covid 19 case study for grade 5

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The COVID-19 impact on reading achievement growth of Grade 3–5 students in a U.S. urban school district: variation across student characteristics and instructional modalities

• Published: 14 November 2022
• Volume 36 , pages 317–346, ( 2023 )

Cite this article

• Jackie Eunjung Relyea   ORCID: orcid.org/0000-0002-7560-7136 1 ,
• Patrick Rich   ORCID: orcid.org/0000-0001-8268-0502 2 ,
• James S. Kim   ORCID: orcid.org/0000-0002-6415-5496 3 &
• Joshua B. Gilbert   ORCID: orcid.org/0000-0003-3496-2710 3  

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The current study aimed to explore the COVID-19 impact on reading achievement growth by Grade 3–5 students in a large urban school district in the U.S. and whether the impact differed by students’ demographic characteristics and instructional modality. Specifically, using administrative data from the school district, we investigated to what extent students made gains in reading during the 2020–2021 school year relative to the pre-COVID-19 typical school year in 2018–2019. We further examined whether the effects of students’ instructional modality on reading growth varied by demographic characteristics. Overall, students had lower average reading achievement gains over the 9-month 2020–2021 school year than the 2018–2019 school year with a learning loss effect size of 0.54, 0.27, and 0.28 standard deviation unit for Grade 3, 4, and 5, respectively. Substantially reduced reading gains were observed from Grade 3 students, students from high-poverty backgrounds, English learners, and students with disabilities. Additionally, findings indicate that among students with similar demographic characteristics, higher-achieving students tended to choose the fully remote instruction option, while lower-achieving students appeared to opt for in-person instruction at the beginning of the 2020–2021 school year. However, students who received in-person instruction most likely demonstrated continuous growth in reading over the school year, whereas initially higher-achieving students who received remote instruction showed stagnation or decline, particularly in the spring 2021 semester. Our findings support the notion that in-person schooling during the pandemic may serve as an equalizer for lower-achieving students, particularly from historically marginalized or vulnerable student populations.

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Introduction

Countries around the globe have faced unprecedented challenges in trying to support children’s learning amidst and beyond the COVID-19 era. The global pandemic outbreak has forced school closures to prevent the transmission of the coronavirus; this heavily disrupted children’s learning opportunities, methods, and resources. Recent studies that estimated the impact of pandemic-related school closures on student learning progress among U.S. students from multiple states (e.g., Domingue et al., 2022 ; Education Policy Innovation Collaborative [EPIC], 2021 ; Kuhfeld et al., 2022 ; Pier et al., 2021 ) indicate that children’s learning and academic development have suffered substantial setbacks during the pandemic school year when compared to a typical year unaffected by COVID-19. A report from the North Carolina Department of Public Instruction ( 2021 ) shows that the average proficiency rates in reading in spring 2021 declined significantly, ranging from 7.4% (Grade 8) to 25.5% (Grade 6), compared to spring 2019, which means that fewer students were proficient in reading during the pandemic than a non-pandemic school year. Educators, researchers, and policymakers have expressed mounting concerns that short-term learning loss could continue to accumulate, even after school re-opening, resulting in prolonged learning loss over years (e.g., Bailey et al., 2021 ; Kuhfeld et al., 2020b ).

Although the existing projections of educational outcomes provide information and insights on the potential overall impact on students’ academic performance, the scope of the pandemic’s impact on academic achievement levels and growth, particularly in reading, is currently preliminary and scant. There is a common belief that many children from historically marginalized or vulnerable groups are disproportionately affected by the COVID-19 school disruptions (Amplify Education, 2021 ), yet limited robust evidence exists to support our understanding of the extent to which learning losses or gains have occurred to at-risk student population groups in the United States. In a recent study, Kuhfeld et al. ( 2022 ) explored racial-ethnic group differences in reading gains during the 2020–2021 school year and revealed that Black students exhibited significantly less gains than White students, resulting in widening racial/ethnic inequality gaps over time. Although this study provides insight into how the pandemic has affected historically marginalized race/ethnic groups of students, further evidence is needed to determine the extent to which learning losses or gains have occurred within other vulnerable groups of students, such as English learners and students with disabilities, over the pandemic period.

Furthermore, as school and district leaders currently concentrate on making important decisions for pandemic-related recovery efforts, it is important to comprehensively understand for whom, and to what extent, reading losses or gains have occurred during the pandemic year within a school district to effectively target recovery strategies and resources to the students most in need. Although available evidence has documented variation in students’ reading levels and growth during the pandemic based on nationwide samples (e.g., Curriculum Associates, 2020 ; Kuhfeld et al., 2022 ; Renaissance Learning, 2020 ), inferences founded on analyses of national databases may mislead or be insufficient for a school district to accurately assess and target student learning needs. Recent analyses that include 16% of the U.S. public schools serving Grade 3–8 students reveal substantial between-district variability in students’ reading achievement and growth distributions during the pandemic (Goldhaber et al., 2022 ).

Therefore, assuming that national trends apply to a specific school district may lead to inaccurate inferences about the predicted impact of COVID-19 on student reading growth. More importantly, school district policymakers and educators can benefit from a case study of a single school district in learning about how district-level education policies in response to COVID-19 have impacted student reading outcomes and progress and whether the impacts have differed across student population groups. Specifically, some school districts in North Carolina offered students and parents/guardians the option of starting the fall 2020 semester with in-person or remote instruction, but it is unknown whether the impact of COVID-19 on students’ reading growth varied by the instructional modality that students experienced. Research evidence on the influence of instructional modality (e.g., in-person or remote instruction) on students’ reading outcomes and growth during the 2020–2021 school year will enlarge understanding of the association between instructional modality and reading performance, thus influencing a school district’s policy implementation and evaluation efforts.

In the current study, drawing upon administrative data from a large urban school district in North Carolina, we examined the extent of learning losses or gains in reading that occurred among Grade 3–5 students during the pandemic and how it varied across demographic subgroups of students [e.g., socioeconomic status (SES), language status, disability status] within the school district. Specifically, we estimated reading losses or gains by comparing two same-grade cohorts: (a) the COVID-19 cohort of students who experienced COVID-19-related school closures and distance learning during the 2020–2021 school year and (b) the pre-COVID-19 cohort of students in the 2018–2019 school year. With the COVID-19 cohort of students, we further explored reading growth over the 2020–2021 school year to gauge the extent to which reading growth varied as a function of the instructional modality that students received, and how their demographic characteristics interacted with instructional modality.

Reading achievement during COVID-19

Learning loss can be conceptualized as the discrepancy between students’ assessed academic knowledge and skills and grade-level curricular expectations due to extended gaps or discontinuities in students’ education progress (Pier et al., 2021 ). This concept has often been discussed with reference to summer slides or setbacks even before COVID-19. There is well-documented evidence that the absence of formal schooling over the summer months has resulted in significant learning losses or slowdowns (e.g., Alexander et al., 2001 ; Downey et al., 2004 ; Quinn et al., 2016 ). Cooper et al.’s ( 1996 ) meta-analysis of 39 studies concerning summer learning loss indicates that U.S. students, on average, make one month of academic progress during the three-month summer break. Likewise, Atteberry and McEachin ( 2021 ) have found that the average U.S. students in Grade 1–8 achieve nearly 25–34% of school-year learning gains during the summer months. They have also found much higher variability in summer learning gains across students than during school years, which can contribute to widening race/ethnicity and socioeconomic achievement disparities in later school years (von Hippel & Hamrock, 2019 ). The negative effect of the absence or interruption of all schooling on student learning appears to accumulate over time, which may lead to a substantial impact on academic performance and social and educational inequalities (Hernandez, 2011 ; Lloyd, 1978 ).

School lockdown for nearly one-third of the school year in the wake of COVID-19 can be considered an extended time of summer break for many students. There is consensus that the historic interrupted or unfinished schooling has largely exerted a negative influence on students’ academic achievement levels and growth to an even greater degree than during summer break. Recent estimates of the COVID-19 learning slide or loss, drawn upon the NWEA Measure of Academic Progress (MAP) Growth assessment from multiple states in the United States (Kuhfeld et al., 2022 ), show that Grade 3–8 students’ average reading scores at the end of the 2020–2021 school year were, on average, 0.06–0.11 standard deviations lower than those from the 2018–2019 school year, with the largest year-difference for Grade 4 and 5 students. Kuhfeld et al. ( 2022 ) also found that students exhibited a positive, but modest, growth in reading, yet variability in growth rates within a grade level in the 2020–2021 school year was larger than that observed in the 2018–2019 school year.

A serious concern is that these short-term learning slowdowns can continue to accumulate over time, which might lead to much larger and long-lasting consequences in that many students who fell behind during the pandemic would struggle to catch up. For example, current Grade 3 students could fall further behind pre-pandemic expectations, resulting in a loss of 1.5 years’ worth of learning by the time they reach Grade 10 (Kaffenberger, 2020 ).

The COVID-19 impact on students with diverse backgrounds

To obtain a more comprehensive understanding of the profound impact of the pandemic on students’ academic attainment and growth, it is critical to consider the heterogeneous effects on different groups of students. Despite a rapidly growing number of studies on the COVID-19 impact, only a few studies to date have rigorously explored the heterogeneity of the pandemic-induced learning losses or gains as a function of students’ demographic characteristics.

Recent evidence suggests that school closures and rapid transition to home-based virtual learning during the pandemic disproportionately affected elementary and middle school students, especially Black and Hispanic students and those in high-poverty schools (e.g., Goldhaber et al., 2022 ). However, the negative impact of the pandemic on reading achievement is likely more profound for students in the early elementary grades as compared to upper elementary and secondary grades (e.g., Amplify Education, 2021 ; Georgiou, 2021 ; Kuhfeld et al., 2022 ; Tomasik et al., 2020 ). This may be because younger children require more instructional support and systemic scaffolding and, at the COVID-19 outbreak, their competencies for independent and self-regulated online learning had not yet sufficiently developed.

Moreover, the COVID-19 slide has had a particularly harmful effect on the academic achievement of students from low-income backgrounds, in general, amplifying existing income-based achievement disparities and inequalities (e.g., Engzell et al., 2021 ; EPIC, 2021 ; Gore et al., 2021 ; Kuhfeld et al., 2022 ; Maldonado & De Witte, 2020 ). Children in lower SES environments have experienced reduced access to human and educational resources as well as unstable technology and internet connectivity during remote learning (UNESCO, 2021 ). The significant differences between SES groups in reading and literacy development observed over the summer months in the previous studies (e.g., Cooper et al., 1996 ; Downey et al., 2004 ; Entwisle et al., 1997 ; Kim & Quinn, 2013 ) can be exacerbated by the global health crisis, considering the prevailing inequalities and unequal access to learning opportunities. Building upon the existing evidence on the impact of the absence of traditional schooling on students’ achievement outcomes, the current study sought to further quantify how the pandemic-related reading gains or losses can vary across students from low, medium, and high SES backgrounds in the same school district.

The COVID-19 impact on learning outcomes of other historically marginalized and vulnerable subgroups of the student population, such as English learners and students with disabilities, is less well understood. Many English learners in U.S. schools are children from low-income immigrant families and under-resourced communities. Despite the rich and diverse linguistic and cultural resources such students bring to schools, they often experience inequitable and limited access to rigorous learning opportunities, especially in content areas (e.g., science, social studies; Callahan & Shifrer, 2016 ; Hopkins et al., 2015 ). COVID-19 has been projected to widen existing opportunity and achievement gaps between English learners and their English-fluent peers. With the sudden transition to distance learning in the wake of COVID-19, English learners were isolated in a home environment in which English is not spoken as a primary language. As a result, they may have experienced a lack of opportunities to develop English language skills through peer interaction and academic conversation; remote learning resources that were inadequate and not tailored to support English learners; parents’ limited capacities to support their children’s home-based learning; and coping with compounding stressors including anti-immigration sentiments and racism related to COVID-19 (Sugarman & Lazarín, 2020 ). Therefore, the COVID-19 disruptions had disproportionately detrimental impacts on English learners’ learning, yet it is unclear to what extent English learners’ English reading achievement and growth have been affected by the pandemic-related school closures.

Likewise, students with disabilities represent a uniquely vulnerable group of students who may have been significantly affected by COVID-19 school closures. The shift to remote instruction due to school lockdown can be immensely challenging for many students with disabilities who often experience difficulties with information processing or sustaining attention and focus to complete instructional tasks (Swanson, 1987 ). Particularly, for students with attention deficit hyperactivity disorder (ADHD) who experience inattention, hyperactivity, and impulsivity, their condition makes it hard to pay attention or control behaviors in an online learning environment (Lupas et al., 2021 ). Special education services or individualized education programs (IEP) were suspended to mitigate the spread of COVID-19. Regardless of how well an online learning curriculum was designed, reasonable accommodations and accessibility for students with disabilities and their needs were not sufficiently considered (Petretto et al., 2020 ). Consequently, most teachers faced many challenges in teaching remotely while trying to accommodate the unique needs of students with disabilities. Students with disabilities typically attain lower-than-average achievement scores (Gilmour et al., 2019 ) and the disability-based disparities in academic achievement may have been exacerbated by the pandemic.

How might instructional modality affect student reading outcomes?

Pre-pandemic studies on the effects of remote instruction on students’ academic achievement often reported a negative association between an online or distance learning mode and students’ academic achievement (e.g., Ahn & McEachin, 2017 ; Buddin & Zimmer, 2005 ; Center for Research on Education Outcomes [CREDO], 2015 ; Fitzpatrick et al., 2020 ). Despite the advent of new technologies that elevated students’ learning and engagement, research evidence shows that K-12 students who have attended online schooling are likely to perform lower on reading and mathematics assessments than their peers in traditional face-to-face learning environments (e.g., Ahn & McEachin, 2017 ; CREDO, 2015 ). In most virtual learning environments, students tend to participate in self-paced instruction with limited student–teacher and peer-to-peer interactions (Gill et al., 2015 ) such that students in online learning environments generally learn less than their peers who physically participate in active learning in their schools.

Even if internet access and the quality of remote learning improved over the pandemic, a lack of engagement and chronic absenteeism was more pronounced among students from high-poverty backgrounds, those who were English learners, and students with disabilities, when they were learning virtually (Patrick et al., 2021 ). In an online learning environment, students may need to work more independently through curriculum and lesson materials which increasingly requires self-regulatory learning and metacognitive skills to manage their learning (Azevedo, 2005 ). With limited scaffolding and guidance in distance settings, these skills may not be developed enough to foster learning for some students, particularly those younger and more vulnerable groups of children.

Emerging research evidence suggests that students who spent more in-person school days during the pandemic attained higher academic outcomes than peers who chose a full-distance learning option (e.g., Goldhaber et al., 2022 ; Halloran et al., 2021 ; Molnar, 2021 ; Tomasik et al., 2020 ). In the current study, we sought to examine the differential impact of instructional modality (i.e., in-person vs. remote instruction) on students’ reading growth rate over the pandemic school year. Figure  1 displays a conceptual framework of how types of instructional modality would affect students’ reading gains over time. It is expected that, among students with similar demographic characteristics, lower-achieving students are more likely to choose the in-person schooling option, while higher-achieving students tend to prefer the remote instruction option (National Center for Education Statistics, 2022 ). This may be because remote learning environments require high levels of independent and self-regulated learning skills to learn and access academic content with a limited amount of support from teachers and administrators, and these skills are more feasible for higher-achieving students than for lower-achieving students. However, we hypothesize that lower-achieving students would benefit from in-school learning experiences that can stimulate cognitive and social development, making greater reading gains than their higher-achieving peers who tended to participate in remote learning instruction during the pandemic. In-person schooling may thus offset inequalities in learning opportunities, and consequently, result in narrowing achievement differences to some degree.

Conceptual framework of how instructional modality affects reading achievement levels and growth rates during the 2020–2021 school year

This conceptualization aligns with the faucet theory (Entwisle et al., 1997 ) and an accumulating body of knowledge about seasonal learning patterns (e.g., Alexander et al., 2001 ; Downey et al., 2004 ). During the school year, the resource faucet is turned on for all children; as a result, children with varying economic backgrounds benefit nearly equally. However, when a school session ends or is canceled, the resource faucet is turned off, thereby creating inequalities in educational opportunities and widening achievement gaps between students from high-poverty and low-poverty backgrounds. In out-of-school learning environments, the accumulation of learning losses and achievement gaps due to school closures occurs more substantively among low-achieving students, students from high-poverty environments, or students from historically marginalized vulnerable groups who may have unequal access to resources both inside and outside schools. Existing research suggests that high-quality summer school programs can serve to prevent learning losses and mitigate educational inequalities (Borman et al., 2005 ; Cooper et al., 1996 ; Kim & Quinn, 2013 ). We hypothesize that under pandemic circumstances, in-person schooling may serve as an equalizer for lower-achieving students, particularly from historically marginalized or vulnerable student populations (Alexander et al., 2001 ; Downey et al., 2004 ; Raudenbush & Eschmann, 2015 ).

The current study

The current study aimed to assess the COVID-19 impact on reading achievement levels and growth rates of Grade 3–5 students in the U.S. and whether the impact differed by students’ demographic characteristics (i.e., SES, language status, disability status) and instructional modality (i.e., in-person, remote instruction). Although a growing number of studies have documented COVID-19 learning loss or gain phenomenon around the globe, there is limited evidence of quantifying differential impacts on reading achievement gains and growth. Focusing on demographic subgroups can provide insights into the heterogeneity of the pandemic impact on reading attainment and can inform reading instruction and intervention as school districts continue to address local learning recovery needs.

Using administrative data drawn from an urban school district in North Carolina, we investigated to what extent upper elementary grades students made gains in reading during the 2020–2021 school year relative to those students in the same grade level who did not experience the pandemic in the 2018–2019 school year. We were particularly interested in inter- and intra-group differences to determine the dynamics of the impact of COVID-19 school closures on reading achievement in Grade 3 to 5 to contextualize our findings with other state (e.g., Pier et al., 2021 ) and national (e.g., Goldhaber et al., 2022 ; Kuhfeld et al., 2022 ) analyses focusing on those upper elementary grades. Furthermore, we examined whether students’ instructional modality affected the rates of reading growth over the 2020–2021 school year, particularly by focusing on whether the effects of instructional modality on reading growth varied by students’ SES, language status, and disability status. In pursuing this endeavor, our goals were not only to contribute to the literature in the field of the COVID-19 impact analysis but also to offer insights to educators and school and district leaders that are grounded by district-specific administrative data and evidence. Two research questions that guide this study are as follows:

To what extent did Grade 3–5 students’ reading gains during the 2020–2021 school year vary by grade level, SES, language status, and disability status compared to the 2018–2019 school year?

Did the association between Grade 3–5 students’ instructional modality and reading growth rates during the 2020–2021 school year differ by SES, language status, and disability status?

Data source

This study used administrative data drawn from 180 elementary schools in an urban school district in North Carolina, USA, from the 2018–2019 and 2020–2021 school years. The primary data source for this study was the Measure of Academic Progress (MAP) Growth Reading assessment from the Northwest Evaluation Association (NWEA), a nationally normed, anonymous assessment database. We accessed the data based on a data-sharing agreement stemming from a research-practice partnership with the school district.

Analytic sample

The full analytic sample comprised 52,525 students from the two cohorts: 28,924 students from the pre- COVID-19 cohort (2018–2019) and 23,601 students from the COVID-19 cohort (2020–2021). Table 1 displays the demographic characteristics of the two-cohort samples by grade. The demographic characteristics of the two cohorts were similar across grade levels: 50% male, 34–36% Black, 26–28% White, 27–28% Hispanic, 7–9% Asian, 17–20% English learners, and 8–9% students with disabilities. The proportion of students from low SES neighborhoods (35–37%) was slightly higher than those of students from medium (30–32%) and high (29–31%) SES backgrounds.

Table 2 shows demographic characteristics of the COVID-19 cohort in 2020–2021 by a choice of instructional modality. Students and parents/guardians were given the option to select either in-person or fully remote instruction options for the 2020–2021 school year in summer 2020. Overall, 62% of students opted to receive in-person instruction, while 38% selected the full remote instruction option. Within-subgroup variability existed in instructional modality preference. Specifically, nearly 59% of students from low SES neighborhoods chose in-person instruction, whereas 57% and 71% of students from medium and high SES, respectively, opted for in-person instruction. Approximately 66% of English learners and 66% of students with disabilities opted to participate in in-person instruction.

• Reading achievement

The NWEA MAP Growth assessment on student reading achievement is a computer-adaptive test aligned to the Common Core and state standards and is designed to serve as a benchmarking assessment to monitor and analyze students’ progress and needs throughout the school year (NWEA, 2019 ). The MAP reading scores are calculated using the Rasch unit (RIT) vertical scale that places a student’s ability and item difficulty estimates on the same scale. This vertical scale allows for comparisons of students’ learning growth within and across grades over time. The MAP reading composite score is computed based on the four strands: foundational skills, language and writing, vocabulary usage and functions, and narrative and informational text comprehension. As an adaptive test, the MAP assessment was designed to initially provide a student with question items appropriate for the student’s grade level, and then adjust the difficulty of each item depending on the student’s responses to previous items. Although this computer-adaptive assessment was administered remotely for many students in the beginning of the 2020–2021 school year, the test mode (i.e., in-classroom vs. remote) did not compromise the test quality (Kuhfeld et al., 2020a ). Test–retest reliabilities, calculated by the vendor, range from .89 to .96 (NWEA, 2019 ). The concurrent validity estimates show that Grade 3–5 MAP reading scores are highly correlated ( r  = .79 to .80) with other U.S. state-specific assessments, including ACT Aspire, Partnership for Assessment of Readiness for College and Careers, and Smarter Balanced Assessment Consortium assessments) (NWEA, 2019 ). The MAP testing periods during a school year occurred in fall (late September), winter (late January), and spring (mid-April).

Student demographic characteristics

Three types of student demographic characteristics of interest were obtained from school district administrative data: SES, language status, and disability status. The SES variable had three categories—low, medium, and high SES—based on the census tract information. Students’ language status was to identify whether an individual was an English learner who came from households where a language other than English was primarily spoken. Disability status was to determine students with disabilities who received special education and related services under the Individuals with Disabilities Education Act according to an Individualized Education Program or other services plans.

• Instructional modality

Instructional modality was operationalized as the assignment of students to either an (a) in-person instruction option or (b) remote instruction option for the 2020–2021 school year when both options were offered to students and their parents/guardians in summer 2020. Students who opted into the in-person schooling option physically attended school face-to-face for at most 10 days in the fall 2020 semester (2 days per week between November 2 and December 14) and 48 days in the spring 2021 semester (2–4 days per week between February 15 and May 28). They participated in remote instruction at home throughout the remainder of the school year. By contrast, students who chose the remote instruction option exclusively received virtual instruction without physical school attendance throughout the 2020–2021 school year.

Data analysis

Research questions 1: reading gains and variability.

To address the first research question regarding Grade 3–5 students’ reading gains during the 2020–2021 school year and the variation across subgroups, we first obtained 9-month MAP reading gain scores for individual students in the COVID-19 cohort (2020–2021 school year) and pre-COVID-19 cohort (2018–2019 school year) by subtracting the score at the beginning of the school year (late September) from the score at the end of the school year (mid-April). To further contextualize how reading gains prior to the pandemic compared to reading gains during the pandemic for each grade level, we estimated the standardized difference (in 2018–2019 standard deviation units) between 2018–2019 and 2020–2021 means by grade level by standardizing the 9-month gains for 2020–2021 to the mean and standard deviation of the 9-month gains for 2018–2019. Then, we calculated the means and standard deviations of the gained scores by the subgroup samples (e.g., SES, language status, disability status) of the two cohorts. Subsequently, we estimated the percentage increase in means and standard deviations achieved by the COVID-19 cohort relative to the pre-COVID-19 cohort within the subgroups.

Research question 2: instructional modality difference in reading growth

To examine the effects of different instructional modality use, either in-person or fully remote instruction, on reading growth rates during the 2020–2021 school year, we employed a series of piecewise growth curve models (Singer & Willett, 2003 ). An initial inspection of the average MAP reading scores at the three assessment time points (i.e., beginning, middle, and end of the school year) (see Table 3 ) indicated that students’ reading progression patterns across the three-time points appeared to be nonlinear. We specified linear growth slopes for two separate intervals: (a) fall semester: between the beginning (fall 2020) and middle of the school year (winter 2021) and (b) spring semester: between the middle and end of the school year (spring 2021). Three-level piecewise growth curve models were specified (time nested within students within schools). The level 1 (within individual) model is expressed as follows:

where Y tij represents the MAP reading score at time t for student i in school j ; \(\uppi _{0ij}\) denotes the predicted score for student i in school j at fall 2020; and \(\uppi _{1ij}\) and \(\uppi _{2ij}\) refer to monthly learning rates for student ij over the fall 2020 and spring 2021 semesters, respectively. The error term, \({\upvarepsilon}_{{tij}}\) is assumed to be normally distributed with a mean of zero.

At level 2 (between individual), we included the instructional modality variable (i.e., REMOTE ) and demographic indicators such as SES (low SES vs. medium/high SES), language status [English learners (EL) vs. English-fluent students], and disability status [students with (SwD) vs. without disabilities] as a main-effect predictor of intercept (the beginning of the 2020–2021 school year) and growth rates over the fall and spring semesters. To examine the interaction effects between instructional modality and demographic characteristics on MAP reading level at intercept and growth rates in the fall and spring semesters, we additionally included a set of interaction terms. The level 3 model was specified to represent the variability among schools. The equations for level 2 and 3 are presented below:

Note that β 000 is the overall mean at the beginning of the 2020–2021 school year; β 010 denotes the initial difference between in-person and remote instruction students; β 110 and β 210 represent monthly reading growth rates over the fall and spring semester, respectively; β 150 , β 160 , and β 170 denote the interaction effects of instructional modality with subgroups ( Low SES , EL , and SwD , respectively) on the fall-semester growth rate, while β 250 , β 260 , and β 270 refer to the interaction effects on the spring-semester growth rate, controlling for the effects of covariates ( COV ; i.e., gender, race/ethnicity).

Research question 1: COVID-19 reading gains and variability

Table 4 shows means and standard deviations of the MAP reading achievement scores at the beginning and end of the school year for Grade 3–5 students in the 2018–2019 and 2020–2021 school year cohorts. Figure  2 displays the percentages of MAP reading achievement score gains of the 2020–2021 school year (or COVID-19) cohort relative to the 2018–2019 school year (or pre-COVID-19) cohort by student grade levels and demographic subgroups. Overall, the COVID-19 cohort achieved lower 9-month reading gains than the pre-COVID-19 cohort, with a learning loss effect size of 0.54, 0.27, and 0.28 standard deviation units for Grade 3, 4, and 5, respectively. Among the COVID-19 cohort students, reading losses were evident compared to the typical school year (i.e., 2018–2019), particularly for Grade 3 students. Overall, Grade 3 students in the COVID-19 cohort achieved 48% gains of the pre-COVID-19 cohort in reading, on average, whereas Grade 4 and 5 students achieved 65% and 58% gains, respectively. Moreover, there was much more variability in reading gains for the COVID-19 cohort, especially in the earlier grades. As shown in Fig.  3 , the standard deviation of reading scores of the COVID-19 cohort increased by 56%, 40%, and 29% for Grade 3, 4, and 5 students, respectively.

Percentages of Measure of Academic Progress (MAP) reading gains between beginning of year and end of year for the 2020–2021 school year cohort relative to the 2018–2019 school year cohort by student grade levels and demographic Characteristics. Note . SES socioeconomic status

Percentages of increase in Measure of Academic Progress (MAP) Reading variability for the 2020–2021 school year cohort relative to the 2018–2019 school year cohort by student grade levels and demographic characteristics. Note . SES socioeconomic status

We further examined relative reading gains and variability of the COVID-19 cohort within a grade level across subgroups. Among Grade 3 students, the COVID-19 cohort students from high SES backgrounds achieved 61% of pre-COVID-19 cohort reading gains, while students from low and medium SES backgrounds made 40% and 43% of the typical gains, respectively, during the pandemic. Moreover, low- and medium-SES students’ reading gains showed much greater variabilities (62% and 63% respectively) than high-SES students (38%). Likewise, Grade 4 students from high SES environments attained over 70% of typical reading gains whereas their peers from the low and medium SES groups made nearly 60% of typical gains. Reading gains variabilities for low- and medium-SES students (41% and 43% respectively) were slightly higher than that for high-SES students (34%). However, for Grade 5 students, conversely, low SES group ended the 2020–2021 school year with 63% of their prior-year reading gains compared to medium- and high-SES groups who made 52% and 58% of typical reading gains, respectively. The increase in variability for Grade 5 was smaller than that for Grade 3 and 4 students and consistent across SES groups (28–32%).

In terms of relative reading gains among English learners and English-fluent learners, Grade 3 and 4 English learners experience 41% and 60% of typical reading gains, respectively, lower than their English-fluent peers (49% and 66%, respectively). Notably, Grade 5 English learners showed 68% of typical gains with a small increase (16%) in variability, while English-fluent students made 54% of typical gains with a twice larger variability (32%) than their counterparts.

Finally, students with disabilities demonstrated much lower gains in reading than what would have been observed in normal conditions. Grade 3, 4, and 5 students with disabilities achieved only 18%, 28%, and 53%, respectively, of pre-COVID-19 reading gains, whereas students without disabilities made 50%, 68%, and 59% of typical gains for the respective grades. The increase in spread of reading scores was especially stark for Grade 3 and 4 students with disabilities (87% and 86%, respectively), compared to students without disabilities (53% and 34%, respectively).

Research question 2: association between instructional modality and reading growth rates by subgroups

Table 5 shows the results of the full piecewise growth curve models by grade level. Overall, across the Grade 3, 4, and 5 models, there was a statistically significant difference between in-person and remote instruction modality groups at the beginning of the 2020–2021 school (Grade 3: β 010  = 4.83, SE  = 0.59; Grade 4: β 010  = 3.47, SE  = 0.53; Grade 3: β 010  = 3.86, SE  = 0.50; ps  < .001), indicating that students who opted for remote instruction started the school year with higher MAP reading scores than their peers who chose in-person instruction. As depicted in Fig.  4 , during the fall semester, reading growth rates were not statistically significantly different between in-person and remote instruction groups across grade levels and subgroups ( ps  > .05), holding all else constant. However, variations in reading growth rates became apparent over the spring semester (between winter and spring 2021). Students who participated in remote instruction exhibited significantly lower growth rates than their peers who received in-person instruction during the spring semester (Grade 3: β 210  = − 0.51, SE  = 0.10; Grade 4: β 210  = − 0.55, SE  = 0.08; Grade 3: β 210  = − 0.56, SE  = 0.08; ps  < .001). To shed light on whether the association between instructional modality and reading growth rates varied by students’ demographic subgroups, we further examined the interactions between instructional modality and subgroup (i.e., SES, language status, disability status) in each grade level.

Piecewise growth curve trajectories of COVID-19 cohort students’ Measure of Academic Progress (MAP) reading by instructional modality (in-person or remote instruction) for A Grade 3, B Grade 4, and C Grade 5

The interaction between low SES and remote instruction was not statistically significant in predicting intercept (beginning of fall 2020) and growth rates over the fall and spring semesters ( ps  > .05). The interaction between English learner and remote instruction was not statistically significant in predicting intercept and growth rate in fall ( ps  > .05), but significantly predicted growth rate in spring (β 260  = − 0.30, SE  = 0.15, p  < .05). Likewise, the interaction between student with disabilities and remote instruction statistically significantly predicted growth rate in spring (β 270  = − 0.52, SE  = 0.23, p  < .05), but not intercept and growth rate in fall ( ps  > .05).

Figure  5 displays these significant differences in fitted growth trajectories in the spring semester. As shown in Fig.  5 A, both Grade 3 English-fluent students and English learners who participated in in-person instruction showed a steady increase in reading, while their peers who received fully remote instruction had a decrease in reading growth rate during the spring semester. By the end of the school year, English learners with in-person instruction narrowed the initial differences in reading with their English learners and English-fluent peers who received remote instruction. Additionally, among English-fluent students, the initial reading achievement difference between in-person and remote instruction groups narrowed at the end of the school year. In Fig.  5 B, a similar pattern of the closed gap between instructional modality groups was observed among students without disabilities. However, students with disabilities who received remote instruction exhibited a decline in reading over the spring semester, while students with disabilities with in-person instruction made very little reading growth in reading over time.

Piecewise growth curve trajectories of Grade 3 COVID-19 cohort students’ Measure of Academic Progress (MAP) reading by A language status and instructional modality and B disability status and instructional modality

The interaction between low SES and remote instruction was statistically significant in predicting intercept (β 050  = 3.67, SE  = 0.84, p  < .001) and growth rate in spring (β 250  = − 0.25, SE  = 0.11, p  < .05), but not in fall ( p  < .05). As shown in Fig.  6 A, there were substantial variations in reading levels at the outset and growth trajectories over the spring semester based on the interaction between low SES and remote instruction. Specifically, among students from low SES neighborhoods, those with remote instruction started the school year with a higher reading level than their peers with in-person instruction, yet their difference in reading became indistinguishable as the remote instruction group made slower progress, while the in-person group continued to grow over the spring semester. A similar pattern emerged between the in-person and remote instruction groups among students from medium/high SES backgrounds.

Piecewise growth curve trajectories of Grade 4 COVID-19 cohort students’ Measure of Academic Progress (MAP) reading by A socioeconomic status (SES) and instructional modality, B language status and instructional modality, and C disability status and instructional modality

The interaction between English learners and remote instruction was statistically significant in predicting reading growth rate in spring (β 260  = 0.39, SE  = 0.13, p  < .01), but not intercept and growth rate in fall ( ps  > .05). This significant difference in spring may be particularly attributable to English-fluent students, in which those with the in-person option made continuous growth, whereas those with the remote instruction option showed a slowdown (see Fig.  6 B). Notably, the initial and persistent reading difference that existed between English-fluent students with remote instruction and English learners with in-person instruction over the fall semester gradually diminished during the spring semester.

Similarly, the interaction between students with disabilities and remote instruction statistically significantly predicted growth rate only in spring (β 270  = − 0.31, SE  = 0.19, p  < .01). As displayed in Fig.  6 C, the pre-existing difference between the in-person and remote groups among students without disabilities disappeared by the end of spring as those who received in-person instruction continuously grew through the spring semester. However, both instructional modality groups among students with disabilities experienced negative growth in spring with their growth trajectories parallel to each other.

The interaction effect between low SES and remote instruction was marginally significant on intercept ( p  < .10) and statistically significant on growth rate only for the fall semester (β 150  = − 0.25, SE  = 0.09, p  < .01). Figure  7 A depicts that among Grade 5 students from low SES environments, those who opted for remote instruction started the fall semester with nearly 5 RIT higher than their peers who chose in-person instruction. However, the low-SES group students who participated in in-person instruction achieved a positive growth, while those who received fully remote instruction hardly showed any gains in reading. As a result, the gap identified in fall between the instruction modality groups vanished by the end of spring. A similar pattern was observed among students from medium/high SES backgrounds. Notably, in the group of students who decided to receive fully remote instruction, an initial difference between low and medium/high SES groups at the beginning of fall became slightly larger by the end of spring, whereas the SES-based difference within the in-person group remained persistent.

Piecewise growth curve trajectories of the Grade 5 COVID-19 cohort (2020–2021 school year) students’ Measure of Academic Progress (MAP) reading by A socioeconomic status (SES) and instructional modality and B language status and instructional modality

In addition, the interaction effect between language status and instructional modality was statistically significant on intercept (β 060  = 5.01, SE  = 0.99, p  < .001) but not growth rates ( ps  > .05). Notably, as shown in Fig.  7 B, among English learners, the initial difference between the in-person and remote instruction groups was nearly 6 RIT and this difference sustained throughout the fall semester. Yet, the difference narrowed by about half by the end of spring as the reading growth rate for English learners who participated in in-person instruction accelerated over the spring semester, while English learners who received remote instruction experienced a growth plateau during that time.

Drawing upon the school district administrative data, the present study explored Grade 3–5 students’ reading gains during the 2020–2021 school year and the association between instructional modality and reading growth rates, focusing on the variations across demographic characteristics. Previous analyses on the pandemic-related impact on student academic achievement and growth have focused on students’ racial and ethnic backgrounds (e.g., Kuhfeld et al., 2022 ) and poverty levels (e.g., Maldonado & De Witte, 2020 ; Pier et al., 2021 ) with limited attention being paid to English learners and students with disabilities. Two main findings emerged from the study. First, the COVID-19 cohort students’ reading achievement gains from the beginning to end of the 2020–2021 school year were lower than reading gains of the pre-COVID-19 cohort students in the 2018–2019 school year with substantially reduced gains for younger students, students from low SES backgrounds, English learners, and students with reading disabilities. Second, among students with similar demographic characteristics, higher-achieving students and their parents/guardians tended to choose the remote instruction option, while lower-achieving students appeared to opt for in-person instruction at the beginning of the 2020–2021 school year. However, those students who received in-person instruction most likely demonstrated positive growth continuously over the school year, whereas initially higher-achieving students who received remote instruction showed stagnation or decline in reading in the spring semester. We found substantial variation in reading levels and growth rates as a function of the interaction between instructional modality and students’ demographic subgroups.

COVID-19 reading gains and variability

With the current data from an urban school district in the United States, we provide evidence that Grade 3, 4, and 5 students ended the 2020–2021 school year with 0.54, 0.27, and 0.28 standard deviations behind the 2018–2019 school year reading, suggesting that students’ reading achievement levels declined during the pandemic school closures. The degree of reading loss experienced by students in the urban school district in North Carolina over the 9-month school year was larger than the 12-month-based estimates of learning loss obtained from the results from multiple states in the U.S. (cf. Kuhfeld et al., 2022 ). Furthermore, consistent with recent evidence on COVID-19 learning loss by grade level (e.g., Goldhaber et al., 2022 ; Kuhfeld et al., 2022 ; Tomasik et al., 2020 ), our cross-cohort comparisons of reading gains in the pandemic (2020–2021) and typical (2018–2019) school year suggest that younger students lost substantially more ground in reading relative to older students during school lockdowns. Grade 3 students achieved only 48% of the learning gains in reading over the 9-month pandemic school year compared to the pre-pandemic school year, indicating nearly five months behind where they would have been under normal circumstances (cf. Dorn et al., 2020 ). This estimated magnitude of pandemic-related reading loss for Grade 3 students was much lower than those for Grade 4 and 5 students (65% and 58%, respectively). Grade 3 students’ substantial reading loss is plausibly associated with the reduction in daily instructional time usually devoted to developing foundational literacy skills and promoting language and reading comprehension. From a developmental perspective, Grade 3 is a stage in which students develop more advanced phonemic awareness, phonics knowledge, and word decoding skills to be fluent readers with greater comprehension skills (Chall, 1983 ; Ehri, 2014 ; Kilpatrick, 2015 ). This requires sufficient instructional time in which children are actively and repeatedly involved in engaging, efficient, and systematic literacy practice. With the significant amount of disruption to instructional time during the extended school closures, Grade 3 students experienced a lack of opportunity to gain and build foundational reading skills that are essential to effective comprehension, critical thinking, and content knowledge development, which may potentially lead to negative long-term consequences in future years (Kaffenberger, 2020 ).

The large average reductions in reading gains during the pandemic have been compounded with substantially increased variation in scores. The circumstances of COVID-19 created a much greater spread in scores compared to the pre-pandemic, particularly with earlier grade (e.g., Grade 3) students and more vulnerable students (e.g., low-SES group, English learners, students with disabilities) who attained a much wider range of scores relative to later grade (i.e., Grade 4 or 5) students and less vulnerable students (e.g., high-SES group, English-fluent students, students without disabilities).

Our findings suggest that the negative impact of pandemic-related school closures on reading was especially profound for students from low SES environments, English learners, and students with disabilities. Young children with a high poverty status, English learner status, and disability status appear more vulnerable to the pandemic school disruptions. This finding converges with previous projections, in which the detrimental pandemic influence on student learning may have disproportionally affected the historically marginalized and vulnerable groups of students (Amplify Education, 2021 ). For students from low SES backgrounds, particularly in Grade 3 and 4, the estimated percentages of increase in reading between the beginning and end of the pandemic school year relative to the typical year were even lower than high-SES group students. For example, Grade 3 low-SES group students made only 40% of the pre-pandemic reading gains while medium- and high-SES students achieved more than 60%. This finding supports the notion that COVID-19 has magnified pre-existing SES-based achievement gaps and inequalities (e.g., Gore et al., 2021 ; Maldonado & De Witte, 2020 ) due to a lack of access to learning opportunities, appropriate digital devices, and reliable internet at home that students from high-poverty neighborhoods faced during school closures.

Similarly, English learners who were most likely from low-SES immigrant families and under-served communities demonstrated positive gains in 2020–2021, but their reading gains lagged relative to the pre-pandemic school year. We provide evidence that Grade 3 and 4 English learners’ relative reading gains in percentage (41% and 60% of the pre-pandemic reading gains, respectively) were smaller than their English-fluent peers’ relative reading gains (49% and 66%, respectively). This finding is consistent with pre-pandemic research evidence (e.g., Lawrence, 2012 ) that English learners experience greater summer setback in their English vocabulary development than English-fluent students during the summer months. This is partially because for many English learners, school is their primary context for exposure to, and development of, academic language that is central to academic success. However, the detrimental impact of COVID-19-related school disruptions on English learners could be even more pronounced because the absence of formal schooling and a lack of collaborative peer learning opportunities can influence English language and literacy development years later (Sugarman & Lazarín, 2020 ).

In addition, we found that students with disabilities were likely to struggle the most. Particularly, Grade 3 and 4 students with disabilities ended the 2020–2021 school year with only 18% and 28% of the pre-pandemic-year reading gains, leaving them nearly seven to eight months behind in reading. They may have experienced reduced access to differentiated instructional support and inadequate accommodation and accessibility during COVID-19 (Petretto et al., 2021 ). As many students with special needs rely on established routines and a vibrant network of services in their communities, dramatic decreases in services from school staff and community organizations and remote instruction have been a significant challenge to attention and motivation in reading (Sciberras et al., 2020 ).

Instructional modality and reading growth during COVID-19

Our second major finding based on the COVID-19 (2020–2021) school year cohort students indicates that when schools began to re-open in the fall of the school year, there existed educational disparities from the choice of instructional modality. We found that, conditional on students’ demographic characteristics, higher-achieving students were likely to start the school year with the online schooling option in contrast to lower-achieving students who tended to choose the in-person option. However, our results indicate that there was some variation in the magnitude of these disparities. The reading achievement gap between lower-achieving students (or students with the in-person option) and higher-achieving students (or students with the remote instruction option) was particularly bigger among English learners compared to other subgroups such as low SES and students with disabilities. This may be because young English learners with relatively low reading ability in English in the urban areas were likely coming from immigrant or refugee families who were mostly constrained in their educational options and tended to opt into in-person schooling mode.

There has been a concern that the pre-existing academic achievement gaps would be exacerbated in the absence of schooling during the pandemic (e.g., Bailey et al., 2021 ). However, we provide evidence that many lower-achieving students who had in-person schooling experience showed steeper reading growth trajectories than higher-achieving peers who did not, especially during the spring 2021 semester. This finding suggests that schools helped lower-achieving groups of students with similar demographic characteristics catch up to higher-achieving groups over the COVID-19 school year, supporting our conceptual framework (Fig.  1 ) grounded by the notion that schools generally play an equalizing role in academic disparities between student groups (e.g., Alexander et al., 2001 ; Downey et al., 2004 ; Quinn et al., 2016 ). It is noteworthy that the major difference between the in-person and fully remote instructional modality in this study was the duration of in-person school attendance. Students with the face-to-face schooling option physically attended schools for 10 days in the fall semester and 48 days in the spring semester, while peers with the fully remote instruction option exclusively participated in school instruction virtually. With the 10-day school attendance during the fall semester, the average reading scores for both instructional modality groups increased gradually in parallel, yet in-person school attendance for 48 days over the spring semester appeared to make a substantial difference, contributing to reading growth trajectories. The relative benefits of in-person instruction align with recent research evidence on the association of instructional modality with learning outcomes during the pandemic (e.g., Goldhaber et al., 2022 ; Halloran et al., 2021 ; Molnar, 2021 ; Tomasik et al., 2020 ).

Students who began the pandemic school year with relatively weaker reading ability benefitted from the opportunities to develop language and literacy skills by interacting with educators and peers in in-person environments, resulting in making greater gains in reading over time. Particularly, Grade 3–5 English learners in the in-person instructional modality group experienced continuously positive growth over the school year, but their English-fluent students in the remote instruction group remained stagnant or declined during the spring semester.

However, an inconsistent pattern of schools as equalizers emerged for students with disabilities who participated in in-person instruction. Despite their face-to-face attendance to general classroom instruction, their reading growth stagnated or fell especially over the spring semester, possibly due to limited special education services or IEP offered to students with special needs during the pandemic. This pattern of school attendance not contributing to learning trajectories for students with disabilities is consistent with recent research evidence on summer learning rates (e.g., Cooc & Quinn, 2022 ; Gershenson & Hayes, 2017 ). Furthermore, the widening academic inequality between students with and without disabilities observed regardless of instructional modality during the pandemic school year is aligned with evidence of the Matthew effect (Stanovich, 2009 ), in which students with initially higher levels of reading ability experience greater learning gains than their counterparts, leading to growing disparities over time.

Limitation and future research

The current study findings must be interpreted within several limitations of the study that can inform future research. First, an important caveat for interpreting the results of the current study is that descriptive comparisons of reading gains between the two cohorts do not make causal claims about the COVID-19 impact on reading gains. Thus, we acknowledge that any causal interpretations of our findings should be made with caution. Second, a lack of contextual information on in-person and remote instructional settings in the current study is an important study limitation to note. Although the current study used existent administrative data as a source of large quantitative information readily available from an urban U.S. school district, administrative records that contain vast amounts of qualitative information on students, families/homes, teachers, and schools obtained during COVID-19 may provide insights into mechanisms leading to pandemic-related reading losses. Particularly, to provide a more comprehensive picture of how and why in-person instruction was positively associated with students’ reading growth over the pandemic school year, future research should delve into features of instructional practices and students’ interactions with peers and teachers in face-to-face settings, distinctive from those via an online platform. For example, there is emerging causal evidence that in-person tutoring (Nickow et al., 2020 ) has substantially larger effects on students’ reading achievement than online or remote tutoring (Kraft et al., 2022 ). More causal intervention studies that compare in-person to face-to-face instruction along with detailed contextual information would permit a deeper understanding of how and why the in-person learning mode provides enhanced learning opportunities for students to make continuous growth in reading during the pandemic, particularly for lower-achieving students, and what online instructional approaches and resources need to be considered in remote schooling to meet the diverse learning needs of students.

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Relyea, J.E., Rich, P., Kim, J.S. et al. The COVID-19 impact on reading achievement growth of Grade 3–5 students in a U.S. urban school district: variation across student characteristics and instructional modalities. Read Writ 36 , 317–346 (2023). https://doi.org/10.1007/s11145-022-10387-y

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The pandemic has had devastating impacts on learning. What will it take to help students catch up?

Subscribe to the brown center on education policy newsletter, megan kuhfeld , megan kuhfeld director of growth modeling and data analytics - nwea jim soland , jim soland assistant professor, school of education and human development - university of virginia, affiliated research fellow - nwea karyn lewis , and karyn lewis vice president of research and policy partnerships - nwea emily morton emily morton research scientist - nwea.

March 3, 2022

As we reach the two-year mark of the initial wave of pandemic-induced school shutdowns, academic normalcy remains out of reach for many students, educators, and parents. In addition to surging COVID-19 cases at the end of 2021, schools have faced severe staff shortages , high rates of absenteeism and quarantines , and rolling school closures . Furthermore, students and educators continue to struggle with mental health challenges , higher rates of violence and misbehavior , and concerns about lost instructional time .

As we outline in our new research study released in January, the cumulative impact of the COVID-19 pandemic on students’ academic achievement has been large. We tracked changes in math and reading test scores across the first two years of the pandemic using data from 5.4 million U.S. students in grades 3-8. We focused on test scores from immediately before the pandemic (fall 2019), following the initial onset (fall 2020), and more than one year into pandemic disruptions (fall 2021).

Average fall 2021 math test scores in grades 3-8 were 0.20-0.27 standard deviations (SDs) lower relative to same-grade peers in fall 2019, while reading test scores were 0.09-0.18 SDs lower. This is a sizable drop. For context, the math drops are significantly larger than estimated impacts from other large-scale school disruptions, such as after Hurricane Katrina—math scores dropped 0.17 SDs in one year for New Orleans evacuees .

Even more concerning, test-score gaps between students in low-poverty and high-poverty elementary schools grew by approximately 20% in math (corresponding to 0.20 SDs) and 15% in reading (0.13 SDs), primarily during the 2020-21 school year. Further, achievement tended to drop more between fall 2020 and 2021 than between fall 2019 and 2020 (both overall and differentially by school poverty), indicating that disruptions to learning have continued to negatively impact students well past the initial hits following the spring 2020 school closures.

These numbers are alarming and potentially demoralizing, especially given the heroic efforts of students to learn and educators to teach in incredibly trying times. From our perspective, these test-score drops in no way indicate that these students represent a “ lost generation ” or that we should give up hope. Most of us have never lived through a pandemic, and there is so much we don’t know about students’ capacity for resiliency in these circumstances and what a timeline for recovery will look like. Nor are we suggesting that teachers are somehow at fault given the achievement drops that occurred between 2020 and 2021; rather, educators had difficult jobs before the pandemic, and now are contending with huge new challenges, many outside their control.

Clearly, however, there’s work to do. School districts and states are currently making important decisions about which interventions and strategies to implement to mitigate the learning declines during the last two years. Elementary and Secondary School Emergency Relief (ESSER) investments from the American Rescue Plan provided nearly $200 billion to public schools to spend on COVID-19-related needs. Of that sum, $22 billion is dedicated specifically to addressing learning loss using “evidence-based interventions” focused on the “ disproportionate impact of COVID-19 on underrepresented student subgroups. ” Reviews of district and state spending plans (see Future Ed , EduRecoveryHub , and RAND’s American School District Panel for more details) indicate that districts are spending their ESSER dollars designated for academic recovery on a wide variety of strategies, with summer learning, tutoring, after-school programs, and extended school-day and school-year initiatives rising to the top.

Comparing the negative impacts from learning disruptions to the positive impacts from interventions

To help contextualize the magnitude of the impacts of COVID-19, we situate test-score drops during the pandemic relative to the test-score gains associated with common interventions being employed by districts as part of pandemic recovery efforts. If we assume that such interventions will continue to be as successful in a COVID-19 school environment, can we expect that these strategies will be effective enough to help students catch up? To answer this question, we draw from recent reviews of research on high-dosage tutoring , summer learning programs , reductions in class size , and extending the school day (specifically for literacy instruction) . We report effect sizes for each intervention specific to a grade span and subject wherever possible (e.g., tutoring has been found to have larger effects in elementary math than in reading).

Figure 1 shows the standardized drops in math test scores between students testing in fall 2019 and fall 2021 (separately by elementary and middle school grades) relative to the average effect size of various educational interventions. The average effect size for math tutoring matches or exceeds the average COVID-19 score drop in math. Research on tutoring indicates that it often works best in younger grades, and when provided by a teacher rather than, say, a parent. Further, some of the tutoring programs that produce the biggest effects can be quite intensive (and likely expensive), including having full-time tutors supporting all students (not just those needing remediation) in one-on-one settings during the school day. Meanwhile, the average effect of reducing class size is negative but not significant, with high variability in the impact across different studies. Summer programs in math have been found to be effective (average effect size of .10 SDs), though these programs in isolation likely would not eliminate the COVID-19 test-score drops.

Figure 1: Math COVID-19 test-score drops compared to the effect sizes of various educational interventions

Source: COVID-19 score drops are pulled from Kuhfeld et al. (2022) Table 5; reduction-in-class-size results are from pg. 10 of Figles et al. (2018) Table 2; summer program results are pulled from Lynch et al (2021) Table 2; and tutoring estimates are pulled from Nictow et al (2020) Table 3B. Ninety-five percent confidence intervals are shown with vertical lines on each bar.

Notes: Kuhfeld et al. and Nictow et al. reported effect sizes separately by grade span; Figles et al. and Lynch et al. report an overall effect size across elementary and middle grades. We were unable to find a rigorous study that reported effect sizes for extending the school day/year on math performance. Nictow et al. and Kraft & Falken (2021) also note large variations in tutoring effects depending on the type of tutor, with larger effects for teacher and paraprofessional tutoring programs than for nonprofessional and parent tutoring. Class-size reductions included in the Figles meta-analysis ranged from a minimum of one to minimum of eight students per class.

Figure 2 displays a similar comparison using effect sizes from reading interventions. The average effect of tutoring programs on reading achievement is larger than the effects found for the other interventions, though summer reading programs and class size reduction both produced average effect sizes in the ballpark of the COVID-19 reading score drops.

How Hybrid Learning Is (and Is Not) Working During COVID-19: 6 Case Studies

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Most U.S. school districts are currently using “hybrid learning”—a mix of in-person and online instruction. The precise nature of that mix, though, varies greatly from school to school, based on factors including the local rate of COVID-19 transmission, the availability of funds to support new instructional approaches, and the willingness of students and staff to return to buildings.

Many students chose to learn entirely in-person or entirely online this school year. Others are spending a couple days a week in person and the rest at home. Some schools have set aside the bulk of slots for in-person instruction for vulnerable groups like students with special needs, English-language learners, and students experiencing homelessness.

These approaches aren’t static. Increases in COVID-19 spread have forced some schools in hybrid mode to revert back to full-time remote learning, while others started out fully remote and are now slowly transitioning more students to some in-person instruction.

Close to two-thirds of district leaders said their school systems are doing hybrid learning, according to an Education Week Research Center survey last month .

As with almost everything schools are doing during the pandemic, hybrid learning has inspired a wide range of reactions. Many parents and students are grateful schools are finding creative ways to bring their children back to school buildings while taking precautions against COVID-19. Others have protested schools’ reluctance to fully resume in-person instruction or expressed confusion over complex school plans that seem to be constantly changing. Some teachers find the new demands of hybrid instruction overwhelming, while others are more eager to adapt.

“Hybrid learning can be a best of both worlds, or a worst of both worlds reality,” said Bree Dusseault, practitioner-in-residence at the University of Washington’s Center for Reinventing Public Education, which has been surveying schools throughout the pandemic.

In the best-case scenario, schools can keep students and staff safe while providing them with valuable in-person instruction that gives them the tools to do meaningful schoolwork at home. At worst, teachers are forced to cut corners on instruction, schools struggle to transition students seamlessly from in-person to remote and vice versa, and students who are learning at home get left behind compared with students who choose to spend at least some time in person.

That last possibility threatens to further widen equity gaps along racial lines. In an EdWeek survey this fall , Latino, Black, and Asian parents were more likely than white parents to report their children would engage in full-time remote learning.

Pulling off an instructional approach that’s completely new to most U.S. schools during a pandemic is no easy feat, either. The challenges partially come from a lack of adequate resources: Congress has yet to follow through on plans for a second multi-billion-dollar stimulus package for education, and school budgets are increasingly stretched thin as the pandemic takes a toll on state and local finances.

At Scofield Magnet Middle School in Stamford, Conn., students have chosen either full-time remote learning or a hybrid model with in-person classes a few days a week and remote instruction for the rest. Teachers are not live-streaming classwork to any students who are learning at home. Placing cameras in classrooms was difficult, and connectivity issues were common for the school’s students, half of whom are eligible for free and reduced-price meals.

“If you have two or three kids in a home and you have them all logged in live-streaming all day, that’s going to eat up your data pretty quick,” said Scott Clayton, the school’s principal.

The trickiest part, according to Clayton, has been getting students to complete assignments at home, where they might have other responsibilities like child care or a part-time job.

Many schools also have struggled to balance investments in personal protective equipment and other safety precautions for in-person instruction with the technology and professional development necessary to reach students who will be learning at home part- or full-time, Dusseault said.

She recommends schools actively survey parents and students, and try to structure classes to make the most of students’ time either in person or at home, in whatever hybrid configuration they choose.

“They have to be putting resources into everything that it takes to result in a quality classroom experience: the materials, the training, the curriculum,” she said. (For more on how to do this work, visit Education Week’s guides to balancing in-person and remote instruction and pivoting back to full-time remote learning if necessary .)

The ongoing chaos of the pandemic sometimes obscures the lessons schools are learning and the strategies they’re employing to overcome steep challenges. Education Week talked to educators from school districts across the country about how they developed their hybrid learning models, how they’re working so far, and what they have planned for the months ahead. Here is a look at hybrid models in six school districts and the challenges of making those approaches work.

VICTORIA INDEPENDENT SCHOOL DISTRICT, Texas

Enrollment: 14,000

The Model: Students chose at the beginning of the year from two options: Attend school in person five days a week, or attend school virtually five days a week. Teachers’ classes are a mix of in-person and virtual students.

The Challenges: Jennifer Atkins, a 7th grade English teacher at Howell Middle School, typically enjoys walking around her classroom to engage students. Social distancing and masks make that teaching style virtually impossible.

She’s also had to deal with the ongoing evolution of the composition of her classes. When school started, roughly half her students were online. But as parents have grown more comfortable with sending students back to school, that proportion has shifted—roughly 90 of her students attend in person, and 50 are at home.

“I have the same kids, the same roster, but now I’ve got a new group that’s coming face to face that I haven’t met in person,” Atkins said. “They have been away from some of their friends for so long. It’s interesting to see how the class dynamic changes.”

Atkins posts textbook PDFs online because some students don’t have the book at home, even though the school set up times for parents to pick up the books. Grading takes longer because she has to look at some hard copies and then log in online for the rest.

Howell students aren’t required to keep their cameras on during videoconference instruction, so Atkins worries that some students may have logged in at the beginning but aren’t actually paying attention. “Without being here and constantly reminded to stay on task, it is probably enticing to log into the meeting and then just walk away,” she said.

The Benefits: Atkins has been able to use technology tools to keep better track of which students are struggling. If they don’t open an assignment, for instance, “something’s got to be wrong,” and she has a tangible record of the student’s progress, she said.

Hybrid learning has also forced her to consider more innovative use of technology in her teaching. A handful of teachers were offered interactive whiteboards that students can access from their desks, and Atkins accepted. Prior to COVID-19, she might have resisted a big change like this because she saw it as unnecessary, but the rising use of technology as a teaching tool has made her think differently.

A Small Victory: To help students at home hear her voice better through the mask, Atkins logs into the virtual meeting on her laptop and her smartphone, and talks into the microphone on her phone, addressing the remote and in-person students simultaneously, while using a clicker to scroll through PowerPoint slides on the computer.

The Takeaway: “It is nothing short of exhausting,” Atkins said. “It’s basically like teaching two different classes at the same time in one class period.”

SANTA FE PUBLIC SCHOOLS, New Mexico

Enrollment: 13,000

The Model: The district is gradually bringing students into school buildings based on the number of teachers who are willing to return and the amount of space in classrooms to allow for adequate social distancing. Special education students and English-language learners are prioritized for in-person instruction, and students who eventually want to go back to face-to-face instruction are placed with the teachers who are teaching from the school building.

The Challenges: Managing in-person and virtual instruction simultaneously requires more digital devices than many teachers have in their classrooms, said Tom Ryan, chief information and strategy officer for the district. Ideally, they need one for the lesson, one for seeing the students’ faces, and one to monitor what students are doing on their school-issued devices. Cameras that pivot when a teacher moves are also ideal to prevent teachers from constantly exiting the frame when they move around.

Meanwhile, the digital divide remains a significant barrier for equitable remote instruction. Some students attend day-care facilities with inadequate internet connections for videoconferencing. Other students have school-provided hotspots that may not be sufficient for the amount of strain remote learning puts on the connection. Efforts to determine the minimum bandwidth necessary for what’s required of students learning at home are still underway, Ryan said.

The Benefits: Teachers who wanted to return to classrooms are eager to serve as test cases for how in-person instruction can work during these unprecedented times, said Ryan. Giving teachers the option to stay home engenders more goodwill and prevents people with underlying health conditions from having to choose between their job and their safety.

So far, Ryan’s team has found teachers need a microphone to amplify their voices through their masks, and that simply replicating face-to-face instruction while livestreaming to students may not be as effective as offering online students differently structured activities from their in-person counterparts. Younger students and English-language learners are particularly likely to struggle when they can’t see a teacher’s mouth movements, Ryan said.

A Small Victory: Ryan’s daughter, a 5th grade teacher in the district, said she’s had more robust contact with parents than ever before. One student learning remotely in her class was constantly disrupting the class, pulling out inappropriate household objects, and sleeping on camera. After communicating with his parents, Ryan’s daughter decided to work with him individually after school hours, when his parents could be there by his side.

“I’m not saying I recommend this for all the teachers,” Ryan said. But “there are options that are available now that weren’t available last year.”

The Takeaway: “This isn’t a comparison between online versus face to face. This is between having nothing at all or something that is still engaging the kids and instruction can happen,” Ryan said. “Some are very successful and other kids are struggling.”

MARSHALL PUBLIC SCHOOLS, Mich.

Enrollment: 1,000

The Model: Elementary school students attend school in person four days a week, and middle and high school students attend school in person three days a week. In both cases, students are split into five groups, with each one having their remote learning on a different day of the week. The district tried to ensure that students who live in the same household have the same remote learning day. A handful of English-language learners, students with special needs, and newcomers to the district attend school in person every day. And some students opted to learn at home full-time for the school year.

The Challenges: “I would say our teachers are very overwhelmed,” said Beth Ritter, the district’s director of teaching and learning. “I’m not going to sugarcoat it.”

Each day, teachers have some students who are missing, which means it’s hard to keep all students on the same page. The students who are at home full time could easily get lost in the shuffle if teachers don’t put in extra work to engage them. And the quality of instruction this year needs to be higher than in the spring, when emergency remote teaching set everyone back.

“We have that experience to fall back on, but yet teachers are doing so much more this year,” Ritter said.

The Benefits: Hybrid learning has led to some positive changes. Meetings with multilingual families have gone a lot smoother for interpreters than usual. Rather than having to rush from room to room in the school building on a busy night of in-person conferences, all they have to do is open a new Microsoft Teams meeting to enter a video conversation. Families also appreciate that they don’t have to scramble for day-care options when they need to meet with their students’ teachers.

The hybrid model also forces teachers to be more intentional about how they structure their lessons. Elementary teachers now focus on reading, math, and social-emotional learning when students are in person, while home assignments build on what students learned in class.

A Small Victory: The district has appointed “assurance of mastery coaches” in elementary schools to check in with students during their remote learning day. Students get to have some interaction with the school even when they’re not in the building, and teachers get a small reprieve from yet another responsibility.

The Takeaway: With big changes like a heightened emphasis on social-emotional learning, school administrators need to communicate clearly and regularly with teachers and staff who will be implementing these changes. “We’ve always known it, but we’ve really found that this year,” Ritter said.

MILTON AREA SCHOOL DISTRICT, Pa.

Enrollment: 2,000

The Model: Students who chose a mix of in-person and remote instruction attend school buildings on Monday, Tuesday, Thursday, and Friday. Other students are doing 100 percent synchronous online instruction, or largely asynchronous instruction through the Milton Cyber Academy, which existed prior to the pandemic.

The Challenge: Students learning remotely—particularly the older ones—have been reluctant to turn on their cameras and keep their microphones unmuted. “K-5 is absolutely great—they are happy to see their classmates,” said Cathy Keegan, the district’s superintendent.

But some groups of older students have been very quiet, forcing teachers to get more creative with ensuring that they’re engaged. As of this month, the district is now specifying to students doing synchronous learning that they’re expected to be ready to speak and be seen when a teacher calls on them.

Some parents have fallen behind on notifying the school when their student won’t be attending at-home instruction that day. “We’re reinforcing that,” Keegan said.

The Benefits: Discipline rates in the district have been sharply down this year compared with previous years, Keegan said. “We genuinely believe—this is just a feeling—that kids are just happy to be back,” she said. Keeping them at home might have exacerbated the social isolation that has prompted many experts to urge schools to find safe ways to reopen.

A Small Victory: The president of the district’s teachers union told Keegan she and other teachers were tired of spending valuable time at the start of each class period asking students to type their name in the chat as a means of taking attendance. Keegan’s team helped advise her on integrating a discussion question into the Microsoft Teams platform that teachers can use to jump-start that day’s lesson and take attendance simultaneously.

The Takeaway: Efforts to transform an American education model that hasn’t been comprehensively updated in generations are happening at a breakneck pace, Keegan said. It’s painful and necessary work: “We may still be back here in 2022.”

NORTHERN LEHIGH SCHOOL DISTRICT, Pa.

Enrollment: 1,550

The Model: Students can attend in-person instruction up to two days a week: Monday and Tuesday for students with last names starting with the letters A through L, and Thursday and Friday for students with last names starting with M through Z. When students aren’t in school buildings, they’re learning at home, and Wednesdays are reserved for one-on-one check-ins for all students. Nearly three-quarters of students have chosen that option.

Slightly less than a fifth of students have chosen to learn from home all week. Some teachers have been assigned to work exclusively with fully online students.

Another less popular option (3 percent of the district’s students) is an existing online program offered by the school but managed by a third-party vendor; the district has revamped that asynchronous online program to include more direct involvement from a district teacher for students in grades K-8.

The Challenge: Teachers have had to adjust to a curriculum that must be more streamlined than usual. District leaders have urged teachers to consider which aspects of the learning material are essential and which could be optional. “We don’t want the curriculum to become a barrier to achieving success,” said Matthew Link, the district’s superintendent.

Early in the school year, many virtual students weren’t showing up or turning in work on time. The district’s professional development efforts have helped teachers get more creative in engaging students who are at home. Still, for certain students, “we need to double down on our efforts to make sure they’re active participants in the process,” Link said.

A Small Victory: District administrators are recognizing more than ever the value of teachers collaborating with each other, said Tania Stoker, the district’s assistant superintendent. One teacher might be using a tool another teacher doesn’t know about it; that kind of sharing is much more common now than it used to be.

The Takeaway: “Know that it’s OK that when you’re developing your plan and you think it’s done, it’s probably not. You’re going to go through different iterations constantly,” Link said. “Don’t feel bad if you have to change something that you thought was the answer.”

WALL TOWNSHIP SCHOOLS, N.J.

Enrollment: 3,400

The Model: Elementary students are either fully remote or fully in-person.

In grades 6-8, students attend school in person every other day (except Wednesday). Teachers have the same students in their class each day—the only thing that changes is which ones are in person and which ones are online. On Wednesdays, all students learn online.

In-person instruction is reserved for lessons on math, English, and social studies. Next semester, they’ll switch to science instruction. “We had been hopeful and optimistic that we would be in fully live instruction when we really need that practical application in lab,” but that may not be the case, said Lisa Gleason, the district’s director of curriculum and instruction.

The Challenge: Simply having a Chromebook doesn’t mean all the problems are solved. The district has found those devices can’t support all the resources and instructional technology programs that teachers use. “We had to pivot and start acquiring more PCs,” Gleason said. The district also was hit recently with a cyberattack that prompted some teachers to work from home until the problem was resolved.

Substitute teachers who think they’re capable of teaching online or comfortable with the health risks of teaching in person have been difficult to find, even as the number of teachers who need to take time off for legitimate reasons is higher than usual.

A Small Victory: Some teachers who are particularly worried about COVID-19 exposure can teach remotely from a separate area of the school building that students don’t visit. Some students in those teachers’ classes are attending school in person, but they are supervised by another teacher who is in a physical classroom with them, while others are at home, in the same Google Meet link as the remote teacher.

“We had really analyzed what our needs were back in late August,” Gleason said. “We were able to craft teachers’ schedules around that.”

The Takeaway: “When you put all your eggs in the basket of technology being the main vehicle for delivering instruction, even in the hybrid model, it takes away that stability of having a human being in the classroom who can deliver instruction no matter what,” Gleason said.

Alyson Klein, Assistant Editor contributed to this article. A version of this article appeared in the November 25, 2020 edition of Education Week as How Hybrid Learning Is (and Is Not) Working During COVID-19: 6 Case Studies

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The Challenges of Remote K–12 Education During the COVID-19 Pandemic: Differences by Grade Level

• Nancy L Leech University of Colorado Denver
• Sophie Gullett University of Colorado Denver
• Miriam Howland Cummings University of Colorado Denver
• Carolyn A Haug Colorado Department of Education

The transition to remote teaching in K–12 schools during the spring of 2020 as a result of the coronavirus pandemic (COVID-19) presented new challenges to teachers across the United States. This survey-based mixed methods study investigates these challenges, as well as differences by grade level, to better understand teachers’ experiences remote teaching. A total of 604 teachers who had completed the survey were included in this study. Findings indicate that some challenges were experienced by teachers across grade levels, with common challenges including student engagement, adjusting curriculum to the remote format, and the loss of the personal connection of teaching. Differences were also found by grade level, with elementary teachers struggling more with varying attitudes of parents regarding remote learning and adjusting their curriculum to an online format, and secondary teachers more often reporting student engagement and a general feeling of being lost or unsupported in their teaching as challenges. These challenges provide important context around the experience of remote teaching, as well as what supports teachers need to continue remote teaching.

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Science Lessons That Tap Into Student Curiosity About COVID-19

Teaching about coronavirus can make learning more relevant while helping students cope with feelings of uncertainty and instability.

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Some students aren’t just wearing masks to class; they’re experimenting on them.

Inspired by the daily use of masks during the pandemic, fifth-grade students at New Albany Intermediate School in Ohio set out to measure the effectiveness of different mask types and brands by their ability to prevent droplet transmission. Using black lights, food coloring, and a range of mask brands, students learned how aerosol particles travel, how masks work to mitigate transmission, and how different types of masks offer varying levels of protection, says teacher Pete Barnes.

Barnes’s students aren’t the only ones using the pandemic as a teachable moment—educators all around the country have been developing lesson plans to help students make sense of the unprecedented time in history and take appropriate precautions to protect themselves, even as students increasingly return to in-person schooling.

“Kids think and talk about the pandemic all of the time, so it’s important they get accurate information based in science,” says Barnes. “When they research [the pandemic] on their own and perform experiments, they have deeper levels of understanding and ownership over topics that otherwise just seem scary and unpleasant.”

Though educators may be worried about inundating students with doom and gloom, weaving real-world context into lessons, especially during challenging times, can make students feel that their learning has more purpose and relevance . Additionally, having children explore their fears and unanswered questions can help them cope with feelings of uncertainty and instability, common during the pandemic, say psychologists. Just be careful not to dismiss or minimize their concerns outright, and give students the opportunity to opt out or choose other activities if learning about the pandemic is too much to bear.

“It’s not helpful to remove all mention of current events from the classroom, and... it’s also not helpful to spend all day, every day, engaging in heavy conversations,” writes Alex Shevrin Venet , a trauma-informed expert. “The key here is balance.”

The Science of Protecting Yourself

Mask testing: Before they launched into their experiments, Barnes says, students had their own opinions—and preferences—on masks but were curious about testing out what they’d heard from adults outside of class.

In one experiment, students put green food coloring in their mouths, exercised for two minutes while wearing masks, and then used a black light to spot how much food coloring transferred to the outside of their masks. This helped students understand how germs penetrate their masks and determine which cloth mask would be best for exercising.

Another group of students tested three different mask types (N95, surgical, and cloth masks) by spraying colored water on the inside of the mask. They found that the N95 mask was most effective at stopping the water from going to the outside; surgical masks ranked second, and cloth masks were third. In doing so, students “fulfilled standards related to scientific inquiry, data collection, forming hypotheses, and drawing conclusions,” says Barnes.

Wash your hands: Stephanie Kearney’s students happened to be knee-deep in a science unit on microbes when the pandemic hit last year. To investigate infectious diseases, they attempted to diagnose a fictitious patient based on symptoms, says Kearney, who teaches seventh-grade students at Penn Alexander School in Philadelphia, Pennsylvania. Her students added COVID-19 as a potential cause of illness but ultimately determined that their patient had the common cold.

The project ended with students collecting data from scientific journals about the effect of hand hygiene on infectious disease risk, which they then used to determine the best method of handwashing. They shared what they learned in public service announcements (PSAs), which were posted around the school buildings. While the activity was originally planned for in-person instruction, students were still able to collaborate with their peers from a distance using digital tools like Jamboard, says Kearney.

Social distancing: As states reopen schools for in-person learning, teachers and students are gearing up for ways to safely return to the classroom. Second-grade teacher Melissa Collins of John P. Freeman Optional School in Memphis, Tennessee, says her students are working on a project called “Flatten the Curve.” After hearing a doctor present information on social distancing, students were tasked with thinking about ways to socialize with their friends safely, like using FaceTime or having air hugs. To show what they learned, they could make a skit, write a poem, or create a prototype.

Nanobots and Gizmos

Attacking the virus: At Coppell Middle School East in Texas, science teacher Jodie Deinhammer developed an engineering activity called “COVID Nanobots,” where her seventh-grade students designed a nanobot, or a microscopic robot, that mimicked a human cell but was able to attack and kill the coronavirus. Students familiarized themselves with COVID facts, considered which cell organelles their virus-buster would use to imitate real cell behavior, and sketched out a rough prototype of the nanobot on their iPads. In developing their nanobot concept, students answered questions such as “How does the nanobot get energy?” and “Is the nanobot cell more similar to a plant, an animal, or a bacteria cell?”

How viruses spread: Jennifer Sweaks, a biology teacher at Allen High School in Texas, developed a multitiered lesson plan that reflected the progression of the pandemic. In the early weeks of the module, Sweaks’s students learned about epidemiology by doing research on the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) websites.

In addition, they completed an interactive simulation called Gizmo (this lesson was free, with an account), focused on disease spread, and explored the transmission and treatment of HIV using research studies by the National Institute of Allergy and Infectious Diseases. To incorporate multimedia, Sweaks created lesson plans on TEDEd that showcased how viruses jump from animals to humans and how funding for virus monitoring programs—and the lack thereof—have impacted global efforts on curbing emerging diseases.

Putting it into perspective: In a module designed by Heather Milo, instructional specialist with the Institute for School Partnership at Washington University in St. Louis, and middle school science teacher Mary Bueckendorf of Hawthorn Leadership School for Girls in St. Louis, Missouri, students shared their own experiences with the COVID-19 pandemic and the questions they had about the virus. Students then embarked on a quest to find out about pandemics of the past, how the coronavirus spreads, and how the spread can be contained. They also critically evaluated media and public health information about the virus and used social media to amplify preventive measures to reduce transmission.

The lesson has since been shared with local teachers in the entire St. Louis region, and one district even added a virtual field trip to the module where students watched a COVID test being performed in real life while having the opportunity to pose questions to the chief operating officer of the St. Louis County Department of Health.

The Antidote to Misinformation

Combating misinformation: Stephanie Toro, a former teacher and now an assistant professor at the Universidad de los Andes in Bogotá, Colombia, has been teaching her students how to read and interpret data with a focus on the misinterpretation of science around COVID-19. Her students analyzed both popular articles and more scientific articles from magazines like Scientific American , using a guide that helped them determine how scientific the articles were.

Toro asked students to examine the data presented in the articles separately, arrive at a conclusion themselves, and then compare with the narrative in the article. Having designed this lesson years ago, Toro has modified the selection of articles to make it appropriate for middle school and high school, and to fit whatever topic is timely—in this case, COVID-19.

Effective vs. ineffective treatment: In later modules of Sweaks’s multilesson plan, students explored the research on hydroxychloroquine, a medicine used to treat malaria and autoimmune disorders, which was briefly touted as a possible drug to prevent and treat COVID-19. Students read the results of controlled studies on the medicine in a TEDEd that Sweaks created that included a video about a couple who drank fish tank cleaner, believing it could prevent the coronavirus. To round out the module, Sweaks included a lesson on ecology that emphasized how protecting wildlife habitats could help prevent the next pandemic.

Vaccines and the future: Biology teacher Oshen Wallin teamed up with her coworker Leslie Schoof at Madison High School in Marshall, North Carolina, to help students conduct research about COVID-19 based on the questions they had about the virus, including what the vaccine trials entail and how the different COVID-19 vaccines work. Through the project, they learned how to conduct proper research and identify and analyze reputable, unbiased sources.

Working with school nurses and the county library system, students at Madison High then summarized what they learned and developed a website to display their information. The students even went on to present their research to the school superintendent, and they have plans to present to the school’s administration.

“The goal is to distribute their research to the community and beyond in hopes to inform others about COVID-19 with reputable information and possibly help save lives,” adds Wallin.

Global Education Coalition

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Education: From COVID-19 school closures to recovery

After the historic disruption of the COVID-19 pandemic, most schools are back open worldwide but education is still in recovery assessing the damage done and lessons learned. Education: The pandemic affected more than 1.6 billion students and youth globally, with the most vulnerable learners being hit hardest. Some gains already made towards the goals of the 2030 Education Agenda were lost. 

From the outset UNESCO's Education Sector worked with ministries of education, public and private partners and civil society to ensure continued learning for all children and youth. The Sector's work is now focused on prioritizing education as a public good for everyone in order to avoid a generational catastrophe and drive sustainable recovery. 

• Read more on UNESCO's initiatives during and after the pandemic

A multi-sector Coalition to protect the right to education during unprecedented disruption from response to recovery #LearningNeverStops

Monitoring of school closures

Throughout the pandemic, in close cooperation with ministers of education, UNESCO monitored the evolution of school closures around the world. Data presented in the interactive map show the evolution from February 2020 to June 2022. Download the data here .

UNESCO's campaigns

Everyone can play a role in supporting girls’ education

Two years into the COVID-19 crisis: Students and teachers share their stories

Evidence of good practices, practical tips and references to mitigate the impact of school closures

Explore UNESCO database for useful resources.

Video messages from the first group of partners who joined UNESCO’s Global Education Coalition.

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Coronavirus disease (COVID-19): Schools

So far, data suggests that children under the age of 18 years represent about 8.5% of reported cases, with relatively few deaths compared to other age groups and usually mild disease. However, cases of critical illness have been reported. As with adults, pre-existing medical conditions have been suggested as a risk factor for severe disease and intensive care admission in children.

Further studies are underway to assess the risk of infection in children and to better understand transmission in this age group.

The role of children in transmission is not yet fully understood. To date, few outbreaks involving children or schools have been reported. However, the small number of outbreaks reported among teaching or associated staff to date suggests that spread of COVID-19 within educational settings may be limited.

As children generally have milder illness and fewer symptoms, cases may sometimes go unnoticed. Importantly, early data from studies suggest that infection rates among teenagers may be higher than in younger children.

Considering that many countries are starting to slowly lift restrictions on activities, the longer-term effects of keeping schools open on community transmission are yet to be evaluated. Some modelling studies suggest that school re-opening might have a small effect on wider transmission in the community, but this is not well understood. Further studies are underway on the role of children in transmission in and outside of educational settings. WHO is collaborating with scientists around the world to develop protocols that countries can use to study COVID-19 transmission in educational institutions. Click here to access this information .

Whether a child should go to school depends on their health condition, the current transmission of COVID-19 within their community, and the protective measures the school and community have in place to reduce the risk of COVID-19 transmission. While current evidence suggests that the risk of severe disease for children is lower overall than for adults, special precautions can be taken to minimize the risk of infection among children, and the benefits of returning to school should also be considered.

Current evidence suggests that people with underlying conditions such as chronic respiratory illness including asthma (moderate-to-severe), obesity, diabetes or cancer, are at higher risk of developing severe disease and death than people without other health conditions. This also appears to be the case for children, but more information is still needed.

Adults 60 years and older and people with underlying health conditions are at higher risk for severe disease and death. The decision to return to a teaching environment depends on the individual and should include consideration of local disease trends, as well as the measures being put in place in schools to prevent further spread.

The incubation period for children is the same as in adults. The time between exposure to COVID-19 and when symptoms start is commonly around 5 to 6 days, and ranges from 1 to 14 days.

Deciding to close, partially close or reopen schools should be guided by a risk-based approach, to maximize the educational, well-being and health benefit for students, teachers, staff, and the wider community, and help prevent a new outbreak of COVID-19 in the community.

Several elements should be assessed in deciding to re-open schools or keep them open:

• The epidemiology of COVID-19 at the local level: This may vary from one place to another within a country
• Transmission intensity in the area where the school operates: No cases, sporadic transmission; clusters transmission or community transmission
• Overall impact of school closures on education, general health and wellbeing; and on vulnerable and marginalized populations (e.g. girls, displaced or disabled)
• Effectiveness of remote learning strategies
• Detection and response: Are the local health authorities able to act quickly?
• The capacity of schools/educational institutions to operate safely
• Collaboration and coordination: Is the school collaborating with local public health authorities?
• The range of other public health measures being implemented outside school

School closures have clear negative impacts on child health, education and development, family income and the overall economy.

The decision to reopen schools should include consideration of the following benefits:

• Allowing students to complete their studies and continue to the next level
• Essential services, access to nutrition, child welfare, such as preventing violence against children
• Social and psychological well-being
• Access to reliable information on how to keep themselves and others safe
• Reducing the risk of non-return to school
• Benefit to society, such as allowing parents to work

There are several actions and requirements that should be reviewed and put in place to prevent the introduction and spread of COVID-19 in schools and into the community; and to ensure the safety of children and school staff while at school. Special provisions should be considered for early childhood development, higher learning institutions, residential schools or specialized institutions.

WHO recommends the following:

Community-level measures: Carry out early detection, testing, contact tracing and quarantine of contacts; investigate clusters; ensure physical distancing, hand and hygiene practices and age-appropriate mask use; shield vulnerable groups. Community-led initiatives such as addressing misleading rumors also play an important role in reducing the risk of infection.

Policy, practice and infrastructure : Ensure the necessary resources, policies and infrastructure, are in place that protect the health and safety of all school personnel, including people at higher risk.

Behavioral aspects : Consider the age and capacity of students to understand and respect measures put in place. Younger children may find it more difficult to adhere to physical distancing or the appropriate use of masks.

Safety and security : School closure or re-opening may affect the safety and security of students and the most vulnerable children may require special attention, such as during pick-up and drop-off.

Hygiene and daily practices at the school and classroom level : Physical distancing of at least 1 metre between individuals including spacing of desks, frequent hand and respiratory hygiene, age-appropriate mask use, ventilation and environmental cleaning measures should be in place to limit exposure. Schools should educate staff and students on COVID-19 prevention measures, develop a schedule for daily cleaning and disinfection of the school environment, facilities and frequently touches surfaces, and ensure availability of hand hygiene facilities and national/local guidance on the use of masks.

Screening and care of sick students, teachers and other school staff : Schools should enforce the policy of “staying home if unwell”, waive the requirement for a doctor’s note, create a checklist for parents/students/staff to decide whether to go to school (taking into consideration the local situation), ensure students who have been in contact with a COVID-19 case stay home for 14 days, and consider options for screening on arrival.

Protection of individuals at high-risk: Schools should identify students and teachers at high-risk with pre-existing medical conditions to come up with strategies to keep them safe; maintain physical distancing and se of medical masks as well as frequent hand hygiene and respiratory etiquette.

Communication with parents and students : Schools should keep students and parents informed about the measures being implemented to ensure their collaboration and support.

Additional school-related measures such as immunization checks and catch-up vaccination programmes : Ensure continuity or expansion of essential services, including school feeding and mental health and psycho-social support.

Physical distancing outside classrooms : Maintain a distance of at least 1 metre for both students (all age groups) and staff, where feasible.

Physical distancing inside classrooms:

In areas with community transmission of COVID-19, maintain a distance of at least 1 metre between all individuals of all age groups, for any schools remaining open. This includes increasing desk spacing and staging recesses, breaks and lunchbreaks; limiting the mixing of classes and of age groups; considering smaller classes or alternating attendance schedules, and ensuring good ventilation in classrooms.

In areas with cluster-transmission of COVID-19, a risk-based approach should be taken when deciding whether to keep a distance of at least 1 metre between students. Staff should always keep at least 1 metre apart from each other and from students and should wear a mask in situations where 1-metre distance is not practical.

In areas with sporadic cases/no cases of COVID-19, children under the age of 12 should not be required to keep physical distance at all times. Where feasible, children aged 12 and over should keep at least 1 metre apart from each other.  Staff should always keep at least 1 metre from each other and from students and should wear a mask in situations where 1-metre distance is not practical. Remote learning : Where children cannot attend classes in person, support should be given to ensure students have continued access to educational materials and technologies (internet, texting radio, radio, or television), (e.g. delivering assignments or broadcasting lessons). Shutting down educational facilities   should only be considered when no alternatives are available.

• Monitor your child’s health and keep them home from school if they are ill.
• Teach and model good hygiene practices for your children:
• Wash your hands with soap and safe water frequently. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. Always wash hands with soap and water, if hands are visibly dirty.
• Ensure that safe drinking water is available and toilets or latrines are clean and available at home.
• Ensure waste is safely collected, stored and disposed of.
• Cough and sneeze into a tissue or your elbow and avoid touching your face, eyes, mouth and nose.
• Encourage your children to ask questions and express their feelings with you and their teachers. Remember that your child may have different reactions to stress; be patient and understanding.
• Prevent stigma by using facts and reminding students to be considerate of one another.
• Coordinate with the school to receive information and ask how you can support school safety efforts (though parent-teacher committees, etc),.
• In a situation like this it is normal to feel sad, worried, confused, scared or angry. Know that you are not alone and talk to someone you trust, like your parent or teacher so that you can help keep yourself and your school safe and healthy.
• Ask questions, educate yourself and get information from reliable sources.
• Protect yourself and others:
• Wash your hands frequently, always with soap and water for at least 20 seconds.
• Remember to not touch your face, eyes, nose and mouth.
• Do not share cups, eating utensils, food or drinks with others.
• Be a leader in keeping yourself, your school, family and community healthy.
• Share what you learn about preventing disease with your family and friends, especially with younger children
• Model good practices such as sneezing or coughing into your elbow and washing your hands, especially for younger family members.
• Don’t stigmatize your peers or tease anyone about being sick; remember that the virus doesn’t follow geographical boundaries, ethnicities, age or ability or gender.
• Tell your parents, another family member, or a caregiver if you feel sick, and ask to stay home.

The following adaptations to transport to and from school should be implemented to limit unnecessary exposure of school or staff members.

• Promote and put in place respiratory and hand hygiene, physical distancing measures and use of masks in transportation such as school buses, in accordance with local policy.
• Provide tips for how to safely commute to and from school, including for public transportation.
• Organize only one child per seat and ensure physical distancing of at least 1 metre between passengers in school buses, if possible. This may require more school buses per school.
• If possible and safe, keep the windows of the buses, vans, and other vehicles open.

In countries or areas where there is intense community transmission of COVID-19 and in settings where physical distancing cannot be achieved, the following criteria for use of masks in schools are recommended:

1. Children aged 5 years and under should not be required to wear masks.

2. For children between six and 11 years of age, a risk-based approach should be applied to the decision to use a mask, considering:

• intensity of transmission in the area where the child is and evidence on the risk of infection and transmission in this age group.
• beliefs, customs and behaviours.
• the child’s capacity to comply with the correct use of masks and availability of adult supervision.
• potential impact of mask wearing on learning and development.
• additional considerations such as sport activities or for children with disabilities or underlying diseases.

3. Children and adolescents 12 years or older should follow the national mask guidelines for adults.

4. Teacher and support staff may be required to wear masks when they cannot guarantee at least a 1-metre distance from others or there is widespread transmission in the area.

Types of mask:

Fabric masks are recommended to prevent onward transmission in the general population in public areas, particularly where distancing is not possible, and in areas of community transmission. This could include the school grounds in some situations. Masks may help to protect others, because wearers may be infected before symptoms of illness appear. The policy on wearing a mask or face covering should be in line with national or local guidelines. Where used, masks  should be worn, cared for and disposed of properly. 

The use of masks by children and adolescents in schools should only be considered as one part of a strategy to limit the spread of COVID-19.

Yes, ensure adequate ventilation and increase total airflow supply to occupied spaces, if possible. Clean, natural ventilation (i.e., opening windows) should be used inside buildings where possible, without re-circulating the air. If heating, ventilation and air conditioning systems are used they should be regularly inspected, maintained and cleaned. Rigorous standards for installation, maintenance and filtration are essential to make sure they are effective and safe. Consider running the systems at maximum outside airflow for two hours before and after times when the building is occupied, according to the manufacturer’s recommendations.

The following should be monitored:

• effectiveness of symptoms-reporting, monitoring, rapid testing and tracing of suspected cases
• the effects of policies and measures on educational objectives and learning outcomes
• the effects of policies and measures on health and well-being of children, siblings, staff, parents and other family members
• the trend in school dropouts after lifting the restrictions
• the number of cases in children and staff in the school, and frequency of school-based outbreaks in the local administrative area and the country.
• Assessment of impact of remote teaching on learning outcomes.

Based on what is learned from this monitoring, further modifications should be made to continue to provide children and staff with the safest environment possible.

Based on guidance: Considerations for school-related public health measures in the context of COVID-19

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Based on guidance: Considerations for school-related public health measures in the context of COVID-19 

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Effectiveness of Face Mask or Respirator Use in Indoor Public Settings for Prevention of SARS-CoV-2 Infection — California, February–December 2021

Weekly / February 11, 2022 / 71(6);212–216

On February 4, 2022, this report was posted online as an MMWR Early Release.

Kristin L. Andrejko 1 ,2, *; Jake M. Pry, PhD 2, *; Jennifer F. Myers, MPH 2 ; Nozomi Fukui 2 ; Jennifer L. DeGuzman, MPH 2 ; John Openshaw, MD 2 ; James P. Watt, MD 2 ; Joseph A. Lewnard, PhD 1 ,3 ,4 ; Seema Jain, MD 2 ; California COVID-19 Case-Control Study Team ( View author affiliations )

What is already known about this topic?

Face masks or respirators (N95/KN95s) effectively filter virus-sized particles in laboratory settings. The real-world effectiveness of face coverings to prevent acquisition of SARS-CoV-2 infection has not been widely studied.

What is added by this report?

Consistent use of a face mask or respirator in indoor public settings was associated with lower odds of a positive SARS-CoV-2 test result (adjusted odds ratio = 0.44). Use of respirators with higher filtration capacity was associated with the most protection, compared with no mask use.

What are the implications for public health practice?

In addition to being up to date with recommended COVID-19 vaccinations, consistently wearing a comfortable, well-fitting face mask or respirator in indoor public settings protects against acquisition of SARS-CoV-2 infection; a respirator offers the best protection.

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The use of face masks or respirators (N95/KN95) is recommended to reduce transmission of SARS-CoV-2, the virus that causes COVID-19 ( 1 ). Well-fitting face masks and respirators effectively filter virus-sized particles in laboratory conditions ( 2 , 3 ), though few studies have assessed their real-world effectiveness in preventing acquisition of SARS-CoV-2 infection ( 4 ). A test-negative design case-control study enrolled randomly selected California residents who had received a test result for SARS-CoV-2 during February 18–December 1, 2021. Face mask or respirator use was assessed among 652 case-participants (residents who had received positive test results for SARS-CoV-2) and 1,176 matched control-participants (residents who had received negative test results for SARS-CoV-2) who self-reported being in indoor public settings during the 2 weeks preceding testing and who reported no known contact with anyone with confirmed or suspected SARS-CoV-2 infection during this time. Always using a face mask or respirator in indoor public settings was associated with lower adjusted odds of a positive test result compared with never wearing a face mask or respirator in these settings (adjusted odds ratio [aOR] = 0.44; 95% CI = 0.24–0.82). Among 534 participants who specified the type of face covering they typically used, wearing N95/KN95 respirators (aOR = 0.17; 95% CI = 0.05–0.64) or surgical masks (aOR = 0.34; 95% CI = 0.13–0.90) was associated with significantly lower adjusted odds of a positive test result compared with not wearing any face mask or respirator. These findings reinforce that in addition to being up to date with recommended COVID-19 vaccinations, consistently wearing a face mask or respirator in indoor public settings reduces the risk of acquiring SARS-CoV-2 infection. Using a respirator offers the highest level of personal protection against acquiring infection, although it is most important to wear a mask or respirator that is comfortable and can be used consistently.

This study used a test-negative case-control design, enrolling persons who received a positive (case-participants) or negative (control-participants) SARS-CoV-2 test result, from among all California residents, without age restriction, who received a molecular test result for SARS-CoV-2 during February 18–December 1, 2021 ( 5 ). Potential case-participants were randomly selected from among all persons who received a positive test result during the previous 48 hours and were invited to participate by telephone. For each enrolled case-participant, interviewers enrolled one control-participant matched by age group, sex, and state region; thus, interviewers were not blinded to participants’ SARS-CoV-2 infection status. Participants who self-reported having received a previous positive test result (molecular, antigen, or serologic) or clinical diagnosis of COVID-19 were not eligible to participate. During February 18–December 1, 2021, a total of 1,528 case-participants and 1,511 control-participants were enrolled in the study among attempted calls placed to 11,387 case- and 17,051 control-participants (response rates were 13.4% and 8.9%, respectively).

After obtaining informed consent from participants, interviewers administered a telephone questionnaire in English or Spanish. All participants were asked to indicate whether they had been in indoor public settings (e.g., retail stores, restaurants or bars, recreational facilities, public transit, salons, movie theaters, worship services, schools, or museums) in the 14 days preceding testing and whether they wore a face mask or respirator all, most, some, or none of the time in those settings. Interviewers recorded participants’ responses regarding COVID-19 vaccination status, sociodemographic characteristics, and history of exposure to anyone known or suspected to have been infected with SARS-CoV-2 in the 14 days before participants were tested. Participants enrolled during September 9–December 1, 2021, (534) were also asked to indicate the type of face covering typically worn (N95/KN95 respirator, surgical mask, or cloth mask) in indoor public settings.

The primary analysis compared self-reported face mask or respirator use in indoor public settings 14 days before SARS-CoV-2 testing between case- (652) and control- (1,176) participants. Secondary analyses accounted for consistency of face mask or respirator use all, most, some, or none of the time. To understand the effects of masking on community transmission, the analysis included the subset of participants who, during the 14 days before they were tested, reported visiting indoor public settings and who reported no known exposure to persons known or suspected to have been infected with SARS-CoV-2. An additional analysis assessed differences in protection against SARS-CoV-2 infection by the type of face covering worn, and was limited to a subset of participants enrolled after September 9, 2021, who were asked to indicate the type of face covering they typically wore; participants who indicated typically wearing multiple different mask types were categorized as wearing either a cloth mask (if they reported cloth mask use) or a surgical mask (if they did not report cloth mask use). Adjusted odds ratios comparing history of mask-wearing among case- and control-participants were calculated using conditional logistic regression. Match strata were defined by participants’ week of SARS-CoV-2 testing and by county-level SARS-CoV-2 risk tiers as defined under California’s Blueprint for a Safer Economy reopening scheme. † Adjusted models accounted for self-reported COVID-19 vaccination status (fully vaccinated with ≥2 doses of BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna] or 1 dose of Ad.26.COV2.S [Janssen (Johnson & Johnson)] vaccine >14 days before testing versus zero doses), household income, race/ethnicity, age, sex, state region, and county population density. Statistical significance was defined by two-sided Wald tests with p-values <0.05. All analyses were conducted using R software (version 3.6.1; R Foundation). This activity was approved as public health surveillance by the State of California Health and Human Services Agency Committee for the Protection of Human Subjects.

A total of 652 case- and 1,176 control-participants were enrolled in the study equally across nine multi-county regions in California ( Table 1 ). The majority of participants (43.2%) identified as non-Hispanic White; 28.2% of participants identified as Hispanic (any race). A higher proportion of case-participants (78.4%) was unvaccinated compared with control-participants (57.5%). Overall, 44 (6.7%) case-participants and 42 (3.6%) control-participants reported never wearing a face mask or respirator in indoor public settings ( Table 2 ), and 393 (60.3%) case-participants and 819 (69.6%) control-participants reported always wearing a face mask or respirator in indoor public settings. Any face mask or respirator use in indoor public settings was associated with significantly lower odds of a positive test result compared with never using a face mask or respirator (aOR = 0.51; 95% CI = 0.29­–0.93). Always using a face mask or respirator in indoor public settings was associated with lower adjusted odds of a positive test result compared with never wearing a face mask or respirator (aOR = 0.44; 95% CI = 0.24–0.82); however, adjusted odds of a positive test result suggested stepwise reductions in protection among participants who reported wearing a face mask or respirator most of the time (aOR = 0.55; 95% CI = 0.29–1.05) or some of the time (aOR = 0.71; 95% CI = 0.35–1.46) compared with participants who reported never wearing a face mask or respirator.

Wearing an N95/KN95 respirator (aOR = 0.17; 95% CI = 0.05–0.64) or wearing a surgical mask (aOR = 0.34; 95% CI = 0.13­–0.90) was associated with lower adjusted odds of a positive test result compared with not wearing a mask ( Table 3 ). Wearing a cloth mask (aOR = 0.44; 95% CI = 0.17–1.17) was associated with lower adjusted odds of a positive test compared with never wearing a face covering but was not statistically significant.

During February–December 2021, using a face mask or respirator in indoor public settings was associated with lower odds of acquiring SARS-CoV-2 infection, with protection being highest among those who reported wearing a face mask or respirator all of the time. Although consistent use of any face mask or respirator indoors was protective, the adjusted odds of infection were lowest among persons who reported typically wearing an N95/KN95 respirator, followed by wearing a surgical mask. These data from real-world settings reinforce the importance of consistently wearing face masks or respirators to reduce the risk of acquisition of SARS-CoV-2 infection among the general public in indoor community settings.

These findings are consistent with existing research demonstrating that face masks or respirators effectively filter viruses in laboratory settings and with ecological studies showing reductions in SARS-CoV-2 incidence associated with community-level masking requirements ( 6 , 7 ). While this study evaluated the protective effects of mask or respirator use in reducing the risk the wearer acquires SARS-CoV-2 infection, a previous evaluation estimated the additional benefits of masking for source control, and found that wearing face masks or respirators in the context of exposure to a person with confirmed SARS-CoV-2 infection was associated with similar reductions in risk for infection ( 8 ). Strengths of the current study include use of a clinical endpoint of SARS-CoV-2 test result, and applicability to a general population sample.

The findings in this report are subject to at least eight limitations. First, this study did not account for other preventive behaviors that could influence risk for acquiring infection, including adherence to physical distancing recommendations. In addition, generalizability of this study is limited to persons seeking SARS-CoV-2 testing and who were willing to participate in a telephone interview, who might otherwise exercise other protective behaviors. Second, this analysis relied on an aggregate estimate of self-reported face mask or respirator use across, for some participants, multiple indoor public locations. However, the study was designed to minimize recall bias by enrolling both case- and control-participants within a 48-hour window of receiving a SARS-CoV-2 test result. Third, small strata limited the ability to differentiate between types of cloth masks or participants who wore different types of face masks in differing settings, and also resulted in wider CIs and statistical nonsignificance for some estimates that were suggestive of a protective effect. Fourth, estimates do not account for face mask or respirator fit or the correctness of face mask or respirator wearing; assessing the effectiveness of face mask or respirator use under real-world conditions is nonetheless important for developing policy. Fifth, data collection occurred before the expansion of the SARS-CoV-2 B.1.1.529 (Omicron) variant, which is more transmissible than earlier variants. Sixth, face mask or respirator use was self-reported, which could introduce social desirability bias. Seventh, small strata limited the ability to account for reasons for testing in the adjusted analysis, which may be correlated with face mask or respirator use. Finally, this analysis does not account for potential differences in the intensity of exposures, which could vary by duration, ventilation system, and activity in each of the various indoor public settings visited.

The findings of this report reinforce that in addition to being up to date with recommended COVID-19 vaccinations, consistently wearing face masks or respirators while in indoor public settings protects against the acquisition of SARS-CoV-2 infection ( 9 , 10 ). This highlights the importance of improving access to high-quality masks to ensure access is not a barrier to use. Using a respirator offers the highest level of protection from acquisition of SARS-CoV-2 infection, although it is most important to wear a well-fitting mask or respirator that is comfortable and can be used consistently.

California COVID-19 Case-Control Study Team

Yasmine Abdulrahim, California Department of Public Health; Camilla M. Barbaduomo, California Department of Public Health; Julia Cheunkarndee, California Department of Public Health; Miriam I. Bermejo, California Department of Public Health; Adrian F. Cornejo, California Department of Public Health; Savannah Corredor, California Department of Public Health; Najla Dabbagh, California Department of Public Health; Zheng N. Dong, California Department of Public Health; Ashly Dyke, California Department of Public Health; Anna T. Fang, California Department of Public Health; Diana Felipe, California Department of Public Health; Paulina M. Frost, California Department of Public Health; Timothy Ho, California Department of Public Health; Mahsa H. Javadi, California Department of Public Health; Amandeep Kaur, California Department of Public Health; Amanda Lam, California Department of Public Health; Sophia S. Li, California Department of Public Health; Monique Miller, California Department of Public Health; Jessica Ni, California Department of Public Health; Hyemin Park, California Department of Public Health; Diana J. Poindexter, California Department of Public Health; Helia Samani, California Department of Public Health; Shrey Saretha, California Department of Public Health; Maya Spencer, California Department of Public Health; Michelle M. Spinosa, California Department of Public Health; Vivian H. Tran, California Department of Public Health; Nikolina Walas, California Department of Public Health; Christine Wan, California Department of Public Health; Erin Xavier, California Department of Public Health.

Corresponding authors: Seema Jain, [email protected] ; Kristin L. Andrejko, [email protected] .

1 Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, California; 2 California Department of Public Health; 3 Division of Infectious Diseases & Vaccinology, School of Public Health, University of California, Berkeley, California; 4 Center for Computational Biology, College of Engineering, University of California, Berkeley, California.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Joseph A. Lewnard discloses receipt of research grants and consulting fees from Pfizer, Inc., unrelated to the current study. No other potential conflicts of interest were disclosed.

* These authors contributed equally to this report.

† https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/COVID19CountyMonitoringOverview.aspx

• CDC. Science brief: community use of cloth masks to control the spread of SARS-CoV-2. Atlanta, GA: US Department of Health and Human Services, CDC; 2020. https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/masking-science-sars-cov2.html
• Pan J, Harb C, Leng W, Marr LC. Inward and outward effectiveness of cloth masks, a surgical mask, and a face shield. Aerosol Sci Technol 2021;55:718–33. https://doi.org/10.1080/02786826.2021.1890687
• Brooks JT, Beezhold DH, Noti JD, et al. Maximizing fit for cloth and medical surgical masks to improve performance and reduce SARS-CoV-2 transmission and exposure, 2021. MMWR Morb Mortal Wkly Rep 2021;70:254–7. https://doi.org/10.15585/mmwr.mm7007e1 PMID:33600386
• Howard J, Huang A, Li Z, et al. An evidence review of face masks against COVID-19. Proc Natl Acad Sci U S A 2021;118:e2014564118. https://doi.org/10.1073/pnas.2014564118 PMID:33431650
• Lewnard JA, Patel MM, Jewell NP, et al. Theoretical framework for retrospective studies of the effectiveness of SARS-CoV-2 vaccines. Epidemiology 2021;32:508–17. https://doi.org/10.1097/EDE.0000000000001366 PMID:34001753
• Brooks JT, Butler JC. Effectiveness of mask wearing to control community spread of SARS-CoV-2. JAMA 2021;325:998–9. https://doi.org/10.1001/jama.2021.1505 PMID:33566056
• Chughtai AA, Seale H, Macintyre CR. Effectiveness of cloth masks for protection against severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis 2020;26:e200948. https://doi.org/10.3201/eid2610.200948 PMID:32639930
• Andrejko KL, Pry J, Myers JF, et al.; California COVID-19 Case-Control Study Team. Predictors of SARS-CoV-2 infection following high-risk exposure. Clin Infect Dis . Epub December 21, 2021. https://doi.org/10.1093/cid/ciab1040 PMID:34932817
• California Department of Public Health. Guidance for the use of face masks. Sacramento, CA: California Department of Public Health. 2022. Accessed January 14, 2022. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/guidance-for-face-coverings.aspx
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* A random sample of California residents with a molecular SARS-CoV-2 test result was invited to participate in a telephone-based survey to document frequency of face mask or respirator use and type of face mask or respirator typically worn in indoor public settings 2 weeks before testing. For each enrolled case-participant (person with a positive SARS-CoV-2 test result), interviewers attempted to enroll one control-participant (person with a negative SARS-CoV-2 test result) whose test result was posted to the reportable disease registry during the 48 hours preceding the call and matched the case-participant by age group, sex, and state region. Among 1,947 case- and control-participants who visited indoor public settings and did not report a known or suspected exposure to SARS-CoV-2 in the 14 days before getting a SARS-CoV-2 test, 119 (6.1%) participants were unable to report face mask use and were excluded from analysis. Parents or guardians served as proxy respondents and answered questions throughout the telephone survey on behalf of children aged <13 years. † California counties were divided into nine geographic regions. Counties included in each geographic region are listed online in Table S1. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciab640/6324500#supplementary-data § Vaccination status was defined using self-reported dates and manufacturers of doses received. Participants were asked to reference their COVID-19 vaccination card while providing vaccination history. Participants who could not provide a complete vaccination history (dates of doses received and manufacturers) were coded as unknown. Full vaccination was defined as receipt of 2 doses of BNT162b2 [Pfizer-BioNTech] or mRNA-1273 [Moderna], or receipt of 1 dose of Ad.26.COV2.S (Janssen [Johnson & Johnson]) >14 days before SARS-CoV-2 testing. Of the 492 fully vaccinated participants, 22 (4.5%) had received a booster dose at the time of enrollment. All other participants were considered unvaccinated or incompletely vaccinated. ¶ Reopening tiers in California were determined by the Blueprint for a Safer Economy the State of California implemented during February 24 to June 15, 2021. This was a tiered system of public health restrictions tied to county-level positive test results and incidence. On June 15, 2021, California retired the tiered reopening system and removed most restrictions on public gatherings, while some counties maintained guidelines for guests and workers to show proof of vaccination or a negative test result to gather in certain types of venues and workplaces. The tier of a given participant was determined by using the date that occurred 14 days before the SARS-CoV-2 specimen collection date recorded for each participant in the California Reportable Disease Registry. ** Case- and control-participants were asked to indicate their reasons for seeking a SARS-CoV-2 test as a free-text response. Trained interviewers (N = 29) recategorized the free-text response into the categories listed in the table. Interviewers were trained to ask probing questions if the free-text response could not be categorized into the reasons listed above. Probing questions and coding decisions may slightly vary by interviewer. Reasons for testing might sum to numbers larger than the total number of case-participants or control-participants because participants could indicate more than one reason for seeking a SARS-CoV-2 test.

Abbreviation: Ref = referent group. * Trained interviewers administered a structured telephone-based questionnaire and asked participants to indicate whether they attended indoor public spaces during the 2 weeks before seeking a SARS-CoV-2 test. Participants who indicated attending these settings were further asked to specify whether they typically wore a face mask or respirator all, most, some, or none of the time while in these settings. † Conditional logistic regression models were used to estimate the unadjusted odds of mask use by type of face mask or respirator worn in indoor public settings during the 2 weeks before testing. Models included matching strata defined by (for the period before June 15, 2021) the reopening tier of California in the county of residence and the week of SARS-CoV-2 testing. § Conditional logistic regression models were used to estimate the odds of face mask or respirator use in indoor public settings during the 2 weeks before testing, adjusting for COVID-19 vaccination status, household income, race/ethnicity, age group, sex, state region, and county population density. All models included matching strata defined by (for the period before June 15, 2021) the reopening tier of California in the county of residence, and the week of SARS-CoV-2 testing. To understand the effects of masking in community settings, this analysis was restricted to a subset of persons who did not indicate a known or suspected exposure to a SARS-CoV-2 case within 14 days of seeking a SARS-CoV-2 test. Adjusted models used a complete case analysis (454 case-participants and 789 control-participants). A sensitivity analysis using multiple imputation of missing covariate values obtained results similar to those reported in the table: adjusted odds ratios were 0.54 (95% CI = 0.33–0.89) for any mask use, 0.44 (95% CI = 0.27–0.73) for mask use all of the time, 0.62 (95% CI = 0.37–1.04) for mask use most of the time, and 0.77 (95% CI = 0.43–1.40) for mask use some of the time. An additional sensitivity analysis was conducted with additional adjustment for the reasons for SARS-CoV-2 testing as listed in Table 1 (experiencing symptoms, testing required for medical procedure, routine screening through work or school, pre-travel test, just wanted to see if I was infected, test required for admission to an event or gathering). The adjusted odds ratio was 0.42 (95% CI = 0.20–0.89) for any mask use as compared to no mask use upon additional adjustment for testing indications.

Abbreviation: Ref = referent group. * Trained interviewers administered a structured telephone-based questionnaire and asked participants enrolled after September 9, 2021, to identify the type of face covering typically worn in indoor public settings during the 2 weeks before seeking a SARS-CoV-2 test. Participants who indicated typically wearing multiple different mask types were categorized as wearing either a cloth mask (if they reported cloth mask use) or a surgical mask (if they didn’t report cloth mask use). † Conditional logistic regression models were used to estimate the unadjusted odds of mask use by type of face mask or respirator worn in indoor public settings during the 2 weeks before testing. Models included matching strata defined by the week of SARS-CoV-2 testing. § This analysis was not restricted to persons with no self-reported known or suspected SARS-CoV-2 contact given that this secondary analysis was underpowered upon exclusion of these participants (N = 316) because adjusted models did not converge. Instead, models adjusted for history of known or suspected contact as a covariate. In a sensitivity analysis restricting to participants who did not report known or suspected contact (N = 316), conditional logistic regression models were used to estimate that the unadjusted odds ratios of face mask use by type of face mask with matching strata defined by the week of SARS-CoV-2 testing: 0.13 (95% CI = 0.03–0.61), 0.32 (95% CI = 0.12–0.89), and 0.36 (95% CI = 0.13–1.00) for N95/KN95 respirators, surgical masks, or cloth masks, respectively, relative to no face mask or respirator use.

Suggested citation for this article: Andrejko KL, Pry JM, Myers JF, et al. Effectiveness of Face Mask or Respirator Use in Indoor Public Settings for Prevention of SARS-CoV-2 Infection — California, February–December 2021. MMWR Morb Mortal Wkly Rep 2022;71:212–216. DOI: http://dx.doi.org/10.15585/mmwr.mm7106e1 .

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Open Access

Study Protocol

Assessing the effect of the COVID-19 pandemic, shift to online learning, and social media use on the mental health of college students in the Philippines: A mixed-method study protocol

Roles Funding acquisition, Writing – original draft

Affiliation College of Medicine, University of the Philippines, Manila, Philippines

Roles Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing

Affiliations Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila, Philippines, Institute of Clinical Epidemiology, National Institutes of Health, University of the Philippines, Manila, Philippines

Roles Methodology

Affiliation Department of Psychiatry, College of Medicine, University of the Philippines, Manila, Philippines

Roles Conceptualization, Funding acquisition, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Leonard Thomas S. Lim, 
• Zypher Jude G. Regencia, 
• J. Rem C. Dela Cruz, 
• Frances Dominique V. Ho, 
• Marcela S. Rodolfo, 
• Josefina Ly-Uson, 
• Emmanuel S. Baja

• Published: May 3, 2022
• https://doi.org/10.1371/journal.pone.0267555
• Peer Review
• Reader Comments

Introduction

The COVID-19 pandemic declared by the WHO has affected many countries rendering everyday lives halted. In the Philippines, the lockdown quarantine protocols have shifted the traditional college classes to online. The abrupt transition to online classes may bring psychological effects to college students due to continuous isolation and lack of interaction with fellow students and teachers. Our study aims to assess Filipino college students’ mental health status and to estimate the effect of the COVID-19 pandemic, the shift to online learning, and social media use on mental health. In addition, facilitators or stressors that modified the mental health status of the college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning will be investigated.

Methods and analysis

Mixed-method study design will be used, which will involve: (1) an online survey to 2,100 college students across the Philippines; and (2) randomly selected 20–40 key informant interviews (KIIs). Online self-administered questionnaire (SAQ) including Depression, Anxiety, and Stress Scale (DASS-21) and Brief-COPE will be used. Moreover, socio-demographic factors, social media usage, shift to online learning factors, family history of mental health and COVID-19, and other factors that could affect mental health will also be included in the SAQ. KIIs will explore factors affecting the student’s mental health, behaviors, coping mechanism, current stressors, and other emotional reactions to these stressors. Associations between mental health outcomes and possible risk factors will be estimated using generalized linear models, while a thematic approach will be made for the findings from the KIIs. Results of the study will then be triangulated and summarized.

Ethics and dissemination

Our study has been approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-099-01). The results will be actively disseminated through conference presentations, peer-reviewed journals, social media, print and broadcast media, and various stakeholder activities.

Citation: Lim LTS, Regencia ZJG, Dela Cruz JRC, Ho FDV, Rodolfo MS, Ly-Uson J, et al. (2022) Assessing the effect of the COVID-19 pandemic, shift to online learning, and social media use on the mental health of college students in the Philippines: A mixed-method study protocol. PLoS ONE 17(5): e0267555. https://doi.org/10.1371/journal.pone.0267555

Editor: Elisa Panada, UNITED KINGDOM

Received: June 9, 2021; Accepted: April 11, 2022; Published: May 3, 2022

Copyright: © 2022 Lim et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: This project is being supported by the American Red Cross through the Philippine Red Cross and Red Cross Youth. The funder will not have a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

The World Health Organization (WHO) declared the Coronavirus 2019 (COVID-19) outbreak as a global pandemic, and the Philippines is one of the 213 countries affected by the disease [ 1 ]. To reduce the virus’s transmission, the President imposed an enhanced community quarantine in Luzon, the country’s northern and most populous island, on March 16, 2020. This lockdown manifested as curfews, checkpoints, travel restrictions, and suspension of business and school activities [ 2 ]. However, as the virus is yet to be curbed, varying quarantine restrictions are implemented across the country. In addition, schools have shifted to online learning, despite financial and psychological concerns [ 3 ].

Previous outbreaks such as the swine flu crisis adversely influenced the well-being of affected populations, causing them to develop emotional problems and raising the importance of integrating mental health into medical preparedness for similar disasters [ 4 ]. In one study conducted on university students during the swine flu pandemic in 2009, 45% were worried about personally or a family member contracting swine flu, while 10.7% were panicking, feeling depressed, or emotionally disturbed. This study suggests that preventive measures to alleviate distress through health education and promotion are warranted [ 5 ].

During the COVID-19 pandemic, researchers worldwide have been churning out studies on its psychological effects on different populations [ 6 – 9 ]. The indirect effects of COVID-19, such as quarantine measures, the infection of family and friends, and the death of loved ones, could worsen the overall mental wellbeing of individuals [ 6 ]. Studies from 2020 to 2021 link the pandemic to emotional disturbances among those in quarantine, even going as far as giving vulnerable populations the inclination to commit suicide [ 7 , 8 ], persistent effect on mood and wellness [ 9 ], and depression and anxiety [ 10 ].

In the Philippines, a survey of 1,879 respondents measuring the psychological effects of COVID-19 during its early phase in 2020 was released. Results showed that one-fourth of respondents reported moderate-to-severe anxiety, while one-sixth reported moderate-to-severe depression [ 11 ]. In addition, other local studies in 2020 examined the mental health of frontline workers such as nurses and physicians—placing emphasis on the importance of psychological support in minimizing anxiety [ 12 , 13 ].

Since the first wave of the pandemic in 2020, risk factors that could affect specific populations’ psychological well-being have been studied [ 14 , 15 ]. A cohort study on 1,773 COVID-19 hospitalized patients in 2021 found that survivors were mainly troubled with fatigue, muscle weakness, sleep difficulties, and depression or anxiety [ 16 ]. Their results usually associate the crisis with fear, anxiety, depression, reduced sleep quality, and distress among the general population.

Moreover, the pandemic also exacerbated the condition of people with pre-existing psychiatric disorders, especially patients that live in high COVID-19 prevalence areas [ 17 ]. People suffering from mood and substance use disorders that have been infected with COVID-19 showed higher suicide risks [ 7 , 18 ]. Furthermore, a study in 2020 cited the following factors contributing to increased suicide risk: social isolation, fear of contagion, anxiety, uncertainty, chronic stress, and economic difficulties [ 19 ].

Globally, multiple studies have shown that mental health disorders among university student populations are prevalent [ 13 , 20 – 22 ]. In a 2007 survey of 2,843 undergraduate and graduate students at a large midwestern public university in the United States, the estimated prevalence of any depressive or anxiety disorder was 15.6% and 13.0% for undergraduate and graduate students, respectively [ 20 ]. Meanwhile, in a 2013 study of 506 students from 4 public universities in Malaysia, 27.5% and 9.7% had moderate and severe or extremely severe depression, respectively; 34% and 29% had moderate and severe or extremely severe anxiety, respectively [ 21 ]. In China, a 2016 meta-analysis aiming to establish the national prevalence of depression among university students analyzed 39 studies from 1995 to 2015; the meta-analysis found that the overall prevalence of depression was 23.8% across all studies that included 32,694 Chinese university students [ 23 ].

A college student’s mental status may be significantly affected by the successful fulfillment of a student’s role. A 2013 study found that acceptable teaching methods can enhance students’ satisfaction and academic performance, both linked to their mental health [ 24 ]. However, online learning poses multiple challenges to these methods [ 3 ]. Furthermore, a 2020 study found that students’ mental status is affected by their social support systems, which, in turn, may be jeopardized by the COVID-19 pandemic and the physical limitations it has imposed. Support accessible to a student through social ties to other individuals, groups, and the greater community is a form of social support; university students may draw social support from family, friends, classmates, teachers, and a significant other [ 25 , 26 ]. Among individuals undergoing social isolation and distancing during the COVID-19 pandemic in 2020, social support has been found to be inversely related to depression, anxiety, irritability, sleep quality, and loneliness, with higher levels of social support reducing the risk of depression and improving sleep quality [ 27 ]. Lastly, it has been shown in a 2020 study that social support builds resilience, a protective factor against depression, anxiety, and stress [ 28 ]. Therefore, given the protective effects of social support on psychological health, a supportive environment should be maintained in the classroom. Online learning must be perceived as an inclusive community and a safe space for peer-to-peer interactions [ 29 ]. This is echoed in another study in 2019 on depressed students who narrated their need to see themselves reflected on others [ 30 ]. Whether or not online learning currently implemented has successfully transitioned remains to be seen.

The effect of social media on students’ mental health has been a topic of interest even before the pandemic [ 31 , 32 ]. A systematic review published in 2020 found that social media use is responsible for aggravating mental health problems and that prominent risk factors for depression and anxiety include time spent, activity, and addiction to social media [ 31 ]. Another systematic review published in 2016 argues that the nature of online social networking use may be more important in influencing the symptoms of depression than the duration or frequency of the engagement—suggesting that social rumination and comparison are likely to be candidate mediators in the relationship between depression and social media [ 33 ]. However, their findings also suggest that the relationship between depression and online social networking is complex and necessitates further research to determine the impact of moderators and mediators that underly the positive and negative impact of online social networking on wellbeing [ 33 ].

Despite existing studies already painting a picture of the psychological effects of COVID-19 in the Philippines, to our knowledge, there are still no local studies contextualized to college students living in different regions of the country. Therefore, it is crucial to elicit the reasons and risk factors for depression, stress, and anxiety and determine the potential impact that online learning and social media use may have on the mental health of the said population. In turn, the findings would allow the creation of more context-specific and regionalized interventions that can promote mental wellness during the COVID-19 pandemic.

Materials and methods

The study’s general objective is to assess the mental health status of college students and determine the different factors that influenced them during the COVID-19 pandemic. Specifically, it aims:

• To describe the study population’s characteristics, categorized by their mental health status, which includes depression, anxiety, and stress.
• To determine the prevalence and risk factors of depression, anxiety, and stress among college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning.
• To estimate the effect of social media use on depression, anxiety, stress, and coping strategies towards stress among college students and examine whether participant characteristics modified these associations.
• To estimate the effect of online learning shift on depression, anxiety, stress, and coping strategies towards stress among college students and examine whether participant characteristics modified these associations.
• To determine the facilitators or stressors among college students that modified their mental health status during the COVID-19 pandemic, quarantine, and subsequent shift to online learning.

Study design

A mixed-method study design will be used to address the study’s objectives, which will include Key Informant Interviews (KIIs) and an online survey. During the quarantine period of the COVID-19 pandemic in the Philippines from April to November 2021, the study shall occur with the population amid community quarantine and an abrupt transition to online classes. Since this is the Philippines’ first study that will look at the prevalence of depression, anxiety, and stress among college students during the COVID-19 pandemic, quarantine, and subsequent shift to online learning, the online survey will be utilized for the quantitative part of the study design. For the qualitative component of the study design, KIIs will determine facilitators or stressors among college students that modified their mental health status during the quarantine period.

Study population

The Red Cross Youth (RCY), one of the Philippine Red Cross’s significant services, is a network of youth volunteers that spans the entire country, having active members in Luzon, Visayas, and Mindanao. The group is clustered into different age ranges, with the College Red Cross Youth (18–25 years old) being the study’s population of interest. The RCY has over 26,060 students spread across 20 chapters located all over the country’s three major island groups. The RCY is heterogeneously composed, with some members classified as college students and some as out-of-school youth. Given their nationwide scope, disseminating information from the national to the local level is already in place; this is done primarily through email, social media platforms, and text blasts. The research team will leverage these platforms to distribute the online survey questionnaire.

In addition, the online survey will also be open to non-members of the RCY. It will be disseminated through social media and engagements with different university administrators in the country. Stratified random sampling will be done for the KIIs. The KII participants will be equally coming from the country’s four (4) primary areas: 5–10 each from the national capital region (NCR), Luzon, Visayas, and Mindanao, including members and non-members of the RCY.

Inclusion and exclusion criteria

The inclusion criteria for the online survey will include those who are 18–25 years old, currently enrolled in a university, can provide consent for the study, and are proficient in English or Filipino. The exclusion criteria will consist of those enrolled in graduate-level programs (e.g., MD, JD, Master’s, Doctorate), out-of-school youth, and those whose current curricula involve going on duty (e.g., MDs, nursing students, allied medical professions, etc.). The inclusion criteria for the KIIs will include online survey participants who are 18–25 years old, can provide consent for the study, are proficient in English or Filipino, and have access to the internet.

Sample size

A continuity correction method developed by Fleiss et al. (2013) was used to calculate the sample size needed [ 34 ]. For a two-sided confidence level of 95%, with 80% power and the least extreme odds ratio to be detected at 1.4, the computed sample size was 1890. With an adjustment for an estimated response rate of 90%, the total sample size needed for the study was 2,100. To achieve saturation for the qualitative part of the study, 20 to 40 participants will be randomly sampled for the KIIs using the respondents who participated in the online survey [ 35 ].

Study procedure

Self-administered questionnaire..

The study will involve creating, testing, and distributing a self-administered questionnaire (SAQ). All eligible study participants will answer the SAQ on socio-demographic factors such as age, sex, gender, sexual orientation, residence, household income, socioeconomic status, smoking status, family history of mental health, and COVID-19 sickness of immediate family members or friends. The two validated survey tools, Depression, Anxiety, and Stress Scale (DASS-21) and Brief-COPE, will be used for the mental health outcome assessment [ 36 – 39 ]. The DASS-21 will measure the negative emotional states of depression, anxiety, and stress [ 40 ], while the Brief-COPE will measure the students’ coping strategies [ 41 ].

For the exposure assessment of the students to social media and shift to online learning, the total time spent on social media (TSSM) per day will be ascertained by querying the participants to provide an estimated time spent daily on social media during and after their online classes. In addition, students will be asked to report their use of the eight commonly used social media sites identified at the start of the study. These sites include Facebook, Twitter, Instagram, LinkedIn, Pinterest, TikTok, YouTube, and social messaging sites Viber/WhatsApp and Facebook Messenger with response choices coded as "(1) never," "(2) less often," "(3) every few weeks," "(4) a few times a week," and “(5) daily” [ 42 – 44 ]. Furthermore, a global frequency score will be calculated by adding the response scores from the eight social media sites. The global frequency score will be used as an additional exposure marker of students to social media [ 45 ]. The shift to online learning will be assessed using questions that will determine the participants’ satisfaction with online learning. This assessment is comprised of 8 items in which participants will be asked to respond on a 5-point Likert scale ranging from ‘strongly disagree’ to ‘strongly agree.’

The online survey will be virtually distributed in English using the Qualtrics XM™ platform. Informed consent detailing the purpose, risks, benefits, methods, psychological referrals, and other ethical considerations will be included before the participants are allowed to answer the survey. Before administering the online survey, the SAQ shall undergo pilot testing among twenty (20) college students not involved with the study. It aims to measure total test-taking time, respondent satisfaction, and understandability of questions. The survey shall be edited according to the pilot test participant’s responses. Moreover, according to the Philippines’ Data Privacy Act, all the answers will be accessible and used only for research purposes.

Key informant interviews.

The research team shall develop the KII concept note, focusing on the extraneous factors affecting the student’s mental health, behaviors, and coping mechanism. Some salient topics will include current stressors (e.g., personal, academic, social), emotional reactions to these stressors, and how they wish to receive support in response to these stressors. The KII will be facilitated by a certified psychologist/psychiatrist/social scientist and research assistants using various online video conferencing software such as Google Meet, Skype, or Zoom. All the KIIs will be recorded and transcribed for analysis. Furthermore, there will be a debriefing session post-KII to address the psychological needs of the participants. Fig 1 presents the diagrammatic flowchart of the study.

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0267555.g001

Data analyses

Quantitative data..

Descriptive statistics will be calculated, including the prevalence of mental health outcomes such as depression, anxiety, stress, and coping strategies. In addition, correlation coefficients will be estimated to assess the relations among the different mental health outcomes, covariates, and possible risk factors.

Several study characteristics as effect modifiers will also be assessed, including sex, gender, sexual orientation, family income, smoking status, family history of mental health, and Covid-19. We will include interaction terms between the dichotomized modifier variable and markers of social media use (total TSSM and global frequency score) and shift to online learning in the models. The significance of the interaction terms will be evaluated using the likelihood ratio test. All the regression analyses will be done in R ( http://www.r-project.org ). P values ≤ 0.05 will be considered statistically significant.

Qualitative data.

After transcribing the interviews, the data transcripts will be analyzed using NVivo 1.4.1 software [ 50 ] by three research team members independently using the inductive logic approach in thematic analysis: familiarizing with the data, generating initial codes, searching for themes, reviewing the themes, defining and naming the themes, and producing the report [ 51 ]. Data familiarization will consist of reading and re-reading the data while noting initial ideas. Additionally, coding interesting features of the data will follow systematically across the entire dataset while collating data relevant to each code. Moreover, the open coding of the data will be performed to describe the data into concepts and themes, which will be further categorized to identify distinct concepts and themes [ 52 ].

The three researchers will discuss the results of their thematic analyses. They will compare and contrast the three analyses in order to come up with a thematic map. The final thematic map of the analysis will be generated after checking if the identified themes work in relation to the extracts and the entire dataset. In addition, the selection of clear, persuasive extract examples that will connect the analysis to the research question and literature will be reviewed before producing a scholarly report of the analysis. Additionally, the themes and sub-themes generated will be assessed and discussed in relevance to the study’s objectives. Furthermore, the gathering and analyzing of the data will continue until saturation is reached. Finally, pseudonyms will be used to present quotes from qualitative data.

Data triangulation.

Data triangulation using the two different data sources will be conducted to examine the various aspects of the research and will be compared for convergence. This part of the analysis will require listing all the relevant topics or findings from each component of the study and considering where each method’s results converge, offer complementary information on the same issue, or appear to contradict each other. It is crucial to explicitly look for disagreements between findings from different data collection methods because exploration of any apparent inter-method discrepancy may lead to a better understanding of the research question [ 53 , 54 ].

Data management plan.

The Project Leader will be responsible for overall quality assurance, with research associates and assistants undertaking specific activities to ensure quality control. Quality will be assured through routine monitoring by the Project Leader and periodic cross-checks against the protocols by the research assistants. Transcribed KIIs and the online survey questionnaire will be used for recording data for each participant in the study. The project leader will be responsible for ensuring the accuracy, completeness, legibility, and timeliness of the data captured in all the forms. Data captured from the online survey or KIIs should be consistent, clarified, and corrected. Each participant will have complete source documentation of records. Study staff will prepare appropriate source documents and make them available to the Project Leader upon request for review. In addition, study staff will extract all data collected in the KII notes or survey forms. These data will be secured and kept in a place accessible to the Project Leader. Data entry and cleaning will be conducted, and final data cleaning, data freezing, and data analysis will be performed. Key informant interviews will always involve two researchers. Where appropriate, quality control for the qualitative data collection will be assured through refresher KII training during research design workshops. The Project Leader will check through each transcript for consistency with agreed standards. Where translations are undertaken, the quality will be assured by one other researcher fluent in that language checking against the original recording or notes.

Ethics approval.

The study shall abide by the Principles of the Declaration of Helsinki (2013). It will be conducted along with the Guidelines of the International Conference on Harmonization-Good Clinical Practice (ICH-GCP), E6 (R2), and other ICH-GCP 6 (as amended); National Ethical Guidelines for Health and Health-Related Research (NEGHHRR) of 2017. This protocol has been approved by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-099-01 dated March 25, 2021).

The main concerns for ethics were consent, data privacy, and subject confidentiality. The risks, benefits, and conflicts of interest are discussed in this section from an ethical standpoint.

Recruitment.

The participants will be recruited to answer the online SAQ voluntarily. The recruitment of participants for the KIIs will be chosen through stratified random sampling using a list of those who answered the online SAQ; this will minimize the risk of sampling bias. In addition, none of the participants in the study will have prior contact or association with the researchers. Moreover, power dynamics will not be contacted to recruit respondents. The research objectives, methods, risks, benefits, voluntary participation, withdrawal, and respondents’ rights will be discussed with the respondents in the consent form before KII.

Informed consent will be signified by the potential respondent ticking a box in the online informed consent form and the voluntary participation of the potential respondent to the study after a thorough discussion of the research details. The participant’s consent is voluntary and may be recanted by the participant any time s/he chooses.

Data privacy.

All digital data will be stored in a cloud drive accessible only to the researchers. Subject confidentiality will be upheld through the assignment of control numbers and not requiring participants to divulge the name, address, and other identifying factors not necessary for analysis.

Compensation.

No monetary compensation will be given to the participants, but several tokens will be raffled to all the participants who answered the online survey and did the KIIs.

This research will pose risks to data privacy, as discussed and addressed above. In addition, there will be a risk of social exclusion should data leaks arise due to the stigma against mental health. This risk will be mitigated by properly executing the data collection and analysis plan, excluding personal details and tight data privacy measures. Moreover, there is a risk of psychological distress among the participants due to the sensitive information. This risk will be addressed by subjecting the SAQ and the KII guidelines to the project team’s psychiatrist’s approval, ensuring proper communication with the participants. The KII will also be facilitated by registered clinical psychologists/psychiatrists/social scientists to ensure the participants’ appropriate handling; there will be a briefing and debriefing of the participants before and after the KII proper.

Participation in this study will entail health education and a voluntary referral to a study-affiliated psychiatrist, discussed in previous sections. Moreover, this would contribute to modifications in targeted mental-health campaigns for the 18–25 age group. Summarized findings and recommendations will be channeled to stakeholders for their perusal.

Dissemination.

The results will be actively disseminated through conference presentations, peer-reviewed journals, social media, print and broadcast media, and various stakeholder activities.

This study protocol rationalizes the examination of the mental health of the college students in the Philippines during the COVID-19 pandemic as the traditional face-to-face classes transitioned to online and modular classes. The pandemic that started in March 2020 is now stretching for more than a year in which prolonged lockdown brings people to experience social isolation and disruption of everyday lifestyle. There is an urgent need to study the psychosocial aspects, particularly those populations that are vulnerable to mental health instability. In the Philippines, where community quarantine is still being imposed across the country, college students face several challenges amidst this pandemic. The pandemic continues to escalate, which may lead to fear and a spectrum of psychological consequences. Universities and colleges play an essential role in supporting college students in their academic, safety, and social needs. The courses of activities implemented by the different universities and colleges may significantly affect their mental well-being status. Our study is particularly interested in the effect of online classes on college students nationwide during the pandemic. The study will estimate this effect on their mental wellbeing since this abrupt transition can lead to depression, stress, or anxiety for some students due to insufficient time to adjust to the new learning environment. The role of social media is also an important exposure to some college students [ 55 , 56 ]. Social media exposure to COVID-19 may be considered a contributing factor to college students’ mental well-being, particularly their stress, depression, and anxiety [ 57 , 58 ]. Despite these known facts, little is known about the effect of transitioning to online learning and social media exposure on the mental health of college students during the COVID-19 pandemic in the Philippines. To our knowledge, this is the first study in the Philippines that will use a mixed-method study design to examine the mental health of college students in the entire country. The online survey is a powerful platform to employ our methods.

Additionally, our study will also utilize a qualitative assessment of the college students, which may give significant insights or findings of the experiences of the college students during these trying times that cannot be captured on our online survey. The thematic findings or narratives from the qualitative part of our study will be triangulated with the quantitative analysis for a more robust synthesis. The results will be used to draw conclusions about the mental health status among college students during the pandemic in the country, which will eventually be used to implement key interventions if deemed necessary. A cross-sectional study design for the online survey is one of our study’s limitations in which contrasts will be mainly between participants at a given point of time. In addition, bias arising from residual or unmeasured confounding factors cannot be ruled out.

The COVID-19 pandemic and its accompanying effects will persistently affect the mental wellbeing of college students. Mental health services must be delivered to combat mental instability. In addition, universities and colleges should create an environment that will foster mental health awareness among Filipino college students. The results of our study will tailor the possible coping strategies to meet the specific needs of college students nationwide, thereby promoting psychological resilience.

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Carfì A , Bernabei R , Landi F , for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020;324(6):603–605. doi:10.1001/jama.2020.12603

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Persistent Symptoms in Patients After Acute COVID-19

• 1 Geriatrics Department, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
• Medical News & Perspectives As Their Numbers Grow, COVID-19 “Long Haulers” Stump Experts Rita Rubin, MA JAMA
• Medical News & Perspectives An Inside Look at a Post–COVID-19 Clinic Kristin Walter, MD, MS JAMA
• Research Letter Clinical Characteristics of Patients with Asymptomatic vs Symptomatic Coronavirus Disease 2019 in Wuhan, China Rongrong Yang, PhD; Xien Gui, MBBS; Yong Xiong, PhD JAMA Network Open
• Observation Sudden and Complete Olfactory Loss of Function as a Possible Symptom of COVID-19 Michael Eliezer, MD; Charlotte Hautefort, MD; Anne-Laure Hamel, MD; Benjamin Verillaud, MD; Philippe Herman, MD, PhD; Emmanuel Houdart, MD, PhD; Corinne Eloit, MD JAMA Otolaryngology–Head & Neck Surgery
• Original Investigation Evolution of Loss of Smell or Taste in COVID-19 Paolo Boscolo-Rizzo, MD; Daniele Borsetto, MD; Cristoforo Fabbris, MD; Giacomo Spinato, MD; Daniele Frezza, MD; Anna Menegaldo, MD; Francesca Mularoni, MD; Piergiorgio Gaudioso, MD; Diego Cazzador, MD; Silvia Marciani, MD; Samuele Frasconi, MD; Maria Ferraro, MD; Cecilia Berro, MD; Chiara Varago, MD; Piero Nicolai, MD; Giancarlo Tirelli, MD; Maria Cristina Da Mosto, MD; Rupert Obholzer, MA, MBBS; Roberto Rigoli, MD; Jerry Polesel, ScD; Claire Hopkins, MBBS JAMA Otolaryngology–Head & Neck Surgery
• Research Letter Assessment of SARS-CoV-2 RNA Test Results Among Patients Who Recovered From COVID-19 With Prior Negative Results Flora Marzia Liotti, PhD; Giulia Menchinelli, PhD; Simona Marchetti, BSc; Brunella Posteraro, PhD; Francesco Landi, MD; Maurizio Sanguinetti, MD; Paola Cattani, MD JAMA Internal Medicine

In Italy, a large proportion of patients with coronavirus disease 2019 (COVID-19) presented with symptoms (71.4% of 31 845 confirmed cases as of June 3, 2020). 1 Common symptoms include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/dysgeusia. 2 - 4 However, information is lacking on symptoms that persist after recovery. We assessed persistent symptoms in patients who were discharged from the hospital after recovery from COVID-19.

In the waning phase of the pandemic, beginning on April 21, 2020, the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome, Italy, established a postacute outpatient service for individuals discharged from the hospital after recovery from COVID-19. All patients who met World Health Organization criteria for discontinuation of quarantine (no fever for 3 consecutive days, improvement in other symptoms, and 2 negative test results for severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] 24 hours apart) were followed up. At enrollment in the study, real-time reverse transcriptase–polymerase chain reaction for SARS-CoV-2 was performed and patients with a negative test result were included.

Patients were offered a comprehensive medical assessment with detailed history and physical examination. Data on all clinical characteristics, including clinical and pharmacological history, lifestyle factors, vaccination status, and body measurements, were collected in a structured electronic data collection system. The COVID-19 postacute outpatient service is currently active, and further details about the patient evaluation protocol are described elsewhere. 5

In particular, data on specific symptoms potentially correlated with COVID-19 were obtained using a standardized questionnaire administered at enrollment. Patients were asked to retrospectively recount the presence or absence of symptoms during the acute phase of COVID-19 and whether each symptom persisted at the time of the visit. More than 1 symptom could be reported. The EuroQol visual analog scale was used to ask patients to score their quality of life from 0 (worst imaginable health) to 100 (best imaginable health) before COVID-19 and at the time of the visit. A difference of 10 points defined worsened quality of life. All analyses were performed using R version 3.6.3 (R Foundation).

This study was approved by the Università Cattolica and Fondazione Policlinico Gemelli IRCCS Institutional Ethics Committee. Written informed consent was obtained from all participants.

From April 21 to May 29, 2020, 179 patients were potentially eligible for the follow-up post–acute care assessment; 14 individuals (8%) refused to participate and 22 had a positive test result. Thus, 143 patients were included. The mean age was 56.5 (SD, 14.6) years (range, 19-84 years), and 53 (37%) were women. During hospitalization, 72.7% of participants had evidence of interstitial pneumonia. The mean length of hospital stay was 13.5 (SD, 9.7) days; 21 patients (15%) received noninvasive ventilation and 7 patients (5%) received invasive ventilation. The characteristics of the study population are summarized in the Table .

Patients were assessed a mean of 60.3 (SD, 13.6) days after onset of the first COVID-19 symptom; at the time of the evaluation, only 18 (12.6%) were completely free of any COVID-19–related symptom, while 32% had 1 or 2 symptoms and 55% had 3 or more. None of the patients had fever or any signs or symptoms of acute illness. Worsened quality of life was observed among 44.1% of patients. The Figure shows that a high proportion of individuals still reported fatigue (53.1%), dyspnea (43.4%), joint pain, (27.3%) and chest pain (21.7%).

This study found that in patients who had recovered from COVID-19, 87.4% reported persistence of at least 1 symptom, particularly fatigue and dyspnea. Limitations of the study include the lack of information on symptom history before acute COVID-19 illness and the lack of details on symptom severity. Furthermore, this is a single-center study with a relatively small number of patients and without a control group of patients discharged for other reasons. Patients with community-acquired pneumonia can also have persistent symptoms, suggesting that these findings may not be exclusive to COVID-19. 6

Clinicians and researchers have focused on the acute phase of COVID-19, but continued monitoring after discharge for long-lasting effects is needed.

Corresponding Author: Angelo Carfì, MD, Centro Medicina dell’Invecchiamento, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy ( [email protected] ).

Accepted for Publication: June 23, 2020.

Published Online: July 9, 2020. doi:10.1001/jama.2020.12603

Author Contributions: Drs Carfì and Landi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Drafting of the manuscript: Carfì, Landi.

Critical revision of the manuscript for important intellectual content: Bernabei, Landi.

Statistical analysis: Carfì.

Supervision: Bernabei, Landi.

Conflict of Interest Disclosures: None reported.

Additional Information: The members of the Gemelli Against COVID-19 Post-Acute Care Study Group are listed in reference 5.

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• Published: 21 September 2024

Changes in the epidemiology of pediatric brain abscesses pre- and post-COVID-19 pandemic: a single-center study

• Yuchen Liu 1 ,
• Zhenjiang Bai 2 ,
• Tianquan Yang 1 ,
• Bin Yuan 1 ,
• Yong Han 1 ,
• Yongjun Xiang 1 ,
• Ruxuan Zhou 1 ,
• Jingxuan Sun 1 ,
• Min Chen 1 ,
• Chuangli Hao 3 &
• Hangzhou Wang 1  

BMC Pediatrics volume  24 , Article number:  600 ( 2024 ) Cite this article

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An increased incidence of brain abscesses was observed post-COVID-19 pandemic. However, it remains unclear how the COVID-19 pandemic influenced the epidemiology of brain abscesses. This study aimed to investigate changes in the epidemiology of brain abscesses pre- and post-COVID-19 pandemic.

A retrospective study of demographic, clinical, radiological, and laboratory characteristics of patients with brain abscesses in Children's Hospital of Soochow University from 2015–2023 was performed.

A total of 34 patients were admitted to the hospital during the study. The post-COVID-19 cohort had an average of 5.5 cases/year, which is a 129.2% increase compared to the pre-COVID-19 cohort's average of 2.4 cases/year. Additionally, the rates of fever upon admission (86.36% vs 50%, p  = 0.04) and experiencing high-grade fever within 6 weeks before admission (40.91% vs 8.33%, p  = 0.044) were significantly increased. A potential rise in the rate of intensive care unit admission was observed (36.36% vs 8.33%, p  = 0.113). The average value of globulin in the post-COVID cohort was significantly higher compared to the pre-COVID cohort (31.60 ± 5.97 vs 25.50 ± 5.08, p  = 0.009). Streptococcal infections were the predominant cause of brain abscesses in both cohorts (40% vs 43.75%, p  = 0.57).

Conclusions

There was a significant increase in the number of brain abscess patients after the COVID-19 pandemic. This underscores the importance of children receiving the streptococcal vaccine.

Peer Review reports

Brain abscess is a localized infection of the central nervous system, characterized by a 20% mortality rate within one year, and survivors may still experience neurological sequelae [ 1 ]. Over the past few decades, a decline in the incidence of brain abscesses has been observed due to factors such as vaccination, correction of early congenital heart defects, and appropriate antimicrobial therapy [ 2 , 3 , 4 ]. However, an increased incidence of brain abscesses was observed post-COVID-19 pandemic.

The COVID-19 pandemic is a global phenomenon, impacting people's lifestyles and social interactions worldwide [ 5 ]. Several studies have indicated that COVID-19 can lead to widespread and enduring immune dysfunction [ 6 , 7 , 8 , 9 , 10 ]. Unfortunately, the incidence of brain abscesses is higher in individuals with immune dysfunction [ 11 ]. In 2022, the American Centers for Disease Control and Prevention (CDC) reported a multicenter study involving 40 children's hospitals, suggesting a possible increasing trend in pediatric brain abscesses following the COVID-19 pandemic [ 12 ].

However, this report still has limitations as it focused only on streptococcal infections and lacked more detailed information due to its reliance on administrative databases. It remains unclear how the COVID-19 pandemic influenced the epidemiology of brain abscesses. The objective of this study was to investigate changes in the epidemiology of brain abscesses pre- and post-COVID-19 pandemic by comparing individuals' demographics, clinical presentations, management strategies, imaging findings, and laboratory tests.

Study design and setting

The Children’s Hospital of Soochow University is the only tertiary children's hospital in Suzhou, China. The hospital provides services to most children in the Suzhou area, admitting more than 70,000 inpatients annually. All patients aged ≤ 18 years with a primary or secondary discharge diagnosis of intracranial abscess, subdural abscess, or extradural abscess from January 2015 to December 2023 were included. This retrospective study was approved by the medical ethics committee at the Children’s Hospital of Soochow University (2024CS061). Due to the retrospective nature of this study, the need for informed consent was waived by the Research Ethics Committee.

COVID-19 pandemic in Suzhou, China

In January 2020, Suzhou reported its first case of COVID-19 and officially implemented a city-wide lockdown on January 24 of the same year. Public places were mandated to close during the lockdown, and residents were encouraged to stay home as much as possible. From January to August 2020, Suzhou reported only 87 cases of COVID-19. However, the reopening of the city in August 2020 led to an abrupt outbreak of COVID-19. It has been reported that after China terminated its zero-COVID policy, 80% of the population was infected by January 22, 2023 [ 13 ]. Although China declared the epidemic to be over in February 2023, widespread outbreaks of influenza A began at that time [ 10 ].

Patient cohort and data collection

Patients are categorized into the pre-COVID-19 cohort if their hospital admission precedes January 1, 2020, and into the post-COVID-19 cohort if their admission follows September 1, 2020. Electronic medical records were reviewed retrospectively to collect basic demographic, clinical, radiological, and laboratory data by clinicians. Clinical data included the patient's history of infections within 6 weeks before admission, symptoms at admission, treatments during hospitalization, and outcomes at discharge. Children under the age of 5 were assessed using the children's Glasgow Coma Scale (GCS), while those over 5 years old were evaluated with the standard GCS [ 14 ]. Fever was classified as an axillary temperature of 37.5 °C or higher, and altered mental status was considered as a GCS score below 15. The criteria for admission to the Intensive Care Unit (ICU) typically include patients in critical condition who require intensive monitoring and treatment. The specific criteria are as follows: (1) Persistent cyanosis with oxygen saturation below 90% despite oxygen therapy or the need for ventilatory support; (2) Patients with concurrent sepsis; (3) Worsening consciousness leading to coma; (4) Patients who underwent emergency surgery due to brain herniation caused by an abscess visible on a cranial CT scan. Outcomes were assessed using the Glasgow Outcome Scale (GOS). A GOS score of 5 was classified as a favorable outcome, while scores of 1–4 were classified as unfavorable. The radiological features of brain abscesses were obtained from the descriptions provided by radiologists in the magnetic resonance imaging (MRI) reports. The laboratory data were obtained from blood routine, biochemistry, and coagulation function tests conducted upon admission.

Statistical analysis

The data were analyzed using SPSS 26.0, and graphical representations were created using Origin 2021. Descriptive statistics were performed using mean and standard deviation for normally distributed continuous variables, the median and interquartile range for continuous variables, and frequency and percentage for categorical variables. Fisher’s exact test, χ 2 -test, Mann–Whitney U test, or t-test were used to compare variables between the pre-COVID-19 and post-COVID-19 cohorts. Two-tailed tests with p  < 0.05 were considered significant.

A total of 34 patients were enrolled. The number of patients with brain abscesses from 2015 to 2023 were 2 (5.9%), 3 (8.8%), 3 (8.8%), 2 (5.9%), 2 (5.9%), 3 (8.8%), 5 (14.7%), 6 (17.6%), and 8 (23.5%), respectively. After the COVID-19 pandemic, a sustained rise in brain abscess cases has been observed, persistently exceeding the average over three consecutive years and culminating in a peak in 2023 (Fig.  1 ).

The annual number of patients with brain abscesses from 2015 to 2023

Patient characteristics

The pre-COVID-19 cohort included 12 (35.3%) patients, at an average rate of 2.4 cases/year, while the post-COVID-19 cohort included 22 (64.7%) patients, at an average rate of 5.5 cases/year. The average of cases/year of the post-COVID-19 cohort increased by 129.2% compared to the pre-COVID-19 cohort. Additionally, the incidence rate of respiratory infections within 6 weeks before admission in the post-COVID-19 cohort was 68.18% (15/22), significantly higher than the 25% (3/12) in the pre-COVID-19 cohort. The distributions of age at admission, sex, body mass index (BMI), and underlying health conditions showed no significant differences between cohorts (Table  1 ).

Overall, there was a marked rise in the number of patients with brain abscesses following the COVID-19 pandemic, with a larger proportion of these patients having a history of respiratory infections.

Clinical presentation and management

The proportion of fever patients in the post-COVID-19 cohort was significantly higher than that in the pre-COVID-19 cohort (86.36% vs 50%, p  = 0.04) (Table  2 ). In addition, 40.91% (9/22) of patients in the post-COVID-19 cohort experienced high-grade fever within 6 weeks before admission, which was significantly higher than the 8.33% (1/12) observed in the pre-COVID-19 cohort (Fig.  2 ).

Comparison of fever occurrence within 6 weeks before admission for patients before and after the COVID-19 pandemic. If the maximum temperature within 6 weeks before admission of patients was < 37.5 °C, it was considered a normal temperature; ≥ 39 °C was categorized as a high-grade fever, otherwise it was categorized as a low-grade fever

Moreover, after the COVID-19 pandemic, patients appeared to exhibit more clinical symptoms and required a greater extent of treatment (Fig.  3 ).

Comparisons of clinical symptoms and treatments for patients before and after the COVID-19 pandemic

Radiological and laboratory data

MRI of the brain examined all patients. Among them, brain abscesses were located in the parietal lobe in 10/34 (29.41%), in the occipital lobe in 2/34 (5.88%), in the frontal lobe in 4/34 (11.76%), in the temporal lobe in 7/34 (20.59%), in the deep brain structures in 3/34 (8.82%), in the epidural space in 3/34 (8.82%), and 5/34 (14.71%) had multiple brain abscesses. At the time of diagnosis, the median cross-sectional area of brain abscesses in the pre-COVID-19 cohort was 5.64 cm 2 (IQR:4.34, 11.89), compared to 7.12 cm 2 (IQR: 2.02, 23.68) in the post-COVID-19 cohort (Table  3 ).

All patients underwent blood routine, biochemistry, and coagulation function tests upon admission. The median C-reactive protein was 28.31 mg/L (IQR: 10.56, 67.69) and the median white blood cell count was 11.06 × 10 9 /L (IQR: 9.57, 14.13), showing similar in both cohorts. The average value of globulin (GLB) in the post-COVID cohort was significantly higher compared to the pre-COVID cohort (31.60 ± 5.97 vs 25.50 ± 5.08, p  = 0.009). Similar laboratory test results from both cohorts are presented in the Supplementary Table  1 . Abscess cultures were performed in 26/34 cases (76.47%). The most frequent organism identified was Streptococcus (42.31%). In 46.15% of cases, cultures remained sterile after the patients had already been on antibiotics. Blood cultures were performed in 28/34 cases (82.35%). Only 3/31 cases (15%) yielded positive results, all of which were in the post-COVID cohort (Table  3 ).

Previous epidemiological studies of brain abscesses reported an incidence ranging from 0.4 to 0.9 cases per 100,000 individuals [ 15 , 16 ]. However, in this retrospective study, it was observed that the annual hospital admission rates for brain abscesses more than doubled following the COVID-19 pandemic compared to the period prior. Moreover, patients appeared to exhibit more clinical symptoms and required a greater extent of treatment.

Increase in brain abscess patients post-COVID-19 pandemic

An increase in the number of brain abscesses was also observed in both the American and European populations [ 12 , 17 , 18 , 19 ]. Our research additionally offers corroborative evidence, particularly in the Chinese population. The study conducted by the American CDC reported an increase in cases starting from the summer of 2021. By March 2022, the cases had peaked before starting to decline. Ultimately, the CDC concluded that these trends were within historical norms [ 12 ]. However, until the end of the study period, we also did not observe a declining trend. This could potentially be attributed to the American study's exclusive focus on streptococcal infections. Additionally, respiratory virus infections were found to be associated with pediatric invasive bacterial infections [ 20 , 21 ]. The continued presence of widespread respiratory infections in China following the COVID-19 pandemic, including influenza, respiratory syncytial virus (RSV), and adenovirus, may contribute to the increased incidence of brain abscesses [ 22 , 23 ]. This underscores the need to enhance the management of patients with respiratory infections and maintain early vigilance for potential central nervous system infections.

Heightened severity of brain abscess patients post-COVID-19 pandemic

In this study, patients in the post-COVID-19 cohort were observed to present more clinical symptoms, consistent with findings from American and European studies [ 18 , 19 ]. In our study, further investigation revealed increases in the proportion of ICU admissions and repeated neurosurgical interventions. This may indicate that the presentation of patients with brain abscesses became more severe post-COVID-19 pandemic. Previous studies also indicated that neurological complications were associated with severe COVID-19 disease in hospitalized children [ 24 , 25 ]. This appears to account for the heightened need for ICU admissions for mechanical ventilation support among patients with brain abscesses.

Regarding laboratory tests, consistent with similar studies, no significant changes were observed in CRP levels and WBC counts in patients following the COVID-19 pandemic. Continuing our analysis of other blood test results, it was interesting to find that patients with brain abscesses exhibited higher levels of GLB. GLB is a protein produced by immune organs, consisting of various pro-inflammatory proteins, and reflects the immune status [ 26 ]. A high GLB level during infection may suggest a more severe or active immune response to infection [ 27 ]. However, due to the limited existing research, the pathophysiological mechanisms underlying the exacerbation of symptoms in brain abscesses associated with GLB remain unclear and require further investigation.

Potential associations between the COVID-19 pandemic and Brain abscesses

Epidemiological changes in brain abscesses following the COVID-19 pandemic were observed. However, due to the limitations of the study, causality cannot be confirmed. We have speculated on several reasons for the increased incidence of brain abscesses in populations after the COVID-19 pandemic.

Induction of immune dysfunction

Several studies have indicated the potential for SARS-CoV-2 infection to persist in the body for several months [ 28 ]. Unfortunately, immune dysfunction can be induced under conditions of persistent viral infection. Current evidence suggests that in acute cases of SARS-CoV-2 infection, both the number and functional activity of dendritic cells (DC) are significantly reduced, and DC dysfunction may persist long-term [ 6 ]. Furthermore, COVID-19 patients may experience a decrease in natural killer cell count, leading to immune dysfunction [ 7 ]. Additionally, even patients with mild or moderate COVID-19 may experience immune dysfunction, which may last for up to eight months [ 9 ]. SARS-CoV-2 infection may lead to immune dysfunction, potentially increasing the risk of developing brain abscesses.

Impact on trained immunity

Recent studies have indicated that frequent exposure to various pathogens and subsequent "training" can enhance the effectiveness of innate immunity [ 29 ]. Following the COVID-19 outbreak, strict public health measures were implemented worldwide, including social distancing, mask-wearing, hand hygiene, and stay-at-home orders. These non-pharmaceutical interventions (NPIs) led to reduced exposure of children to specific pathogens associated with brain abscesses, potentially resulting in decreased immune training. Consequently, this may lower innate immunity in children, rendering a higher proportion of the population more susceptible to subsequent occurrences of brain abscesses.

Streptococcal vaccination delayed

Nearly half of the brain abscesses in our study were associated with streptococci. A study from Italy reported that streptococcal vaccination can effectively reduce the incidence of brain abscesses [ 4 ]. However, during the COVID-19 pandemic, many countries implemented lockdown policies. The strict NPIs resulted in almost all immunization programs being affected [ 30 ]. The American CDC reported a 21.5% decrease in childhood vaccination coverage in 2020 [ 31 ]. Moreover, vaccination rates did not fully recover after the end of the lockdown period. Therefore, the decrease in streptococcal vaccine coverage could be one of the contributing factors to the rising incidence of brain abscesses.

This limited study was conducted at a single institution with a small sample size, affecting the power of the statistical analysis. Despite the apparent rise in ICU admission rates, the increase did not reach statistical significance, highlighting the need for multi-center studies with larger sample sizes. Additionally, after China lifted lockdown policies, there was a successive outbreak of respiratory infections caused by various pathogens, making it challenging for many patients to recall whether they had experienced SARS-CoV-2 infection. We were unable to establish a direct association between COVID-19 and brain abscesses. Regarding laboratory testing, the majority of abscess cultures did not undergo high-throughput sequencing, leading to a lack of microbiological characteristic-related data. Furthermore, many patients lacked immunological examinations, limiting us to analyzing changes in patients' immune cell levels.

The most crucial aspect of this study is demonstrating the increase in the number of brain abscess patients compared to before the COVID-19 pandemic. This suggests the need to strengthen awareness of streptococcal vaccination. Furthermore, a further multicenter cohort study is needed to clarify whether children with brain abscesses after the COVID-19 pandemic exhibit more symptoms and have higher ICU admission rates.

Availability of data and materials

The data are available from the corresponding author upon reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Non-pharmaceutical interventions

Glasgow Coma Scale

Glasgow outcome scale

Magnetic resonance imaging

Interquartile range

Standard deviation

Body mass index

Intensive care unit

C-reaction protein

White blood cell

Respiratory syncytial virus

Dendritic cells

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The authors thank all the patients and colleagues in the Children’s Hospital of Soochow University for supporting this study.

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Yuchen Liu, Tianquan Yang, Bin Yuan, Yong Han, Yongjun Xiang, Ruxuan Zhou, Jingxuan Sun, Min Chen & Hangzhou Wang

Pediatric Intensive Care Unit, Children’s Hospital of Soochow University, Suzhou, Jiangsu, 215006, China

Zhenjiang Bai

Department of Respiratory Medicine, Children’s Hospital of Soochow University, Suzhou, Jiangsu, 215006, China

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Liu, Y., Bai, Z., Yang, T. et al. Changes in the epidemiology of pediatric brain abscesses pre- and post-COVID-19 pandemic: a single-center study. BMC Pediatr 24 , 600 (2024). https://doi.org/10.1186/s12887-024-05082-6

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Impact of COVID-19 on Life of Students: Case Study in Hong Kong

1 Centre for Health Education and Health Promotion, The Chinese University of Hong Kong, 4/Floor, Lek Yuen Health Centre, Shatin, Hong Kong, China; kh.ude.khuc@gnuekarev (V.M.W.K.); kh.ude.khuc@ualtnecniv (V.T.C.L.); kh.ude.khuc@gnuehcnivlac (C.K.M.C.); kh.ude.khuc@olailema (A.S.C.L.)

2 School of Public Health, Prince of Wales Hospital, Shatin, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, 4/Floor, School of Public Health, Prince of Wales Hospital, Shatin, Hong Kong, China

Vera M. W. Keung

Vincent t. c. lau, calvin k. m. cheung, amelia s. c. lo, associated data.

Not applicable.

COVID-19 has an impact on the day-to-day life of students, with school closure and detrimental effects on health and well-being that cannot be underestimated. A study collected data reflecting the health and well-being of secondary school students entering a programme entitled “Healthy Life Planning: Assist Students to Acquire and Practice Health Knowledge and Skills” (ASAP study) in September and October 2019 before the outbreak of COVID-19. Follow-up data were collected in June and July 2020, over half a year since the spread of COVID-19, which facilitated analyses of its impact on the health behaviours and well-being of young people. Comparative analyses between baseline and the follow-up period were conducted on weight status, sleep pattern and quality, pattern of sedentary lifestyle, pattern of physical activity, attitudes and perceived barriers for exercise, and hand hygiene. Attitudes toward precautionary measures and influenza vaccination, self-reported changes in hygiene practices, exercise habits and eating habits were analysed. Although hygiene habits and risk perceptions among young people have improved in many aspects, the level of physical activity has declined as well as the beliefs and attitudes on increasing time on electronic media and change in sleep hygiene. Attitudes and beliefs towards influenza vaccination have declined, which would reflect the slow increase in the uptake rate of COVID-19 vaccination. Health education should equip students with the knowledge and skills to cultivate beliefs and attitudes to face health challenges.

1. Background and Introduction

Since the COVID-19 pandemic was declared, lockdown measures have been implemented in many parts of the world. Implementation of physical measures to interrupt or reduce the spread of respiratory viruses based on sustained physical distancing, restriction of social gathering, and “shut-down” measures has a strong potential to reduce the magnitude of the peak of the COVID-19 pandemic [ 1 ].

However, impacts on other aspects of health must not be underestimated. A study during the semi-lockdown period has shown males with BMI 24 or above had lost weight, but all other subjects had gained weight as a result of a significant decline in the amount of moderate or vigorous exercise [ 2 ]. Obesity has been shown to increase the risk of mortality of COVID-19 after adjusting for confounding factors such as age in different parts of the world [ 3 ].

A study by Fong et al. in 2020 found that 65.3% of participants experienced increased stress due to staying at home and 29.7% experienced moderate to severe levels of depressive symptoms; increases in the use of electronic devices and decreases in outside activities were positively associated with a higher level of depression severity [ 4 ]. Studies have also found increasing prevalence of obesity [ 5 ] and myopia [ 6 ] among school children due to longer screen times, lack of physical activity, and living in small, crowded living and learning spaces at home. Increasing physical activity and maintaining a healthy diet, leading to positive changes to their physical health, have also been shown to be associated with better mental health [ 7 , 8 ]. Non-communicable diseases such as cardiovascular diseases, chronic lung diseases, cancer and diabetes are still constituting the main health burdens of society [ 9 ]. The main drivers for an unhealthy diet and lack of physical activity would be a lack of places and opportunities to be physically active and industries’ opposition to public health interventions [ 10 ]. Behavioural, environmental and occupational, and metabolic risks can explain half of the global mortality and more than one-third of global disability-adjusted life year (DALY) [ 11 ]. A substantial burden of global cardiovascular disease morbidity and mortality is attributable to a sedentary lifestyle, and the attributable burden of high BMI has increased in the past 23 years; physical inactivity and unhealthy eating are the key underlying causes [ 11 ].

COVID-19 also has an impact on the day-to-day life of students with school closures [ 12 ]. Results of one study have shown a dramatic decline in assessment during COVID-19 in schools, suggesting lower performance when students start school in 2020 [ 13 ]. Schools may need to leverage decision-making frameworks, such as the Multi-Tiered Systems of Support/Response-to-Intervention (MTSS/RTI) framework [ 14 ] to identify needs and target instruction where it matters most when school begins in late 2020. During the first half of the academic year in 2020 in Hong Kong, schools were closed during the spring term with online learning, with half-day sessions in the summer term before closure again due to a third wave in July 2020 in Hong Kong. Schools reopened after the summer break in September 2020, with half-day sessions, and closed again in early December 2020 due to the fourth wave. Schools reopened in February 2021 with half-day sessions. The government has imposed restrictions on social gathering including numbers of people grouped together and the operation of restaurants and recreation facilities. Many recreation facilities including public utilities were closed or operated under strict control of people flow periodically in 2020. There is a need to study the impact of COVID-19 on student life with disruption of usual school life and social interaction during that period.

The Centre for Health Education and Health Promotion of the Chinese University of Hong Kong (CHEHP) has pioneered the Healthy School/Health Promoting School (HPS) movement in Hong Kong and neighbouring countries over the last two decades [ 15 , 16 ]. It has developed many initiatives, making use of the HPS framework to improve the health literacy of students [ 15 ]. Recently, it launched the ASAP study (Healthy Life Planning: Assist Students to Acquire and Practice Health Knowledge and Skills) to enrich the knowledge and skills of students on a variety of health-related matters. The ASAP Project provided health educational materials covering nine teaching units designed for junior secondary schools. Topics covered sleep hygiene, infectious disease control, travellers’ health, physical activity, body image, stress management, etc. From these, teachers chose one or more units for school-based curriculum enrichment. They were also required to develop experiential learning activities for students based on the topics they have taught. Students might conduct project learning on them as well.

The impact of COVID-19 on the lives of students who received the ASAP program is being studied. The aim of this study is to investigate the impact of COVID-19 on student health and well-being by collecting data reflecting the health and well-being of students at the entry of ASAP (before COVID-19 outbreak), then at a yearly interval (after the outbreak), to analyse any changes.

2. Materials and Methods

2.1. study design.

For this case study, comparative analyses between baseline and follow-up periods were conducted to identify potential changes in students’ weight status, sleep pattern and quality, pattern of sedentary lifestyle, pattern of physical activity, attitudes and perceived barriers for exercise, and hand hygiene. The attitudes toward precautionary measures to COVID-19 and influenza vaccination, self-reported changes in daily living habits, exercise habits, eating habits and hygiene practices were analysed.

The study has been approved by the Survey and Behaviour Research Ethics Committee (SBRE-19-104). The surveys were anonymous. The participating schools have obtained consent from parents and students and students’ participation was entirely voluntarily with no adverse repercussions.

2.2. Study Population

The study targeted students studying in grades between Secondary 1 (S1) and Secondary 3 (S3), aged about 11–15 years.

2.3. Sample Population

Eleven secondary schools in Hong Kong that participated in the ASAP study were invited to the pre-and-post questionnaire survey. School teachers were allowed to use the teaching materials provided by the programme to enrich their health-related curricula such as Physical Education, Technology and Living, Biology, and the school-based health curriculum. The teaching materials covered various health contents such as physical activities, sleep hygiene, stress management, body image, infectious disease control, dental health, the prevention of prolonged use of electronic devices, etc. At least one grade between S1 and S3 of the participating schools was beneficial to the study and eligible for the survey. A total of 1355 students studying in the selected grades were invited, and 1102 completed two administrations of the questionnaire, giving a response rate of 81.3%. The survey was anonymous and used the class number of each responding student to match the questionnaires completed in two administrations in September and October 2019 (baseline) and June and July 2020 (follow-up), respectively.

2.4. Measuring Tools

The Hong Kong Student Health Survey Questionnaire (HKSHQ) was used to collect data reflecting lifestyles, including hygiene practice and general health status. HKSHQ adopts a system of surveillance of student health status, taking reference from the US Centres for Disease Control and Prevention (CDC) Youth Risk Behavioural Surveillance (YRBS) [ 17 , 18 ] and Wessex Healthy School Award [ 19 ], which has been used by CHEHP [ 20 , 21 , 22 ] with continuous refinement as a tool for assessing student health status and health-related outcomes [ 16 ].

The parameters on demography include date of birth, gender, and self-rated health status (3 questions). The survey also uses the Family Affluence Scale (FAS), which was utilised to reflect the economic status of the respondents’ family from the following criteria (4 questions): the number of vehicles owned by the respondent’s family; whether the respondent has a separate bedroom; the number of family trips; and the number of computers owned by the family [ 23 , 24 ]. The Pittsburgh Sleep Quality Index was utilised to measure sleep quality [ 25 ].

Self-reported body weight of students was classified into wasting, desirable, and obese according to the weight-for-height charts in a local guide to childhood growth and nutrition assessment by Leung [ 26 ]. The charts are gender-specific, in which obesity is defined as body weight values above 120% of the median weight-for-height, while wasting is defined as body weight values below 80% of the median weight-for-height. When the body height value of a subject exceeds the data available in the charts, Body Mass Index (BMI) cut-offs for Asian adult populations are used to interpret the subject’s body weight, where a value between 18.5 kg/m 2 and 22.9 kg/m 2 is considered normal [ 27 ].

The Theory of Planned Behaviour by Ajzen [ 28 ] was applied in this survey to assess the attitudes and perceived behavioural control on physical activity ( Appendix A ). Similarly, the study also assessed the attitudes and perceived behavioural control on the uptake of influenza vaccination. COVID-19 vaccination was not available at the time of data collection, so their attitudes towards influenza vaccination would help us understand their perspectives on vaccination. Since follow-up data were collected during the COVID-19 pandemic, questions reflecting the respondents’ risk perception (such as the wearing of face masks, hand hygiene, social distancing, actions taken with suspected symptoms) were added to the questionnaire.

The Rosenberg Self-esteem Scale (RSE) by Morris Rosenberg was adopted in this survey to evaluate self-esteem in teenagers at the baseline of the study [ 29 , 30 ]. Leung and Wong [ 31 ] studied the validity and reliability of the Chinese translation of the RSE and gave recommendations on the Chinese wordings in some of the items. The current study adopted the Chinese translations recommended by Leung and Wong for item 3 (“I feel like a person who has a number of good qualities”), 7 (“I feel that I am a person of worth, at least on an equal plane with others”) and 8 (“I wish that I could have more respect for myself”) to optimise the reliability. The RSE and the Theory of Planned Behaviours [ 28 ] give a complete description of the non-cognitive development of the participants and a clear indication of the effects of the interventions in developing the habit of doing exercise and receiving a flu vaccine to prevent them from being infected.

The Mental Toughness Scale for Adolescents (MTS-A) by McGeown, St. Clair-Thompson and Putwain [ 32 ] was adopted in this survey to examine the mental toughness of teenagers before and after the interventions. The scale is an 18-item Likert scale with items answered on a four-point scale from “strongly disagree” to “strongly agree”. The concept of mental toughness in adolescents includes six domains: challenge, interpersonal confidence, confidence in abilities, emotion control, control of life, and commitment. Three statements describe each of the above domains in the teenager context, and respondents have to indicate how strongly they agree or disagree with each sentence. The author of MTS-A has granted the research team permission to use the scale supplemented with the Chinese translation.

2.5. Data Collection

The study collected data reflecting the health and well-being of students at the beginning and then at a yearly interval to monitor any changes. The baseline data were collected in September and October 2019 at the beginning of the academic year before the outbreak of COVID-19, and follow up data were collected in June and July 2020, half a year after its outbreak.

2.6. Data Analysis

The McNemar test was used to determine if there were differences among dichotomous dependent variables (such as whether the subjects had played ball games over the last seven days) between pre and post groups. Paired t-test was used for similar purposes but for comparing the means of continuous dependent variables (such as the subjects’ attitude score toward physical activities). A difference was considered statistically significant if the p -value was <0.05. Data were analysed by SPSS Statistics, version 25.0.

3. Findings

Table 1 describes the background demographic characteristics of the subjects, including socioeconomic status. The subjects had an average age of 13.28 years at baseline and 13.99 years at follow-up (standard deviation: 1.07 year). Sixty percent (60.2%) of them were female because two participating schools were girls’ schools, while the other nine were co-education. The subjects came from schools in urban settings, semi-urban settings and satellited towns.

Demographic characteristics of the subjects (N = 1102).

a Semi-urban setting b Urban setting. c Satellite towns (evolved from rural areas to urban setting).

About 50% of students came from the middle affluence group and about one-quarter from either high or low affluence groups. Most of the schools in this study are located in districts with monthly median domestic household incomes below the overall median level in Hong Kong. The sample is not skewed towards higher socioeconomic groups.

Results of the current study show that the proportion of students classified as obese decreased from 23.0% to 20.5% and 13.3% to 12.0% among male and female students, respectively. The changes were not statistically significant.

The percentage of students engaged in 60 min of moderate to vigorous exercise decreased with statistical significance from 40.8% to 30.1%, particularly those rigorous activities taking place in groups or in public, or vigorous activities such as running and jogging, ball games, swimming, playground activities, skating, and martial arts ( Table 2 ). The item “stretching” was added to the post-test questionnaire. Over one-fourth of students (26.6%) reported that they had done some stretching during the seven days before the post-survey, but no baseline data were available for direct comparison.

Level of physical activity.

Footnote . The item “stretching” was added to the post-test questionnaire. Over one-fourth of students (26.6%) reported that they had done some stretching during the seven days before the post-survey, but no baseline data were available. McNemar Test was performed. Arrows indicate the direction of significant changes. NS: non-significant.

Higher proportion of students spent more than two hours on an average school day watchng video programmes as well as internet surfing (not for academic purpose) on both ordinary school days and during holiday with statistical significance ( Table 3 ). The percentage of students who perceived no influence on the prolonged use of electronic media increased, and those who perceived eye fatigue and shoulder discomfort reduced ( Table 3 ). However, an increased impact on their concentration and study was reported with statistical significance ( Table 3 ). The proportion of students going to bed after 11:00 pm increased from 43.5% to 66.1%, and that of students getting up after 8:00 am increased from 10.0% to 32.9% with statistical significance, though sleep quality was not affected significantly ( Table 3 ). Self-reported handwashing behaviours improved, with a higher proportion of students washing hands thoroughly and a smaller proportion not taking handwashing seriously with statistical significance ( Table 4 ).

Time spent on electronic media (non-academic purpose) and sleep time.

Footnote . McNemar Test was performed except for comparing the average sleep hours and the scores of Pittsburgh Sleep Quality Index (PSQI). A PSQI score above 5 indicates poor sleep quality in the respondent. Paired t-test was performed to compare means. Arrows indicate the direction of significant changes. NS: non-significant.

Self-reported handwashing behaviours (number of valid cases = 971).

Footnote . McNemar Test performed. Arrows indicate the direction of significant changes.

Table 5 shows the changes in attitudes and beliefs towards physical activities from baseline to follow-up. The decline is observed in the goal of action, attitudes, subjective norm, perceived behavioural control, behavioural beliefs and norm beliefs with statistical significance. The behavioural intention and control beliefs also declined, although statistical significance was not detected.

Attitudes and beliefs toward physical activities.

Footnote . Paired t-test was performed to compare means. NS: non-significant.

Regarding the changes in attitudes and beliefs towards influenza vaccination from baseline to follow-up, Table 6 shows a decline in all domains with statistical significance, particularly behavioural intention and subjective norm and perceived behavioural control. Students are a target group for influenza vaccination in Hong Kong. Table 7 shows that a high proportion of students would continue wearing face masks and handwashing, but there was a lower proportion for other hygiene measures. This is reflected by just over half of students (54.9%) reporting a significant change in hygiene habits. More than half of students (52.8%) reported a decrease in physical activities such as running and walking, and 41.2% reported fewer ball games, and only a low proportion of students reported having participated in other physical activities such as outdoor activities ( Table 7 ). Although students tend to eat healthier at home, this proportion (55.0%) is not very high, and less than one-fifth of students (17.5%) had a significant change in eating habits ( Table 7 ).

Attitudes and beliefs toward influenza vaccination.

Footnote . Paired t-test was performed to compare means.

Change in health and hygiene behaviours during COVID-19.

Table 8 shows students’ intention to maintain precautionary measures over the next three months post-test. The majority of students would continue to wear a face mask and be meticulous about handwashing, in line with findings of current practices, shown in Table 6 . About half of the students would like to see a relaxation on physical distancing and restriction of gathering to allow more interaction. Students have a higher risk perception of respiratory symptoms; they would not go to school or activities and would only continue if no fever and reporting symptoms ( Table 8 ).

Intention to maintain precautionary measures over next three months post-test.

4. Discussion

The decline in the level of physical activity and the prolonged use of electronic media, with increasing effects on students’ learning, concentration, and sleep pattern (going to bed late and getting up late), are worrying ( Table 2 and Table 3 ). Socioecological models state that a person’s health status is not only influenced by individual behaviours, but also by factors situated in a person’s environment [ 33 , 34 ]. The concept of “environment” captures multiple dimensions, and a Built Environment (BE) can be defined broadly as “the human-made space in which people live, work and recreate on a day-to-day basis” [ 35 ]. During the COVID-19 pandemic, the BE has been altered due to various preventive and lockdown measures. It not only encompasses green spaces and parks, but also includes the internal environment and social capital (defined as social networks and interactions that inspire trust and reciprocity among citizens) [ 36 ]. The social environment, part of the BE, refers to factors such as social support and social networks, social deprivation, and social cohesion and systems [ 37 ]. BE shapes individual health behaviour through diverse mechanisms and can be adverse or beneficial for health [ 38 ]. Neighbourhoods that are more walkable, either leisure-oriented or destination-driven, are associated with increased physical activity, increased social capital, lower overweight rates, lower reports of depression, and less reported alcohol use [ 39 ]. Better street connectivity or walkability tended to be positively related to increased physical activity and walking [ 40 ].

One study has found that adolescents undertook more physical activity during lockdown if they had stronger prior physical activity habits, but some were unsure of what to do when they did not have instruction from a coach. Some adolescents reported that physical activity became a method of entertainment during lockdown, and this mindset change increased the level of physical activity [ 41 ]. Living space is very limited in Hong Kong, making physical activity at home not feasible for many young people. Online coach-led physical activity sessions have helped encourage and support adolescents to follow online exercise routines [ 41 ]. The implementation of lockdown measures and school closures has a significant impact on the BE, not only in terms of walkability and connectivity but also in terms of social connectivity and support. Apart from the effect on physical activities, we must not underestimate its negative effect on other aspects of health, such as psycho-social well-being, as a result of the impact of COVID on the BE diminishing social capital. This might be reflected by less positive beliefs and attitudes towards physical activities ( Table 5 ). Around half of the students reported a decreased frequency of walking or running and ball games without much increase in other types of indoor physical activities ( Table 7 ).

Although staying at home should enable students to eat healthier, this proportion is not high and less than 20% of students had a significant change in eating habits ( Table 7 ). Previous studies have revealed a low level of physical activities and healthy eating among secondary students [ 42 , 43 ]. COVID-19 might have worsened these conditions.

Some previous studies stated that lockdown and school closures might exacerbate childhood obesity [ 44 ] and cause unhealthy changes to the diet of students [ 45 , 46 ]. Past studies also support the claim that when students are not in school, they tend to have less healthy diets [ 47 ]. The findings of our survey showed similar results, with 29.2% students consuming unhealthy takeaway food, and one-fifth of students having increased consumption of soft drinks (20.2%), desserts (19.8%) and crispy food (19.7%). However, over half of the students (55.0%) indicated that they had healthier meals at home, and 38.6% of them consumed more fresh fruits, implying that the COVID-19 pandemic might have brought not only negative impacts but also some positive changes to the diet of students. Such positive changes may partly be explained by the fact that before the pandemic, most secondary students in Hong Kong consumed their lunch at nearby restaurants or fast food shops when they had whole-day classes on average school days [ 14 ]. School suspension as well as the fear of infection drove students to stay home for food, while lockdown and work-from-home arrangements also allowed more parents to prepare meals for their children. Further studies are required to investigate whether such changes will lead to any changes in childhood obesity in Hong Kong.

The percentage of students who perceived no influence on the prolonged use of electronic media increased, but those who perceived eye fatigue and shoulder discomfort reduced ( Table 3 ). This may be due to adaptation. However, prolonged use had an impact on their studies and concentration as well as sleep pattern ( Table 3 ).

It is encouraging to observe the improvement in hand hygiene reflected by more serious handwashing ( Table 4 ). However, it is disappointing and alarming to find the decline in beliefs and attitudes, including motivation and perceived control, towards influenza vaccination with statistical significance (most showing p-value lower than 0.001) ( Table 6 ). This could be due to school suspension during the pandemic, and so, they perceived having a lower risk of being infected. However, the scores at baseline were already low, which makes it difficult to identify a further significant decline. This might reflect the weak perception of the beneficial effect of influenza vaccination. It might also account for the slow increase in the uptake of COVID-19 vaccination in Hong Kong [ 48 ], which is also observed in other parts of the world [ 49 ]. Previous studies on predictive factors of influenza vaccination suggested that factors related to health belief models such as perceived adverse effects and efficacy and advice given by health care professionals are determinant factors for the uptake of vaccination [ 50 , 51 ].

The uptake rate of COVID-19 vaccines in Hong Kong is still unsatisfactory, despite the availability and accessibility of the vaccine. There is room for improvement to enhance the health beliefs and attitudes towards vaccines for preventing the disease. A study on the acceptance of the COVID-19 vaccine found that people who perceived the seriousness of the infection, vaccine conferring benefits, and received calls to action were significantly more likely to accept the vaccine [ 52 ]. Conversely, perception of barriers to accessibility and potential harm of the vaccine were found negatively to be associated with their acceptance. Recommendation by the government stood out as the most important cue. Public health intervention programmes focusing on increasing the perception of the benefits of vaccination and perceived susceptibility to infection while reducing the identified barriers should be warranted [ 53 ]. The study also revealed that the public values efficacy and safety more than the cost of vaccines. Another study in the US found that a greater likelihood of COVID-19 vaccine acceptance was associated with more knowledge about vaccines, less acceptance of vaccine conspiracies, elevated COVID-19 threat appraisals, and being up to date with influenza immunisation [ 49 ]. The other demographic predictors of a likelihood of being vaccinated against COVID-19 were higher income group (income of USD 120,000 or higher) and being a Democrat (in comparison to the reference category Republican), and respondents relying on social media for information about COVID-19 anticipated a lower likelihood of COVID-19 vaccine acceptance. More public health interventions targeting those factors facilitating and hindering uptake should be put in place.

The closure of schools during COVID-19 could result in the loss of opportunity to foster positive beliefs and attitudes in students towards influenza vaccination. It could also have an impact on the low uptake rate of COVID-19 vaccination. From the findings of this study, there is room to enhance the perception of the benefits of vaccination against infectious disease in students, particularly before pandemics and the potential consequences if not vaccinated. Health education should cultivate a positive and supportive culture to support family members and friends to receive the vaccination. Health literacy includes access and analysing health information and problem solving such as breaking the barriers to access these services. This would help to improve the acceptance and uptake rate. A recent study in Hong Kong has found a higher level of vaccine acceptance among the youngest adult group (age 18 to 24), which would be due to better exposure to vaccine education and receiving the free vaccine at birth [ 52 ]. Findings from this study have shown that students perceived the importance of wearing face masks in public places, were meticulous about handwashing and highly vigilant with regard to respiratory symptoms ( Table 8 ). Risk perceptions are a critical determinant of health behaviour, and the profile of risk perceptions and accuracy of perception would affect the association between risk perceptions and health behaviours [ 54 ]. Although a high level compliance of facemask wearing was observed and more people maintained social distancing and used alcohol hand rub during the pandemic, decreasing willingness to accept the COVID-19 vaccines was also observed. This might be associated with increasing concerns about vaccine safety and growing compliance of personal protection behaviours [ 55 ]. Therefore, the concept of “ASAP” should be adopted for school curriculum development to assist students in acquiring and practicing health knowledge and skills, including health risk perception and preventive measures for infectious diseases from a broader perspective that includes vaccination.

A substantial proportion of students expressed their wishes to relax social distancing and restriction of gathering ( Table 8 ). Although measures such as closing and restricting most places where people gather in smaller or larger numbers for extended periods (businesses, bars, schools and so on) are most effective, they can cause substantial collateral damage to society, the economy, trade and human rights [ 56 ]. This study has shown the collateral damage to students’ health and well-being and their health beliefs and attitudes. The COVID-19 pandemic has also been found to lead to an increase in myopia among young children in Hong Kong; the prevalence of myopia among school-age children during the pandemic has increased significantly compared to a study conducted before the outbreak [ 57 ]. Prolonged exposure to screens and less time spent outdoors were linked to faster progress in myopia, according to researchers. One study found several highly effective measures that are less intrusive, including land border restrictions, governmental support to vulnerable populations and risk-communication strategies [ 58 ]. Therefore, governments and other stakeholders should consider adopting non-pharmaceutical interventions tailored to the local context when infection numbers surge (or surge a second time) before choosing those intrusive options. Less drastic measures may also foster better compliance from the population [ 52 ].

There are limitations to this study. The subjects are participants of the ASAP study, not a random sample of secondary students. The demography of the students is not markedly different from the demography of students in Hong Kong. They do not skew towards particular demographic characteristics except for the subjects’ gender as two schools are girls’ schools while the others are co-education.

There is a potential bias that they are more health-conscious and have better knowledge and more positive attitudes towards health. Most of the schools are located in districts with median monthly household income below the median in Hong Kong. The sample is not skewed towards higher socioeconomic groups. The students should be more resilient towards the impact of COVID-19 on healthy living. The findings of the study that reflect the beliefs, attitudes, perceived control, and behaviours of students under the pandemic have significant implications. There is an assumed hypothesis that students with better health literacy will maintain positive health beliefs and positive attitudes and behaviours towards healthy living. The findings will help to test this assumption and shed light on which aspects of their beliefs, attitudes and behaviours can be sustained under adverse conditions (such as COVID-19) and how young people should be supported further, notwithstanding that they might have enriched knowledge and skills in health.

Another limitation is the lack of a control group. It is technically difficult to engage more students and schools to participate in the survey under the COVID-19 situation. Moreover, there will not be a perfect control group as schools and students cannot be controlled to receive information and skills enhancement to fight against COVID-19. However, the study has included studies on belief, perceived barriers of control, and attitudes. The findings would partially explain why students behave in a particular way during the COVID-19 period. The global impact of the COVID-19 pandemic has not been experienced for nearly a century. Data reflecting the impact on students’ life would provide useful insights for combating similar challenges in the near future.

5. Conclusions

The current study reveals the changes in physical activities, hygiene and dietary behaviours in Hong Kong adolescents between September 2019 and July 2020, when the novel coronavirus disease (COVID-19) started to hit many parts of the world, resulting in the pandemic. These changes include less moderate and rigorous physical activities, and the attitudes and beliefs of students towards physical activities have become less positive and less persistent. Although hygiene habits and risk perceptions among young people have improved in many aspects, attitudes and beliefs towards influenza vaccination have declined, which would reflect the slow increase in the uptake rate of COVID-19 vaccination. This study has shown the changes in students’ health behaviours, beliefs and attitudes. Health education targeting young people and the public should equip them with the knowledge and skills to cultivate beliefs and attitudes and this would have impact on risk perceptions and behaviours to face health challenges.

Acknowledgments

We would also like to thank the school teachers for using the teaching materials provided by the ASAP study and facilitating students to complete the survey.

• Attitude (4 items): “My taking regular physical activity over the next six months would be…” (harmful to beneficial; unpleasant to pleasant; unenjoyable to enjoyable) and “My attitude towards doing physical activity is…” (from very negative to very positive)
• Perceived Barrier Control (2 items): “For me to exercise for at least 60 minutes every day for the next fortnight will be…” (from very easy to very difficult) and “I am confident that I can accumulate 60 minutes of physical activity every day in the next two weeks.” (from strongly disagree to strongly agree)

Author Contributions

Conceptualization, A.L. and V.M.W.K.; methodology and analysis, V.M.W.K. and V.T.C.L.; writing—original draft preparation, A.L.; writing—reviewing and editing, V.M.W.K., C.K.M.C. and A.S.C.L. All authors have read and agreed to the published version of the manuscript.

Keung M.W., Cheung K.M. and Lau T.C. were supported by a grant from the Quality Education Fund (QEF 2017/1070) awarded to Lee A. QEF was established in 1998 by the Government of the Hong Kong Special Administrative Region for educational initiatives and projects within the ambit of school education of Hong Kong, including kindergarten, primary, secondary and special education.

Institutional Review Board Statement

The survey was approved by the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong (SBRE-19-104).

Informed Consent Statement

School consent was obtained from each participating school.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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