.org/10.1007/s42438-020-00174-9

Bond, M. (2020). Schools and emergency remote education during the COVID-19 pandemic: A living rapid systematic review. Asian Journal of Distance Education, 15 (2), 191–247. https://doi.org/10.5281/zenodo.4425683

Bozkurt, A. (2019). Intellectual roots of distance education: A progressive knowledge domain analysis. Distance Education, 40 (4), 497–514. https://doi.org/10.1080/01587919.2019.1681894

Bozkurt, A. (2022). Resilience, adaptability, and sustainability of higher education: A systematic mapping study on the impact of the coronavirus (COVID-19) pandemic and the transition to the new normal. Journal of Learning for Development (JL4D), 9 (1), 1–16. https://doi.org/10.5281/zenodo.6370948

Bozkurt, A., & Sharma, R. C. (2020a). Emergency remote teaching in a time of global crisis due to CoronaVirus pandemic. Asian Journal of Distance Education, 15 (1), i–vi. https://doi.org/10.5281/zenodo.3778083

Bozkurt, A., & Sharma, R. C. (2020b). Education in normal, new normal, and next normal: Observations from the past, insights from the present and projections for the future. Asian Journal of Distance Education, 15 (2), i–x. https://doi.org/10.5281/zenodo.4362664

Bozkurt, A., & Sharma, R. C. (2021). On the verge of a new renaissance: Care and empathy oriented, human-centered pandemic pedagogy. Asian Journal of Distance Education, 16 (1), i–vii. https://doi.org/10.5281/zenodo.5070496

Bozkurt, A., Jung, I., Xiao, J., Vladimirschi, V., Schuwer, R., Egorov, G., Lambert, S. R., Al-Freih, M., Pete, J., Olcott, D., Jr., Rodes, V., Aranciaga, I., Bali, M., Alvarez, A. V., Jr., Roberts, J., Pazurek, A., Raffaghelli, J. E., Panagiotou, N., de Coëtlogon, P., … Paskevicius, M. (2020). A global outlook to the interruption of education due to COVID-19 pandemic: Navigating in a time of uncertainty and crisis. Asian Journal of Distance Education, 15 (1), 1–126. https://doi.org/10.5281/zenodo.3878572

Brooks, S. K., Webster, R. K., Smith, L. E., Woodland, L., Wessely, S., Greenberg, N., & Rubin, G. J. (2020). The psychological impact of quarantine and how to reduce it: Rapid review of the evidence. The Lancet, 395 (10227), 912–920. https://doi.org/10.1016/S0140-6736(20)30460-8

Cao, W., Fang, Z., Hou, G., Han, M., Xu, X., Dong, J., & Zheng, J. (2020). The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Research, 287 , 112934. https://doi.org/10.1016/j.psychres.2020.112934

Crawford, J., Butler-Henderson, K., Rudolph, J., Malkawi, B., Glowatz, M., Burton, R., ... & Lam, S. (2020). COVID-19: 20 countries' higher education intra-period digital pedagogy responses. Journal of Applied Learning & Teaching, 3 (1), 1–20. https://doi.org/10.37074/jalt.2020.3.1.7

Czerniewicz, L., Trotter, H., & Haupt, G. (2019). Online teaching in response to student protests and campus shutdowns: Academics’ perspectives. International Journal of Educational Technology in Higher Education, 16 (1), 43. https://doi.org/10.1186/s41239-019-0170-1

DePietro, A. (2020). Here’s a look at the impact of coronavirus (COVID-19) on colleges and universities in the U.S. Forbes.  https://www.forbes.com/sites/andrewdepietro/2020/04/30/impact-coronavirus-covid-19-colleges-universities/?sh=20a7121461a6 . Accessed 15 Apr 2022

Dwivedi, Y. K., Hughes, D. L., Coombs, C., Constantiou, I., Duan, Y., Edwards, J. S., Gupta, B., Lal, B., Misra, S., Prashant, P., Raman, R., Rana, N. P., Sharma, S. K., & Upadhyay, N. (2020). Impact of COVID-19 pandemic on information management research and practice: Transforming education, work and life. International Journal of Information Management, 55 , 102211. https://doi.org/10.1016/j.ijinfomgt.2020.102211

Fayyad, U., Grinstein, G. G., & Wierse, A. (Eds.). (2002). Information visualization in data mining and knowledge discovery . Morgan Kaufmann.

Google Scholar  

Freire, P. (1985). The politics of education: Culture, power and liberation . Bergin & Garvey.

Book   Google Scholar  

Greenhow, C., Lewin, C., & Staud Willet, K. B. (2020). The educational response to Covid-19 across two countries: A critical examination of initial digital pedagogy adoption. Technology, Pedagogy and Education . https://doi.org/10.1080/1475939X.2020.1866654

Guitton, M. J. (2020). Cyberpsychology research and COVID-19. Computers in Human Behavior, 111 , 106357. https://doi.org/10.1016/j.chb.2020.106357

Hansen, D. L., Shneiderman, B., Smith, M. A., & Himelboim, I. (2020). Analyzing social media networks with NodeXL: Insights from a connected world (2nd ed.). Morgan Kaufmann.

Hern, A. (2020). Covid19 could cause permanent shift towards home working. The Guardian.  http://www.miamidadetpo.org/library/2020-03-13-uk-covid19-could-cause-permanent-shift-towards-home-working.pdf . Accessed 15 Apr 2022

Hodges, C., Moore, S., Lockee, B., Trust, T., & Bond, A. (2020). The difference between emergency remote teaching and online learning . EDUCAUSE Review.  https://er.educause.edu/articles/2020/3/the-difference-between-emergency-remote-teaching-and-online-learning . Accessed 15 Apr 2022

Hodges, C. B., Moore, S. L., Lockee, B. B., Aaron Bond, M., Jewett, A. (2021). An Instructional Design Process for Emergency Remote Teaching. In Burgos, D., Tlili, A., Tabacco, A. (Eds), Radical Solutions for Education in a Crisis Context. Lecture Notes in Educational Technology (pp. 37–51). Singapore: Springer. https://doi.org/10.1007/978-981-15-7869-4_3

Imad, M. (2020). Leveraging the neuroscience of now. Inside Higher Ed .  https://www.insidehighered.com/advice/2020/06/03/seven-recommendations-helping-students-thrive-times-trauma . Accessed 15 Apr 2022

Islam, M. A., Barna, S. D., Raihan, H., Khan, M. N. A., & Hossain, M. T. (2020). Depression and anxiety among university students during the COVID-19 pandemic in Bangladesh: A web-based cross-sectional survey. PLoS One, 15 (8), e0238162. https://doi.org/10.1371/journal.pone.0238162

Johnson, N., Veletsianos, G., & Seaman, J. (2020). U.S. faculty and administrators’ experiences and approaches in the early weeks of the COVID-19 pandemic. Online Learning, 24 (2), 6–21. https://doi.org/10.24059/olj.v24i2.2285

Karakaya, K. (2021). Design considerations in emergency remote teaching during the COVID-19 pandemic: A human-centered approach. Education Technology Research and Development, 69 , 295–299. https://doi.org/10.1007/s11423-020-09884-0

König, J., Jäger-Biela, D. J., & Glutsch, N. (2020). Adapting to online teaching during COVID-19 school closure: Teacher education and teacher competence effects among early career teachers in Germany. European Journal of Teacher Education, 43 (4), 608–622. https://doi.org/10.1080/02619768.2020.1809650

Korkmaz, G., & Toraman, Ç. (2020). Are we ready for the post-COVID-19 educational practice? An investigation into what educators think as to online learning. International Journal of Technology in Education and Science, 4 (4), 293–309. https://doi.org/10.46328/ijtes.v4i4.110

Lorenzo, G. (2008). The Sloan Semester. Journal of Asynchronous Learning Networks, 12 (2), 5–40. https://doi.org/10.24059/olj.v12i2.1693

Mishra, S., Sahoo, S., & Pandey, S. (2021). Research trends in online distance learning during the COVID-19 pandemic. Distance Education, 42 (4), 494–519. https://doi.org/10.1080/01587919.2021.1986373

Moore, S., Trust, T., Lockee, B. B., Bond, A., & Hodges, C. (2021). One year later... and counting: Reflections on emergency remote teaching and online learning. EDUCAUSE Review.  https://er.educause.edu/articles/2021/11/one-year-later-and-counting-reflections-on-emergency-remote-teaching-and-online-learning . Accessed 15 Apr 2022

Nicola, M., Alsafi, Z., Sohrabi, C., Kerwan, A., Al-Jabir, A., Iosifidis, C., ... & Agha, R. (2020). The socio-economic implications of the coronavirus and COVID-19 pandemic: A review. International Journal of Surgery, 78 , 185-193. https://doi.org/10.1016/j.ijsu.2020.04.018

Noddings, N. (1984). Caring: A feminine approach to ethics . Moral Education.

Oldekop, J. A., Horner, R., Hulme, D., Adhikari, R., Agarwal, B., ... Zheng, Y. (2020). Covid-19 and the case for global development. World Development, 134 , 105044.

Pelletier, K., Brown, M., Brooks, D. C., McCormack, M., Reeves, J., Arbino, N., Bozkurt, A., Crawford, S., Czerniewicz, L., Gibson, R., Linder, K., Mason, J., & Mondelli, V. (2021). 2021 EDUCAUSE Horizon Report Teaching and Learning Edition . EDUCAUSE.  https://www.learntechlib.org/p/219489/ . Accessed 15 Apr 2022

Purdue University Innovative Learning. (n.d.). Hy-flex and resilient pedagogy resources.  https://www.purdue.edu/innovativelearning/teaching-remotely/pedagogy.aspx . Accessed 15 Apr 2022 

Quilter-Pinner, H., & Ambrose, A. (2020). The new normal: The future of education after Covid-19 . The Institute for Public Policy Research.

Rapp, C., Gülbahar, Y., & Adnan, M. (2016). e-Tutor: A multilingual open educational resource for faculty development to teach online. International Review of Research in Open and Distributed Learning, 17 (5), 284–289. https://doi.org/10.19173/irrodl.v17i5.2783

Robinson, H., Al-Freih, M., & Kilgore, W. (2020). Designing with care: Towards a care-centered model for online learning design. The International Journal of Information and Learning Technology, 37 (3), 99–108. https://doi.org/10.1108/IJILT-10-2019-0098

Rodrigues, M., Franco, M., & Silva, R. (2020). COVID-19 and Disruption in Management and Education Academics: Bibliometric Mapping and Analysis. Sustainability, 12 (18), 7362. https://doi.org/10.3390/su12187362

Rose, S. (2020). Medical student education in the time of COVID-19. JAMA, 323 (21), 2131–2132. https://doi.org/10.1001/jama.2020.5227

Sahu, P. (2020). Closure of universities due to coronavirus disease 2019 (COVID-19): impact on education and mental health of students and academic staff. Cureus, 12 (4). https://doi.org/10.7759/cureus.7541

Schwab, M., & Malleret, T. (2020). Covid-19: The great reset . World Economic Forum.

Shim, T. E., & Lee, S. Y. (2020). College students’ experience of emergency remote teaching due to COVID-19. Children and Youth Services Review, 119 , 105578. https://doi.org/10.1016/j.childyouth.2020.105578

Smith, A. E., & Humphreys, M. S. (2006). Evaluation of unsupervised semantic mapping of natural language with Leximancer concept mapping. Behavior Research Methods, 38 (2), 262–279. https://doi.org/10.3758/bf03192778

Suleri, J. (2020). Learners’ experience and expectations during and post COVID-19 in higher education. Research in Hospitality Management, 10 (2), 91–96. https://doi.org/10.1080/22243534.2020.1869463

Talidong, K. J. B., & Toquero, C. M. D. (2020). Philippine teachers’ practices to deal with anxiety amid COVID-19. Journal of Loss and Trauma, 25 (6–7), 573–579. https://doi.org/10.1080/15325024.2020.1759225

Thurmond, V. A. (2001). The point of triangulation. Journal of Nursing Scholarship, 33 (3), 253–258. https://doi.org/10.1111/j.1547-5069.2001.00253.x

Time (2020). The great reset: cover image.  https://time.com/collection/great-reset/ . Accessed 15 Apr 2022

Tull, S., Dabner, N., & Ayebi-Arthur, K. (2017). Social media and e-learning in response to seismic events: Resilient practices. Journal of Open, Flexible & Distance Learning , 21 (1), 63–76.  http://www.jofdl.nz/index.php/JOFDL/article/view/405 . Accessed 15 Apr 2022

UNESCO. (2020). COVID-19 education response.  https://en.unesco.org/covid19/educationresponse/ . Accessed 15 Apr 2022

Unger, S., & Meiran, W. R. (2020). Student attitudes towards online education during the COVID-19 viral outbreak of 2020: Distance learning in a time of social distance. International Journal of Technology in Education and Science, 4 (4), 256–266. https://doi.org/10.46328/ijtes.v4i4.107

Van Lancker, W., & Parolin, Z. (2020). COVID-19, school closures, and child poverty: A social crisis in the making [published online ahead of print, 2020 Apr 7]. T he Lancet Public Health, 5 (5), e243–e244. https://doi.org/10.1016/S2468-2667(20)30084-0

Viner, R. M., Russell, S. J., Croker, H., Packer, J., Ward, J., Stansfield, C., ... & Booy, R. (2020). School closure and management practices during coronavirus outbreaks including COVID-19: A rapid systematic review. The Lancet Child & Adolescent Health, 4 (5), 397-404. https://doi.org/10.1016/S2352-4642(20)30095-X

West, D., & Allen, J. (2020). How to address inequality exposed by the COVID-19 pandemic. Tech Crunch .  https://techcrunch.com/2020/10/27/how-to-address-inequality-exposed-by-the-covid-19-pandemic/ . Accessed 15 Apr 2022

Williamson, B., Eynon, R., & Potter, J. (2020). Pandemic politics, pedagogies and practices: Digital technologies and distance education during the coronavirus emergency. Learning, Media and Technology, 45 (2), 107–114. https://doi.org/10.1080/17439884.2020.1761641

Xiao, J. (2021). From equality to equity to justice: Should online education be the new normal in education?. In Bozkurt, A. (Eds.), Handbook of research on emerging pedagogies for the future of education: Trauma-informed, care, and pandemic pedagogy (pp. 1–15). IGI Global. https://doi.org/10.4018/978-1-7998-7275-7.ch001

Zhu, X., & Liu, J. (2020). Education in and after Covid-19: Immediate responses and long-term visions. Postdigital Science and Education, 2 , 695–699. https://doi.org/10.1007/s42438-020-00126-3

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Acknowledgements

This paper is dedicated to all educators and instructional/learning designers who ensured the continuity of education during the tough times of the COVID-19 pandemic.

This article is produced as a part of the 2020 AECT Mentoring Program.

This paper is supported by Anadolu University, Scientific Research Commission with grant no: 2106E084.

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Bozkurt, A., Karakaya, K., Turk, M. et al. The Impact of COVID-19 on Education: A Meta-Narrative Review. TechTrends 66 , 883–896 (2022). https://doi.org/10.1007/s11528-022-00759-0

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Coronavirus and schools: Reflections on education one year into the pandemic

Subscribe to the center for universal education bulletin, daphna bassok , daphna bassok nonresident senior fellow - governance studies , brown center on education policy lauren bauer , lauren bauer fellow - economic studies , associate director - the hamilton project stephanie riegg cellini , stephanie riegg cellini nonresident senior fellow - governance studies , brown center on education policy helen shwe hadani , helen shwe hadani former brookings expert michael hansen , michael hansen senior fellow - brown center on education policy , the herman and george r. brown chair - governance studies douglas n. harris , douglas n. harris nonresident senior fellow - governance studies , brown center on education policy , professor and chair, department of economics - tulane university brad olsen , brad olsen senior fellow - global economy and development , center for universal education richard v. reeves , richard v. reeves president - american institute for boys and men jon valant , and jon valant director - brown center on education policy , senior fellow - governance studies kenneth k. wong kenneth k. wong nonresident senior fellow - governance studies , brown center on education policy.

March 12, 2021

• 11 min read

One year ago, the World Health Organization declared the spread of COVID-19 a worldwide pandemic. Reacting to the virus, schools at every level were sent scrambling. Institutions across the world switched to virtual learning, with teachers, students, and local leaders quickly adapting to an entirely new way of life. A year later, schools are beginning to reopen, the $1.9 trillion stimulus bill has been passed, and a sense of normalcy seems to finally be in view; in President Joe Biden’s speech last night, he spoke of “finding light in the darkness.” But it’s safe to say that COVID-19 will end up changing education forever, casting a critical light on everything from equity issues to ed tech to school financing.

Below, Brookings experts examine how the pandemic upended the education landscape in the past year, what it’s taught us about schooling, and where we go from here.

In the United States, we tend to focus on the educating roles of public schools, largely ignoring the ways in which schools provide free and essential care for children while their parents work. When COVID-19 shuttered in-person schooling, it eliminated this subsidized child care for many families. It created intense stress for working parents, especially for mothers who left the workforce at a high rate.

The pandemic also highlighted the arbitrary distinction we make between the care and education of elementary school children and children aged 0 to 5 . Despite parents having the same need for care, and children learning more in those earliest years than at any other point, public investments in early care and education are woefully insufficient. The child-care sector was hit so incredibly hard by COVID-19. The recent passage of the American Rescue Plan is a meaningful but long-overdue investment, but much more than a one-time infusion of funds is needed. Hopefully, the pandemic represents a turning point in how we invest in the care and education of young children—and, in turn, in families and society.

Congressional reauthorization of Pandemic EBT for  this school year , its  extension  in the American Rescue Plan (including for summer months), and its place as a  central plank  in the Biden administration’s anti-hunger agenda is well-warranted and evidence based. But much more needs to be done to ramp up the program–even  today , six months after its reauthorization, about half of states do not have a USDA-approved implementation plan.

In contrast, enrollment is up in for-profit and online colleges. The research repeatedly finds weaker student outcomes for these types of institutions relative to community colleges, and many students who enroll in them will be left with more debt than they can reasonably repay. The pandemic and recession have created significant challenges for students, affecting college choices and enrollment decisions in the near future. Ultimately, these short-term choices can have long-term consequences for lifetime earnings and debt that could impact this generation of COVID-19-era college students for years to come.

Many U.S. educationalists are drawing on the “build back better” refrain and calling for the current crisis to be leveraged as a unique opportunity for educators, parents, and policymakers to fully reimagine education systems that are designed for the 21st rather than the 20th century, as we highlight in a recent Brookings report on education reform . An overwhelming body of evidence points to play as the best way to equip children with a broad set of flexible competencies and support their socioemotional development. A recent article in The Atlantic shared parent anecdotes of children playing games like “CoronaBall” and “Social-distance” tag, proving that play permeates children’s lives—even in a pandemic.

Tests play a critical role in our school system. Policymakers and the public rely on results to measure school performance and reveal whether all students are equally served. But testing has also attracted an inordinate share of criticism, alleging that test pressures undermine teacher autonomy and stress students. Much of this criticism will wither away with  different  formats. The current form of standardized testing—annual, paper-based, multiple-choice tests administered over the course of a week of school—is outdated. With widespread student access to computers (now possible due to the pandemic), states can test students more frequently, but in smaller time blocks that render the experience nearly invisible. Computer adaptive testing can match paper’s reliability and provides a shorter feedback loop to boot. No better time than the present to make this overdue change.

A third push for change will come from the outside in. COVID-19 has reminded us not only of how integral schools are, but how intertwined they are with the rest of society. This means that upcoming schooling changes will also be driven by the effects of COVID-19 on the world around us. In particular, parents will be working more from home, using the same online tools that students can use to learn remotely. This doesn’t mean a mass push for homeschooling, but it probably does mean that hybrid learning is here to stay.

I am hoping we will use this forced rupture in the fabric of schooling to jettison ineffective aspects of education, more fully embrace what we know works, and be bold enough to look for new solutions to the educational problems COVID-19 has illuminated.

There is already a large gender gap in education in the U.S., including in  high school graduation rates , and increasingly in college-going and college completion. While the pandemic appears to be hurting women more than men in the labor market, the opposite seems to be true in education.

Looking through a policy lens, though, I’m struck by the timing and what that timing might mean for the future of education. Before the pandemic, enthusiasm for the education reforms that had defined the last few decades—choice and accountability—had waned. It felt like a period between reform eras, with the era to come still very unclear. Then COVID-19 hit, and it coincided with a national reckoning on racial injustice and a wake-up call about the fragility of our democracy. I think it’s helped us all see how connected the work of schools is with so much else in American life.

We’re in a moment when our long-lasting challenges have been laid bare, new challenges have emerged, educators and parents are seeing and experimenting with things for the first time, and the political environment has changed (with, for example, a new administration and changing attitudes on federal spending). I still don’t know where K-12 education is headed, but there’s no doubt that a pivot is underway.

• First, state and local leaders must leverage commitment and shared goals on equitable learning opportunities to support student success for all.
• Second, align and use federal, state, and local resources to implement high-leverage strategies that have proven to accelerate learning for diverse learners and disrupt the correlation between zip code and academic outcomes.
• Third, student-centered priority will require transformative leadership to dismantle the one-size-fits-all delivery rule and institute incentive-based practices for strong performance at all levels.
• Fourth, the reconfigured system will need to activate public and parental engagement to strengthen its civic and social capacity.
• Finally, public education can no longer remain insulated from other policy sectors, especially public health, community development, and social work.

These efforts will strengthen the capacity and prepare our education system for the next crisis—whatever it may be.

Higher Education K-12 Education

Brookings Metro Economic Studies Global Economy and Development Governance Studies

Brown Center on Education Policy Center for Universal Education

Christine Apiot Okudi, Atenea Rosado-Viurques, Jennifer L. O’Donoghue

August 23, 2024

Sudha Ghimire

August 22, 2024

Online only

11:00 am - 12:00 pm EDT

COVID-19 and education: The lingering effects of unfinished learning

As this most disrupted of school years draws to a close, it is time to take stock of the impact of the pandemic on student learning and well-being. Although the 2020–21 academic year ended on a high note—with rising vaccination rates, outdoor in-person graduations, and access to at least some in-person learning for 98 percent of students—it was as a whole perhaps one of the most challenging for educators and students in our nation’s history. 1 “Burbio’s K-12 school opening tracker,” Burbio, accessed May 31, 2021, cai.burbio.com. By the end of the school year, only 2 percent of students were in virtual-only districts. Many students, however, chose to keep learning virtually in districts that were offering hybrid or fully in-person learning.

Our analysis shows that the impact of the pandemic on K–12 student learning was significant, leaving students on average five months behind in mathematics and four months behind in reading by the end of the school year. The pandemic widened preexisting opportunity and achievement gaps, hitting historically disadvantaged students hardest. In math, students in majority Black schools ended the year with six months of unfinished learning, students in low-income schools with seven. High schoolers have become more likely to drop out of school, and high school seniors, especially those from low-income families, are less likely to go on to postsecondary education. And the crisis had an impact on not just academics but also the broader health and well-being of students, with more than 35 percent of parents very or extremely concerned about their children’s mental health.

The fallout from the pandemic threatens to depress this generation’s prospects and constrict their opportunities far into adulthood. The ripple effects may undermine their chances of attending college and ultimately finding a fulfilling job that enables them to support a family. Our analysis suggests that, unless steps are taken to address unfinished learning, today’s students may earn $49,000 to $61,000 less over their lifetime owing to the impact of the pandemic on their schooling. The impact on the US economy could amount to $128 billion to $188 billion every year as this cohort enters the workforce.

Federal funds are in place to help states and districts respond, though funding is only part of the answer. The deep-rooted challenges in our school systems predate the pandemic and have resisted many reform efforts. States and districts have a critical role to play in marshaling that funding into sustainable programs that improve student outcomes. They can ensure rigorous implementation of evidence-based initiatives, while also piloting and tracking the impact of innovative new approaches. Although it is too early to fully assess the effectiveness of postpandemic solutions to unfinished learning, the scope of action is already clear. The immediate imperative is to not only reopen schools and recover unfinished learning but also reimagine education systems for the long term. Across all of these priorities it will be critical to take a holistic approach, listening to students and parents and designing programs that meet academic and nonacademic needs alike.

What have we learned about unfinished learning?

As the 2020–21 school year began, just 40 percent of K–12 students were in districts that offered any in-person instruction. By the end of the year, more than 98 percent of students had access to some form of in-person learning, from the traditional five days a week to hybrid models. In the interim, districts oscillated among virtual, hybrid, and in-person learning as they balanced the need to keep students and staff safe with the need to provide an effective learning environment. Students faced multiple schedule changes, were assigned new teachers midyear, and struggled with glitchy internet connections and Zoom fatigue. This was a uniquely challenging year for teachers and students, and it is no surprise that it has left its mark—on student learning, and on student well-being.

As we analyze the cost of the pandemic, we use the term “unfinished learning” to capture the reality that students were not given the opportunity this year to complete all the learning they would have completed in a typical year. Some students who have disengaged from school altogether may have slipped backward, losing knowledge or skills they once had. The majority simply learned less than they would have in a typical year, but this is nonetheless important. Students who move on to the next grade unprepared are missing key building blocks of knowledge that are necessary for success, while students who repeat a year are much less likely to complete high school and move on to college. And it’s not just academic knowledge these students may miss out on. They are at risk of finishing school without the skills, behaviors, and mindsets to succeed in college or in the workforce. An accurate assessment of the depth and extent of unfinished learning will best enable districts and states to support students in catching up on the learning they missed and moving past the pandemic and into a successful future.

Students testing in 2021 were about ten points behind in math and nine points behind in reading, compared with matched students in previous years.

Unfinished learning is real—and inequitable

To assess student learning through the pandemic, we analyzed Curriculum Associates’ i-Ready in-school assessment results of more than 1.6 million elementary school students across more than 40 states. 2 The Curriculum Associates in-school sample consisted of 1.6 million K–6 students in mathematics and 1.5 million in reading. The math sample came from all 50 states, but 23 states accounted for 90 percent of the sample. The reading sample came from 46 states, with 21 states accounting for 90 percent of the sample. Florida accounted for 29 percent of the math and 30 percent of the reading sample. In general, states that had reopened schools are overweighted given the in-school nature of the assessment. We compared students’ performance in the spring of 2021 with the performance of similar students prior to the pandemic. 3 Specifically, we compared spring 2021 results to those of historically matched students in the springs of 2019, 2018, and 2017. Students testing in 2021 were about ten points behind in math and nine points behind in reading, compared with matched students in previous years.

To get a sense of the magnitude of these gaps, we translated these differences in scores to a more intuitive measure—months of learning. Although there is no perfect way to make this translation, we can get a sense of how far students are behind by comparing the levels students attained this spring with the growth in learning that usually occurs from one grade level to the next. We found that this cohort of students is five months behind in math and four months behind in reading, compared with where we would expect them to be based on historical data. 4 The conversion into months of learning compares students’ achievement in the spring of one grade level with their performance in the spring of the next grade level, treating this spring-to-spring difference in historical scores as a “year” of learning. It assumes a ten-month school year with a two-month summer vacation. Actual school schedules vary significantly, and i-Ready’s typical growth numbers for a “year” of learning are based on 30 weeks of actual instruction between the fall and the spring rather than on a spring-to-spring calendar-year comparison.

Unfinished learning did not vary significantly across elementary grades. Despite reports that remote learning was more challenging for early elementary students, 5 Marva Hinton, “Why teaching kindergarten online is so very, very hard,” Edutopia, October 21, 2020, edutopia.org. our results suggest the impact was just as meaningful for older elementary students. 6 While our analysis only includes results from students who tested in-school in the spring, many of these students were learning remotely for meaningful portions of the fall and the winter. We can hypothesize that perhaps younger elementary students received more help from parents and older siblings, and that older elementary students were more likely to be struggling alone.

It is also worth remembering that our numbers capture the “average” progress by grade level. Especially in early reading, this average can conceal a wide range of outcomes. Another way of cutting the data looks instead at which students have dropped further behind grade levels. A recent report suggests that more first and second graders have ended this year two or more grade levels below expectations than in any previous year. 7 Academic achievement at the end of the 2020–2021 school year , Curriculum Associates, June 2021, curriculumassociates.com. Given the major strides children at this age typically make in mastering reading, and the critical importance of early reading for later academic success, this is of particular concern.

While all types of students experienced unfinished learning, some groups were disproportionately affected. Students of color and low-income students suffered most. Students in majority-Black schools ended the school year six months behind in both math and reading, while students in majority-white schools ended up just four months behind in math and three months behind in reading. 8 To respect students’ privacy, we cannot isolate the race or income of individual students in our sample, but we can look at school-level demographics. Students in predominantly low-income schools and in urban locations also lost more learning during the pandemic than their peers in high-income rural and suburban schools (Exhibit 1).

In fall 2020, we projected that students could lose as much as five to ten months of learning in mathematics, and about half of that in reading, by the end of the school year. Spring assessment results came in toward the lower end of these projections, suggesting that districts and states were able to improve the quality of remote and hybrid learning through the 2020–21 school year and bring more students back into classrooms.

Indeed, if we look at the data over time, some interesting patterns emerge. 9 The composition of the fall student sample was different from that of the spring sample, because more students returned to in-person assessments in the spring. Some of the increase in unfinished learning from fall to spring could be because the spring assessment included previously virtual students, who may have struggled more during the school year. Even so, the spring data are the best reflection of unfinished learning at the end of the school year. Taking math as an example, as schools closed their buildings in the spring of 2020, students fell behind rapidly, learning almost no new math content over the final few months of the 2019–20 school year. Over the summer, we assume that they experienced the typical “summer slide” in which students lose some of the academic knowledge and skills they had learned the year before. Then they resumed learning through the 2020–21 school year, but at a slower pace than usual, resulting in five months of unfinished learning by the end of the year (Exhibit 2). 10 These lines simplify the pattern of typical learning through the year. In a typical year, students learn more in the fall and less in the spring, and only learn during periods of instruction (the chart includes the well-documented learning loss that happens during the summer, but does not include shorter holidays when students are not in school receiving instruction).

In reading, however, the story is somewhat different. As schools closed their buildings in March 2020, students continued to progress in reading, albeit at a slower pace. During the summer, we assume that students’ reading level stayed roughly flat, as in previous years. The pace of learning increased slightly over the 2020–21 school year, but the difference was not as great as it was in math, resulting in four months of unfinished learning by the end of the school year (Exhibit 3). Put another way, the initial shock in reading was less severe, but the improvements to remote and hybrid learning seem to have had less impact in reading than they did in math.

Before we celebrate the improvements in student trajectories between the initial school shutdowns and the subsequent year of learning, we should remember that these are still sobering numbers. On average, students who took the spring assessments in school are half a year behind in math, and nearly that in reading. For Black and Hispanic students, the losses are not only greater but also piled on top of historical inequities in opportunity and achievement (Exhibit 4).

Furthermore, these results likely represent an optimistic scenario. They reflect outcomes for students who took interim assessments in the spring in a school building 11 Students who took the assessment out of school are not included in our sample because we could not guarantee fidelity and comparability of results, given the change in the testing environment. Out-of-school students represent about a third of the students taking i-Ready assessments in the spring, and we will not have an accurate understanding of the pandemic’s impact on their learning until they return to school buildings, likely in the fall. —and thus exclude students who remained remote throughout the entire school year, and who may have experienced the most disruption to their schooling. 12 Initial results from Texas suggest that districts with mostly virtual instruction experienced more unfinished learning than those with mostly in-person instruction. The percent of students meeting math expectations dropped 32 percent in mostly virtual districts but just 9 percent in mostly in-person ones. See Reese Oxner, “Texas students’ standardized test scores dropped dramatically during the pandemic, especially in math,” Texas Tribune , June 28, 2021, texastribune.org. The Curriculum Associates data cover a broad variety of schools and states across the country, but are not fully representative, being overweighted for rural and southeastern states that were more likely to get students back into the classrooms this year. Finally, these data cover only elementary schools. They are silent on the academic impact of the pandemic for middle and high schoolers. However, data from school districts suggest that, even for older students, the pandemic has had a significant effect on learning. 13 For example, in Salt Lake City, the percentage of middle and high school students failing a class jumped by 60 percent, from 2,500 to 4,000, during the pandemic. To learn about increased failure rates across multiple districts from the Bay Area to New Mexico, Austin, and Hawaii, see Richard Fulton, “Failing Grades,” Inside Higher Ed , March 8, 2021, insidehighered.com.

The harm inflicted by the pandemic goes beyond academics

Students didn’t just lose academic learning during the pandemic. Some lost family members; others had caregivers who lost their jobs and sources of income; and almost all experienced social isolation.

These pressures have taken a toll on students of all ages. In our recent survey of 16,370 parents across every state in America, 35 percent of parents said they were very or extremely concerned about their child’s mental health, with a similar proportion worried about their child’s social and emotional well-being. Roughly 80 percent of parents had some level of concern about their child’s mental health or social and emotional health and development since the pandemic began. Parental concerns about mental health span grade levels but are slightly lower for parents of early elementary school students. 14 While 30.7% percent of all K–2 parents were very or extremely concerned, a peak of 37.6% percent of eighth-grade parents were.

Parents also report increases in clinical mental health conditions among their children, with a five-percentage-point increase in anxiety and a six-percentage-point increase in depression. They also report increases in behaviors such as social withdrawal, self-isolation, lethargy, and irrational fears (Exhibit 5). Despite increased levels of concern among parents, the amount of mental health assessment and testing done for children is 6.1 percent lower than it was in 2019 —the steepest decline in assessment and testing rates of any age group.

Broader student well-being is not independent of academics. Parents whose children have fallen significantly behind academically are one-third more likely to say that they are very or extremely concerned about their children’s mental health. Black and Hispanic parents are seven to nine percentage points more likely than white parents to report higher levels of concern. Unaddressed mental-health challenges will likely have a knock-on effect on academics going forward as well. Research shows that trauma and other mental-health issues can influence children’s attendance, their ability to complete schoolwork in and out of class, and even the way they learn. 15 Satu Larson et al., “Chronic childhood trauma, mental health, academic achievement, and school-based health center mental health services,” Journal of School Health , 2017, 87(9), 675–86, escholarship.org.

In our recent survey of 16,370 parents across every state in America, 35 percent of parents said they were very or extremely concerned about their child’s mental health.

The impact of unfinished learning on diminished student well-being seems to be playing out in the choices that students are making. Some students have already effectively dropped out of formal education entirely. 16 To assess the impact of the pandemic on dropout rates, we have to look beyond official enrollment data, which are only published annually, and which only capture whether a child has enrolled at the beginning of the year, not whether they are engaged and attending school. Chronic absenteeism rates provide clues as to which students are likely to persist in school and which students are at risk of dropping out. Our parent survey suggests that chronic absenteeism for eighth through 12th graders has increased by 12 percentage points, and 42 percent of the students who are new to chronic absenteeism are attending no school at all, according to their parents. Scaled up to the national level, this suggests that 2.3 million to 4.6 million additional eighth- to 12th-grade students were chronically absent from school this year, in addition to the 3.1 million who are chronically absent in nonpandemic years. State and district data on chronic absenteeism are still emerging, but data released so far also suggest a sharp uptick in absenteeism rates nationwide, particularly in higher grades. 17 A review of available state and district data, including data released by 14 states and 11 districts, showed increases in chronic absenteeism of between three and 16 percentage points, with an average of seven percentage points. However, many states changed the definition of absenteeism during the pandemic, so a true like-for-like comparison is difficult to obtain. According to emerging state and district data, increases in chronic absenteeism are highest among populations with historically low rates. This is reflected also in our survey results. Black students, with the highest historical absenteeism rates, saw more modest increases during the pandemic than white or Hispanic students (Exhibit 6).

It remains unclear whether these pandemic-related chronic absentees will drop out at rates similar to those of students who were chronically absent prior to the pandemic. Some students could choose to return to school once in-person options are restored; but some portion of these newly absent students will likely drop out of school altogether. Based on historical links between chronic absenteeism and dropout rates, as well as differentials in absenteeism between fully virtual and fully in-person students, we estimate that an additional 617,000 to 1.2 million eighth–12th graders could drop out of school altogether because of the pandemic if efforts are not made to reengage them in learning next year. 18 The federal definition of chronic absenteeism is missing more than 15 days of school each year. According to the Utah Education Policy Center’s research brief on chronic absenteeism, the overall correlation between one year of chronic absence between eighth and 12th grade and dropping out of school is 0.134. For more, see Utah Education Policy Center, Research brief: Chronic absenteeism , July 2012, uepc.utah.edu. We then apply the differential in chronic absenteeism between fully virtual and fully in-person students to account for virtual students reengaging when in-person education is offered. For students who were not attending school at all, we assumed that 50 to 75 percent would not return to learning. This estimation is partly based on The on-track indicator as a predictor of high school graduation from the UChicago Consortium on School Research, which estimates that up to 75 percent of high school students who are “off track”—either failing or behind in credits—do not graduate in five years. For more, see Elaine Allensworth and John Q. Easton, The on-track indicator as a predictor of high school graduation , UChicago Consortium on School Research, 2005, consortium.uchicago.edu.

Even among students who complete high school, many may not fulfill their dreams of going on to postsecondary education. Our survey suggests that 17 percent of high school seniors who had planned to attend postsecondary education abandoned their plans—most often because they had joined or were planning to join the workforce or because the costs of college were too high. The number is much higher among low-income high school seniors, with 26 percent abandoning their plans. Low-income seniors are more likely to state cost as a reason, with high-income seniors more likely to be planning to reapply the following year or enroll in a gap-year program. This is consistent with National Student Clearinghouse reports that show overall college enrollment declines, with low-income, high-poverty, and high-minority high schools disproportionately affected. 19 Todd Sedmak, “Fall 2020 college enrollment update for the high school graduating class of 2020,” National Student Clearinghouse, March 25, 2021, studentclearinghouse.org; Todd Sedmak, “Spring 2021 college enrollment declines 603,000 to 16.9 million students,” National Student Clearinghouse, June 10, 2021, studentclearinghouse.org.

Unfinished learning has long-term consequences

The cumulative effects of the pandemic could have a long-term impact on an entire generation of students. Education achievement and attainment are linked not only to higher earnings but also to better health, reduced incarceration rates, and greater political participation. 20 See, for example, Michael Grossman, “Education and nonmarket outcomes,” in Handbook of the Economics of Education, Volume 1 , ed. Eric Hanushek and Finis Welch (Amsterdam: Elsevier, 2006), 577–633; Lance Lochner and Enrico Moretti, “The effect of education on crime: Evidence from prison inmates, arrests, and self-reports,” American Economic Review , 2004, Volume 94, Number 1, pp. 155–89; Kevin Milligan, Enrico Moretti, and Philip Oreopoulos, “Does education improve citizenship? Evidence from the United States and the United Kingdom,” Journal of Public Economics , August 2004, Volume 88, Number 9–10, pp. 1667–95; and Education transforms lives , UNESCO, 2013, unesdoc.unesco.org. We estimate that, without immediate and sustained interventions, pandemic-related unfinished learning could reduce lifetime earnings for K–12 students by an average of $49,000 to $61,000. These costs are significant, especially for students who have lost more learning. While white students may see lifetime earnings reduced by 1.4 percent, the reduction could be as much as 2.4 percent for Black students and 2.1 percent for Hispanic students. 21 Projected earnings across children’s lifetimes using current annual incomes for those with at least a high school diploma, discounting the earnings by a premium established in Murnane et al., 2000, which tied cognitive skills and future earnings. See Richard J. Murnane et al., “How important are the cognitive skills of teenagers in predicting subsequent earnings?,” Journal of Policy Analysis and Management , September 2000, Volume 19, Number 4, pp. 547–68.

Lower earnings, lower levels of education attainment, less innovation—all of these lead to decreased economic productivity. By 2040 the majority of this cohort of K–12 students will be in the workforce. We anticipate a potential annual GDP loss of $128 billion to $188 billion from pandemic-related unfinished learning. 22 Using Hanushek and Woessmann 2008 methodology to map national per capita growth associated with decrease in academic achievement, then adding additional impact of pandemic dropouts on GDP. For more, see Eric A. Hanushek and Ludger Woessmann, “The role of cognitive skills in economic development,” Journal of Economic Literature , September 2008, Volume 46, Number 3, pp. 607–68.

This increases by about one-third the existing hits to GDP from achievement gaps that predated COVID-19. Our previous research indicated that the pre-COVID-19 racial achievement gap was equivalent to $426 billion to $705 billion in lost economic potential every year (Exhibit 7). 23 This is the increase in GDP that would result if Black and Hispanic students achieved the same levels of academic performance as white students. For more information on historical opportunity and achievement gaps, please see Emma Dorn, Bryan Hancock, Jimmy Sarakatsannis, and Ellen Viruleg, “ COVID-19 and student learning in the United States: The hurt could last a lifetime ,” June 1, 2020.

What is the path forward for our nation’s students?

There is now significant funding in place to address these critical issues. Through the Coronavirus Aid, Relief, and Economic Security Act (CARES Act); the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSAA); and the American Rescue Plan (ARP), the federal government has already committed more than $200 billion to K–12 education over the next three years, 24 The CARES Act provided $13 billion to ESSER and $3 billion to the Governor’s Emergency Education Relief (GEER) Fund; CRRSAA provided $54 billion to ESSER II, $4 billion to Governors (GEER II and EANS); ARP provided $123 billion to ESSER III, $3 billion to Governors (EANS II), and $10 billion to other education programs. For more, see “CCSSO fact sheet: COVID-19 relief funding for K-12 education,” Council of Chief State School Officers, 2021, https://753a0706.flowpaper.com/CCSSOCovidReliefFactSheet/#page=2. a significant increase over the approximately $750 billion spent annually on public schooling. 25 “The condition of education 2021: At a glance,” National Center for Education Statistics, accessed June 30, 2021, nces.ed.gov. The majority of these funds are routed through the Elementary and Secondary School Emergency Relief Fund (ESSER), of which 90 percent flows to districts and 10 percent to state education agencies. These are vast sums of money, particularly in historical context. As part of the 2009 American Recovery and Reinvestment Act (ARRA), the Obama administration committed more than $80 billion toward K–12 schools—at the time the biggest federal infusion of funds to public schools in the nation’s history. 26 “The American Recovery and Reinvestment Act of 2009: Saving and Creating Jobs and Reforming Education,” US Department of Education, March 7, 2009, ed.gov. Today’s funding more than doubles that previous record and gives districts much more freedom in how they spend the money. 27 Andrew Ujifusa, “What Obama’s stimulus had for education that the coronavirus package doesn’t,” Education Week , March 31, 2020, www.edweek.org.

However, if this funding can mitigate the impact of unfinished learning, it could prevent much larger losses to the US economy. Given that this generation of students will likely spend 35 to 40 years in the workforce, the cumulative impact of COVID-19 unfinished learning over their lifetimes could far exceed the investments that are being made today.

Furthermore, much of today’s federal infusion will likely be spent not only on supporting students in catching up on the unfinished learning of the pandemic but also on tackling deeper historical opportunity and achievement gaps among students of different races and income levels.

As districts consider competing uses of funding, they are juggling multiple priorities over several time horizons. The ARP funding needs to be obligated by September 2023. This restricts how monies can be spent. Districts are balancing the desire to hire new personnel or start new programs with the risk of having to close programs because of lack of sustained funds in the future. Districts are also facing decisions about whether to run programs at the district level or to give more freedom to principals in allocating funds; about the balance between academics and broader student needs; about the extent to which funds should be targeted to students who have struggled most or spread evenly across all students; and about the balance between rolling out existing evidence-based programs and experimenting with innovative approaches.

It is too early to answer all of these questions decisively. However, as districts consider this complex set of decisions, leading practitioners and thinkers have come together to form the Coalition to Advance Future Student Success—and to outline priorities to ensure the effective and equitable use of federal funds. 28 “Framework: The Coalition to Advance Future Student Success,” Council of Chief State School Officers, accessed June 30, 2021, learning.ccsso.org.

These priorities encompass four potential actions for schools:

• Safely reopen schools for in-person learning.
• Reengage students and reenroll them into effective learning environments.
• Support students in recovering unfinished learning and broader needs.
• Recommit and reimagine our education systems for the long term.

Across all of these actions, it is important for districts to understand the changing needs of parents and students as we emerge from the pandemic, and to engage with them to support students to learn and to thrive. The remainder of this article shares insights from our parent survey of more than 16,000 parents on these changing needs and perspectives, and highlights some early actions by states and districts to adapt to meet them.

1. Safely reopen schools for in-person learning

The majority of school districts across the country are planning to offer traditional five-days-a-week in-person instruction in the fall, employing COVID-19-mitigation strategies such as staff and student vaccination drives, ongoing COVID-19 testing, mask mandates, and infrastructure updates. 29 “Map: Where Were Schools Required to Be Open for the 2020-21 School Year?,” Education Week , updated May 2021, edweek.org. The evidence suggests that schools can reopen buildings safely with the right protocols in place, 30 For a summary of the evidence on safely reopening schools, see John Bailey, Is it safe to reopen schools? , CRPE, March 2021, crpe.org. but health preparedness will likely remain critical as buildings reopen. Indeed, by the end of the school year, a significant subset of parents remain concerned about safety in schools, with nearly a third still very or extremely worried about the threat of COVID-19 to their child’s health. Parents also want districts to continue to invest in safety—39 percent say schools should invest in COVID-19 health and safety measures this fall.

2. Reengage and reenroll students in effective learning environments

Opening buildings safely is hard enough, but encouraging students to show up could be even more challenging. Some students will have dropped out of formal schooling entirely, and those who remain in school may be reluctant to return to physical classrooms. Our survey results suggest that 24 percent of parents are still not convinced they will choose in-person instruction for their children this fall. Within Black communities, that rises to 34 percent. But many of these parents are still open to persuasion. Only 4 percent of parents (and 6 percent of Black parents) say their children will definitely not return to fully in-person learning—which is not very different from the percentage of parents who choose to homeschool or pursue other alternative education options in a typical year. For students who choose to remain virtual, schools should make continual efforts to improve virtual learning models, based on lessons from the past year.

For parents who are still on the fence, school districts can work to understand their needs and provide effective learning options. Safety concerns remain the primary reason that parents remain hesitant about returning to the classroom; however, this is not the only driver. Some parents feel that remote learning has been a better learning environment for their child, while others have seen their child’s social-emotional and mental health improve at home.

Still, while remote learning may have worked well for some students, our data suggest that it failed many. In addition to understanding parent needs, districts should reach out to families and build confidence not just in their schools’ safety precautions but also in their learning environment and broader role in the community. Addressing root causes will likely be more effective than punitive measures, and a broad range of tactics may be needed, from outreach and attendance campaigns to student incentives to providing services families need, such as transportation and childcare. 31 Roshon R. Bradley, “A comprehensive approach to improving student attendance,” St. John Fisher College, August 2015, Education Doctoral, Paper 225, fisherpub.sjfc.edu; a 2011 literature review highlights how incentives can effectively be employed to increase attendance rates. Across all of these, a critical component will likely be identifying students who are at risk and ensuring targeted outreach and interventions. 32 Elaine M. Allensworth and John Q. Easton, “What matters for staying on-track and graduating in Chicago Public Schools: A close look at course grades, failures, and attendance in the freshman year,” Consortium on Chicago School Research at the University of Chicago, July 2007, files.eric.ed.gov.

Chicago Public Schools, in partnership with the University of Chicago, has developed a student prioritization index (SPI) that identifies students at highest risk of unfinished learning and dropping out of school. The index is based on a combination of academic, attendance, socio-emotional, and community vulnerability inputs. The district is reaching out to all students with a back-to-school marketing campaign while targeting more vulnerable students with additional support. Schools are partnering with community-based organizations to carry out home visits, and with parents to staff phone banks. They are offering various paid summer opportunities to reduce the trade-offs students may have to make between summer school and summer jobs, recognizing that many have found paid work during the pandemic. The district will track and monitor the results to learn which tactics work. 33 “Moving Forward Together,” Chicago Public Schools, June 2021, cps.edu.

In Florida’s Miami-Dade schools, each school employee was assigned 30 households to contact personally, starting with a phone call and then showing up for a home visit. Superintendent Alberto Carvalho personally contacted 30 families and persuaded 23 to return to in-person learning. The district is starting the transition to in-person learning by hosting engaging in-person summer learning programs. 34 Hannah Natanson, “Schools use home visits, calls to convince parents to choose in-person classes in fall,” Washington Post , July 7, 2021, washingtonpost.com.

3. Support students in recovering unfinished learning and in broader needs

Even if students reenroll in effective learning environments in the fall, many will be several months behind academically and may struggle to reintegrate into a traditional learning environment. School districts are therefore creating strategies to support students  as they work to make up unfinished learning, and as they work through broader mental health issues and social reintegration. Again, getting parents and students to show up for these programs may be harder than districts expect.

Our research suggests that parents underestimate the unfinished learning caused by the pandemic. In addition, their beliefs about their children’s learning do not reflect racial disparities in unfinished learning. In our survey, 40 percent of parents said their child is on track and 16 percent said their child is progressing faster than in a usual year. Black parents are slightly more likely than white parents to think their child is on track or better, Hispanic parents less so. However, across all races, more than half of parents think their child is doing just fine. Only 14 percent of parents said their child has fallen significantly behind.

Even if programs are offered for free, many parents may not take advantage of them, especially if they are too academically oriented. Only about a quarter of parents said they are very likely to enroll their child in tutoring, after-school, or summer-school programs, for example. Nearly 40 percent said they are very likely to enroll their students in enrichment programs such as art or music. Districts therefore should consider not only offering effective evidence-based programs, such as high-dosage tutoring and vacation academies, but also ensuring that these programs are attractive to students.

In Rhode Island, for example, the state is taking a “Broccoli and Ice Cream” approach to summer school to prepare students for the new school year, combining rigorous reading and math instruction with fun activities provided by community-based partners. Enrichment activities such as sailing, Italian cooking lessons, and Olympic sports are persuading students to participate. 35 From webinar with Angélica Infante-Green, Rhode Island Department of Education, https://www.ewa.org/agenda/ewa-74th-national-seminar-agenda. The state-run summer program is open to students across the state, but the Rhode Island Department of Education has also provided guidance to district-run programs, 36 Learning, Equity & Accelerated Pathways Task Force Report , Rhode Island Department of Education, April 2021, ride.ri.gov. encouraging partnerships with community-based organizations, a dual focus on academics and enrichment, small class sizes, and a strong focus on relationships and social-emotional support.

In Louisiana, the state has provided guidance and support 37 Staffing and scheduling best practices guidance , Louisiana Department of Education, June 3, 2021, louisianabelieves.com. to districts in implementing recovery programs to ensure evidence-based approaches are rolled out state-wide. The guidance includes practical tips on ramping up staffing, and on scheduling high-dosage tutoring and other dedicated acceleration blocks. The state didn’t stop at guidance, but also flooded districts with support and two-way dialogue through webinars, conferences, monthly calls, and regional technical coaching. By scheduling acceleration blocks during the school day, rather than an add-on after school, districts are not dependent on parents signing up for programs.

For students who have experienced trauma, schools will likely need to address the broader fallout from the pandemic. In southwest Virginia, the United Way is partnering with five school systems to establish a trauma-informed schools initiative, providing teachers and staff with training and resources on trauma recovery. 38 Mike Still, “SWVA school districts partner to help students in wake of pandemic,” Kingsport Times News, June 26, 2021, timesnews.net. San Antonio is planning to hire more licensed therapists and social workers to help students and their families, leveraging partnerships with community organizations to place a licensed social worker on every campus. 39 Brooke Crum, “SAISD superintendent: ‘There are no shortcuts’ to tackling COVID-related learning gaps,” San Antonio Report, April 12, 2021, sanantonioreport.org.

4. Recommit and reimagine our education systems for the long term

Opportunity gaps have existed in our school systems for a long time. As schools build back from the pandemic, districts are also recommitting to providing an excellent education to every child. A potential starting point could be redoubling efforts to provide engaging, high-quality grade-level curriculum and instruction delivered by diverse and effective educators in every classroom, supported by effective assessments to inform instruction and support.

Beyond these foundational elements, districts may consider reimagining other aspects of the system. Parents may also be open to nontraditional models. Thirty-three percent of parents said that even when the pandemic is over, the ideal fit for their child would be something other than five days a week in a traditional brick-and-mortar school. Parents are considering hybrid models, remote learning, homeschooling, or learning hubs over the long term. Even if learning resumes mostly in the building, parents are open to the use of new technology to support teaching.

Edgecombe County Public Schools in North Carolina is planning to continue its use of learning hubs this fall to better meet student needs. In the district’s hub-and-spoke model, students will spend half of their time learning core content (the “hub”). For the other half they will engage in enrichment activities aligned to learning standards (the “spokes”). For elementary and middle school students, enrichment activities will involve interest-based projects in science and social studies; for high schoolers, activities could include exploring their passions through targeted English language arts and social studies projects or getting work experience—either paid or volunteer. The district is redeploying staff and leveraging community-based partnerships to enable these smaller-group activities with trusted adults who mirror the demographics of the students. 40 “District- and community-driven learning pods,” Center on Reinventing Public Education, crpe.org.

In Tennessee, the new Advanced Placement (AP) Access for All program will provide students across the state with access to AP courses, virtually. The goal is to eliminate financial barriers and help students take AP courses that aren’t currently offered at their home high school. 41 Amy Cockerham, “TN Department of Education announces ‘AP Access for All program,’” April 28, 2021, WJHL-TV, wjhl.com.

The Dallas Independent School District is rethinking the traditional school year, gathering input from families, teachers, and school staff to ensure that school communities are ready for the plunge. More than 40 schools have opted to add five additional intercession weeks to the year to provide targeted academics and enrichment activities. A smaller group of schools will add 23 days to the school year to increase time for student learning and teacher planning and collaboration. 42 “Time to Learn,” Dallas Independent School District, dallasisd.org.

It is unclear whether all these experiments will succeed, and school districts should monitor them closely to ensure they can scale successful programs and sunset unsuccessful ones. However, we have learned in the pandemic that some of the innovations born of necessity met some families’ needs better. Continued experimentation and fine-tuning could bring the best of traditional and new approaches together.

Thanks to concerted efforts by states and districts, the worst projections for learning outcomes this past year have not materialized for most students. However, students are still far behind where they need to be, especially those from historically marginalized groups. Left unchecked, unfinished learning could have severe consequences for students’ opportunities and prospects. In the long term, it could exact a heavy toll on the economy. It is not too late to mitigate these threats, and funding is now in place. Districts and states now have the opportunity to spend that money effectively to support our nation’s students.

Emma Dorn is a senior expert in McKinsey’s Silicon Valley office; Bryan Hancock and Jimmy Sarakatsannis are partners in the Washington, DC, office; and Ellen Viruleg is a senior adviser based in Providence, Rhode Island.

The authors wish to thank Alice Boucher, Ezra Glenn, Ben Hayes, Cheryl Healey, Chauncey Holder, and Sidney Scott for their contributions to this article.

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COVID-19 and its impact on education, social life and mental health of students: A survey

The outbreak of COVID-19 affected the lives of all sections of society as people were asked to self-quarantine in their homes to prevent the spread of the virus. The lockdown had serious implications on mental health, resulting in psychological problems including frustration, stress, and depression. In order to explore the impacts of this pandemic on the lives of students, we conducted a survey of a total of 1182 individuals of different age groups from various educational institutes in Delhi - National Capital Region (NCR), India. The article identified the following as the impact of COVID-19 on the students of different age groups: time spent on online classes and self-study, medium used for learning, sleeping habits, daily fitness routine, and the subsequent effects on weight, social life, and mental health. Moreover, our research found that in order to deal with stress and anxiety, participants adopted different coping mechanisms and also sought help from their near ones. Further, the research examined the student’s engagement on social media platforms among different age categories. This study suggests that public authorities should take all the necessary measures to enhance the learning experience by mitigating the negative impacts caused due to the COVID-19 outbreak.

1. Introduction

The emergence of Corona Virus disease (COVID-19) has led the world to an unprecedented public health crisis. Emergency protocols were implemented in India to control the spread of the virus which resulted in restrictions on all non-essential public movements ( Saha et al. 2020 ). With the closure of educational institutions, the need for a rapid transition from physical learning to the digital sphere of learning emerged ( Kapasia et al. 2020 ). Online learning has been observed as a possible alternative to conventional learning ( Adnan and Anwar 2020 ). However, according to a meta-analysis on e-learning ( Cook 2009 ), it is reported that online learning is better than nothing and similar to conventional learning. To improve the e-learning experience, the education institutions are required to comply with the guidelines and recommendations by government agencies, while keeping students encouraged to continue learning remotely in this tough environment ( Aucejo et al. 2020 ). Bao (2020 ) addresses five high-impact guidelines for the efficient conduct of online education.

This rapid evolution at such a large scale has influenced the students of all age groups ( Hasan and Bao 2020 ). It is expected that the continued spread of the disease, travel restrictions and the closure of educational institutions across the country would have a significant effect on the education, social life, and mental health of students ( Odriozola-gonzález et al. 2020 ). The students from the less privileged backgrounds have experienced larger negative impacts due to the Covid-19 outbreak ( Aucejo et al. 2020 ). Reduction in family income, limited access to digital resources, and the high cost of internet connectivity have disrupted the academic life of the students. Moreover, 1.5 billion students across the world are now deprived of basic education ( Lee 2020 ) leading to a serious psychological impact on their health. Moreover, changes in daily routine including lack of outdoor activity, disturbed sleeping patterns, social distancing have affected the mental well-being of the students. ( Cao et al. 2020 ) uses 7-item Generalized Anxiety Disorder Scale (GAD-7) as a diagnostic tool for the assessment of anxiety disorders, panic disorders, and social phobia. Further, ( Ye et al. 2020 ) analyses mediating roles of resilience, coping, and social support to deal with psychological symptoms.

In this paper, we investigated and analyzed the potential consequences of the COVID-19 pandemic on the life of students. Our research shows that there is a wide gap between the government's policy aspirations and the implementation of these online education policies at the grassroots level. Moreover, our study attempts to assess the mental situation of students of different age groups using different parameters including sleeping habits, daily fitness routine, and social support. Further, we analyse different coping mechanisms used by students to deal with the current situation.

2. Objective and methods

A 19-set questionnaire was developed, which included a variety of multiple-choice questions, Likert scale and for a few questions, the respondents were allowed to enter free texts. The survey was administered using the Google Forms platform, which requires subjects to be logged in to an e-mail account to participate in the survey, it restricted multiple entries from an individual account. The distribution of the questionnaire was conducted through the outreach of social media platforms, e-mail, and standard messaging services. Clear instructions with the google form were provided to ensure the respondent must be a student.

2.1. Study design

A web-based survey was conducted to students through the medium of Google online platforms from July 13 to July 17, 2020. The online survey questionnaire contained four subgroups:

• (a) Participants were asked to describe their general demographics, such as age, the region of residence.
• (b) Information about the daily online learning routine following the transition from offline learning in educational institutions in India: average time spent for online study (hours) /day; medium for online study; average time spent for self-study (hours)/day.
• (c) Assessment of the experience of online learning to evaluate the levels of satisfaction among students.
• (d) Assessment of health due to the change in lifestyle: average time spent on sleep (hours)/day; change in weight; average time spent on fitness (hours)/day; the number of meals/days; also, we considered further questions about the medium of stress busters during the pandemic, cohesion with family members, etc.

The aim of this survey study is to investigate the impact of the COVID-19 pandemic on the education, health, and lifestyle of students from different age-groups.

2.2. Statistical analysis

In this study, we conducted a cross-sectional survey with a sample size of 1182 students from different educational institutions. A summary of demographic details in the form of numbers and percentages is provided. Mean at 95% Confidence Interval limit was calculated for learning hours for online classes and self-study, duration of sleep, time spent on fitness and sleep. Kruskal Wallis test, a non-parametric test was used to assess the significant difference in the time spent on the aforementioned activities among different age distributions. Fisher’s exact test was performed to assess the differences between respondent’s health with the variables of interest. In order to analyse the association between age categories and different variables such as change in weight, health issues faced, stress busters, etc, the Pearson Chi Square test was used. JMP Version 15.2.1 from SAS was used for analysis. A statistically significant value of P < 0.05 was considered.

2.3. Ethical consideration

The following survey was done in a properly informed set up and consent from the individuals was taken for the participation. No individual was forced against their will and no identifying information was collected.

3.1. Participants characteristics

A total of 1182 subjects from different educational institutions including schools, colleges, and universities in the Delhi-National Capital Region (NCR) participated in the online questionnaire. The demographic detail of the participants is shown in Table 1 . The mean age is 20.16 years (95% confidence interval (CI), 19.8–20.4) (range, 7–59). The age of the participants was normally distributed (‘7–17’ year old, 303; ‘18–22’ year old, 694; ‘23–59’ year old, 185). 728 (61.62%) of the respondents lived in Delhi-NCR and the rest were living outside of Delhi-NCR during the period of the pandemic.

Demographic data of the respondents to the online survey questionnaire.

3.2. Assessment of online learning

According to Table 2 , the Kruskal Wallis test was used to assess the difference in the time spent by different age categories for daily routine activities. The average time spent on online classes for students was 3.20 h/day (95% confidence interval (CI), 3.08–3.32). However, the average time spent on online classes was significantly higher for students with age group ‘7–17’ years (3.69 h/day), and lower for students with age groups, ‘18–22’ years (2.98 h/day) and ‘23–59’ years (2.66 h/day) (P < 0.0001*). Further, respondents were asked about the time they allot per day for self-study, however, there was no significant difference among different age group categories (P = 0.106). Overall, 2.91 h/day (95% CI, 2.78–3.03) was the average time spent on self-study. According to the assessment of satisfaction level among students (see Fig. 1 .a), 38.3% of students had negative response towards online classes (2.6% poor and 35.7% very poor), 33.4% considered it average while 28.4% (19.9% good and 8.5% excellent) gave a positive review. Surprisingly, the in-depth analysis showed the satisfaction levels varied significantly with different age groups. There were 51.6% (48.6% very poor and 3% poor) negative online class reviews from subjects in the ‘18–22’ age group, compared to 31.5% (29.1% very poor and 2.4% poor) negative reviews from subjects in the ‘7–17’ age group who spent more time on online classes.

Table showing how different variables (time spent on online class, self-study, fitness, sleep, and social media) changes with different age distributions.

Kruskal Wallis test was used to produce a P-value that analyzes significant difference between different age distributions. *Statistically significant (P < 0.05).

Visualizations demonstrate a) Likert analysis of Online classes for the sample and for different age categories b) Medium for the online classes b) Learning medium used by different age categories.

The respondents were further asked about the medium of their online learning (see Fig. 1 .b), 57.3% in the age group ‘7–17’ used smartphones while the majority of students from age group ‘18–22’ (56.4%) and age group ‘23–59’ (57.8%) used laptop/desktop for study. However, only a small portion of the total students (3.1%, n = 37) used tablet. With regard to the time spent in online classes, there was a statistically significant difference between the various mediums used (P = 0.0002). As shown in Table 3 , 4.29 h/day (95% CI, 3.63–4.96) was the average time spent on online classes using tablets, 3.43 h/day (95% CI, 3.25–3.61) when using laptop/desktop, and 3.06 h/day (95% CI, 2.90–3.23) when using smartphones.

Time spent on online classes using different learning medium.

3.3. Assessment of health in educational institutions

Among the respondents from different age groups (see Fig. 2 ), 13.6% (n = 160) faced health-related issues during the period of nationwide travel restrictions. Further respondents were asked about the change in body weight within this period, 37.1% reported an increase in weight, 17.7% reported a decrease in weight, and 45.3% reported no change in weight. When asked whether they are satisfied with their utilization of time, the majority of respondents (51.4%, n = 608) answered in ‘NO’, and the rest (n = 575) answered with ‘YES’. Also, 70.3% of the respondents stated that they were socially connected with their family members.

Visualizations demonstrate a) Pie Chart for Likert questions: whether the respondent faced health issues; whether the respondent utilized the time efficiently; whether the respondent is socially well connected. b) Stacked bar chart to analyze the change in weight during the period of lockdown.

According to Table 4 , fisher’s exact test indicated that the respondents who were not socially well connected and believed that they did not utilize their time in lockdown, had a significant impact on their state of health. Also, in Table 5 , the Pearson Chi Square test for Likert analysis on ‘time utilized’ (P < 0.0001*), ‘health issue faced’ (P < 0.0001*), and ‘socially well connected’ (P = 0.0002*) rejected the null hypothesis that there is no association between these variables with the different distribution of age groups. To maintain a state of health and well-being, it is necessary to perform a certain amount of exercise daily. The findings of Table 2 showed that the time spent on fitness was statistically different for different age groups (P = 0.039*, Kruskal Wallis test). And, the average time spent on sleep was 7.87 h/day (95% Confidence Interval, 7.77–7.96). The differences between the age groups in terms of duration of sleep were statistically significant.

Fisher’s exact test to analyse the effect of multiple factors on health.

*Statistically significant (P < 0.05).

Pearson Chi Square test for the association between different variables and age distribution.

Further, respondents were questioned about the measures adopted to cope with the rising stress levels during the pandemic. According to the Pearson Chi Square test in Table 4 , there was a significant difference in the measures used by the different age categories. Fig. 3 shows the detailed distribution of different stress reliever activities used among different age categories.

Visualization demonstrate the distribution of stress relieving activities among different age categories.

3.4. Social media

According to Fig. 3 , a significant number of individuals from different age categories used social media as a medium for stress reliever. Further in Fig. 4 . a, the findings provide the distribution of the sample for the use of different platforms. While the majority of respondents used social media, 1.44% did not have an account on any platform. Fig. 4 . b gives the detailed distribution of platforms for age-wise groups. YouTube (39%) was the preferred platform for the age group '7–17,' followed by Whatsapp (35%) and Instagram (17%). Most of the social networking sites in India restricts individuals below 13 years of age to have an account on their platforms. However, some individuals under 13 years of age used Instagram (n = 2), Whatsapp (n = 16), and Snapchat (n = 1). For the age group ‘18-22’, Instagram (39%) was the most preferred networking site, and the respondents in the age-group ‘23-59’ preferred WhatsApp (38%).

Visualization demonstrate the distribution of preferred social media platform for a) the sample and b) among different age categories.

As shown in Table 2 , the average time spent on social media for the age group ‘7-17’ was 1.68 h/day (95% Confidence Interval, 1.52–1.85), 2.64 h/day (95% Confidence Interval, 2.50–2.78) for the age group ‘18-22’, and for the age group ‘23-59’, it was 2.37 h/day (95% Confidence Interval, 2.14–2.61). The difference between the groups was statistically different (P < 0.0001*).

4. Discussion

The outbreak of Covid-19 has upended the lives of all parts of the society. One of the most immediate changes introduced was the closure of educational institutions to slow the transmission of the virus. In order to prevent further interruption of studies, new teaching methods for the online delivery of education were introduced ( Johnson et al., 2020 , Di Pietro et al., 2020 ). However, these measures can have long-term consequences on the lives of students ( Cohen et al. 2020 ). Therefore, there is a strong need to record and study the effects of the changes being made. In this study, our aim is to analyze the impact of the COVID-19 pandemic on the education, health, social life of the students, and demonstrate results about its subsequent effect on their daily routine amid travel restrictions. The findings indicate that the time spent by students on online classes did not comply with the guidelines issued by the Ministry of Human Resources Development (MHRD) ( Department of School Education & Literacy Ministry of Human Resource Development 2020 ). Limited class interaction and inefficient time table significantly affected the satisfaction levels among students. The peer-to-peer impact in the school environment motivates individuals to work hard and learn social skills, which may not be possible in an online setting. Moreover, the biggest challenge for online learning is the requirement of efficient digital infrastructure and digital skillset for both students and teachers.

Further, this study analyses the impact of different factors to measure stress levels among students. Alarmingly, 51.4% of respondents reported that they did not utilize their time during the period of lockdown. Furthermore, sleeping habits, daily fitness routines, and social interaction significantly affected their health conditions. The government agencies imposed measures such as social distancing and restrictions on travel but they did not take into account the health implications. Although, these measures are necessary to regulate safe conditions, there is no strategy to safeguard the psychological impact due to the Covid-19 pandemic. Our research also explores the different coping mechanisms used by students of different age groups. Moreover, we analyzed various digital social media tools used by students as a self-management strategy for mental health. Our statistical analysis addresses key concerns related to online education and health due to the Covid-19 pandemic.

5. Opinions and recommendations

Once the COVID-19 pandemic ends and educational institutions re-open, the concerned authorities should continue to invest in online education to enhance learning experience. They should carefully analyze the issues experienced during sudden transition to online learning and prepare for any future situations. Proper training of educators for the digital skills and improved student-teacher interaction must be conducted. For disadvantaged students, availability of digital infrastructure with proper internet availability and access to gadgets must be ensured to avoid any disruption to their study.

Due to the situation in Covid-19, many students are likely to suffer from stress, anxiety, and depression, so it is necessary to provide emotional support to students. Future work in this direction could be to analyze the association of different stress busters on the mental health of the students. Moreover, guidelines should be created to anticipate the needs of the vulnerable student population. Improved healthcare management would ensure the delivery of mental health support.

6. Limitations

There are some limitations to our study that should be noted. The first limitation is the sampling technique used. It relies on digital infrastructure and voluntary participation that increases selection bias. The imposed travel restrictions limited the outreach to students who do not have access to online learning. Second, the study is obtained from one specific area, given the lockdown orders and the online medium of classes, we expect these results to be fairly generalizable for schools and universities nationwide. Another limitation of this study is the cross-sectional design of the survey, there was no follow-up period for the participants.

7. Conclusion

In this study, our findings indicated that the Covid-19 outbreak has made a significant impact on the mental health, education, and daily routine of students. The Covid-19 related interruptions highlight key challenges and provide an opportunity to further evaluate alternate measures in the education sector. The new policies and guidelines in this direction would help mitigate some of the negative effects and prepare educators and students for the future health crisis.

Declaration of Competing Interest

There is no conflict of interest.

• Adnan M., Anwar K. Ed606496. Journal of Pedagogical Sociology and Psychology. 2020; 2 :2–8. [ Google Scholar ]
• Aucejo E.M., French J., Ugalde Araya M.P., Zafar B. The impact of COVID-19 on student experiences and expectations: Evidence from a survey. Journal of Public Economics. 2020; 191 doi: 10.1016/j.jpubeco.2020.104271. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bao W. COVID-19 and online teaching in higher education: A case study of Peking University. Human Behavior and Emerging Technologies. 2020; 2 :113–115. doi: 10.1002/hbe2.191. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cao W., Fang Z., Hou G., et al. The psychological impact of the COVID-19 epidemic on college students in China. Psychiatry Research. 2020; 287 doi: 10.1016/j.psychres.2020.112934. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cohen A.K., Hoyt L.T., Dull B. A descriptive study of coronavirus disease 2019–related experiences and perspectives of a national sample of college students in spring 2020. Journal of Adolescent Health. 2020; 2019 :1–7. doi: 10.1016/j.jadohealth.2020.06.009. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cook D.A. The failure of e-learning research to inform educational practice, and what we can do about it. Medical Teacher. 2009; 31 :158–162. doi: 10.1080/01421590802691393. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Department of School Education & Literacy Ministry of Human Resource Development (2020) PRAGYATA: Guidelines for Digital Education.
• Di Pietro, G., Biagi, F., Costa, P., et al. (2020) The Likely Impact of COVID-19 on Education: Reflections based on the Existing Literature and Recent International Datasets.
• Hasan N., Bao Y. Impact of “e-Learning crack-up” perception on psychological distress among college students during COVID-19 pandemic: A mediating role of “fear of academic year loss” Children and Youth Services Review. 2020; 118 doi: 10.1016/j.childyouth.2020.105355. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Johnson N., Veletsianos G., Seaman J. U.S. Faculty and Administrators’ Experiences and Approaches in the Early Weeks of the COVID-19 Pandemic. Online Learn. 2020; 24 [ Google Scholar ]
• Kapasia N., Paul P., Roy A., et al. Impact of lockdown on learning status of undergraduate and postgraduate students during COVID-19 pandemic in West Bengal, India. Children and Youth Services Review. 2020; 116 doi: 10.1016/j.childyouth.2020.105194. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Lee J. Reflections Features Mental health effects of school closures during COVID-19. The Lancet Child & Adolescent Health. 2020; 4 :421. doi: 10.1016/S2352-4642(20)30109-7. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Odriozola-gonzález P., Planchuelo-gómez Á., Jesús M., De Luis-garcía R. Psychological effects of the COVID-19 outbreak and lockdown among students and workers of a Spanish university. Psychiatry Research. 2020; 290 doi: 10.1016/j.psychres.2020.113108. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Saha J., Barman B., Chouhan P. Lockdown for COVID-19 and its impact on community mobility in India: An analysis of the COVID-19 Community Mobility Reports, 2020. Children and Youth Services Review. 2020; 116 doi: 10.1016/j.childyouth.2020.105160. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ye, Z., Yang, X., Zeng, C., et al. (2020) Resilience, Social Support, and Coping as Mediators between COVID-19-related Stressful Experiences and Acute Stress Disorder among College Students in China. https://doi.org/10.1111/aphw.12211. [ PMC free article ] [ PubMed ]

The Impact of COVID-19 on Education – Recommendations and Opportunities for Ukraine

Robin Donnelly, Harry A. Patrinos, James Gresham

School closures due to COVID-19 have brought significant disruptions to education across Europe . Emerging evidence from some of the region’s highest-income countries indicate that the pandemic is giving rise to learning losses and increases in inequality. To reduce and reverse the long-term negative effects, Ukraine and other less-affluent lower-middle-income countries, which are likely to be even harder hit, need to implement learning recovery programs, protect educational budgets, and prepare for future shocks by “building back better.”

At the peak of the pandemic, 45 countries in the Europe and Central Asia region closed their schools , affecting 185 million students . Given the abruptness of the situation, teachers and administrations were unprepared for this transition and were forced to build emergency remote learning systems almost immediately.

One of the limitations of emergency remote learning is the lack of personal interaction between teacher and student . With broadcasts, this is simply not possible. However, several countries showed initiative by using other methods to improve the remote educational experience, including social media, email, telephone, and even the post office.

Ukraine also implemented measures to support remote teaching and learning , starting with broadcasting video lessons via television and using online distance learning platforms. Organizations like EdCamp Ukraine organized online professional development and peer-to-peer learning opportunities for teachers to meet remotely and share experiences with online learning during the COVID-19 crisis. Ukraine also conducted information campaigns, such as “Schools, We Are Ready,” together with UNICEF, to inform teachers, administrators, students, and parents about the guidelines for safe and sustained learning under COVID-19 in the 2020–21 school year.

Unfortunately, despite best efforts to set up a supportive remote learning experience, evidence is emerging to show that school closures have resulted in actual learning loss es . Research analyzing these outcomes is ongoing, but early results from Belgium , the Netherlands , Switzerland,  and the United Kingdom indicate both learning losses and increases in inequality. Alarmingly, these losses are found to be much higher among students whose parents have less education, a finding reinforced by a study showing that children from socioeconomically advantaged families have received more parental support with their studies during the school closure period.

These emerging data, which provide insights into the region’s highest-income countries, can also be used to predict outcomes in middle-income countries. Despite their substantial technological capability, even Europe’s high-income countries have experienced learning losses and increased inequality as a result of the abrupt transition to virtual learning. These outcomes are likely to be even more acute in middle- and lower-income countries like Ukraine, where there is much less technological capability and a larger share of families live below the poverty line.

Outside the classroom, learning losses may translate into even greater long-term challenges. It has long been known that decreases in test scores are associated with future declines in  employment . Conversely, increases in student  achievement  lead to significant increases in future income, as do additional years  of schooling, which are associated with an  8–9 percent  gain in lifetime earnings. In the absence of any intervention, the learning losses arising from the COVID-19 pandemic are likely to have a long-term compounding negative effect on many children’s future well-being. These learning losses could translate into less access to higher education, lower labor market participation, and  lower future earnings .

To mitigate these challenges while also building a more resilient system that can withstand future crises, we make three core recommendations for Ukraine and other countries: implementing learning recovery programs, protecting education budgets, and preparing for future shocks.

1.     Implement learning recovery programs. Most immediately, governments must ensure that students who have fallen behind receive the support that they need to catch up to expected learning targets. The first step must be to carry out just-in-time assessments to identify these students and their support needs. Research  has shown that 12-week programs of  tutoring  can help students make the kind of progress that would be expected from three to five months of normal  schooling . In  Italy , middle school students who received three hours of online tutoring a week via a computer, tablet, or smartphone saw a 4.7 percent boost in their performance in math, English, and Italian.

Ukraine is implementing learning continuity programs, including through the establishment of the All-Ukrainian Online School platform for distance and blended learning for students in grades 5–11. The project, organized by Ukraine’s Ministry of Education and Science (MOES) and Ministry of Digital Transformation, helps teachers and students to remain connected, gain access to educational materials, and continue schooling during the period of enhanced quarantine measures when schools are closed. The platform contains lessons in 18 basic subjects and consists of videos, tests, and a compendium of lessons. Students also have the opportunity to track their learning progress. Even so, studies confirm that limited internet connectivity and access to devices for online learning (especially in rural areas), compounded by inadequate public support for distance learning, poses challenges. In addition to learning continuity programs, Ukraine could consider supporting ”just-in-time” student assessments to measure the extent of learning losses and identify the students who have fallen behind and may need additional targeted support to catch up.  Accelerated learning or tutoring programs could help address the learning gap.  

2.     Protect the education budget . Given the significant financial strain that economies have been under during the pandemic, some countries may face government budget cuts that could jeopardize the gains that have been made in recent years in terms of access to education and improved learning  outcomes . To ensure a resilient recovery, it is essential that the education budget be protected and that the schools that need financing the most are supported. To help the most vulnerable students, governments should prioritize by directing much of the funding and resources to support schools delivering remote instruction, particularly if those schools are serving high-poverty and high-minority populations . To encourage students to remain in school, incentives  such as scholarships may need to be implemented. Yet learning recovery programs will not be feasible without substantial financial support. In the presence of budget cuts, affluent families will be able to continue to fund educational boosts like tutoring; however, lower-income families will not as easily be able to fill this gap. For example, the  United Kingdom  announced a £1 billion pupil catch-up fund that contained a portion set aside for tutoring and the National Tutoring Programme with a £76 million budget. Clearly, significant budget allocations and further actions will be needed to return to previous  levels of learning.

Ukraine has taken steps to protect and shore up education spending in 2021 by increasing transfers to local governments for teaching aids and equipment, providing further support and social protection to teachers and academic staff through salary increases, and implementing a new transfer to local governments for school safety and other measures aimed at combating COVID-19. Looking ahead, Ukraine will want to closely monitor overall funding levels for education to ensure that funds are being used efficiently and that resources are available to support learning recovery interventions, particularly for those students who most need them.   

3.     Prepare for future shocks by building back better.  It is imperative that we not only recover from the pandemic but that we use this experience to become better prepared for future crises. To support this aim, countries need to build their capacity to provide blended models of education in the future. Schools should be better prepared to switch easily between face-to-face and remote learning as needed. This will protect the education of students not only during future pandemics, but also during other shocks that might cause school closures, such as natural disasters or adverse weather events. It will also create opportunities for more individualized approaches to teaching and learning. With this in mind, it will be necessary to develop flexible curricula that can be taught in person or online. Additionally, teachers need to be better equipped to manage a wide range of IT devices in the event of future school closures. Offering short training courses to improve their digital skills will help. Using the post-pandemic period to rebuild education systems and make them resilient is a priority. At the same time, it is important to build a future education system that can make better use of blended learning models to reach all learners at their level and to provide more individualized approaches to teaching.

Although this is a long-term process, Ukraine is already taking steps in this area. The authorities have developed regulations for distance education, and efforts are ongoing to continue to expand the number of schools with internet connectivity and access to digital devices and equipment to allow for greater use of blended learning approaches in schools going forward. Even so, “building back better” requires bold action and a vision for the kind of human capital Ukraine will need to grow and thrive in the future. It is critical to continue the larger education reform process that was started initially in 2014, including both the New Ukrainian School (NUS) initiative in school education and the reform of higher education in line with the standards of the European Higher Education Area. Ukraine’s MOES is preparing a project with the World Bank to support learning continuity and operational resilience in higher education through initiatives to expand digitalization in the education sector. These efforts will help higher education institutions to recover from the impacts of COVID-19 while also adapting to more resilient and flexible approaches going forward.

Interview originally published by Dzerkalo Tyzhnia in the Mirror Weekly

When Do Ordinal Ability Rank Effects Emerge? Evidence from the Timing of School Closures

IZA Discussion Paper No. 17222

13 Pages Posted: 19 Aug 2024

Marco Bertoni

University of Padua

Saeideh Parkam

University of Naples Federico II

We leverage the timing of pandemic-induced school closures to learn about the emergence of ordinal rank effects in education. Using administrative data from Italian middle schools for four cohorts of students, our study reveals that disrupting peer interactions during the first year of middle school - when students are still unfamiliar with one another - substantially diminishes the impact of ordinal rank on test scores. Instead, later interruptions to peer interactions do not significantly affect the strength of these interpersonal comparisons.

Keywords: ability peer effect, ordinal ability rank, school closures, COVID-19

JEL Classification: I21, I24, J24

Suggested Citation: Suggested Citation

Marco Bertoni (Contact Author)

University of padua ( email ), university of naples federico ii ( email ).

Naples Italy

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Long COVID: Lasting effects of COVID-19

After any coronavirus disease 2019 (COVID-19) illness, no matter how serious, some people report that symptoms stay for months. This lingering illness has often been called long COVID or post-COVID-19 syndrome. You might hear it called long-haul COVID or post-acute sequelae of SARS-CoV-2 (PASC).

There is no universal definition of long COVID right now.

In the U.S., some experts have defined long COVID as a long-lasting, called chronic, condition triggered by the virus that causes COVID-19. (1p31) The medical term for this is an infection-associated chronic condition.

As researchers learn more about long COVID, this definition may change.

What are the most common symptoms of long COVID?

In research studies, more than 200 symptoms have been linked to long COVID. Symptoms may stay the same over time, get worse, or go away and come back.

Common symptoms of long COVID include:

• Extreme tiredness, especially after activity.
• Problems with memory, often called brain fog.
• A feeling of being lightheaded or dizzy.
• Problems with taste or smell.

Other symptoms of long COVID include:

• Sleep problems.
• Shortness of breath.
• Fast or irregular heartbeat.
• Digestion problems, such as loose stools, constipation or bloating.

Some people with long COVID may have other illnesses. Diseases caused or made worse by long COVID include migraine, lung disease, autoimmune disease and chronic kidney disease.

Diseases that people may be diagnosed with due to long COVID include:

• Heart disease.
• Mood disorders.
• Stroke or blood clots.
• Postural orthostatic tachycardia syndrome, also called POTS.
• Myalgic encephalomyelitis-chronic fatigue syndrome, also called ME-CFS.
• Mast cell activation syndrome.
• Fibromyalgia.
• Hyperlipidemia.

People can get long COVID symptoms after catching the COVID-19 virus even if they never had COVID-19 symptoms. Also, long COVID symptoms can show up weeks or months after a person seems to have recovered.

And while the COVID-19 virus spreads from person to person, long COVID is not contagious and doesn't spread between people.

Why does COVID-19 cause ongoing health problems?

Current research has found that long COVID is a chronic condition triggered by the virus that causes COVID-19. The medical term for this is an infection-associated chronic condition.

Researchers don't know exactly how COVID-19 causes long-term illness, but they have some ideas. Theories include:

• The virus that causes COVID-19 upsets immune system communication. This could lead immune cells to mistake the body's own cells as a threat and react to them, called an autoimmune reaction.
• Having COVID-19 awakens viruses that haven't been cleared out of the body.
• The coronavirus infection upsets the gut's ecosystem.
• The virus may be able to survive in the gut and spread from there.
• The virus affects the cells that line blood vessels.
• The virus damages communication in the brain stem or a nerve that controls automatic functions in the body, called the vagus nerve.

Because the virus that causes COVID-19 continues to change, researchers can't say how many people have been affected by long COVID. Some researchers have estimated that 10% to 35% of people who have had COVID-19 went on to have long COVID.

What are the risk factors for long COVID?

Risk factors for long COVID are just starting to be known. In general, most research finds that long COVID is diagnosed more often in females of any age than in males. The long COVID risk also may be higher for people who have cardiovascular disease before getting sick.

Some research also shows that getting a COVID-19 vaccine may help prevent long COVID.

Many other factors may raise or lower your risk of long COVID, but research is still ongoing.

What should I do if I have long COVID symptoms?

See a healthcare professional if you have long COVID symptoms. Part of long COVID's definition is symptoms that last for three months.

But at this time, no test can say whether you have long COVID. Since you may not have symptoms if you have an infection with the COVID-19 virus, you may not know you had it. Some people have mild symptoms and don't take a COVID-19 test. Others may have had COVID-19 before testing was common.

Long COVID symptoms may come and go or be constant. They also can start any time after you had COVID-19. But symptoms still need to be documented for at least three months in order for a health care professional to diagnose long COVID.

Healthcare professionals may treat your symptoms or conditions before a long COVID-19 diagnosis. And they may work to rule out other conditions over the time you start having symptoms.

Your healthcare team might do lab tests, such as a complete blood count or liver function test. You might have other tests or procedures, such as chest X-rays, based on your symptoms.

The information you give and any test results can help your healthcare professional come up with a treatment plan.

Care for long COVID

It can be hard to get care for long COVID. Treatment may be delayed while you work with healthcare professionals. And people with long COVID may have their health problems dismissed by others, including healthcare professionals, family members or employers.

For people with cultural or language barriers, getting a long COVID diagnosis can be even harder. Pulling together information about symptoms and timing can be a challenge too. This is especially true when medical history is fragmented or when someone is managing symptoms related to memory or that affect the thought process.

Underdiagnosis may be more common among people who have less access to healthcare or who have limited financial resources.

If you're having long COVID symptoms, talk with your healthcare professional. It can help to have your medical records available before the appointment if you are starting to get care at a new medical office.

To prepare for your appointment, write down:

• When your symptoms started and if they come and go.
• What makes your symptoms worse.
• How your symptoms affect your activities.
• Questions you have about your illness.

List medicines and anything else you take, including nutrition supplements and pain medicine that you can get without a prescription. Some people find it helpful to bring a trusted person to the appointment to take notes.

Keep visit summaries and your notes in one place. That can help you track what actions you need to take or what you've already tried to treat your symptoms.

Also, you might find it helpful to connect with others in a support group and share resources.

How long can long COVID last?

The conditions linked as part of long COVID may get better over months or may last for years.

What treatment is available for long COVID?

Healthcare professionals treat long COVID based on the symptoms. For tiredness, your healthcare professional may suggest that you be active only as long as your symptoms stay stable. If you start to feel worse, rest and don't push through your tiredness.

For symptoms of pain, breathlessness or brain fog, work with your healthcare professional to find a treatment plan that works for you. That may include medicine you can get without a prescription for pain, prescription medicine, supplements and referrals to other healthcare team members.

For loss of taste or smell, a process to retrain the nerves involved in those processes may help some people. The process is called olfactory training. For people with POTS or a fast heartbeat, the healthcare professional may suggest prescription medicine as well as a plan to stay hydrated.

Treatment for other long COVID symptoms may be available so contact your healthcare professional for options.

Next steps for Long COVID

Long COVID makes life more difficult for many people. To provide better options for care, research is going on to better understand this illness. In the meantime, adults or children with long COVID may be able to get support for daily activities affected by the illness.

Last Updated Aug 23, 2024

© 2024 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. Terms of Use

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• Published: 23 August 2024

Effects of health education applying role play on decision making in acute myocardial infarction situation among older adults in community

• Samoraphop Banharak 1 ,
• Ampornpan Threeranut 2 &
• Alin Metprommarat 3  

Scientific Reports volume  14 , Article number:  19627 ( 2024 ) Cite this article

Metrics details

• Medical research
• Signs and symptoms

Acute myocardial infarction is a silent killer for people worldwide, especially older adults who often experience atypical symptoms, causing late decision-making and a high mortality rate. The unrecognition of atypical symptoms, unconcerned about their risk, and not knowing how to deal with this critical situation are the barriers to a quick decision to visit the emergency department and delaying treatment, resulting in serious adverse outcomes. Therefore, specific and effective health education among older adults is needed. This double-blinded randomized controlled trial explored the effectiveness of health education by applying a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence among community-dwelling older adults. The participants were 96 community-dwelling older adults in central northeastern Thailand. We collected data between November 2021 and April 2022. The multi-stage sampling was applied to include participants. The intervention was the role-play promoting decision-making ability program and home visit. Outcomes were measured a week before attending and after finishing the intervention. T-tests, Mann–Whitney U test, Chi-square, and Wilcoxon Signed Rank test compared the outcomes between and within groups. Moreover, adjusted analysis was also demonstrated. Results revealed that participants who attended the program improved their knowledge, belief, and decision-making; only perceived susceptibility did not show improvement. Moreover, after demonstrating an adjusted analysis, the program participants had better knowledge about symptoms, perceived benefits, barriers, self-regulation, possible calling 1669, and first action. In conclusion, a role-play promoting decision-making ability program can promote knowledge, belief, and decision-making when expecting acute myocardial infarction occurrence among community-dwelling older adults. This study proved that role-play is one strategy to promote the program's effectiveness by inducing attention before giving older adults health information. Nurses and other healthcare professionals can implement this program as part of standard practice.

Clinical Trial Registration Number: TCTR20210928004 on 28/09/2021.

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Acute myocardial infarction (AMI) occurs when the coronary arteries become acutely obstructed by fatty clots or coronary spasms 1 , 2 . This serious health problem is a silent killer worldwide, especially among older adults who often experience atypical symptoms 1 , 3 , 4 . It is found that over three million people worldwide suffer from acute myocardial infarction 5 . There were 805,000 AMI patients reported by the American Heart Association (AHA) in 2019 6 . Of these, 170,000 had an unusual presentation and asymptomatic/silent MI 3 . These atypical and silent symptoms may result in patients' lack of awareness and late decision-making to seek treatment. As for statistical studies in Thailand, it was found that in 2016, 2017, and 2018, 327,453, 326,946, and 337,441 people experienced AMI. Of these, 21,008, 20,746, and 20,786 resulted in death, respectively 7 , 8 . It also found that people experienced AMI every 40 s 3 , and in every 90 s, they died from AMI 9 . More than 63% of people with AMI die; of this, 45% die before arriving at hospitals and have no chance to receive treatment 10 . A study of the incidence of death in each age group found that 9 out of 10 deaths were older adults aged over 70 years 4 , indicating that AMI was the leading cause of death among older adults 11 , 12 .

Patients with delayed treatment, particularly older ones, tend to have more severe symptoms and a higher risk of death 1 , 10 , 13 . Researchers divided phases of delaying treatment into the patient recognition action, transportation, and hospital phases. Older adults spent the longest time in the patient recognition action phase due to the lack of knowledge and understanding about whether the existing symptom is a symptom of AMI 1 , 10 , 13 , 14 . In addition, non-specific symptoms (atypical symptoms) cause older adults to miss interpretation or interpret symptoms they are experiencing as symptoms of other illnesses or diseases. For example, they interpreted that they were suffering from acid reflux or Gastroesophageal Reflux Disease (GERD) when experiencing heartburn or from peptic ulcer when experiencing abdominal distension or indigestion 13 . As a result, they respond to symptoms unrelated to or specific to myocardial infarction, such as taking antacids or applying massage therapy to relieve abdominal distension, wait-to-see, even praying for recovery from the symptoms. In addition, some older women also believe that acute myocardial infarction and heart disease are specific diseases or conditions for men. Thus, they interpreted their symptoms in a way related to a woman's disease or other ailments 13 .

Older people's knowledge and beliefs are essential influences on delayed treatment 1 , 13 . Inappropriate recognition and management of non-specific symptoms can delay decision-making for treatment, lead to severe complications, and result in sudden death. This situation highlights that a lack of knowledge and inappropriate beliefs about AMI in older adults significantly contribute to misinterpretation of symptoms, improper symptom management, delayed admission, and the negative consequences of postponed treatment, including death before reaching the hospital 1 , 13 . Based on a systematic review, factors contributing to delayed treatment among older adults with AMI can be divided into four groups: socio-demographic factors, environmental factors, psychological and behavioral factors, and clinical characteristics 13 , 15 , 16 , 17 . The primary factors causing delayed treatment were psychological and behavioral. Older adults are often more reluctant and confused about their symptoms and hesitate to bother family members when experiencing atypical or unclear symptoms, especially at inappropriate times such as night or early morning. This hesitation leads to prolonged decision-making before seeking treatment 1 , 16 , 17 , 18 . This phenomenon underscores that if older adults continue to lack knowledge, harbor misunderstandings, and maintain inappropriate beliefs about AMI and its symptoms, delays in receiving treatment will likely persist.

The aging process, multi-pathology, and level of education significantly impact older adults' decision-making abilities. As people age, they often experience sensory and cognitive dysfunctions due to decreased blood supply to the hippocampus and frontal lobe, leading to memory deficits, slower interpretation and analysis of situations, and delayed recall 19 . They also have their own beliefs based on their experience that might be inappropriate 16 . Additionally, older adults frequently suffer from multiple pathologies, such as diabetes mellitus and hypertension, which can distort vascular and nervous systems. Consequently, their chronic diseases cause atypical symptoms of AMI, like shortness of breath, fainting, abdominal or chest discomfort, and sudden confusion when having AMI 13 , 17 . These factors cause older adults to take longer to learn, remember, differentiate, and interpret existing symptoms, resulting in delayed decision-making and seeking treatment compared to younger adults 17 . Furthermore, if they have a combination of aging, multi-pathology, and low education levels, it creates significant barriers to recognizing atypical symptoms and deciding to go to the hospital late 13 , 17 , 18 . This delay prevents them from receiving timely and essential cardiac treatments, leading to severe complications and death 1 , 13 , 20 . The most effective treatment for AMI patients must be administered within the "golden period" of two hours, but older adults often take more than six hours to decide on admission or seek treatment 1 , 6 . Therefore, appropriate and specific ways of educating older adults that concerning their aging process and promoting appropriate beliefs and decision-making are crucial to addressing this problem and improving their outcomes.

Role-play is an innovative method to draw attention and promote appropriate and quick responses/decisions that can be used as an intervention or a part of an intervention 21 , 22 , 23 , 24 . It is changing one’s behavior to assume a role by unconsciously filling a social role and consciously acting out an adopted role; both can be with a group or individuality 23 , 24 . According to Bruce et al., role-playing is crucial for a child's psychological development 24 . According to certain studies, role-playing can lead to behavioral changes. For example, smokers who were instructed to pretend to have lung cancer reported feeling negative about smoking and quit it 25 . Role-playing was also used to promote decision-making for prostate cancer screening among Black male patients and their providers 21 , and empathy promoted interventions for health professionals 22 . The systematic review and meta-analysis found no researcher applied role-play to promote quick and immediate decision-making, such as AMI situation 26 . However, Jasemi et al. reported that role-playing helps nursing students operate ethically and with greater sensitivity 27 , Makarov et al. reported that role-playing has been utilized in interventions to enhance shared decision-making skills among patients and healthcare providers 21 , and Kiosses et al. confirmed that programs applying role-playing have been shown to improve not only the knowledge and skills of participants but also their empathic behavior, which is crucial for effective patient care 22 . Furthermore, role-play and scenarios efficiently foster older persons' emergency response, awareness, and readiness in emergencies like disasters 28 .

It is not only role-playing, but the Health Belief Model (HBM) is also an essential part of the program structure to promote decision-making. This conceptual model links belief components in health decision-making, emphasizing measuring beliefs and decision-making at the individual level. The HBM is widely used to explain why people practice health behaviors or do not follow the advice on protecting their health 29 , 30 . This model was developed to describe a person's decisions regarding health behaviors. The structure of the health belief model has four main components and two subcomponents: perceived susceptibility, perceived severity, perceived benefits of treatment and prevention, perceived barriers, self-efficacy, and cues to action 30 , 31 . In cases of AMI, if older adults know about the AMI symptoms and risk factors and have an appropriate belief through attending the attractive role-playing and health education concerning older adult limitations, this will encourage them to realize the importance and make decisions to seek treatment quickly. Decision-making behavior is individuals' actions and processes when making choices. However, decision-making ability is the cognitive capacity and skills that enable individuals to make decisions 32 , 33 . It involves understanding information, weighing options, considering potential outcomes, and making a choice. In the context of AMI, decision-making ability is critical for patients and healthcare providers to make timely and effective decisions 32 , 33 . This ability is improved by health education interventions by improving knowledge, behavioral interventions by improving self-efficacy, and technological interventions by using applications or decision-support systems. Good decision-making ability can promote appropriate decision-making behavior in AMI situations 32 , 33 , 34 . This study aimed to explore the effectiveness of a health education program applying role-play in promoting decision-making ability to encourage older adults to make appropriate and timely decisions in situations of AMI.

The aim of this study was to study the effectiveness of a role-play promoting decision-making ability program when expecting acute myocardial infarction occurrence on knowledge, belief, and decision making among community dwelling older adults.

Designs/methodologies

Research design, sample and setting.

The study used a double-blinded, randomized controlled trial with a two-group pretest–posttest design; the older adults and outcome evaluators (research assistants) were blinded. The population of interest was community-dwelling older adults living in a semi-urban community in central, northeastern Thailand. We applied multi-stage sampling for this study, starting with cluster sampling, followed by simple random sampling. The cluster sampling was used to select two similar semi-urban communities from 18 communities. The two communities are about 12 km from downtown and super tertiary hospitals, providing call centers, ambulances, emergency services, and advanced cardiac procedures. These two semi-urban communities also had primary care units, and people living there had similar lifestyles and occupations. After study settings randomization was done, a simple random sampling was used to include older adults in each group; this was done by drawing lots (house numbers) from all meeting inclusion criteria from the two communities. The sample size was determined using the equation for experimental research that compares means between two independent groups 35 and based exclusively on a previous study by Sanprakhon, Choosri, and Wongviseskul 30 . With an alpha level of 0.05, a power of 0.95, a variance of 3.12, and a mean difference of 2.23, a power analysis determined that 43 participants would be necessary for each group. However, the 10% possible dropout rate was added for sample size calculation, and 48 older adults for each group would be enough, meaning 96 community-dwelling older adults participated in this study.

Inclusion and exclusion criteria

Eligibility to participate in the study was based on seven criteria: (1) male or female between the ages of 60 and 80 years old; (2) capable of reading and writing Thai; (3) oriented to time and place; (4) no hearing and visual problem; (5) no depression symptom as screening with a 2-question (2Q) depression screening form (Respond “No” for both questions), or dementia as screening with the Thai Mental State Examination (score ≥ 23 points); (6) no disturbing signs/symptoms, such as knee osteoarthritis, severe pain (10-point numerical scale ≥ 5 points) or high fever (axillary temperature ≥ 38.5 °C) to join program activities such as role-play and Emergency Call (1669) situation; and (7) willing to participate in this study by completing consent form. In cases of family members or caregivers of older adults who are required to participate in primary cardiopulmonary resuscitation (CPR), they must not have any health problems or symptoms that limit the practice of CPR, such as heart disease, chest pain, asthma, or chronic obstructive pulmonary disease (COPD), arthritis, severe pain (PS ≥ 5 points), high fever (BT ≥ 38.5 degrees), or abnormal vital signs.

Exclusion criteria were (1) older adults with an acute illness after starting the activity, such as low blood pressure, difficulty breathing, chest pain, and dizziness, and (2) Older adults participating in less than 6 out of 8 activities.

Data collection

The total number of older adults in the two communities was 674; however, 142 did not meet the inclusion criteria, and 31 declined to participate. Only 501 were randomly included in this study using simple random sampling (drawing lots of house numbers). Finally, the 96 participants were randomly included in the control or experimental groups. These two groups lived in different sites and were about 12 km away from downtown, and they did not know they were in control or experimental groups. Moreover, the two research assistants were allowed to participate in this study only for outcomes evaluation, and they did not know they were measuring outcomes for participants in control or experiential groups. The two research assistants not working in these two communities assessed their knowledge, beliefs, and decision-making a week before starting this study. They re-evaluated these outcomes a week after finishing the intervention. The experimental group received a health education applying role-play promoting decision-making ability program and home visits for eight weeks to improve their knowledge, belief, and decision-making, and the control group received routine care, home visits, and brochures during the same period. The study lasted from November 2021 to April 2022.

Research instruments

Screening: The depression symptom was screened using a 2-question (2Q) depression screening form with a sensitivity of 97.3 and a specificity of 45.6 36 . Cognitive function was screened using the Thai Mental State Examination (TMMSE) with a sensitivity of 82 and a specificity of 70 37 . The TMMSE also achieved Cronbach’s alphas as 0.81 38 .

Demographic and clinical information: This included sex, age, marital status, education level, income, occupation, health insurance, health status, chronic diseases, self-experience of AMI, and seeing or knowing other persons experiencing AMI.

Primary outcomes: Knowledge was measured by the 12-item knowledge of coronary artery disease (CAD) risk factors and the 15-item knowledge of AMI symptoms. These two questionnaires had three response items, including “ yes”, “no,” and “ not sure.” If older adults checked “yes” for the correct answer, they got one score, but if they checked “no” for the correct answer, they got zero. Older adults who checked “not sure” got zero for every question. The total scores were 12 and 15, respectively, and the test–retest reliability for these two questionnaires was 0.78 and 0.90, respectively 13 .

The belief was measured by six questionnaires, including the four items of perceived susceptibility, 15 items of perceived severity, four items of perceived benefit, 15 items of perceived barrier, four items of perceived self-regulation, and four items of perceived cue to action. There were six response items for perceived susceptibility and cue to action from 1 (not at all) to 6 (very likely), and six response items for the other four questionnaires for 1 (strongly disagree)–6 (strongly agree). Total scores for each questionnaire were 24, 90, 24, 90, 24, and 24, and Cronbach’s Alpha Coefficients were 0.90, 0.95, 0.92, 0.90, 0.90, and 0.84, respectively 13 , 39 .

The two questions measured decision-making; one asked how likely the older adults were to take seven of any actions (such as calling emergency service/1669, taking medicine, drinking water, and smelling cologne/herb) if they were in the presence of someone having an AMI. This question had seven response items from 1 (not at all) to 7 (certain). We picked only one action, calling 1669, for our analysis, and the other six actions just be provided to not guide the best action for older adults for the next question. The second question asked older adults to choose the best first plan-of-act when they were in the presence of someone having an AMI. This question had seven choices, including seven of the above actions. If older adults checked on calling 1669, one was entered; if they checked on other actions, zero was entered for data analysis. Cronbach's Alpha Coefficient for this questionnaire was 0.95 39 . When analyzing data, we prepared the first question as a continuing variable and the second as a dichotomous one.

Intervention

Based on a systematic review, the researchers developed a health education applying role-play promoting decision-making ability program for community-dwelling older adults 28 . The structure of this program was a health belief model, the details were based on systematic review results, and the content was updated with the content suggested by the American Heart Association. The program content included heart disease and AMI, etiology, signs and symptoms, treatment and management, emergency service and call, appropriate action in AMI situations, cardiopulmonary resuscitation (CPR) training, appropriate decision-making activities, asking for help, and program review. Moreover, role-playing related to each activity was used to draw attention from the older adults before starting the program.

This program was proved by five experts, including two cardiologists, two cardiac nurses, and one researcher who was an expert in gerontological nursing. The program's activities and materials relied on the principle of providing health education concerning aging processes and impairment 40 , 41 , 42 . We spend a short period and divide health education programs into a few short sections. Teaching strategies included both class teaching (lecture) and practicing. The tasks for practicing were uncomplicated, including a few steps, and they were done step by step. Health educators provided a good environment and appropriate places for teaching and training. The teaching style considered the context and culture of older adults. Suitable media were applied to communicate health information to this target group, as well as large letters and visible pictures to read and see.

Moreover, uncomplicated sentences, informal language, and friendly colors were provided. Finally, a handbook was provided for older adults to take back home to review. This program included eight-week activities, which each week started with a greeting and introduction (5 min), role-playing about the situation related to weekly activities (10 min), giving health education/training health activities (15–30 min), and conclusion (5 min). There were between 45 and 60 min in total for each session. Finally, the handbook was prepared using large letters, black letters on a yellow background, simple and informal sentences, clear pictures, and brief content/short text. Before conducting this research, this program was piloted with ten older adults to ensure its feasibility and acceptability. This program was able to draw attention from and suitable for older adults; however, two unclear pictures were suggested to be changed, and the size of the letters was suggested to make it bigger from 18 to 20. Then, it was revised based on the limitations and suggestions of older adults. The final eight-week activities with all details are shown in the figure (Fig.  1 ).

Health education applying role-play promoting decision-making ability program.

In the control group, the participants received brochures and home visits by the registered nurses in their community setting. The participants had chances to ask questions and discuss when measuring vital signs during home visits. This home visit was once a week with or without the participant's family members.

Validity and reliability

The study protocol was developed and prospectively registered to avoid bias, and this study was conducted strictly following the registered protocol. A checklist for all activities was provided and completed to confirm that the primary investigator did all activities and procedures following the protocol. To avoid bias, a randomized was performed two times, including cluster sampling and simple random sampling, and a double-blinded design was applied (research assistants and participants did not know which groups were control or intervention groups). The four actors who performed role-play earned a bachelor's degree in nursing. They were trained and performed acting rehearsals many times until they achieved this program's main points of health information and aims before performing role-play to older adults. Moreover, the two research assistants participated in the recruitment and data collection processes (baseline and post-intervention). However, the principal researcher only implemented intervention using a flipchart and PowerPoint. The two research assistants earned master's degrees in nursing, had research experience, and were trained for screening and data collecting before starting this study. All questionnaires were checked twice and completed before the older adults left the school. The screening process and findings were reported using the diagram and standard statement.

Ethical considerations

The research received approval from the Khon Kaen University Center for Ethics in Human Research (Approval Number: HE642163) on July 15, 2021, following the ethical principles of the Declaration of Helsinki. Volunteers who participated in the study received information about the purpose of the research, confidentiality of data, reporting data in the aggregate, and the ability to withdraw from the study without losing care or medical treatment—those who agreed to participate signed informed consent. Finally, the study protocol was prospectively registered on 28/09/2021, and the clinical trial registration number was TCTR20210928004.

Data analysis

Data were analyzed initially by calculating descriptive statistics using the IBM® SPSS® version 28 statistical software under a university license. Demographic characteristics between control and experimental groups were compared by applying the Chi-square Test, Fisher Exact Test, and Independent t-test. Normal distribution was explored using Kolmogorov–Smirnov and Shapiro–Wilk, Skewness and Kurtosis, Histogram, and normal Q–Q and Box plots before exploring between-groups and within-group comparisons. In normal distributions, independent-sample t -tests were examined for knowledge, belief, and decision-making differences between the experimental and control groups. However, the Mann–Whitney U test was applied for non-normal distribution variables.

In the same way, in cases of normal distribution, paired-sample t-tests compared within-group differences; however, the Wilcoxon (Matched Paired) Signed Rank test was applied for non-normal distribution variables. A Chi-square was generated when comparing a categorical variable, first of action. Finally, the adjusted analysis was performed to explore actual results after we found that sex, income, and knowledge of risk factors differed between control and experimental groups at the baseline.

Participants enrolment and withdrawal

Of the 674 community-dwelling older adults who were screened for eligibility, 173 older adults were excluded. The reasons for exclusion were not meeting the criteria for 142 older adults and declined to participate in this study for 30 older adults (Fig.  2 ). The 501 older adults from each community were randomized into control and experimental groups by drawing their house numbers. All 96 participants (48 participants per group) remained in this study. More females were in the experimental and control groups (Table 1 ), and the proportion of sex was significantly different between the two groups. The average age was 70.56 years ( SD  = 5.99). About half of the participants were widows, and over 80% attended formal education for only four years. Most had yearly incomes between 5001 and 10,000 Thai baht (about $150–$300 in US dollars; most received support from the Thai government about 600–800 Thai baht ($15–$20) a month), and this level of income was significantly different between the intervention and control groups. Most had no occupation or were farmers and used the universal coverage scheme as their health insurance. More than half defined their health status as neutral or good. Almost 70% reported that they had chronic diseases, including hypertension, diabetes mellitus, dyslipidemia, and chronic kidney disease. Only two older adults had direct experience with AMI, and only four older adults took part in the situations of someone having AMI.

CONSORT 2010 flow diagram.

Primary outcomes

At baseline (pretest), there were no statistical differences between groups in knowledge, belief, and decision-making, except in knowledge of risk factors, for which the scores in the control group were slightly higher than in the experimental group. After completing the decision-making ability promoting program, the participants in the experimental group had statistically better knowledge, belief, and decision-making, including knowledge of AMI symptoms, perceived benefit, barrier, self-regulation, possible calling 1669, and appropriate first of action than those in the control group (Table 2 ).

Although participants in the experimental group scored better in knowledge, belief, and decision-making than the control group, these outcomes improved within each group over the eight weeks. Within the control group, perceived susceptibility, barrier, and cue to action scores improved from baseline (pretest) to post-test. In the same way, knowledge of risk factors and AMI symptoms, perceived susceptibility, severity, benefit, self-regulation, cue to action, possible calling 1669, and first of act of older adults in the experimental group improved from baseline (pretest) to post-test (Table 3 ).

Finally, after an adjusted analysis was generated (adjusted by sex, income, and baseline knowledge of risk factors), the participants in the experimental group still had statistically better knowledge, belief, and decision-making, including knowledge of AMI symptoms, perceived benefits, barrier, self-regulation, possible calling 1669, and appropriate first of action, than those in the control group (Table 4 ).

Harms or adverse events

This study found no harm, adverse event or unintended effect happening to the participants in ether groups.

Community-dwelling older adults improved almost all selected outcomes after attending the decision-making ability promoting the program, except for the perceived barrier. These results demonstrated that this program could be used to improve knowledge, belief, and decision-making among community-dwelling older adults. A comprehensive development of the program based on the principle of giving health education concerning aging processes and impairment 40 , 41 is an essential part of this program to promote achievement on improving knowledge, belief, and decision making among community-dwelling older adults for this study. This program was applied not only in a short period, sub-sections, class teaching (lecture) and uncomplicated practicing (few steps, and go step by step), a good environment and appropriate place, integrated context, culture, and lifestyle of learners, but also applied the proper media, large letters, and visible picture to read and see. Moreover, a handbook with uncomplicated sentences, formal language, and friendly colors was also provided so that they could be taken back home to review 40 , 41 , 42 . Tianmongkol pointed out that the Thai Chara front (TH-Chara) size 16–18 is straightforward and easy to read by older adults; this was applied to our handbook 42 . Finally, Sungvorawongphana et al. also proved that pictures and colors of health information materials were significant parts of giving health education to older adults 43 . Letter color and clear, visible pictures to read and see can catch older adults’ attractiveness and promote their understanding. The program materials for this study were a flipchart, PowerPoint, and handbook, which applied huge and clear pictures and used black letters on yellow backgrounds. These three concepts effectively promoted readability and understanding for our target population 43 .

The provided health information is important, but the way to induce older adults' attention and make them ready for the provided health information and activities is also essential. This program always started with role-play, followed by class teaching (Flipchart lecture) or practice (CPR training and calling 1669) and a handbook review. The reason for applying and starting the program with role-play is to make the program attractive, induce older adults' attention, and improve knowledge, belief, and decision-making by giving specific health information related to AMI. Jasemi et al. found that role-play and lectures were more effective in promoting ethical sensitivity and ethical performance among nursing students than those who did not 27 . Moreover, role-play is more effective than the lecture method 27 . This innovative method was used to promote knowledge, belief, decision-making, and skills among healthcare professionals, nurse students, Black, White, and Asian people in the context of quitting smoking, ethic consideration, Empathy, cancer prevention, psychological development, BPH, and disaster 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 . Role-play was proved not only by children and adult groups (nursing students, healthcare professionals, healthy and ill patients) in ethical sensitivity and healthcare prevention issues but also among older adults in emergencies 28 . Seo et al. reported that role-play and scenarios effectively promote emergency response, awareness, and readiness among older adults in emergencies like disasters 28 . With innovative methods, such as role-play, this program reflects a good combination of health information, material, and methods to achieve the best outcomes for this study.

Older adults in the experimental group and older adults in the control group improved their outcomes. We found that perceived susceptibility, perceived benefit, and perceived cue of action among older adults in the control group after finishing this study were higher than baseline. This result is possible because a home visit can reach their awareness and perception. However, knowledge cannot be improved without giving health education. Other studies also found that providing a home visit with giving advice can reach patients’ knowledge, awareness, attention, self-care, self-efficacy, and adopted health behaviors among older adults and other age groups for several health issues such as medication adherence, asthma, blood pressure control, blood sugar level, and heart failure 44 , 45 , 46 , 47 , 48 . However, only a home visit cannot be used to promote all components and provide the most effective outcomes compared to multiple interventions or activities 49 . Moreover, the systematic review and meta-analysis found that the innovative methods, including multiple interventions such as a heart attack survival kit, red cardboard containing essential information, a list of warning signs of AMI, a group discussion, a home visit by the firefighter, strong recommendation to call 911 (calling an ambulance in USA), and primary step for cardiopulmonary resuscitation (CPR) were the most effective method promoting of calling 911 and taking aspirin 26 . Results from the systematic review and meta-analysis can be used to reflect why interventions in our experimental group promoted knowledge, belief, and decision-making more effectively.

The adjustment analysis confirmed that the decision-making ability-promoting program was more effective than the control group. We have found that older adults in the experimental group have higher scores in the knowledge of AMI symptoms, perceived benefit, perceived barrier, perceived self-regulation, possible calling 1669, and appropriate first-of-act planning when experiencing AMI. It was confirmed that multi-method or multifactorial intervention programs are superior to single interventions 49 . However, this program could improve decision-making ability, which might slightly affect or cannot be used to confirm the time to seek treatment and delay the time to receive treatment. This issue is still an area of interest and should be further explored in real situations and long-term studies. Finally, this study found that older adults in the experimental group reported higher scores of perceived barriers than in the control group. This unexpected finding might be because some questions under this component ask about quitting the job, income, and treatment and service costs, and older adults in the experimental group have slightly less income when compared with the control group.

Another point is that the cue to act, which is defined as something to induce awareness or induce people to decide to do something or practice health behaviors 30 , 31 , in the experimental group was improved after attending the program. However, this outcome was similar when compared with the control group. Family members and caregivers greatly support older adults in making decisions and performing health behaviors 50 , 51 , 52 . Although this intervention encouraged family members and caregivers to participate in the program, only 1–2 times joining activities might not be enough for older adults to feel support from their surrounding people and commit action in an AMI situation. This unexpected finding suggests that the family members or caregivers should engage in the program often (almost every time) for future study.

Limitations and recommendations

Although we have tried to develop program activities and materials relying on the principle of giving health education concerning aging processes and sensory impairment, this study was conducted under the COVID-19 pandemic situation and social distancing policy, social distancing seat arrangement, and mask on all the time. Conducting research under this policy may be a barrier when role-playing and providing health education. It may be a reason why older adults only achieve some of the outcomes we have expected and measured. For future studies, this program should be conducted again if the pandemic situation improves (normal situation); if not, the mobile application would be appropriate. Most participants for this study were female; this variable should be a concern when applying this result to future studies and practice. Long-term evaluations should be carried out to determine the persistence of knowledge, belief, and decision-making ability since this study evaluated these outcomes a week after finishing interventions. This study was conducted among older adults for the situation when expecting AMI occurrence; future studies should explore the effectiveness of this program in the actual situation of AMI or study among hospitalized older adults who already experienced AMI after they were discharged.

This study showed that a health education applying role play promoting decision-making ability program could improve knowledge, belief, and decision-making among community-dwelling older adults. Registered nurses or other health care professionals should explore alternative methods to improve these essential outcomes for this target population since they are prone to experience atypical symptoms of AMI and delay treatment. Nurses and healthcare professionals can implement this program as part of standard practice or adjust it to fit the lifestyles and needs of community-dwelling older adults. Role-play might be one strategy to promote the program's effectiveness by inducing attention before giving older adults health information, and this could improve knowledge and belief and promote quick decision-making for this target group of people when experiencing acute myocardial infarction.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to prohibited laws (and/or rules, regulations, and contracts). However, they are available from the corresponding author upon reasonable request.

American Heart Association. (2023). 2023 Heart Disease and Stroke Statistics Update Fact Sheet. 2023 Statistics Update—At-a-Glance Statistics. Retrieved April 4, 2023. https://professional.heart.org/en/science-news/-/media/453448D7D79948B39D5851D1FF2A0CFE.ashx

American Heart Association. Heart disease and stroke statistics—2022 update: A report from the American Heart Association. Circulation 145 , e153–e639. https://doi.org/10.1161/CIR.0000000000001052 (2022).

Article   Google Scholar  

Virani, S. S. et al. Heart disease and stroke statistics—2020 update: A report from the American Heart Association. Circulation 141 (9), e139-596 (2020).

Article   PubMed   Google Scholar  

World Heart Federation. (2017). CVD is the world’s biggest killer. Retrieved October 28, 2018. https://www.world-heart-federation.org/

Sweis, R.N., & Jivan, A. (2022). Acute myocardial infarction. Northwestern University Feinberg School of Medicine. Retrieved April 8, 2023. https://www.msdmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/acute-myocardial-infarction-mi#top .

American Heart Association. Heart disease and stroke statistics 2019 update: A report from the American Heart Association. Circulation 139 , e56–e528. https://doi.org/10.1161/CIR.0000000000000659 (2019).

Division of non-communicable diseases. (2020a). Number and rate of inpatients with ischemic heart disease (I20-I25) per 100,000 population (including all diagnoses) 2007–2015 classified by province, public health service area and country overview (including Bangkok). Retrieved July 12, 2020. http://www.thaincd.com/2016/mission3 .

Division of non-communicable diseases. (2020b). Number and mortality rate of 4 NCD diseases per 100,000 population, 2016–2018 classified by province, public health service area and country overview (including Bangkok). Retrieved July 12, 2020. http://www.thaincd.com/2016/mission3 .

Benjamin, E. J. et al. Heart disease and stroke statistics—2018 update: A report from the American Heart Association. Circulation 137 , e67–e492. https://doi.org/10.1161/CIR.0000000000000558 (2018).

Kanbuala, W., Samartkit, N. & Keeratiyutawong, P. Factors related to decision time for seeking treatment in patients with myocardial infarction. Nursing J. Ministry Public Health 24 (2), 21–36 (2014).

Google Scholar  

World Health Organization. (2018). Cardiovascular disease. Retrieved October 28, 2018. https://www.who.int/cardiovascular_diseases/en/

World Health Organization. (2023). Aging and health. Retrieved April 4, 2023. https://www.who.int/news-room/fact-sheets/detail/ageing-and-health

Banharak, S. (2017). Knowledge belief and decision making about acute myocardial infarction among younger and older adult Thai and Laotian immigrants in the United States. Doctoral Dissertation, School of Nursing, Saint Louis University, USA.

Banharak, S. & Prasankok, C. The effects of delaying treatment among acute myocardial infarction patients: A systematic review. J. Nursing Sci. Health 40 (4), 107–120 (2018).

Kasetkala, P., Watthnakitkrileart, D., Charoenkitkarn, V., Sriprasong, S. & Dumavibhat, C. Factors influencing the duration of decision making for seeking treatment in patients with acute heart failure. J. Nursing Sci. 31 (4), 23–33 (2013).

Banharak, S., Zahrli, T. & Matsuo, H. Public knowledge about risk factors, symptoms, and first decision-making in response to symptoms of heart attack among lay people. Pacif. Rim Int. J. Nursing 22 (1), 24–36 (2018).

Banharak, S., Prasankok, C. & Lach, H. Factors related to a delay in seeking treatment for acute myocardial infarction in older adults: An integrative review. Pacif. Rim Int. J. Nursing Res. 24 (4), 553–568 (2020).

Sungbun, S., Piaseu, N. & Partiprajak, S. Needs of stakeholders in fast-track care for ST-segment elevation myocardial infarction (STEMI). Thai J. Nursing Council 32 (4), 19–38 (2017).

Leto, L. & Feola, M. Cognitive impairment in heart failure patients. J. Geriatr. Cardiol. 11 (4), 316–328 (2014).

CAS   PubMed   PubMed Central   Google Scholar  

Suwanno, J., Petsirasan, R., Suwanno, J., Saisuk, W. & Chanpradit, A. Age and heart failure self-care: A comparison of self-care maintenance between older and younger adults. Songklanagarind Med. J. 27 (4), 335–346 (2009).

Makarov, D. V. et al. Randomized trial of community health worker-led decision coaching to promote shared decision-making for prostate cancer screening among Black male patients and their providers. Trials 22 , 128. https://doi.org/10.1186/s13063-021-05064-4 (2021).

Article   PubMed   PubMed Central   Google Scholar  

Kiosses, V. N., Karathanos, V. T. & Tatsioni, A. Empathy promoting interventions for health professionals: A systematic review of RCTs. J. Compassionate Health Care 3 , 7. https://doi.org/10.1186/s40639-016-0024-9 (2016).

Corsini, R. (2017). Role Playing in Psychotherapy . New Brunswick, NJ: AldineTransaction. p. 21. ISBN 9780202363936.

Bruce, T., Hakkarainen, P. & Bredikyte, M. The Routledge International Handbook of Early Childhood Play 55 (Routledge, 2017).

Book   Google Scholar  

Maio, G. & Haddock, G. The Psychology of Attitudes and Attitude Change 157 (SAGE, 2014).

Banharak, S., Metprommarat, A., Mahikul, W., Jeamjitvibool, T. & Karaket, A. Effectiveness of acute myocardial infarction interventions on selected outcomes among community dwelling-older adults: A systematic review and meta-analysis. Sci. Rep. 13 , 18538. https://doi.org/10.1038/s41598-023-45695-y (2023).

Article   ADS   CAS   PubMed   PubMed Central   Google Scholar  

Jasemi, M., Goli, R., Zabihi, R. E. & Khalkhali, H. Educating ethics codes by lecture or role-play; which one improves nursing students’ ethical sensitivity and ethical performance more? A quasi-experimental study. J. Professional Nursing 40 , 122–129. https://doi.org/10.1016/j.profnurs.2021.11.002 (2022).

Seo, H. J., Son, M. & Hong, A. J. Trends in civic engagement disaster safety education research: Systematic literature review and keyword network analysis. Sustainability 13 (5), 1–18. https://doi.org/10.3390/su13052505 (2021).

Jaihow, S., Klayvised, J., Sangprajong, K. & Petsirasan, R. Health belief and breast self-examination behavior among females student at a university in Nakhon Si Thammarat. J. Police Nurses 10 (1), 154–163 (2018).

Sanprakhon, P., Chusri, O. & Wongwisadkul, S. The effects of health belief application program in older adults with risk of coronary artery disease in a community. Nursing J. Ministry Public Health 28 (3), 87–100 (2018).

Duangkaew, T. & Sirasoonthorn, P. An application of Marshall H. Becker’s Health Belief Model [HBM] in the study of hypertension patients in urban communities in Phitsanulok. J. Community Develop. Res. (Human. Social Sci.) 10 (3), 101–113 (2017).

Dracup, K. et al. The effect of a short-term educational intervention on knowledge, attitudes, and beliefs related to response to acute myocardial infarction. Heart Lung 37 (4), 269–281 (2008).

Whitehead, D. L., Takahashi, R., Ritchie, D. & Dainty, K. N. Interventions to improve patient decision making in acute coronary syndrome: A systematic review. Eur. J. Cardiovasc. Nursing 15 (6), 447–458 (2016).

Tschandl, P. et al. Human–computer collaboration for skin cancer recognition. Nat. Med. 26 (8), 1229–1234 (2020).

Article   CAS   PubMed   Google Scholar  

Chanabun, S. Fundamental Research Methodology in Health Science (Faculty of Nursing, Khon Kaen University, 2021).

Soonthornchaiya, R. et al. The development and construct validity testing of depressive symptom inventory for Thai older persons with depressive disorders. J. Phychiatric Nursing Mental Health 32 (2), 100–112 (2018).

Kanjananopinit, S., Charoensak, S. & Keawpornsawan, T. The study of psychometric properties of cognistat Thai version. J. Psychiatr. Assoc. Thailand. 59 (4), 409–418 (2014).

Undara, W., Singhasenee, U. & Wongnitikul, P. The study of dementia, knowledge and prevention of dementia and the demographic data in the elderly association of royal Thai air force nursing college. J. Police Nurse 8 (1), 23–33 (2016).

Kotsin, R., Banharak, S., Panpanit, L. & Chanaboon, S. A survey of knowledge, belief, decision making when expecting acute myocardial infarction occurrence among community-dwelling older adults in ROI-ET province. J. Health Nursing Res. 36 (6), 1–18 (2020).

Kececi, A., & Bulduk, S. (2012). Health Education for the Elderly, Geriatrics, InTech. Retrieved June 16, 2022. http://www.intechopen.com/books/geriatrics/health

Kim, M. Y. & Oh, S. Nurses’ perspectives on health education and health literacy of older patients. Int. J. Environ. Res. Public Health 17 , 6455. https://doi.org/10.3390/ijerph17186455 (2020).

Thienmongkol, R. The study of fonts legibility for elders: A contextual of Thai alphabets on tablet screen. Veridian E-J. Silpakorn Univ. 10 (3), 1066–1082 (2017).

Sungvorawongphana, N., Subgranon, R., Pungrassamee, P., Sumngern, C. & Obama, T. The color vision of elderly under difference illuminance. J. Faculty Nursing Burapha Univ. 23 (1), 13–25 (2016).

Apter, A. J. et al. Home visits for uncontrolled asthma among low-income adults with patient portal access. J. Allergy Clin. Immunol. 144 (3), 846-853.e11. https://doi.org/10.1016/j.jaci.2019.05.030 (2019).

Bumrungsuk, S. Effects of the self-management training program on self-management behavior and blood pressure levels among elderly people with hypertension. Front. Nursing 9 (1), 71–80. https://doi.org/10.2478/fon-2022-0009 (2022).

Kartika, A. W., Widyatuti, W. & Rekawati, E. The effectiveness of home-based nursing intervention in the elderly with recurrent diabetic foot ulcers: A case report. J. Public Health Res. 10 (2), 2162. https://doi.org/10.4081/jphr.2021.2162 (2021).

Liang, Y. H. et al. Reducing medication problems among minority individuals with low socioeconomic status through pharmacist home visits. Int. J. Environ. Res. Public Health 19 (7), 4234. https://doi.org/10.3390/ijerph19074234 (2022).

Van Spall, H. G. C. et al. Knowledge to action: Rationale and design of the Patient-Centered Care Transitions in Heart Failure (PACT-HF) stepped wedge cluster randomized trial. Am. Heart J. 199 , 75–82. https://doi.org/10.1016/j.ahj.2017.12.013 (2018).

Saraboon, Y., Aree-Ue, S. & Maruo, S. J. The effect of multifactorial intervention programs on health behavior and symptom control among community-dwelling overweight older adults with knee osteoarthritis. Orthop. Nursing 34 (5), 296–308. https://doi.org/10.1097/NOR.0000000000000180 (2015).

Glomsås, H. S., Knutsen, I. R., Fossum, M., Christiansen, K. & Halvorsen, K. Family caregivers’ involvement in caring for frail older family members using welfare technology: A qualitative study of home care in transition. BMC Geriatr. 22 (1), 223. https://doi.org/10.1186/s12877-022-02890-2 (2022).

Liu, H., Yang, R. & Feng, Z. Age-related loss of resources and perceived old age in China. Ageing Society 42 (6), 1280–1298. https://doi.org/10.1017/S0144686X20001440 (2022).

Syse, A., Artamonova, A., Thomas, M. & Veenstra, M. Do characteristics of family members influence older persons’ transition to long-term healthcare services?. BMC Health Services Res. 22 (1), 362. https://doi.org/10.1186/s12913-022-07745-5 (2022).

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Acknowledgements

We would like to thank those who contributed to developing the health education applying role-play promoting decision-making ability program. A special thanks is extended to the community-dwelling older adults who participated in the study. Lastly, we would like to acknowledge the registered nurses at primary care units and staff at older adult schools for their cooperation and participation during the research process.

This research project was financially supported by the young researcher development project of Khon Kaen University (Grant number YRDP-KKU-0212182020). Appreciation is extended to this research project for making this research possible.

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Banharak, S., Threeranut, A. & Metprommarat, A. Effects of health education applying role play on decision making in acute myocardial infarction situation among older adults in community. Sci Rep 14 , 19627 (2024). https://doi.org/10.1038/s41598-024-70747-2

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Received : 20 April 2024

Accepted : 20 August 2024

Published : 23 August 2024

DOI : https://doi.org/10.1038/s41598-024-70747-2

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• Acute myocardial infarction
• Community-dwelling
• Decision making
• Health belief model
• Heart attack
• Randomized controlled trial
• Role playing

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