The Extent and Impact of COVID-19 Infection among Family and Friends: A Scoping Review

1. Introduction Section:

During the winter of 2019, the emerging SARS-COV-2 virus (COVID-19) made both its sudden entry and impact felt throughout the world. The initial outbreak of the disease originated in China and soon spread throughout the world[1].The World Health Organization (WHO) labelled the disease a pandemic due its speed of transmission and its severity in causing health complications in at-risk populations [2]. As of late March 2023, there has been more than 762 million cases and almost 7 million deaths, worldwide [3]. European countries reported the most confirmed cases and African nations reporting the least numbered of cases [3]. The pandemic led to societal lockdowns and social distancing/quarantining protocols which adversely affected individuals in many countries. The lockdowns have not only yielded social consequences but also economic ones. In the United States, it was projected that the pandemic would accrue $16 billion in financial costs [4].

1.1. The Impacts of COVID-19 on Mental Health of Victims

The impact of COVID-19 on infected victims, may not only lead to physical effects but also to emotional/mental ones. Individuals who both contracted COVID-19 and were successfully treated may suffer as much from the psychological vestiges of the disease as with the physical ones. Having been infected with the virus, a victim many suffer from a slew of post-exposure psychological symptoms (e.g., anxiety, depression, stress) [5]. According to one estimate, almost one out of five COVID-19 infected individuals were at risk for developing at least one psychiatric disorder [6]. Even upon successful discharge, hospitalized individuals reported suffering from both social stigma and psychological symptoms [7]. In one study, more than two-thirds of COVID survivors reported suffering from symptoms associated with post-traumatic stress disorder (PTSD) [8]. PTSD symptoms may be reported in both greater prevalence and severity when the survivors were recently discharged from hospital care vs. having been discharged from a longer period [9].

1.2. How Support from Family & Friends Assist COVID-19 Sufferers

The pandemic contributed to an increased need for support provided to those infected with COVID-19. Strong family support was linked to an increase in the self-efficacy or confidence of COVID-19 patients to handle the daily stressors or hassles of life [10]. The lockdowns reportedly had a maladaptive impact on depression sufferers who valued the importance of being present with family members or being able to be physically comforted by them [11]. Those patients who were hospitalized or placed in long-term care were particularly affected by the social distancing protocols [12] which could be linked to lack of social and/or emotional support. Having strong familial or social support system can be viewed as strong protective factors against the psychosocial issues stemming from the pandemic. A trusting family support system not only assists in helping alleviate psychosocial issues but also reinforces more positive attitudes and/or increased acceptance of social distancing practices [13] and the increased adoption of personal protective equipment.

1.3. Importance of Communication Family Members/Friends with both Health Care Providers and Affected Patients

The pandemic has heralded new mediums for communication between healthcare providers and patients’ family members. On many occasions, the family serves as informal caregivers for severely ill patients. Healthcare professionals need to be cognizant that many families of hospitalized COVID-19 victims may also be feel constant pressure in the managing of their daily affairs. The hospitalization of their loved ones coupled with day-to-day hassles may create emotional strains for family members [12].

Since having a hospitalized family member can be stressful, effective communication to keep them abreast of the patient’s status can be of paramount importance. It is recommended, even with physical distancing measures, that to assist in preserving family unity that family members be allowed limited physical presence near the bedsides of hospitalized loved ones [14]. If social distancing or other physical restrictions are placed on hospital visits, providing teleconferencing options or virtual reality visits may be the best options in solidifying communication between patients and their loved ones [14,15].

Due to the social distancing restrictions on hospital visits amidst highly communicable diseases, the use of technology is increasingly utilized as a mode of communication for relatives with their hospitalized loved ones or with healthcare providers. Teleconferencing [15], videoconferencing [16] or innovative family-support teams [17] can assist hospitalized patients and healthcare providers effectively communicate with patients’ relatives or close friends. Online psychosocial support groups can be employed as great assets in moderating the effects of COVID-19-linked caregiving stress [18]. It is deemed imperative that family members, especially those who are caregiving for sickly patients, be concerned for their own emotional health and physical well-being [19].

1.5. COVID-19 and Daily Hassles

During the peak of the pandemic, many societal issues impacted the average person. Due to the societal forced lockdowns, many Americans suffered from economic setbacks. From a survey by Karpman et al.[20] nearly 40% of respondents reported either losing employment, reduced work hours, or loss of work-related income resulting from the pandemic. Those from lower socioeconomic backgrounds may be more adversely affected. One survey study conducted during the peak of the pandemic, found that 43% of family members worried over about their employment, 69% were worried about the availability food, and 50% were concerned about the affordability of food products [21].

The lockdowns and its accompanying social distancing restrictions adversely affected the healthcare systems of many countries [22]. Many indigent individuals had difficulty in accessing and acquiring needed services. Those that lack proper financial resources are more likely to be diagnosed for illnesses in the advanced stages, making it difficult to make full recoveries. The heighten stress, from financial or economic uncertainties, may lead to declines in physical and mental health [23]. One study found that during the pandemic, elderly individuals who lost their jobs and women were more prone to developing symptoms of depression compared to other groups [24].

1.6. The Current Study

The COVID-19 pandemic has profoundly affected how relatives and friends socialized and cared for their diagnosed loved ones. The authors believe that the mental ramifications and daily hassles stemming from having an infected loved one may lead to declines in emotional, mental, and physical health. The pandemic has led to a greater focus on research assessing the mental health outcomes of COVID-19 infected individuals. Currently, there are no scoping or systematic reviews centering on the study’s research question. Currently, there is a dearth of research highlighting the reported mental or emotional health outcomes of the relatives and friends of COVID-19 infected individuals.

The findings from this scoping review may optimistically lead to interventions targeting the alleviation of some of issues that may affect the relatives or close friends of a loved one either diagnosed with COVID-19 or other severe diseases. The findings may help also facilitate future interventions in strengthening or stabilizing the relations between friends and family members, particularly those that may serve as informal caretakers or sources of social support. This scoping review’s aims are to provide answers to the following research question: What are the reported psychosocial impacts and daily hassles amongst family members and friends of COVID-19 infected individuals?

2. Methods

The methodology for this scoping review was conducted by using the first three steps of the framework devised by Arksey et al. [25]. This framework was selected due to its current usage and acceptance among professionals publishing scoping reviews. The first step is identifying and articulating the research question, which guided this scoping review. The authors collected and assessed published articles studying the psychosocial impacts and perceived daily hassles (e.g., economic, or social hardships) of friends and family members of COVID-19 infected individuals.

The 2^nd step in the scoping review was identifying the relevant published studies to answer the research study. The review was conducted by using the PubMed, Google Scholar, and Medline internet databases. Also, employed were reference lists or bibliographies of studies found throughout the database searches. The database searches only included studies published in the English language. The authors employed the keywords/MeSH terms: “COVID-19 patients” family members”, “friends” for the database searches.

The 3^rd step was selecting the articles to be part of the study’s analysis. Only those articles that were published in scholarly, peer reviewed journals and specifically covered COVID-19 were used in the scoping review. Articles covering other diseases were excluded. Studies that were published on websites, newspapers, or newsletters were excluded from the analysis. Articles were included that involved measuring the emotional health or the daily hassles of relatives and friends of COVID-19 diagnosed individuals. Since the authors were looking to gauge findings associated with relatives and friends of COVID-19, studies that covered interventions were excluded from the scoping review.

3. Results Section:

The initial databases’ searches, utilizing the search terms, yielded 9,202 results. After perusing through the searches, the researchers found 45 studies which met the inclusionary criteria for the review. After retrieval and thorough screening, 8 more studies were excluded. Lastly, a total of 37 studies were deemed appropriate for the scoping review [27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63] (Table 1). The flow of the studies’ selection is exhibited though a modified Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) [26] (Figure 1).

Descriptive headings were included for each study on Table 1: Author(s), Participants Relationship to Victim(s), Country; Type of Study; Main Findings. The results from the quantitative studies were included if they met statistical significance (i.e., p<.05). Owing to the prevalence of results yielded from the searches, the findings were placed into corresponding, combined categories (Table 2). This review only included categories that yielded similar findings in three or more studies. Next, the findings were amalgamated into 16 broad categories.

The three most prevalent findings were: Psychosocial feelings (24 studies); Perceived issues with healthcare system(s) (13 studies); Importance of support (11 studies) and Responsibility/caring for COVID-19 patient (11 studies) (Table 2). The rest of the findings are displayed in reduced frequencies. Both quantitative and qualitative studies each comprised 17 of the types of studies (Table 3). Three of the studies utilized a mixed framework, both quantitative and qualitative. All quantitative studies utilized questionnaire/survey methods. All but three qualitative studies employed the interview method. Iran was the country that yielded the most studies (10). Assessing the study population used in the studies, those that contained 0-100 participants were the most prevalent (19).

4. Discussion Section:

Psychological states (e.g., anxiety, stress, depression) linked to COVID-19 diagnoses in relatives or close friends was the most prevalent finding from the review. This finding comprised more than half of all selected studies. This was not surprising due to the range of emotions that may arise from having a friend or family member either diagnosed or having died from the virus. Coupled with the fact that caregiving for severely ill patients, outside of the healthcare setting, is mostly provided by relatives and close friends [64]. This finding is consistent with other studies assessing informal caregiving for other severe illnesses [65,66] The death of a relative or close friend may be a cause for emotional anguish in some survivors. The loss of a family member may not only cause mental distress for survivors but the exacerbation of current mental illnesses or disorders [48].

Caregiving, conducted for long periods of time, may increase risks for developing psychological or emotional issues. The severity and the duration of psychological disorders in affected patients is correlated to increased risks of anxiety and depression in caregivers [67]. Some personal characteristics of caregivers may be linked to greater susceptibility for psychological issues. From one of the selected studies from the review, personal characteristics such as being married, having a higher income, and not exercising were positively associated with higher greater risks for developing depression, anxiety, and stress in caregivers [37]. The results taken from the review were comparable to those derived from similar studies looking into the effects of informal caregiving, regardless of the illnesses, during the pandemic’s peak. Caregivers reported higher levels of depression, anxiety, fatigue, depression, sleep issues, food insecurity when compared to non-caregivers [68] Some psychological states, like loneliness, may lead to increased risks in developing symptoms associated with depression [69].

Perceived problems with the healthcare system(s) was a common theme throughout the review. Many of these types of problems stem from the miscommunication between healthcare professionals and caregivers pertaining to the status of a hospitalized patient. Several studies from the scoping review reported that family members lamented difficulties in both the communication and the comprehension of the medical prognoses of patients [49,53]. Some family members expounded on the importance of being informed of the hospitalized patient’s progress throughout treatment [53]. Access to staff and being informed of a patient’s status was cited as being effective in bolstering the lines of communication and understanding between healthcare staff and relatives [70].

Healthcare workers may use verbiage or assume that caregivers understand directives. Healthcare workers may need to be cognizant to the fact that many caregivers may have low health literacy which substantiates their need for assistance in understanding health information. Therefore, clarification or probing for questions, can be important. Caregivers should be informed alongside the patient, be it either through verbal or written instruction [71]. Ideally, caregivers should be trained, by healthcare providers, to effectively monitor current symptoms and to report any noticeable exacerbation of symptoms [72].

During a pandemic, family members, especially caregivers may feel despaired or overwhelmed with day-to-day responsibilities. They may feel alone or not adequately supported when the COVID-19 infected patient returns from hospitalization or treatment [27,28]. Caregiving for severe or chronic diseases may lead to increased levels of stress [73] or depression [74]. Greater family support is linked to a reported greater health related quality of life in caregivers [75]. Financial woes or economic pressures, which personified the COVID’s peak period, may also lead to perceived burdens in informal caregivers [76].

While COVID-19 may not be as time consuming in caregiving or in treatment, as compared with other more chronic or severe diseases, support is still recommended for caregivers. Both tangible and informational support are integral in assisting caregivers of patients with severe or chronic illnesses [77]. Caregivers, from one study, cited financial assistance as a crucial source of support during trying times [78]. Providing ample social support can be the impetus to alleviating perceived burdens amongst caregivers [79].

During times of medical emergencies, family members and close friends may find themselves becoming responsible for the care of an infected loved one [41]. Some caregivers report an array of different burdens (e.g., economic, physical, psychological) in the long-term caring of others [38]. Devoting more time to caregiving was positively associated with poorer mental health outcomes [80]. Females are more likely to devote more time to caring for infected family members and as such they more likely than males to suffer from higher perceived burdens [81]. Though not all experiences of caregiving are reportedly negative, some caregivers report feeling a sense of positive accomplishments and self-growth throughout their experiences [55].

During the peak of communicable disease control, social distancing protocols are rudimentary precautions to reduce the spread of transmission and to protect immunocompromised individuals. Though many family members try to comply with the protocols [51], the restrictions may still lead to negative impacts on both the patients and their family members [49,62]. These needed protections may lead to a greater likelihood of adverse outcomes. A literature review studying the effects of hospital restrictions on visitations found that family members of COVID-19 infected patients were more likely to suffer from anxiety, excessive worrying, and even increased disturbances at home [82]. Being separated from infected loves ones, may add to feelings of foreboding or dread among relatives and friends [56]. Some may anticipate the worsening of the hospitalized individual’s health stemming from the social isolation. McCleary et al. examining COVID-19 era long term care facilities during the severe acute respiratory syndrome (SARS) reported that relatives perceived drastic declines in the physical and emotional health of their loved ones due to visiting restrictions.

Being isolated from loved ones, may be traumatic to both hospitalized patients and their family members. It may be ideal to include more personal contact times between patients and their relatives, regardless of medical emergencies. Allowing for more personal contact time, regardless of the restrictions, may help mitigate the maladaptive effects associated with feelings of isolation [83]. Some hospitals have found ways to connect families to their hospitalized loves via implemented technological solutions (virtual visits) [84]. A recent study found that while telehealth or other forms of technological communication are preferred to no means of communication, face to face visits are still considered ideal by most families [85].

5. Limitations to the Study:

This scoping review only used those studies that were selected from the database searches. Therefore, some studies contained in other databases may be missing from this review. The 37 published studies may serve as a relatively small sample. A larger sample size may have yielded a different set of results. The authors included only those search words or MeSH terms that they believed would generate the most relevant results. Excluding non-English language published studies may have precluded some prospective studies from being used in the review. It could be surmised that they may have been able to attain additional studies through the utilization of other search words or MeSH terms. Lastly, most of the selected studies included self-reporting from participants, which may lead to potential biases that may affect the results published from those studies.

6. Conclusion:

This scoping review may provide the impetus for future interventions targeting the alleviation of the psychological or emotional issues associated with losing close friends or relatives from severe diseases. The findings from this study could be ideally utilized as a resource for those researchers studying the effects of future pandemics on the psychological stressors or daily hassles of non-professional caregivers, primarily those who are relatives or friends of the affected person. Usually, implemented interventions target the mental health needs of the victim. As such, interventions need to target alleviating the emotional or psychological states that may afflict families or friends of a victim. Family members and close friends increasingly serve as the primary caregivers for loved ones who suffer from severe diseases. Therefore, mental health services (e.g., counseling, medications) may assist the relatives of friends, of severely diseased individuals, to cope with the daily stressors of life.