Coronavirus Disease (COVID-19): Socio-Economic Systems in the Post-Pandemic World: Design Thinking,

Frontiers eBook Copyright Statement

The copyright in the text of individual articles in this eBook is the property of their respective authors or their respective institutions or funders. The copyright in graphics and images within each article may be subject to copyright of other parties. In both cases this is subject to a license granted to Frontiers.

The compilation of articles constituting this eBook is the property of Frontiers. Each article within this eBook, and the eBook itself, are published under the most recent version of the Creative Commons CC-BY licence. The version current at the date of publication of this eBook is CC-BY 4.0. If the CC-BY licence is updated, the licence granted by Frontiers is automatically updated to the new version.

When exercising any right under the CC-BY licence, Frontiers must be attributed as the original publisher of the article or eBook, as applicable.

Authors have the responsibility of ensuring that any graphics or other materials which are the property of others may be included in the CC-BY licence, but this should be checked before relying on the CC-BY licence to reproduce those materials. Any copyright notices relating to those materials must be complied with.

Copyright and source acknowledgement notices may not be removed and must be displayed in any copy, derivative work or partial copy which includes the elements in question.

All copyright, and all rights therein, are protected by national and international copyright laws. The above represents a summary only. For further information please read Frontiers’ Conditions for Website Use and Copyright Statement, and the applicable CC-BY licence.

ISSN 1664-8714 ISBN 978-2-88974-597-5 DOI 10.3389/978-2-88974-597-5

About Frontiers

Frontiers is more than just an open-access publisher of scholarly articles: it is a pioneering approach to the world of academia, radically improving the way scholarly research is managed. The grand vision of Frontiers is a world where all people have an equal opportunity to seek, share and generate knowledge. Frontiers provides immediate and permanent online open access to all its publications, but this alone is not enough to realize our grand goals.

Frontiers Journal Series

The Frontiers Journal Series is a multi-tier and interdisciplinary set of open-access, online journals, promising a paradigm shift from the current review, selection and dissemination processes in academic publishing. All Frontiers journals are driven by researchers for researchers; therefore, they constitute a service to the scholarly community. At the same time, the Frontiers Journal Series operates on a revolutionary invention, the tiered publishing system, initially addressing specific communities of scholars, and gradually climbing up to broader public understanding, thus serving the interests of the lay society, too.

Dedication to Quality

Each Frontiers article is a landmark of the highest quality, thanks to genuinely collaborative interactions between authors and review editors, who include some of the world’s best academicians. Research must be certified by peers before entering a stream of knowledge that may eventually reach the public - and shape society; therefore, Frontiers only applies the most rigorous and unbiased reviews. Frontiers revolutionizes research publishing by freely delivering the most outstanding research, evaluated with no bias from both the academic and social point of view. By applying the most advanced information technologies, Frontiers is catapulting scholarly publishing into a new generation.

What are Frontiers Research Topics?

Frontiers Research Topics are very popular trademarks of the Frontiers Journals Series: they are collections of at least ten articles, all centered on a particular subject. With their unique mix of varied contributions from Original Research to Review Articles, Frontiers Research Topics unify the most influential researchers, the latest key findings and historical advances in a hot research area! Find out more on how to host your own Frontiers Research Topic or contribute to one as an author by contacting the Frontiers Editorial Office: frontiersin.org/about/contact

CORONAVIRUS DISEASE (COVID-19): SOCIO-ECONOMIC SYSTEMS IN THE POST-PANDEMIC WORLD: DESIGN THINKING, STRATEGIC PLANNING, MANAGEMENT, AND PUBLIC POLICY

Topic Editors: Andrzej Klimczuk, Warsaw School of Economics, Poland Eva Berde, Corvinus University of Budapest, Hungary Delali A. Dovie, University of Ghana, Ghana Magdalena Klimczuk-Kochańska, University of Warsaw, Poland Gabriella Spinelli, Brunel University London, United Kingdom

Citation: Klimczuk, A., Berde, E., Dovie, D. A., Klimczuk-Kochańska, M., Spinelli, G., eds. (2022). Coronavirus Disease (COVID-19): Socio-Economic Systems in the Post-Pandemic World: Design Thinking, Strategic Planning, Management, and Public Policy. Lausanne: Frontiers Media SA. doi: 10.3389/978-2-88974-597-5

Table of Contents

06 Editorial: Coronavirus Disease (COVID-19): Socio-Economic Systems in the Post-Pandemic World: Design Thinking, Strategic Planning, Management, and Public Policy Andrzej Klimczuk, Eva Berde, Delali A. Dovie, Magdalena Klimczuk-Kochanska and Gabriella Spinelli

11 Impact of Social Determinants of Health on the Emerging COVID-19 Pandemic in the United States Sravani Singu, Arpan Acharya, Kishore Challagundla and Siddappa N. Byrareddy

21 New Architectural Viewpoint for Enhancing Society’s Resilience for Multiple Risks Including Emerging COVID-19 Izuru Takewaki

25 With Corona Outbreak: Nature Started Hitting the Reset Button Globally Ashwani Kumar, Muneer Ahmad Malla and Anamika Dubey

35 Unemployment, Employability and COVID19: How the Global Socioeconomic Shock Challenged Negative Perceptions Toward the Less Fortunate in the Australian Context Aino Suomi, Timothy P. Schofield and Peter Butterworth

45 COVID-19 Pandemic: Socio-Economic Consequences of Social Distancing Measures in Italy Vincenzo Auriemma and Chiara Iannaccone

53 Fear of Virus or of Competitors? The Decision Rationales of Financial Managers Under COVID-19 Jinlu Sun, Ting Wu and Bo Chen

58 Intervention and Improved Well-Being of Basic Science Researchers During the COVID 19 Era: A Case Study Santosh Kumar, Sunitha Kodidela, Asit Kumar, Kelli Gerth and Kaining Zhi

70 The Discounted Money Value of Human Life Losses Associated With COVID-19 in Mauritius

Laurent Musango, Ajoy Nundoochan and Joses Muthuri Kirigia

80 Predicting Hospital Demand During the COVID-19 Outbreak in Bogotá, Colombia

Claudia Rivera-Rodriguez and Beatriz Piedad Urdinola

88 Role of Railway Transportation in the Spread of the Coronavirus: Evidence From Wuhan-Beijing Railway Corridor Rucheng Liu, Dan Li and Sakdirat Kaewunruen

100 Individual Behaviors and COVID-19 Lockdown Exit Strategy: A Mid-Term Multidimensional Bio-economic Modeling Approach

Ahmed Ferchiou, Remy Bornet, Guillaume Lhermie and Didier Raboisson

113 COVID-19: Technology, Social Connections, Loneliness, and Leisure Activities: An International Study Protocol

Hannah R. Marston, Loredana Ivan, Mireia Fernández-Ardèvol, Andrea Rosales Climent, Madelin Gómez-León, Daniel Blanche-T, Sarah Earle, Pei-Chun Ko, Sophie Colas, Burcu Bilir, Halime Öztürk Çalikoglu, Hasan Arslan, Rubal Kanozia, Ulla Kriebernegg, Franziska Großschädl, Felix Reer, Thorsten Quandt, Sandra C. Buttigieg, Paula Alexandra Silva, Vera Gallistl and Rebekka Rohner

128 Patient Flow Dynamics in Hospital Systems During Times of COVID-19: Cox Proportional Hazard Regression Analysis

Sudhir Bhandari, Amit Tak, Sanjay Singhal, Jyotsna Shukla, Ajit Singh Shaktawat, Jitendra Gupta, Bhoopendra Patel, Shivankan Kakkar, Amitabh Dube, Sunita Dia, Mahendra Dia and Todd C. Wehner

135 E-Leadership and Teleworking in Times of COVID-19 and Beyond: What We Know and Where Do We Go

Francoise Contreras, Elif Baykal and Ghulam Abid

146 Impact of the Healthcare System, Macro Indicator, General Mandatory Quarantine, and Mask Obligation on COVID-19 Cases and Death in Six Latin American Countries: An Interrupted Time Series Study

Adriana Poppe

160 Return-to-School Evaluation Criteria for Children With Suspected Coronavirus Disease 2019

Vasiliki Vlacha and Gavriela Maria Feketea

164 Spatial Autocorrelation and the Dynamics of the Mean Center of COVID-19 Infections in Lebanon

Omar El Deeb

174 Precision Regulation Approach: A COVID-19 Triggered Regulatory Drive in South Korea

Sora Lee and Woojin Kang

178 Transparency in Negotiation of European Union With Big Pharma on COVID-19 Vaccines

Salvatore Sciacchitano and Armando Bartolazzi

184 Socio-Economic Implications of COVID-19 Pandemic in South Asia: Emerging Risks and Growing Challenges

Golam Rasul, Apsara Karki Nepal, Abid Hussain, Amina Maharjan, Surendra Joshi, Anu Lama, Prakriti Gurung, Farid Ahmad, Arabinda Mishra and Eklabya Sharma

198 Data on an Austrian Company’s Productivity in the Pre-Covid-19 Era, During the Lockdown and After Its Easing: To Work Remotely or Not?

Michal Beno and Jozef Hvorecky

208 Covid-19 Response From Global Makers: The Careables Cases of Global Design and Local Production

Barbara Kieslinger, Teresa Schaefer, Claudia Magdalena Fabian, Elisabetta Biasin, Enrico Bassi, Ricardo Ruiz Freire, Nadine Mowoh, Nawres Arif and Paulien Melis

225 Telework and Lifelong Learning

Cecilia Bjursell, Ingela Bergmo-Prvulovic and Joel Hedegaard

233 Global Healthcare Resource Efficiency in the Management of COVID-19 Death and Infection Prevalence Rates

Marthinus C. Breitenbach, Victor Ngobeni and Goodness C. Aye

242 Rethinking the Epidemiogenic Power of Modern Western Societies

Annabelle Lever and Lou Safra

247 Global Agri-Food Sector: Challenges and Opportunities in COVID-19 Pandemic

Saima Hamid and Mohammad Yaseen Mir

258 Compilation and Application of the Scale of Sustainable Knowledge Sharing Willingness in Virtual Academic Community During the Times of the Coronavirus Pandemic (COVID-19)

Huaruo Chen, Fei Liu, Ya Wen, Ling Ling and Xueying Gu

TYPE Editorial

PUBLISHED 30September2022

DOI 10.3389/fcomm.2022.1034562

OPENACCESS

EDITEDANDREVIEWEDBY StaceyConnaughton, PurdueUniversity,UnitedStates

*CORRESPONDENCE

AndrzejKlimczuk klimczukandrzej@gmail.com

SPECIALTYSECTION

Thisarticlewassubmittedto OrganizationalCommunication, asectionofthejournal FrontiersinCommunication

RECEIVED 01September2022

ACCEPTED 06September2022 PUBLISHED 30September2022

CITATION

KlimczukA,BerdeE,DovieDA, Klimczuk-KochanskaMandSpinelliG (2022)Editorial:Coronavirusdisease (COVID-19):Socio-economicsystems inthepost-pandemicworld:Design thinking,strategicplanning, management,andpublicpolicy. Front.Commun. 7:1034562. doi:10.3389/fcomm.2022.1034562

COPYRIGHT

© 2022Klimczuk,Berde,Dovie, Klimczuk-KochanskaandSpinelli.This isanopen-accessarticledistributed underthetermsofthe Creative Commons AttributionLicense(CCBY) The use,distributionorreproduction inotherforumsispermitted,provided theoriginalauthor(s)andthecopyright owner(s)arecreditedandthatthe originalpublicationinthisjournalis cited,inaccordancewithaccepted academicpractice.Nouse,distribution orreproductionispermittedwhich doesnotcomplywiththeseterms.

AndrzejKlimczuk1* , Eva Berde2,DelaliA.Dovie3 , MagdalenaKlimczuk-Kochanska4 andGabriellaSpinelli5

1 DepartmentofPublicPolicy,CollegiumofSocio-Economics,SGHWarsawSchoolofEconomics, Warsaw,Poland, 2 DepartmentofMicroeconomics,DemographyandEconomicsResearchCentre, CorvinusUniversityofBudapest,Budapest,Hungary, 3 CentreforAgeingStudies,Universityof Ghana,Accra,Ghana, 4 FacultyofManagement,UniversityofWarsaw,Warsaw,Poland, 5 Brunel DesignSchool,BrunelUniversityLondon,Uxbridge,UnitedKingdom

KEYWORDS

coronavirusdisease(COVID-19),ecosystems,futureofhealthandhealthcare, internationalsecurity,publichealth,publicpolicy

EditorialontheResearchTopic

Coronavirusdisease(COVID-19):Socio-economicsystemsin thepost-pandemic world:Designthinking,strategicplanning, management,andpublicpolicy

Overview

ThedeclarationoftheCOVID-19pandemicbytheWorldHealthOrganizationon March11,2020,ledtounprecedentedevents.Allregionsoftheworldparticipatedin implementingpreventivehealthmeasuressuchasphysicaldistancing,travelrestrictions, self-isolation,quarantines,andfacilityclosures.Thepandemicstartedglobaldisruption ofsocio-economicsystems,coveringthepostponementorcancellationofpublicevents, supplyshortages,schoolsanduniversities’closure,evacuationofforeigncitizens,arisein unemploymentandinflation,misinformation,theanti-vaccinemovement,andincidents ofdiscriminationtowardpeopleaffectedbyorsuspectedofhavingcoronavirusdisease. Attemptshavebeenmadetoprotecttheoldestagegroupatrisk,butinmanycases,this hasledtoover-restrictionandagediscrimination.

TherationaleforworkingontheResearchTopic“Socio-economic systemsinthepost-pandemicworld:Designthinking,strategicplanning, management,andpublicpolicy”wastheneedtostartreflectingon resilienceandlessonslearnedfromthispublichealtheventthatrevealed theglobalunpreparednessincriticalareas.Also,thepandemictriggered

Editorial:Coronavirusdisease (COVID-19):Socio-economic systemsinthepost-pandemic world:Designthinking,strategic planning,management,and publicpolicy

bothtop-down(e.g.,policytoolstowardlabormarkets) andbottom-up (e.g.,socialandtechnologicalinnovationsin education)responsesthatneededmorein-depthanalyzes.

ThisResearchTopiccoversinterdisciplinarycontributions addressingnewthinking,challenges,andtransformations requiredforpost-pandemicglobal,national,regional,and localrealities.ThepresentedResearchTopiccombinesstudies focusedonrecognizingtheactionsandinterventionsleading totherecoveryofsocio-economicsystemsduringthetailend andafterthepandemic.Thestudiesdeliveredrecommendations regarding,amongothers,thecareofvulnerable,planningsocioeconomicrestart,andimaginingthe“newnormal.”

ThepresentedResearchTopicincludes27articlesprepared by113authorsfromallcontinents.Thissetoftextscontains seventypesofpaperscovering:14originalresearcharticles (BenoandHvorecky; Bhandarietal.; Bjurselletal.; Breitenbach etal.; ElDeeb; Ferchiouetal.; Kieslingeretal.; Liuetal.; Musangoetal.; Poppe; Rasuletal.; Rivera-Rodriguezand Urdinola; Suomiet al.; Chenetal.),twoperspectivearticles (LeeandKang; Takewaki),fourreviewarticles(Contrerasetal.; Kumar,Mallaetal.; Singuetal.; HamidandMir),onestudy protocolarticle (Marstonetal.),threeopinionarticles(Lever andSafra; SciacchitanoandBartolazzi; VlachaandFeketea),one conceptualanalysis article(AuriemmaandIannaccone),and twobriefresearchreports(Kumar,Kodidelaetal.; Sunetal.).

Theeditorshaveidentifiedsixthemesunderpinningand linkingtogetherthefinallyselectedpapers.Theidentifiedmacro themeshelptodistinguishthemaincontributionfocusandthe areasofapplicationofthepublishedresearch.However,these studiesarealsoatestimonyofthepandemic’simpactoneach andeverysignificantaspectofoursocieties.

ThemeI:Resourcemanagementof healthcaresystemsandpublichealth strategies

Thisthemecoverspapersthatexploretheinterrelationships betweensocio-economicconditions,publichealthstrategies, andthepreparednessofhealthcaresystemsduringthe pandemic.Forexample, Singuetal. explorethelinkbetween populationcharacteristicsandtheemergenceandtransmission ofCOVID-19intheUnitedStates,focusingonsocial determinantsandtheirimpactonhealthoutcomes.Thepaper by Poppe focusesonreconsideringtheefficacyofpublic health strategiesusedindevelopedcountriesindifferentsocioeconomicsettings,suchasLatinAmerica,whereinformal andcasualemploymentmaybeprevalent.Thisstudyreveals thatpublichealthpolicieshavevaryingdegreesofadherence, henceefficacy,dependingoncountry-relatedmacroeconomic indicators.Similarly,thepaperby Musangoetal. highlights theimportanceofexistingpopulationcharacteristicsandsocioeconomiccontextswhencalculatingthevaluemoneyofthe

deathtollinMauritius.Thestudyappliesahumancapital approachtodetermineatotaldiscountedmoneyvalueforthe humanliveslostinthecountry.

SeveralpapersinthisResearchTopichavemodeledpossible responsestotheCOVID-19pandemicinthecontextof informeddecision-makingandresourceallocation.Inthe articleby Ferchiouetal.,simulationisusedtofigureout pandemicpreventativemeasuresforvariouspopulationgroups andtransmissionrates.Themodelleadstotheidentification ofseverallockdownstrategiesandrecommendationsfor policymakersregardingbiosecuritycompliancethatmay beachievablebymonitoringgeneralpopulationbehavior. Anothermodelingstudyby Rivera-RodriguezandUrdinola was conductedto supportpolicymakersindevelopingcountries, suchasColombia,todecidewhatpublichealthtools,e.g., lockdown,shouldbedevelopedbasedontheforeseeableneeds ofintensivecareunitbeds. Bhandarietal. applyhazard modelingto forecastthedemandforhospitalbedsduringthe pandemic,lookingattheimpactofselectedpopulationvariables. Afinalcontributionthatusedmodeling,particularlytechnical efficiencyanalysis,isby Breitenbachetal. Thisworkaimsto determinetheefficiencyrateincountry-specificresponseto COVID-19.Theanalysiswasundertakenoverasampleof36 countriesrepresenting90%oftheglobalinfectioncasesand consideredpandemic-relatedinfectionanddeathcasesinthe computation.Thedevelopedmodelhighlightedthatdespite allocatingresourcesforhealthcaresystems,theefficiencyis likelytodegradeduetothelackofasystematicapproachin respondingtothecriticalchallengesraisedbythepandemic.

ThemeII:COVID-19andregulatory issues

The COVID-19stateofemergencyraisedpressureon regulatory frameworksworldwideduetotheurgentdemand forthedevelopmentofeffectivepolicytoolsnotonlyrelatedto health(Bentonetal.,2020).Thepaperby LeeandKang shows that theauthoritiesneededtoaddressthechallengeofmanaging variousformsofregulationsrelatedtoCOVID-19inpeople’s everydaylives.Forexample,SouthKoreahasimplemented streamlinedfast-trackservicesforthebiotechnologyindustry toproducetestkitsswiftly.Thementionedstudyfocuses ontheprecisionregulationapproachthatdeliverstheright regulationmethodsfortherightgroupofpeopleattheright time.Anotheressentialregulationissuethat Sciacchitanoand Bartolazzi underlineis theimportanceoftransparencyin negotiatingCOVID-19 vaccineproductionandfinalvaccine price.Transparencycouldhelpavoidmisconceptionsand strengthenthecollaborationbetweenhealthcaresystemsin EuropeanUnioncountries.Transparencyisalsoessentialto avoid“vaccinenationalism,”whichunderminesglobalefforts toensurefairaccesstovaccinesforeveryoneandfacilitates

thedevelopmentofviralmutations.Accordingtothestudy by Lever andSafra,oneofthemostnoticeablereactionsof governmentsto COVID-19hasbeentoimposelockdownsand restrictionsonfreedomofmovementandassociation.These decisionscanbetemporarymeasurestocontrolormitigate thespreadoftheepidemicwhilewaitingforthevaccineto bedeveloped.However,pharmacologicalsolutionsshouldnot preventconsideringtheendogenousfactorsinthesocieties whichhelpedcatalyzethispandemic.

ThemeIII:Environmentale ects

OneoftheinitialobservationsrelatedtotheCOVID-19 pandemicwasitsimpactontheenvironmentandsustainability management(Barreiro-Genetal.,2020). Kumar,Mallaet al. show thatsocietiesandtheenvironmenthavewitnessed apparentpositive andnegativeimpactsoflockdowns.Closures offacilitiesandmovementrestrictionsalteredenergydemand patternsandcausedaneconomicdownturn.Suchasituation providedunprecedentedinsightsintothedynamicsofnatural andbuiltenvironmentsthatcanleadtoviableconservation pathsandhelpcreatenewrecoveryenvironmentalpathways. Anotherstudyby ElDeeb presentsthespreadoftheCOVID19infectioninLebanon.Theauthorshowsthatcombining andunderstandingthedisease’sspatial,demographic,and geographicaspectsovertimeallowsforregionallyandlocally adjustedhealthpoliciesandmeasuresthatcouldprovidehigher socialandhealthsafety.Thecontributionfrom Liuetal. aims toanalyze thepotentialspreadofthecoronavirusthrough railtransport.Theauthorsalsopresentrecommendationsfor controllingthespreadofthediseaseinWuhan,China.The studytakesintoaccounttheeffectivenessofcontrolmeasures suchaslockdown,theuseofmasks,sanitization,andsocial distancingforrailwayauthoritiesandpassengers.Inthestudy by Takewaki,“resilience”inarchitectureandengineeringhas beeninvestigatedprimarilyintermsofconventionalnatural disasterrisks.Thepapershowsthatarchitecturaldesigners andengineershaveanimportantmandatetothinkaboutthe functionsofbuildingsandtheirsurroundingsinthedisease spread.Finally, HamidandMir provideacloserlookatthefood andtheagriculturesectorthatwashitbylockdownsandmarket shutdownswhichhaveendangeredthesupplyofagricultural andfooditemsacrosscountryborders.Especiallyfoodsecurity andsupplychainstabilityhasbeenaffectedinemergingandless developedcountries.

ThemeIV:Macrosocio-economic e ects

The COVID-19pandemichasalsoimpactedvariousareas ofsocio-economicdevelopmentby,forexample,arisein

economicuncertaintyandchallengestomonetarypolicy,fiscal policy,andtradepolicy(McKibbinandFernando,2021).The paperby Rasuletal. showsthatSouthAsianstateshave encountereda challengingsituationculminatingfrom,among others,alargepopulation,inadequatehealthfacilities,high povertyrates,lowsocio-economicconditions,andlimited accesstowaterandsanitation.Theneedtocontainthe COVID-19spreadhasledtolockdownswitheffectson economicgrowth,increasingthefiscaldeficit,monetaryburden, andmacroeconomicinstability.Accordingto Auriemmaand Iannaccone,theadoptionoflockdownshasprecipitatedsocioeconomicdevelopmentbygeneratingradicalchangesindaily lifeatthenational,supranational,andinternationallevels. Forexample,inItaly,thesuspensionofcommercialactivities ledtoasearchforsmartemploymentsolutionsbutalsoto thedigitaldivideandnewformsofrelationships.Thestudy by Marstonetal. showsthatusingdigitaltechnologiesisan alternativeto maintainingeconomicandsocialactivitiesduring physicaldistancingadherence.Thepaperdescribeshowthe pandemicimpactedsocialinteractions,includingtheassociation oftheuseofdigitaltechnologieswithpsychologicalwellbeing andlevelsofloneliness.Anothersideoftechnology-related issueshasbeeninvestigatedby Kieslingeretal.,whostudied thelackofmedicalhardwaresuppliesduringtheCOVID-19 pandemic.Thissituationledtomoresignificantinnovationin healthcaresystems,especiallythelocalproductionofCOVID19-complianthealthcareproducts(e.g.,faceshieldsandmedical supplies),withimplicationsforreducingdependencieson internationalsupplychainsandmainstreammassproduction.

ThemeV:Laborand employment-relatedchallenges

TheCOVID-19pandemiccausedashockforthelabor marketsworldwide,includingchangesinworkforcemobility, workreorganization,andapplyingvariouslabormarket policymeasurestodecreasetheriskofmassunemployment (InternationalLabourOrganization,2020).Thecontribution by Sunet al. isbasedonasurveyamongfinancialmanagers before thecoronavirusdiseasepeakedinChina.Theauthors analyzedthemanagers’copingstrategies,theriskperception directlycausedbyCOVID-19,andtheindirecteffectthatrefers tomanagers’fearthattheywillnotmaketimelyadjustments. Contrerasetal. explainthatcompanieshadtoswitchfrom physical presencetoteleworkfromonemomenttothenext. Theexistingknowledgeofteleworkingande-leadershipplayed acrucialroleinthereorganizationprocess.Asaresult,the leadingcompaniesinthisfieldhaveenjoyedaconsiderable advantageinbuildingnewproductionstructuresandreaching advantagesinthemarket. Kumar,Kodidelaetal. writethatthe combinationof decreasedproductivityandstayingathomeis likelytocompromisewellbeingbycausingstressandanxiety.

However,organizingvirtualsessionstolearnaboutworkers’ motivation andlistentotheirexperimentshelpeddecrease perceivedandCOVID-19-relatedstressscores.Also,thestudy by Suomietal. showedthatthedifferenceinperceptionsofthe employedand unemployedwasattenuatedduringCOVID-19, withbenefittingrecipientsperceivedasmoreemployableand conscientiousthaninthepre-pandemicperiod.Theseresults addtoknowledgeaboutthedeterminantsofwelfarestigma, highlightingtheimpactoftheglobaleconomicandhealth crisisontheperceptionofothers.Finally, BenoandHvorecky surveyedcompaniesshortlybeforetheepidemic.Giventhe situation,theydecidedtorepeatthesurveyduringadifferent phaseofapandemictofindouttheeffectivenessofe-working andthecausesofdecreasedworkproductivity.

ThemeVI:Education-related challenges

The COVID-19pandemichasalsoimpactedrisk management ineducationalinstitutions,forexample,mental healthmaintenance,staffmobilitycontrol,andonlineeducation schemes(TadesseandMuluye,2020). VlachaandFeketea underlinethatthespreadofCOVID-19andotherwinterrelatedcommon viralinfectionsmayco-existwhileprevalent amongchildren.Resultantly,theremaybeconsequencesfrom children’slackofschoolattendancerangingfromfamily’s financialsecuritytosupportthechildren’seducationalneeds andemotionalwellbeingwithimplicationsforchildcarefor affectedparents.Inessence,thereisaneedforthechildrento attendschoolregularlyandyetfacilitatestudents’protection fromCOVID-19. Bjurselletal. showthatthepandemichas alsoimpactedparticipationinlifelonglearning,withdifferences betweenagegroups,nations,sectors,andprofessions.While astudyby Chenetal. analyzesshiftsinacademicactivities fromoffline toonlineand/orvirtualoperations.Theresearch focusesonsustainableknowledge-sharingwillingnessinvirtual academiccommunities.

Conclusion

ThestudiespresentedinthisResearchTopicallow identifyingat leasteightdirectionsforfurtherinvestigations. Theseare:(1)digitalinnovations,includingartificialintelligence androboticsolutionsaswellasinnovationpolicyinthe publichealthandhealthsector;(2)tensionsbetweennational

andinternationalhealthpoliciesandregulations;(3)redesign andresilienceinthetradepolicies,transportsystems,and supplychains;(4)emergingtransformationsandinequalities atthelabormarkets;(5)planning,management,governance, andevaluationofgovernmentalinterventionsrelatedtothe pandemic(seealso Dunlopetal.,2020);(6)comparativepublic policystudiesfocusingondifferencesacrossnationsandpolicy transfer(seealso LiuandGeva-May,2021);(7)impactofthe pandemicon trustandriskmanagementandcommunication; and(8)theadvancementsintheusageofdesignthinking, co-production,co-design,socialinnovation,andcitizenscience.

Authorcontributions

AlleditorsofthisResearchTopichavecontributedtothis Editorialaswellastotheselectionandreviewofthepapers acceptedinthisResearchTopic.Allauthorslistedhavemadea substantial,direct,andintellectualcontributiontotheworkand approveditforpublication.

Acknowledgments

Wewanttothankalltheauthorsandthereviewerswho contributedto thepresentedarticleResearchTopicfortheir dedicationtoourtopicsandtotheirreadinesstosharetheir knowledgeandtime.Wealsogivethankstothealwayshelpful Frontiersteam,whoseorganizationalskillsandunderstanding madethisResearchTopicpossible.

Conflictofinterest

Theauthorsdeclarethattheresearchwasconductedinthe absence ofanycommercialorfinancialrelationshipsthatcould beconstruedasapotentialconflictofinterest.

Publisher’snote

Allclaimsexpressedinthisarticlearesolelythoseofthe authorsanddonotnecessarilyrepresentthoseoftheiraffiliated organizations,orthoseofthepublisher,theeditorsandthe reviewers.Anyproductthatmaybeevaluatedinthisarticle,or claimthatmaybemadebyitsmanufacturer,isnotguaranteed orendorsedbythepublisher.

10.3389/fcomm.2022.1034562

References

Barreiro-Gen,M.,Lozano,R.,andZafar,A.(2020).Changesinsustainability prioritiesinorganisationsduetotheCOVID-19outbreak:avertingenvironmental reboundeffectsonsociety. Sustainability 12,125031.doi:10.3390/su1212 5031

Benton,D.,Alexander,M.,Fotsch,R.,andLivanos,N.(2020).Lessonslearned andinsightsgained:aregulatoryanalysisoftheimpacts,challenges,andresponses toCOVID-19. Onl.J.Iss.Nurs. 25,No03PPT51.doi:10.3912/OJIN.Vol25No03P PT51

Dunlop,C.A.,Ongaro,E.,andBaker,K.(2020).Researching COVID-19:aresearchagendaforpublicpolicyandadministration scholars. Publ.Pol.Admin. 35,365–383.doi:10.1177/095207672093 9631

InternationalLabourOrganization(2020). ILOMonitor:COVID-19andthe WorldofWork.7thEdn.Geneva:InternationalLabourOrganization.Available onlineat: https://www.ilo.org/global/topics/coronavirus/impacts-and-responses/ WCMS_767028/lang--en/index.htm (accessedSeptember20,2021).

Liu, Z.,andGeva-May,I.(2021).ComparativepublicpolicyanalysisofCOVID19asanaturallyoccurringexperiment. J.Comparat.Pol.Anal.Res.Practice 23, 131–142.doi:10.1080/13876988.2021.1894074

McKibbin,W.,andFernando,R.(2021).Theglobalmacroeconomicimpactsof COVID-19:sevenscenarios. AsianEcon.Pap. 20,1–30.doi:10.1162/asep_a_00796

Tadesse,S.,andMuluye,W.(2020).TheimpactofCOVID-19pandemic oneducationsystemindevelopingcountries:areview. JSS 8,159–170. doi:10.4236/jss.2020.810011

published:21July2020 doi:10.3389/fpubh.2020.00406

Editedby: DelaliA.Dovie, UniversityofGhana, Ghana

Reviewedby: MarielaDeliverska, MedicalUniversity-Sofia,Bulgaria MagdalenaSyrkiewicz-Switala, MedicalUniversityofSilesia,Poland

*Correspondence: SiddappaN.Byrareddy sid.byrareddy@unmc.edu

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 22May2020

Accepted: 09July2020 Published: 21July2020

Citation: SinguS,AcharyaA,ChallagundlaK andByrareddySN(2020)Impactof SocialDeterminantsofHealthonthe EmergingCOVID-19Pandemicinthe UnitedStates. Front.PublicHealth8:406. doi:10.3389/fpubh.2020.00406

ImpactofSocialDeterminantsof HealthontheEmergingCOVID-19 PandemicintheUnitedStates

SravaniSingu 1 ,ArpanAcharya 1 ,KishoreChallagundla 2 andSiddappaN.Byrareddy 1,2,3*

1 DepartmentofPharmacologyandExperimentalNeuroscience,UniversityofNebraskaMedicalCentre,Omaha,NE, UnitedStates, 2 DepartmentofBiochemistryandMolecularBiology,UniversityofNebraskaMedicalCentre,Omaha, NE,UnitedStates, 3 DepartmentofGenetics,CellBiology,andAnatomy,UniversityofNebraskaMedicalCentre,Omaha,NE, UnitedStates

Anovelcoronavirus(2019-nCoV)causedaglobalpandemicinthemonths followingthefirstfourcasesreportedinWuhan,China,onDecember29,2019. Theelderly,immunocompromised,andthosewithpreexistingconditions—suchas asthma,cardiovasculardisease(CVD),hypertension,chronickidneydisease(CKD), orobesity—experiencehigherriskofbecomingseverelyillifinfectedwiththevirus. Systemicsocialinequalityanddiscrepanciesinsocioeconomicstatus(SES)contribute tohigherincidenceofasthma,CVD,hypertension,CKD,andobesityinsegments ofthegeneralpopulation.Suchpreexistingconditionsbringheightenedriskof complicationsforindividualswhocontractthecoronavirusdisease(COVID-19)fromthe virus(2019-nCoV)—alsoknownas“severeacuterespiratorysyndromecoronavirus2” (SARS-CoV-2).Inordertohelpvulnerablegroupsduringtimesofahealthemergency, focusmustbeplacedattherootoftheproblem.Studyingthesocialdeterminantsof health(SDOH),andhowtheyimpactdisadvantagedpopulationsduringtimesofcrisis, willhelpgovernmentstobettermanagehealthemergenciessothateveryindividual hasequalopportunitytostayinghealthy.Thisreviewsummarizestheimpactofsocial determinantsofhealth(SDOH)duringtheCOVID-19pandemic.

Keywords:SDOH,SARS-CoV-2,COVID-19,socialinequality,publichealth,food,economy,education

INTRODUCTION

Thenovelcoronavirus(2019-nCoV)spreadrapidlythroughoutChinaduringtheChineseNew YearinlateJanuaryof2020,atimeofincreaseddomesticandinternationaltravelforChinese people.ThefirstfourcasesofthenovelcoronaviruswerereportedonDecember29,2019.Allfour caseswerelinkedtotheHuananSeafoodWholesaleMarketinWuhan,acitywithmorethan11 millionpeopleandthecapitalofHubeiprovinceincentralChina.Thesymptomsweredescribed asapneumoniaofunknownetiology(1).Earlycasesshowhistoryofcontactwiththeseafood market.Laterandmorerecentcaseswerefoundtobetransmittedviahuman-to-humancontact (2).Thediseasecausedby2019-nCoVwasnamedCOVID-19bytheWorldHealthOrganization (WHO)onFebruary11,2020(3).TheCDCconfirmedthatindividualswithpreexistingdiagnoses ofasthma,cardiovascular(CVD),hypertension,chronickidneydisease(CKD)and/orareelderly, immunocompromised,orobesehavehigherriskofsevereillnessfromCOVID-19(4).Ofthe listedat-riskhealthdemographics,asthma,CVD,hypertension,CKD,andobesitycanbecausedby

discrepanciesinsocioeconomicstatus(SES).TheCDCreports that94%ofpatientswho havediedfromCOVID-19hadat leastonepreexistingcondition(5).Becausetheseconditions specificallyputanindividual athigherriskofbeinginfected withSARS-CoV-2,thesevulnerablepopulationsmustbegiven theresourcesneededtoendureinfectiousoutbreaks.This reviewsummarizestheimpactofsocialdeterminantsofhealth (SDOH)duringapandemicofCOVID-19.Itcanprovide essentialinformationtosupportthegovernment’sdecisionmakingbodytostrategicallymanagehealthemergenciesat community,national,andeveninternationallevelsinthefuture ifasimilarsituationwastoarise.Calculatedmeasurescanbe takentopreventorreducefurthertransmissionsinavulnerable populationthatisatrisk.

SOCIALDETERMINANTSOFHEALTH

Thesocialdeterminantsofhealth(SDOH)aresocialand economicconditionsthatarecategorizedintofivekey determinantsassummarizedin Figure1.Healthandhealth care,socialandcommunitycontext,neighborhoodandbuilt environment,education,andeconomicstability(6).Health andhealthcare includeaccesstohealthcare,accesstoprimary care,healthinsurancecoverage,andhealthliteracy(7).Low healthliteracycancausepatientsdifficultywithnavigatingthe complexhealthcaresystemandunderstandingmedicaladvice orprescriptions.Individualswithouthealthinsuranceareless likelytoutilizeorevenhaveaccesstoprimarycare,whichmakes detectingandmanagingchronicconditions,suchasCVD, asthma,diabetes,andcancer,difficult.Socialandcommunity contextarethecircumstancesapersonlives,learns,andworks in.ThisdomainofSDOHincludescommunityinvolvementand discrimination.Lowermortalityratesareassociatedwithsocial andcommunitysupportandcohesion.Neighborhoodandbuilt environmentincludehousing,neighborhood,transportation, accesstohealthyfoods,airquality,waterquality,andaccessto greenspace(7).Airpollutionhasbeenshowntobeassociated withincidentasthma. TheCDChasconfirmedthatindividuals withasthmaareathigherriskforsevereillnessfromCOVID-19 (8).Safetyplaysamajorroleinhealth.Peoplearemorelikely towalkorrunoutsideif theyfeelsafeintheirneighborhood. Withouttheworryaboutcrimeanddanger,safeneighborhoods alsoallowpeopletomaintaingoodmentalhealth.Immune functionisinfluencedbypsychologicalstress.Algrenetal. statethatindividualslivingindeprivedneighborhoodswere observedtohavemorestresswhencomparedtothoseliving innon-deprivedneighborhoods.Stressorsofthoselivingin deprivedneighborhoodsinclude,“overcrowding,highcrime rates,perceiveddanger,poortransportation,poorhousing, disrepair,limitedservices,poorinfrastructure,andalackof socialsupport”(9).Educationincludeshighschoolgraduation, enrollmentinhighereducation, andlanguageandliteracy. Thehigherone’slevelofeducation,thehigherhisorher lifeexpectancyis(7).Itisimportanttodiscloseinformation regardinghealth inapatient-specificmanner,takinginto accountthepatient’seducationlevel.Economicstabilityincludes

FIGURE1| Thefivedomainsofsocial determinantsofhealth(SDOH).

employment,poverty,foodsecurity,andhousingstability.The AmericanMedicalAssociation(AMA)statesthatasthepoverty levelincreases,thepercentageofadultswhoare25yearsand olderwithanactivity-limitingchronicdiseaseincreases(7). Unemploymentimpactsanindividual’s healthinmanyways,as ithasassociationswithdepression,domesticviolence,substance abuse,andphysicalillness.

SpecificexamplesofSDOHincludeincome,education, employment,andsocialsupport(10).Simplyput,theyare conditionsintowhichoneis born,grows,lives,works,and ages(11).Theylookatthepersonasawhole.Altogether,these conditionsimpacthealth statusofindividualsandcommunities. Disparitiesinanyoftheseconditionsaretranslatedintoa measureofsocialhierarchycalledsocioeconomicstatus(SES). ThelowerindividualsareonthespectrumofSES,thepoorer healthoutcomestheyface.Duetopooroutcomes,lifeexpectancy decreasesforthoseatthelowerendofthespectrum(10). Socioeconomicinequalitypileshealthcomplicationsontopof thefinancialwoesalreadyburdeningdisadvantagedsegmentsof thepopulation.

ThefiveSDOHareinterrelatedandplayedmajorrole duringCOVID-19pandemic.Forexample,educationlevelofan individualcanimpacthisorheroccupation,whichdetermines economicstabilityandincomelevel,whichcanimpactthetype ofhealthcaretheindividualiseligibleforandwhatneighborhood theindividuallivesin,whichthenimpactsthesocialand communitycontexttheindividualissurroundedbyandthose factorsplayedimportantroleincurrentCOVID-19pandemic. Therefore,onecanconcludethatsocioeconomicfactorsplay akeyroleininfectionandmortalityrates.Specificexamples includesomecounty’sinNewYork,suchasBronx,Brooklyn,and Queenshavesufferedhighermortalityratecomparedtoother county’ssuggestedthatlargeofpopulationofindividualswith loweconomicstatuslivedintheseareas.Anotherexampleto considerisfromtheperspectiveofachildgrowingupinafamily

thatdoesnothavemucheconomicstability.Thechild’sparents havelow-incomejobs, whichforcesthemtoliveinpovertystrickenneighborhoodsthatmaynothaveagreatschoolsystem. Thischildwillnotobtainthesamequalityofeducationasachild thatlivesinanaffluentneighborhoodthathasaricherschool district.Since,publicschoolsintheU.S.arefundedbylocal,state, andfederalgovernments(12).Fundingcomesfromincomeand propertytaxes.Affluent neighborhoodsanddistrictscollectmore taxes;therefore,theyhavemorefunding.Low-incomedistricts collectlessfundingandhavesubstandardschoolfacilitiesand teacherswhoaretheleastqualified(12).Therefore,belowaverage qualityofeducationwillnot leadtohighcollegeadmissiontest scores,whichwillkeepthechildoutoftopcollegesifheor shechoosestopursueacollegeeducation.Evenwithalow-tier collegeeducation,thechildmaynothavemanyhigh-incomejob opportunities.Thiswilllandthechildinthesamepositionashis orherparents,withalow-incomejoblivinginapoverty-stricken neighborhood.Hametal.(13)statethatchildrenlivingwiththeir parentsinpoverty-strickenneighborhoodsaremorelikelytoend upinthesamesituationthemselveslaterintheirlife.Thefive determinantscanbethoughtofasacycleofeventsthatimpact oneanotherratherthanasindividualentitiesevenincurrent COVID-19pandemic.

HEALTHANDHEALTHCARE

HealthLiteracy

HealthliteracyisdefinedbytheU.S.DepartmentofHealth andHumanServices(HHS)as“thedegreetowhichindividuals havethecapacitytoobtain,process,andunderstandbasic healthinformationneededtomakeappropriatehealthdecisions” (14).Thisincludestheabilitytoreadandunderstandhealthrelatedpamphlets,prescriptions,written instructionsfroma healthcareprovider,etc.Notbeingabletoreadorunderstand health-relatedinformationmakesitdifficultforindividualsto takecareofthemselves,eveniftheawarenesstodosois present.Lowhealthliteracyisassociatedwithpoorerhealth outcomes.Certainpopulationgroupshavebeennotedtohave lowhealthliteracycomparedtoothergroups(14).Thosewho arelivinginpoverty,nothighlyeducated,fromacertain race/ethnicgroup,orwithdisabilitiesaremorelikelytohave lowhealthliteracy(14).Patientswhodemonstratelowhealth literacymayhave highoverallliteracyandhighverbalfluency, whichcausesthepatienttopresentashavinghighhealth literacy.Itisimportanttorecognizepeoplewhomayhave lowhealthliteracyespeciallyduringtimesofapandemic, becausehealthliteracyisanimportantmeansofpreventing communicablediseases,suchasCOVID-19.Understanding infectiousdiseasestoacertaindegree,includingmodeof transmissionandviabilityofpathogens,willhelppeoplereadily acceptthecircumstancesinsituationslikethisratherthan questiontherecommendations.Healthliteracycanallowpeople tounderstandtheirresponsibilityofadheringtosocialdistancing andotherrecommendedmeasuresduringtheCOVID-19 pandemicandthereasoningbehindthemeasuresbeingtakento preventthespreadofthevirus.

AGalluppollconductedinthemonthsofAprilandMay of2020lookedathowmanyAmericansconsideredsocial distancingtobesignificantbyassessingtheirconfidencelevel intheimpactsocialdistancinghasonreducingthespreadof COVID-19.Further,determinedwhethereachgroupthatwas dividedbyconfidencelevelfollowedsocialdistancing.Thestudy foundthat54%ofAmericanswere“veryconfident”and31% were“moderatelyconfident”intheirbeliefthatsocialdistancing helpssavelivesduringCOVID-19pandemic(15).However, 14%ofAmericanswhoparticipated expressedskepticismabout socialdistancinganditsroleinsavinglives.Overall,88%of Americanswhoparticipatedinthepollreportedthatthey “always”or“veryoften”practicedsocialdistancing,which includedmeasuressuchasavoidingcrowdedplacesandleaving theirhomesunnecessarily.Ofthosewhowere“veryconfident”or “moderatelyconfident”thatsocialdistancingmakesadifference, 95and87%reportedthatthey“veryoften”practicedsocial distancing,respectively.Fifty-sevenpercentageofthosewho expressedskepticism“veryoften”practicedsocialdistancing.The percentagesweredropwhenitcomesto“always”practicingsocial distancing.Seventy-onepercentageofthosewhowere“very confident”thatsocialdistancingmakingadifference“always” practicedit,whereas47%ofthosewhowere“moderately confident”“always”practicedit.Only27%ofthosewhowere skeptical“always”practicedsocialdistancing.Therefore,health literacywasplayedamajorroleinwhetheranindividual understandsahealthemergencysituation,suchasCOVID-19 pandemic,andwhetherheorshewillfollowrecommendations, suchassocialdistancing.

AccesstoHealthCareandPrimaryCare

Accesstohealthcareisdescribedasthe“timelyuseofpersonal healthservicestoachievethebestpossiblehealthoutcomes”by theNationalAcademiesofSciences,Engineering,andMedicine (14).Manypeoplefacebarrierstohealthcare,whichmayhinder theirabilitytotake responsibleactionstowardtheirwell-being. Barriersincludelimitedornoaccesstotransportationforhealth appointments,lackofhealthinsurance,limitededucationabout healthcare,limitedhealthcareresources,providerhourslimited toworkhours,etc.Lackofhealthinsuranceisusuallyseen inpopulationswithlowerincomesandminorities.Astudyby GallupandWestHealthfoundthat14%ofadultsintheU.S. revealedthattheywouldnotseekhealthcareiftheyexperienced afeveranddrycough(16, 17).Feveranddrycougharethemost commonsymptomsofCOVID-19.Whenadults werespecifically askedwhethertheywouldseekhealthcareiftheyhadbelieved theyhadbeeninfectedwithCOVID-19,9%stillansweredthat theywouldnot(16).Theindividualsthatreportedthatthey wouldnotseekhealthcarewerenon-whiteadultsundertheage of30whohadahighschooleducationorlessearninglessthana $40,000incomeperyear(16).

Reluctancetoseekhealthcareisassociatedwith socioeconomicstatus.HispanicsandAfricanAmericans werelesslikelytohavehealthinsurancecomparedtononHispanicwhites(16).Withouthealthinsurance,primarycare visitsmaynotbefeasible,orpeoplemayhesitatetousehealth careresources.Thisputsthosewithouthealthinsuranceatrisk

ofnotbeingscreenedforchronicconditions,suchasCVD, hypertension,asthma,anddiabetes.Accesstohealthcarealso reliesontheavailabilityofresources(14).

Thosewhoareminoritiesand/or havelowincomesalready facedifficulty-accessinghealthcare.Manyofthemprimarily dependonstudent-runclinicsforobtaininghealthcare.The UniversityofNebraskaMedicalCenterCollegeofMedicine hasastudent-runclinic,calledtheStudentHealthAlliance ReachingIndigentNeedyGroups(SHARING)clinic,which provideslow-costprimaryhealthcareandservicestothe underprivilegedpopulationsintheOmahacommunity.This clinichasbeenclosedduetotheCOVID-19pandemic. Therefore,theunderservedpopulationswhoalreadyfacebarriers tohealthcarenowfaceabarriertoaccessprimarycareat thesestudent-runclinics,whicharetheirprimarymeansof maintainingtheirwell-being.

RoleofFoodDesertsonCardiovascular Disease

Fooddesertsareneighborhoodsthataredefinedaslowincome areaswithlittleaccesstohealthyfoodsbytheU.S.Department ofAgriculture(USDA)(18).Astudyfoundthattherewas associationbetweenfooddeserts andcardiovascularriskfactors inanAtlantametropolitanarea.Theyfoundthatincomewas morestronglyassociatedwithCVDriskthanaccesstohealthy food(18).Recognizingthatincomehadagreaterpartthan locationofresidence, theythenstudiedindividualincomevs. neighborhoodincomebyobservingpeoplewithlowindividual incomelivinginlowincomeneighborhoodsandcompared themwithpeoplewithlowindividualincomelivinginhigh incomeneighborhoods.Resultsshowedthatindividualincome isassociatedwithhigherriskofCVDthanneighborhood incomeorfoodaccess.Thosewithhighindividualincomes wholivedinlow-incomeneighborhoodshadlowerCVDrisk thanthosewithlowerindividualincomeswholivedinlowincomeneighborhoods(18).Individualswithhighincomewho livedinneighborhoodswithpoorhealthyfoodaccesshadbetter cardiovascularprofilescomparedtoindividualswithlowincome livinginhigh-incomeneighborhoods.Thisconfirmsthatthe perceivedassociationbetweenfooddesertsandCVDriskispartly duetoindividualincomestatusratherthanaccesstohealthy foods.Further,anotherstudysuggestedthatthereisasimilar relationshipbetweenSESandCVDandfoundthatmortality fromCVDishigherinindividualswithlowereducationlevels andloweroccupationalclass(19).Thecorrelationbetweenlower incomeandheightenedriskof CVD,withCVDincreasingthe riskforseriousillnessrelatedtoinfectionfromCOVID-19, suggestsaninversecorrelationbetweenincomeandCOVID-19 healthcomplications.

RoleofFoodDesertsonHypertensionand ChronicKidneyDisease

Lowincomehasalsobeenassociatedwithhypertensionand CKD.Healthierfoods,suchasfruitsandvegetables,tendto becostlier.Thismakesithardforlow-incomefamiliesto affordhealthydiets.Individualshaveaccesstohighamounts

ofprocessedmeatsandfatsinsteadoffruitsandvegetablesin low-incomeneighborhoodsandfooddeserts.Aqualitativestudy donebySuarezetal.hasrevealedthat80.3%ofparticipants livinginfooddesertsandthosewithlowincomesreported thatthey“always”or“mostofthetime”havefruitavailable athome(20).Thisiscomparedto87.0%ofparticipantsthat donotliveinfooddesertsandareinthehighestincome category.71.6%ofparticipantslivinginfooddesertsandthose withlowincomesreportedthatthey“always”or“mostofthe time”havedarkgreenvegetablesavailableathomecompared to82.0%thatdonotliveinfooddesertsandareinthehighest incomecategory(20).Qualitatively,familyincomedemonstrated astrongerassociationwith diet,bloodpressure,andCKDthan livinginafooddesert(20).

Thesamestudyalsofound thatserumcarotenoidswerelow inindividualslivinginfooddesertsandindividualswithlow incomes(20).Carotenoidsareameasureoffruitandvegetable intake.Theyalsofound thataverageprotein,potassium,sodium, calcium,andmagnesiumintakewereloweramongindividuals livinginfooddesertsandindividualswithlowincomes. Measuringlevelsofthesemineralsgivesinsightintothemeasure ofdietaryacidloadinanindividual’sbody.Lowlevelsofthese mineralsindicateahighermeasureofdietaryacidload(21). Foodsrichinprotein (meat,cheese,eggs,etc.)increaseacid productioninthebody.Fruitsandvegetablesleadtobase production.Dietshighinacidinducemetabolicacidosis,which canleadtohypertension,CKD,insulinresistance,diabetes,and othercomplications(20).Ahighdietaryacidloadhasalsobeen linkedtoobesity(22).

Role ofSDOHonObesity

Fooddesertscontainmorefastfoodrestaurantsthangrocery stores.Individualslivinginafooddeserttendtohaveapoordiet, whichincreasestheriskofobesity(23).Obesityisclassifiedasa BMIgreaterthan orequalto40bytheCDC(8).Individualsliving outsideoffooddesertshavebetteraccesstogrocerystoresandare morelikelytohavedietsconsistingofmorefruitsandvegetables. Theseindividualsarelesslikelytobeatriskofobesity(23). Individualswhoareobeseare athigherriskofbeingdiagnosed withabreathingdisorderknownasobesityhypoventilation syndrome,alsoknownasPickwickiansyndrome.Itisnotclearly understoodwhythissyndromeaffectsobeseindividuals,but itisthoughtthatextrafatontheneck,chest,orabdomen maymakebreathingdeeplydifficult.Thisleadstoabuildupof carbondioxideanddecreasedamountsofoxygenintheblood. Hormonesthataffectbreathingpatternmayalsobesecretedin responsetodifficultyinbreathing(24).

Bodymassindex (BMI)iscalculatedbydividingaperson’s weightinkilogramsbythesquareoftheirheightinmeters (kg/m2).BMIisascreeningtoolusedtodeterminewhethera personisinahealthyweightrange,overweight,orobese.ABMI of <18.5classifiesapersonasunderweight.BMIbetween18.5 and <25isnormal.BMIbetween25.0and <30putsanindividual intheoverweightrange.BMI30.0orhigherputsanindividualin theobeserange(25).

Astudywith24patients who testedpositivewithCOVID19wasconductedinSeattle.Ofthe24patients,7were

classifiedasoverweightand13asobese.Thestudyshowed that85%ofthe obesepatientsrequiredmechanicalventilation (26).Sixty-twopercentageoftheobesepatientsdiedfrom thevirus.Sixty-fourpercentageofnon-obesepatientsrequired mechanicalventilation,and34%ofthemdiedfromthevirus (26).Thepercentagesofrequiringmechanicalventilationand deathsareclearlyhigherinobeseindividualscomparedtononobeseindividuals.

ABMI >40wasfoundtobethesecondstrongestindependent predictorofhospitalizationinpatientswithCOVID-19atan academichospitalinNewYorkCity(27).AstudyinFrance thatcollecteddatafrom124patientswhotestedpositivefor COVID-19reportedthattheoneswhorequiredmechanical ventilationwerethosewhohadaBMIgreaterthanorequal to35.Thestudymentionsthatthereasonbehindwhypatients usuallyrequiremechanicalventilationisbecauseofimpaired respiratorymechanics,increasedairwayresistance,andimpaired gasexchange(28).Inobeseindividuals,respiratoryproblems includelowrespiratorymuscle strength,possibleduetotheextra fatontheneck,chest,orabdomenasmentionedearlier,and lowlungvolumesduetotheextrafatmakingitdifficulttotake deepbreaths(24, 28).Thestudyalsoconcludedthatthedisease severityofCOVID-19increasedwithincreasingBMI(28).

SOCIALANDCOMMUNITYCONTEXT

Discrimination

Unfairor unjustifiedsociallystructuredactionsagainsta certaingrouporpopulationcontributetodiscrimination.These actionstendtofavortheaffluentandpowerfulpopulationat thedetrimentoftheimpoverishedpopulation.Discrimination occursatboththeindividualandstructurallevelinhealthcare (17).Individualdiscriminationincludesnegativeinteractions betweenapatientandahealthcareproviderduetorace,gender, etc.Negativeinteractionsmaylimithealthcareresourcesand well-beingofthepatient.Structuraldiscriminationisseenin theformofresidentialsegregationaccordingtoraceorethnic groups,unequaljobopportunitiesduetogender,unequalaccess toqualityeducation,inequalitiesinincarceration,etc.Formsof structuraldiscriminationcantrickledowntoaffectindividuals andpopulationsintermsofhealthcare.Residentialsegregation playsamajorroleintheinequalitiesobservedbetweenAfrican AmericansandCaucasianpopulations.AfricanAmericansare morelikelytoliveinhigh-povertyneighborhoodsthanother Americans.High-povertyneighborhoodsconsistoflowquality andpoorschools,limitedaccesstohealthcareandjobs,weak socialnetworks,highratesofcrime,pollution,andcongestion (29).Becauseofcongestioninimpoverishedneighborhoods, itcanbedifficultto followsocialisolationrecommendations. Keepingphysicaldistancefromothersmaynotbeanoption forsomefamilies.Manyindividualslivinginpovertyarealsoin apredicamentduringtimeslikethiswhenpeopleareaskedto workfromhome,becauseminoritiesandAfricanAmericansare morelikelytoholdjobsinprofessionsinwhichitisnotfeasible toworkfromhome(30).ManyLatinosandAfricanAmericans arefacingthe dilemmaofhavingtopayrentandputtingfood onthetablevs.stayinghomeandkeepingtheirfamilieshealthy

duringthisCOVID-19outbreak,astheyaretheoneswhoworkin warehouses,foodindustry,construction,janitorialservices,etc., andthesearejobsthatcannotbedonefromhome(30).Though raceandethnicity dataareavailableforonly35%ofthosewho havefallenvictimtothevirus,discriminationisclearlyevidentin theexistingdata(31).NewYorkCity,thehardesthitcityinthe U.S.,hashad moreLatinospercapitafallvictimtoCOVID-19 thananyotherethnicgroups(29).Latinosmakeup29%ofNew YorkCity’spopulation.Approximately34% ofCOVID-19deaths inNewYorkCityareofLatinos.AfricanAmericansmakeup 22%ofthecity’spopulationand28%ofCOVID-19deaths(32). Overall,AfricanAmericans are2.4timesmorelikelytodiefrom thisviruscomparedtotheircounterpartsofotherraces.Broken downbystate,thestatisticsarealarming.AfricanAmericans makeup ∼13%oftheU.S.population,andtheirpopulationasa wholehasendured32%ofCOVID-19deaths.Ontheotherhand, Caucasiansaredisproportionatelyfacingdeathsbasedonwhich U.S.statetheyresidein.Asawhole,Caucasiansarelesslikelyto diethanexpectedat0.8timestheircounterparts(32).

CommunityInvolvementandSocial Cohesion

Socialsupportis animportantcomponentofanindividual’swellbeing.Socialcohesion,oneofthetermsusedtodescribesocial relationships,describeshowstrongrelationshipsareandwhether thereisasenseofsolidarityamongmembersofacommunity (14).Socialcapital,anindicatorofsocialcohesion,measures theextentofsharedgroupresourceswithinacommunity, perceivedfairness,perceivedhelpfulness,groupmembership, andtrust(14).Researchersfoundtheseaforementionedmeasures ofsocialcapitalto beinverselycorrelatedwithmortality(33). Socialcapitaldecreasesasincomeinequalityincreases.Itis believedthatsocialcapitalistheelementthatrelatesincome inequalityandmortality(14).Socialcohesionisassociated withlowerneighborhoodviolence,betterself-ratedhealth, andlessstress/anxiety.Stresshasmanyimpactsonthebody, includingontheimmune,cardiovascular,andneuroendocrine systems.Astudyhasshowedthathigheramountsofsocial supportwereassociatedwithlowerlevelsofatherosclerosisin womenpredisposedtoahigherriskforCVD(34).Another studyinCaliforniademonstratedthatsocialsupportamong Mexicanadultsservedasabarrieragainstthedetrimentsofthe discriminationtheyfaced(35).

Itisevidentthatpeopleandcommunitieshavecometogether duringthisdifficulttime.Medicalstudentshavebeensuspended fromclinicalclerkships,whichpreventsstudentsfromallpatient careactivities.Acrossthenation,medicalstudentshavebeen helpingoutresidentphysiciansandattendingphysicianswhoare onthefront-linewithchildcare,petcare,andrunningerrands. MedicalstudentsfromtheUniversityofNebraskaMedical Centerhavealsobeenutilizingtimeofffromclinicalclerkships byvolunteeringinthecommunity.Thosewhoknowhowtosew havebeensewingmasksforfront-lineworkersduetoashortage ofpersonalprotectiveequipment(PPE).Individualshavebeen runningerrandsfortheelderlywhoaremorevulnerabletofalling illwiththevirus.Duringtimesofaglobalhealthcrisisinwhich

thereisacallforsocialisolation,suchastheonewefacecurrently withtheCOVID-19pandemic,itisimportanttofindwaysto maintaincommunicationandsocialcohesiontopreserveeach other’swell-being.

NEIGHBORHOODANDBUILT ENVIRONMENT

AccesstoHealthyFoods

Foodisanessentialhumanneed.Itplaysamajorroleinan individual’shealthandqualityoflife.Consumptionofhealthy foodsisassociatedwithlowerriskofchronichealthconditions. Ahealthydietconsistsofamyriadoffruit,vegetables,grains, protein-richfoods(seafood,leanmeats,poultry,legumes,soy products,eggs,etc.),andfat-freeorlow-fatdairy.Poordietand nutritionhavebeenlinkedtochronicconditions,suchasCVD, hypertension,diabetes,andevencancer(36).

Theindividualcomponentsofthe neighborhoodand builtenvironmentdomainofSDOHareintertwinedand affectoneanother.Therearemanybarrierstotheaccess ofhealthyfoods.Transportation,anothercomponentof theneighborhoodandbuiltenvironmentdomain,playsa majorroleintheaccesstohealthyfoods.Astudyfrom 2012to2013foundthatonaverage,thenearestgrocery storetohouseholdsintheU.S.was2.19miles(36).This makesitdifficultforthosewithouttheirownvehicles oraccesstopublictransportationtomakeatriptothe grocerystore.

Fooddesertsareneighborhoodsthataredefinedaslow incomeareaswithlittleaccesstohealthyfoodsbytheU.S. DepartmentofAgriculture(USDA)(23).Theseneighborhoods aremorelikelytocontain fastfoodrestaurantsandconvenience storesthangrocerystores.Fastfoodrestaurantsandconvenience storescontainoptionsthatareoflowerqualityandmore unhealthyfoods(highersaturatedand trans-fatandhigher calories).Individualslivinginfooddesertsaremorelikelyto havepoordietsandnutritionasaresult.ComparedtoCaucasian neighborhoods,AfricanAmericanandLatinoneighborhoods aremorelikelytocontainahigheramountoffastfood restaurantsandconveniencestores.Thisexplainswhyminority populationsaremorelikelytohavenegativehealthoutcomes thantheirracialcounterparts.Livinginafooddesertputsan individualatahigherriskofobesity,whichisdiscussedin anothersection.

Incomealsoplaysaroleinaccesstohealthyfoods.Studies haveshownthatlow-incomefamiliesdependoncheapfoods thathappentobelowinnutrientdensity.Healthyfoods,such asfreshfruitsandvegetables,areusuallymoreexpensivethan processedfoods.Thosewhocannotaffordfreshfoodsopttothe processedfoodsoption,whichisunhealthy(36).Itisimportant torecognizefooddeserts andcommunitiesthatdonothave accesstohealthyfoods,especiallyduringapandemic,when suppliesmaybeinshortagetobeginwith.Ifsuppliesarein shortage,itwillbedifficultforthosewhohavelimitedaccess tohealthyfoodsorfoodingeneraltomaintaintheirdiet andnutritionaltogether.Individualswillalsohavetomake

moretripstogrocerystorestoobtaingroceries,whichcanput thematriskofacquiringthevirus.Minorityandlow-income populationslivinginfooddesertsmayfacemoredifficulty accessinghealthyfoodsduringtheCOVID-19pandemicdue tocustomersoverbuyingandstockinggroceries.Thiscouldbe moreofaprobleminareasthatarefooddesertscomparedto affluentareas.

Neighborhood/EnvironmentalConditions

Airquality,waterquality,pollution,housing,andaccessto greenspacecanallbediscussedunderthissection.Health disparitiesduetoneighborhoodandenvironmentalconditions canbeunderstoodbystudyinghowcertainpopulationendsup incertaingeographiclocations.Thereisanassociationbetween racialminoritiesandgeographiclocationoftheirresidences. LatinosandAfricanAmericansaremorelikelytolivein neighborhoodsthathavehigherexposuretopollutionfrom airborneparticlessuchaschlorine,aluminum,andcarbon(37). Thisisduetothe factthathigh-povertyneighborhoodsinwhich LatinosandAfricanAmericanslivearemorelikelytobelocated nearfactories,refineries,andlandfillsthatemitpollutants.For athirdofAmericans,groundwaterwasfoundtobethemajor sourceofdrinkingwater.Groundwaternearfactories,refineries, andlandfillstendstobepollutedwithhazardouswastes(37).

Researchershavesuggestedthatairpollutioncanmake individualsmorevulnerabletoacquiringCOVID-19.They reasonthatpollutionparticlesareactingasvehiclesforthevirus, whichmakesiteasierforthevirustobetransmittedfrompersonto-person.Researcherssaythatairpollutionmayhaveworsened theoutbreak.Thismaybeduetothefactthatairpollution weakenstheimmunesystem,whichdecreasesone’sabilitytofight infections(37).Astudyrecentlyfoundthatanincreaseinthesize ofpollutionparticles,referred toasPM2.5,canhaveaneffecton thespreadofCOVID-19.Thestudyfoundthatanincreaseof1 microgrampercubicmeterwasassociatedwithan8%increasein deathsrelatedtoCOVID-19(38).

Safetyalsoplaysamajorroleinhealth.High-poverty neighborhoodsaremorelikelytocontainhigherratesofcrime, whichdecreasessafetyofcommunitymembers.Peoplearemore likelytoutilizeavailablegreenspaceforwalking,running, orexercising.Anotherissueinhigh-povertyneighborhoodsis availabilityofgreenspace.Theseneighborhoodsarecrowded tothepointwherethereisminimalgreenspaceavailable forresidents.Socialdistancinghasbeenthekeytoflattening thecurveanddecreasingtransmissionofCOVID-19.In neighborhoodsthatarecrowded,socialdistancingmaynotbe feasible.Thisputsindividualslivingincrowdedneighborhoods atahigherriskofbecomingillwiththevirus,aswellasincreases therateoftransmissionofthevirus.

Low-incomefamiliestendtoliveinpublichousingofpoor quality(39).Astudyfoundthatpublichousingwasfoundtohave severalinfestationswithcockroaches,mice,rats,etc.(40).Mold, lackofairconditioning, andtobaccosmokewerealsoacommon find(39).Thisstudyalsofoundthat22%ofchildrenwholivedin publichousingwerediagnosedwithasthmacomparedtoonly7% ofthoselivinginsingle-familyhomes(40).Low-incomefamilies maybeatahigher riskofacquiringCOVID-19.

EDUCATION

HighSchoolGraduation

Formostjobs andhighereducationaldegrees,ahighschool diplomaisrequired(41).Withoutahighschooleducationand diploma,jobopportunitiesbecome slim.Lackoforlessjob opportunitiescanleadtopoverty.Povertycanleadtonegative healthoutcomesasdiscussedpreviously.Thehomeandschool environmentisthemajordeterminantsofwhetherastudent willgraduatehighschool.Studieshavefoundthatstudentswith parentswhoarenotinvolvedintheireducationaremorelikely todropoutofhighschool.Schoolswithhighercrimeratesare morelikelytohigherdropoutrates(41).

Studentsfromlow-incomehouseholds aremorelikelyto attendlowqualityschoolsandhavelessaccesstoeducational resources.DuringtheCOVID-19pandemic,schoolshavehad toswitchtoonlineeducation.Thesechildrenmaynothave accesstocomputers,orinternet.Thismeansthatchildren fromhigh-incomefamiliesareatanadvantagewhenit comestolearningremotely,whilechildrenfromlow-income familiesarelosingground.Childrenwithparentswhoare educatedandhaveobtainedhighereducationaldegreesmay encouragetheirchildrentokeeppursuingtheiracademic work(41).Non-educatedparentsmayundervalueeducation comparedtoeducatedparentsand downplaytheimportance ofmaintainingacademicstandardsfortheirchildren.This doesnotmaketheeducatedparentsbetterthanthenoneducatedparents.Rather,itisamatterofbeingawareofand havingexperiencesofhowtonavigatesituationskeepingin mindthateducationisimportantregardlessofthehardships. Childrenwithnon-educatedparentsmaynotbegettingthe supportthatchildrenwitheducatedparentsaregettingwhile havingtogotoschoolonlineduringthispandemic.Some childrenarestimulatedtodowellinaclassroomsettingand havingtoparticipateindistancelearningmayimpacttheir academicmerit.

LanguageandLiteracy

Individualswithlowerlevelsofeducationandminoritiesare morelikelytohavelimitedEnglish-speakingskillsandlower literacy.Thosewithlanguageandliteracybarrierswerenoted tohaveworsehealthstatus,chronichealthconditions,lack healthinsurance,andhavedifficultyfollowingmedication directions(42).

TheU.S.ishometomany whospeakalanguageotherthan English.Anewinitiative,calledthe“COVID-19HealthLiteracy Project,”startedbymedicalstudentsandphysiciansatHarvard MedicalSchool,isintendedtobridgethelanguagebarriergap. ThisinitiativehastranslatedimportantCOVID-19information inover35languages(43).Languagesthatinformationcan betranslatedintoincludeArabic,Bengali,Chinese,Dutch, Filipino,German,Greek,Gujarati,Japanese,Hindi,andmany more.Informationaboutthevirus,preventionmethodstoavoid becomingillwiththevirus,andtreatmentoptionsavailable areincludedinthefactsheets.Thishasmadeitpossibleto educatethepublicevenwithexistinglanguagebarriers.Creating awarenessofthevirusandeducatingthepublicaboutthe

situationandwhatprecautionstotakeisanimportantstep towardcontrollingthespreadoftheillness.

ECONOMICSTABILITY

Employment

Thelevelofeducationoneobtainsisamajordeterminantof thetypeofjobonehas,theincometheyearn,andbenefits suchashealthinsurance,paidsickleave,andparentalleave(44). Racialdisparitiesalsoexistintheworkplace.Caucasiansaremore likelytoholdwhite-collarclericaljobs,whileAfricanAmericans andminoritiesaremorelikelytoholdblue-collarservicejobs (44).Discriminationintheworkplacecanleadtostress,anxiety, depression,andnegativehealthoutcomes.Individualswhoare unemployedaremorelikelytohavestress-relatedconditions suchasCVD,hypertension,anddiabetes,whichareallrisk factorsforCOVID-19(44).

TheU.S.economicactivity hassloweddownwithstay-athomeandquarantineorders.Manypeoplehavelostincome bylosingtheirjob,havingtheirsalaryreduced,orbeingput onunpaidleave(45).Approximately33.5millionAmericans havefiledforunemploymentaid inthelastsevenweeks(46). Approximately61%ofHispanicsand 44%ofAfricanAmericans havereportedthattheyhavefacedwageorjoblossdueto theCOVID-19pandemiccomparedto38%ofCaucasians (47).Thesepercentageshaveincreasedfrom49,36,and29%, respectively,sinceMarch(47).Unemploymentorjoblossmeans individualsdonothave orlosetheiremployer-sponsoredhealth insurance.Congresshasalloweduninsuredindividualstobe testedforCOVID-19,however,treatmentofthevirusisnot covered(48).

Toaddressthe economicdownfall,thePresidentofthe UnitedStatessignedtheCoronavirusAid,Relief,andEconomic SecurityAct(CARES)stimulusbillintolegislationonMarch 27,2020(45).Thestimulusbillprovidesapaymentof$1,200 foreachU.S. citizenorU.S.residentalienwithanincomeof $75,000orless(49, 50).$500isaddedtothe$1,200foreach dependentchild(45). Thoughitmayseemsimple,thecriteria thathaveto bemettoreceiveastimuluscheckarenumerousand complicated.Aschedulefordistributionofstimuluscheckshas notbeenestablished.Asofnow,onestimuluscheckhasbeensent outtoqualifyingindividuals(50).ThePresidentandCongress havementionedreleasing asecondcheck;however,nothingisset instone(49 51).Onecheckof$1,200maynotbeenoughfor mostfamilies.This couldcertainlybeahindranceforfamiliesto eathealthyfoods,astheywillhavetousethemoneywiselyuntil eitheranothercheckwillbedistributed,orthepandemiccomes toanendandpeoplecanreturntowork.

Thereisafinelinebetweentryingtodecreasethespreadof COVID-19andpreventingtheprogressionofeconomicdecline. Itisevidentthatsocialdistancingandquarantinemethodsare helpingtoflattenthecurve,however,attheexpenseofthe country’seconomicstability.Socialdistancingwasrecommended earlyonbyeachstate’sgovernors,andthenalockdownfollowed. Twostates,GeorgiaandIdaho,demonstratetheriseinincidence ofcasesinthemonthsofMarchandApril,adeclinetowardthe endofMay,andriseagaininthemonthsofJuneandJuly(51, 52).

Georgia’sgovernorissuedalockdownonApril3,2020,and Idaho’sgovernorissuedalockdownonMarch25,2020(53, 54). Duringlockdown,non-essentialworkersweredirectedtostay athomeandonlygoouttothegrocerystoreortoapharmacy ifneeded.Socialdistancingwastobefollowedstrictlyduring lockdown.Georgia’slockdownwasliftedonApril24,2020(55). AttheendofApril, Georgiasawaslightincreaseinincidenceof cases.Bymid-June,theincidenceishigherinGeorgiathanbefore lockdownwasimplemented,anditisonlyincreasing.Idaho’s governor,ontheotherhand,issuedalockdownonMarch25, 2020(54).TherewasariseinincidenceatthebeginningofApril andthenadecline bymid-April.Idaho’slockdownwaslifted onApril30,2020(56).Theincidencewas <40casesin Idaho frommid-ApriltothebeginningofJune.SinceJune1,2020,the incidenceisontherise,anditishigherinJuneandJulycompared towhenlockdownwasimplementedinMarch.Theincidenceof COVID-19casesoverallintheU.S.isshownin Figure2 (57).Itis evidentthatincidenceis onceagainontheriseaslockdownshave beenliftedacrossthenationandsocialdistancingisnolonger beingfollowedasstrictlyasduringthelockdowns(Figure2). Itisunderstandablethatthenation’seconomyisanimportant considerationwhenimplementingalockdownacrossthenation. Wewillhavetowaitandseewhatthefutureholdsforournation’s economywhilewetrytoeradicateCOVID-19.

CONCLUSIONS

Pandemicsaremoreofasocialproblemthanahealthcare problem.Thepopulationthatlivesinpovertyandin neighborhoodsthatareovercrowdedwithpoormaintenanceand sanitationisbeingdisproportionatelyaffectedbyCOVID-19.It isimperativetoprovideadditionalaidforlow-incomefamilies, suchasthestimuluscheck.Thisisespeciallyimportantduring timesofdiseaseoutbreaks,asthisisavulnerablepopulation thatisatriskforseriousillness.Therootcauseofbeingapart ofthevulnerablepopulationatriskduringoutbreakscomes downtoincomelevelandracial/ethnicidentification.Lower incomehasbeenassociatedwithpoordietaryintakeandhabits. Minoritygroups,suchasLatinos,andAfricanAmericansareat adisadvantageduetoindividualandstructuraldiscrimination, andtheyaremorelikelythantheirCaucasiancounterpart tobevulnerabletonegativehealthoutcomes.Therefore,it isevidentthattheSDOHhavebeenoverlookedduringthis pandemic.Dr.RichardClarkeCabot,anAmericanphysician, wasthefirstintheU.S.toconsidersocioeconomic,family,and psychologicalfactorswhenpracticingmedicine(https://www. ncbi.nlm.nih.gov/books/NBK702/).Heobservedthattherewasa correlationbetweenlowersocioeconomicstatusofpatientsand theirprobabilityofsuccumbingtoillness.Historicalreportshave shownthatpoverty,inequalities,andSDOHfacilitatethespread ofinfectiousdiseases.Inequalitiesinhealthandhealthcarecan furtheraddtodisparitiesinmorbidityandmortality.Quinn etal.suggestedthatexistingstudiesofinfluenzapandemicshave notrecognizedtheimportanceofhealthinequalitiesnorhave theyattemptedtoanalyzedifferencesinsocioeconomicfactors andhowtheyimpacthealthduringtimesofahealthemergency

(58).Therefore,itisimperativetorespondrapidlyandeffectively duringtimesofahealthemergency.Inordertoachievethat,it iscrucialtobeeducatedaboutallofthefactorsthatmayplay aroleinhealthandhealthcarebeforeanoutbreakofdisease evenoccurs.Havinginsightintofactorsthatplayaroleinhealth

FIGURE2| Thewaxandwaneinnew casesofCOVID-19perdayinUSA, NewYork,GeorgiaandIdaho.Thegraphsweregeneratedusingtheonline dataformCDCandJohnHopkinswebsites.

andhealthcare,suchasSDOH,canfacilitateaccesstomedical andnon-medicalresourcestothosewhoaresocioeconomically disadvantaged.Publiceducationandcreatingawarenessof theseverityofthevirusisalsoimportant.Awarenessofthe disadvantagedpopulationthatismorevulnerablethanthe averageindividualandtherapidspreadofCOVID-19should motivateindividualstoreduceexposuretootherstostopthe spreadofthedisease.Thekeytofightinganoutbreakistotake intoaccountthevariousfactorsthatplayaroleinthewell-being ofanation.Appropriateandtimelyeducation,healthcare, andsocialservicescanbeeffectivemeasurestakentoaddress outbreaks,suchasCOVID-19.

IntegratingSDOHintoeffortstoeliminatedisparities inhealthandhealthcarecanbethesolutiontoreducing diseaseglobally.Thiscanbedonethroughtheassemblyofan interdisciplinaryteamthatconsistsofhealthcareprofessionals, publichealthprofessionals,anthropologists,sociologists, researchers,governments,NationalInstituteofHealth(NIH), CenterforDiseasesControl(CDC),WorldHealthOrganization (WHO),andothers,whocanallcontributetoanalyzingand understandingthevariousfactorsthatplayaroleincausing healthdisparitiesinpopulationsthatalreadyfacesocioeconomic inequalities.Itisalsocrucialtoassesswhatactionsandmeasures weretakencorrectlyandwhatwentwrongduringthispandemic, sothat,wewillbepreparedtohandlethingsinamoreefficient mannerifanyfuturepandemicsarise.

REFERENCES

1.LiQ,GuanX,WuP,WangX,ZhouL,TongY,etal.Earlytransmission dynamicsinWuhan,China,ofnovelcoronavirus-infectedpneumonia. NEngl JMed.(2020)382:1199–207.doi:10.1056/NEJMoa2001316

2.AdhikariSP,MengS,WuYJ,MaoYP,YeRX,WangQZ,etal.Epidemiology, causes,clinicalmanifestationanddiagnosis,preventionandcontrolof coronavirusdisease(COVID-19)duringtheearlyoutbreakperiod:ascoping review. InfectDisPoverty.(2020)9:29.doi:10.1186/s40249-020-00646-x

3.RothanHA,ByrareddySN.Theepidemiologyandpathogenesisof coronavirusdisease(COVID-19)outbreak. JAutoimmun.(2020) 109:102433.doi:10.1016/j.jaut.2020.102433

4.CDC. PeopleWhoNeedtoTakeExtraPrecautions. Atlanta,GA(2020).

5.CDC.Preliminaryestimatesoftheprevalenceofselectedunderlyinghealth conditionsamongpatientswithcoronavirusdisease2019—UnitedStates, February12–March28,2020. MorbidMortalWeeklyRep.(2020)69:382–6.doi:10.15585/mmwr.mm6913e2

6.USDHHS. SocialDeterminantsofHealth.Washington,DC(2020).

7.AMA. SocialDeterminantsofHealth,HealthSystemsScienceLearningSeries Chicago,IL(2020).

8.CDC. CoronavirusDisease2019(COVID-19):PeopleWhoAreatHigherRisk forSevereIllness.Atlanta,GA(2020).

9.AlgrenMH,EkholmO,NielsenL,ErsbollAK,BakCK,AndersenPT. Associationsbetweenperceivedstress,socioeconomicstatus,andhealth-risk behaviourindeprivedneighbourhoodsinDenmark:across-sectionalstudy. BMCPublicHealth.(2018)18:250.doi:10.1186/s12889-018-5170-x

10.LowcockEC,RosellaLC,FoisyJ,McGeerA,CrowcroftN.The socialdeterminantsofhealthandpandemicH1N12009influenza severity. AmJPublicHealth.(2012)102:e51–8.doi:10.2105/AJPH.2012.3 00814

11.ChapmanAR.Thesocialdeterminantsofhealth,healthequity,andhuman rights. HealthHumRights. (2010)12:17–30.

Everyperson,regardlessofwheretheylive,whatracetheyare, andwhatincometheyhave,shouldhaveequalopportunitiesto stayhealthy.ByincorporatingSDOHintopreventingthespread ofdiseaseandtoapproachpatientcareinaholisticmanner,the unfairdifferencescanbeminimizedsociallyandeconomically.

AUTHORCONTRIBUTIONS

SSdesignedanddrafted/wrotethemanuscript.AAreferencing andeditedthemanuscript.KCeditedthemanuscript.SB designedandedited/wrotethemanuscript.Allauthors contributedtothearticleandapprovedthesubmittedversion.

FUNDING

ThisworkwaspartiallysupportedbyNationalInstituteof AllergyandInfectiousDiseasesGrantR01AI129745,National InstituteofMentalHealthGrantP30MH062261,andFrances E.LageschulteandEvelynB.WeeseNewFrontiersinMedical ResearchFundtoSB.Thefoundershavenoroleindesigning thisstudy.

ACKNOWLEDGMENTS

WethankKabitaPandeyforhelpinpreparationoffigureand DouglasMeigsforeditorialhelp.

12.WatsonK.Whyschoolsinrichareasgetmorefundingthanpoorareas. Global Citizen. (2016).Availableonlineat:https://www.globalcitizen.org/en/content/ cost-of-education-in-us/

13.vanHamM,HedmanL,ManleyD,CoulterR,OsthJ. Intergenerationaltransmissionofneighbourhoodpoverty:ananalysis ofneighbourhoodhistoriesofindividuals. TransInstBrGeogr.(2014) 39:402–17.doi:10.1111/tran.12040

14.ODPHP.Socialcohesion.In: HealthyPeople2020.Washington,DC:U.S. DepartmentofHealthandHumanServices(2020).

15.KluchAvas.Americans’socialdistancingbeliefsandactivity(May, 2020).Availableonlineat:https://news.gallup.com/opinion/gallup/311261/ americans-social-distancing-beliefs-activity.aspx

16.WittersD.InUS.,14%withlikelyCOVID-19toavoidcareduetocost. Well Being (2020).Availableonlineat:https://news.gallup.com/poll/309224/avoidcare-likely-covid-due-cost.aspx

17.ODPHP.Discrimination.In: HealthyPeople2020.Washington,DC:U.S. DepartmentofHealthandHumanServices(2020).

18.KelliHM,HammadahM,AhmedH,KoYA,TopelM,SammanTahhanA,etal.Associationbetweenlivinginfooddeserts andcardiovascularrisk. CircCardiovascQualOutcomes.(2017) 10:e003532.doi:10.1161/CIRCOUTCOMES.116.003532

19.MackenbachJP,CavelaarsAE,KunstAE,GroenhofF.Socioeconomic inequalitiesincardiovasculardiseasemortality;aninternationalstudy. Eur HeartJ.(2000)21:1141–51.doi:10.1053/euhj.1999.1990

20.BanerjeeT,CrewsDC,WessonDE,DharmarajanS,SaranR,RiosBurrowsN, etal.Foodinsecurity,CKD,andsubsequentESRDinUSadults. AmJKidney Dis.(2017)70:38–47.doi:10.1053/j.ajkd.2016.10.035

21.Osuna-PadillaIA,Leal-EscobarG,Garza-GarciaCA,Rodriguez-Castellanos FE.Dietaryacidload:mechanismsandevidenceofitshealthrepercussions. Nefrologia.(2019)39:343–54.doi:10.1016/j.nefroe.2019.08.001

22.AbbasalizadFarhangiM,NikniazL,NikniazZ.Higherdietaryacid loadpotentiallyincreasesserumtriglycerideandobesityprevalencein

adults:anupdatedsystematicreviewandmeta-analysis. PLoSONE.(2019) 14:e0216547.doi:10.1371/journal.pone.0216547

23.Cooksey-StowersK,SchwartzMB,BrownellKD.Foodswampspredictobesity ratesbetterthanfooddesertsintheUnitedStates. IntJEnvironResPublic Health.(2017)14:1366.doi:10.3390/ijerph14111366

24.NIMH. ObesityHypoventilationSyndrome.Bethesda,MD(2013).

25.CDC. DefiningAdultOverweightandObesity.Atlanta,GA(2020).

26.BhatrajuPK,GhassemiehBJ,NicholsM,KimR,JeromeKR,NallaAK,etal. Covid-19incriticallyillpatientsintheseattleregion-caseseries. NEnglJ Med.(2020)382:2012–22.doi:10.1056/NEJMoa2004500

27.PetrilliCM,JonesS,YangJ,RajagopalanH,O’DonnellLF,etal. Factorsassociatedwithhospitalizationandcriticalillnessamong4,103 patientswithCOVID-19diseaseinNewYorkCity. medRxiv.(2020)1–25. doi:10.1101/2020.04.08.20057794

28.SimonnetA,ChetbounM,PoissyJ,RaverdyV,NouletteJ,DuhamelA,etal. HighprevalenceofobesityinsevereacuterespiratorySyndromeCoronavirus2(SARS-CoV-2)requiringinvasivemechanicalventilation. Obesity(Silver Spring). (2020)28:1195–9.doi:10.1002/oby.22831

29.FirebaughG,AcciaiF.ForblacksinAmerica,thegapinneighborhood povertyhasdeclinedfasterthansegregation. ProcNatlAcadSciUSA.(2016) 113:13372–7.doi:10.1073/pnas.1607220113

30.NaniaR. Blacks,HispanicsHitHarderbytheCoronavirus,EarlyU.S.Data Show. Washington,DC:AARP(2020).

31.TNYT. HowtoSaveBlackandHispanicLivesinaPandemic.NewYork, NY(2020).

32.APMResearchLab. TheColorofCoronavirus:COVID-19DeathsbyRaceand EthnicityintheU.S. St.Paul,MN(2020).

33.KawachiI,KennedyBP,LochnerK,Prothrow-StithD.Socialcapital, incomeinequality,andmortality. AmJPublicHealth.(1997)87:1491–8.doi:10.2105/AJPH.87.9.1491

34.KnoxSS,AdelmanA,EllisonRC,ArnettDK,SiegmundK,WeidnerG,etal. Hostility,socialsupport,andcarotidarteryatherosclerosisintheNational Heart,Lung,andBloodInstituteFamilyHeartStudy. AmJCardiol.(2000) 86:1086–9.doi:10.1016/S0002-9149(00)01164-4

35.FinchBK,VegaWA.Acculturationstress,socialsupport,andself-rated healthamongLatinosinCalifornia. JImmigrHealth.(2003)5:109–17. doi:10.1023/A:1023987717921

36.ODPHP.Accesstofoodsthatsupporthealthyeatingpatterns.In: Healthy People2020. Rockville,MD:U.S.DepartmentofHealthandHuman Services(2020).

37.IG.HowairpollutionexacerbatesCovid-19. BBCNews.(2020).

38.WuX,RachekC,SabathBM,BraunD,DominiciF.Exposuretoairpollution andCOVID-19mortalityintheUnitedStates:anationwidecross-sectional study. medRxiv.(2020).p.1–36.doi:10.1101/2020.04.05.20054502

39.ODPHP.Qualityofhousing.In: HealthyPeople2020. Rockville,MD:U.S. DepartmentofHealthandHumanServices(2020).

40.NorthridgeJ,RamirezOF,StingoneJA,ClaudioL.Theroleofhousingtype andhousingqualityinurbanchildrenwithasthma. JUrbanHealth.(2010) 87:211–24.doi:10.1007/s11524-009-9404-1

41.ODPHP.Highschoolgraduation.In: HealthyPeople2020. Rockville,MD: U.S.DepartmentofHealthandHumanServices(2020).

42.ODPHP.Languageandliteracy.In: HealthyPeople2020. Rockville,MD:U.S. DepartmentofHealthandHumanServices(2020).

43.ShafaZ.NeweffortaimstoprovideCovid-19resourcestonon-English speakersinU.S. STATNews (2020).

44.ODPHP.Employment.In: HealthyPeople2020. Rockville,MD:U.S. DepartmentofHealthandHumanServices(2020).

45.iSPARC.Coronaviruseconomicstimuluspayments:whogetsit,how, &impactonotherbenefits. PsychiatryInformationBrief.(2020)17:1–4.doi:10.7191/pib.1148

46.TheNewYorkTimes.StocksRise,WithTechIndexNowUpfor2020.New York,NY(2020,May7).

47.MarkHugoLopezLRaAB.FinancialandhealthimpactsofCOVID-19vary widelybyraceandethnicity(2020,May5).

48.WoolhandlerS,HimmelsteinDU.IntersectingU.S.epidemics:COVID19andlackofhealthinsurance. AnnInternMed.(2020)173:63–4.doi:10.7326/M20-1491

49.AbramsEJ,MyerL,RosenfieldA,El-SadrWM.Preventionofmother-to-child transmissionservicesasagatewaytofamily-basedhumanimmunodeficiency viruscareandtreatmentinresource-limitedsettings:rationaleand internationalexperiences. AmJObstetGynecol.(2007)197(3Suppl):S101–6.doi:10.1016/j.ajog.2007.03.068

50.FriedmanZ.Whatyournextstimulus“Check”reallymightLooklike.Forbes. (2020).

51.TNYT.Georgiacoronavirusmapandcasecount.Availableonline at:https://www.nytimes.com/interactive/2020/us/georgia-coronavirus-cases. html(2020,July5).

52.TNYT.Idahocoronavirusmapandcasecount.Availableonlineat:https:// www.nytimes.com/interactive/2020/us/idaho-coronavirus-cases.html(2020, July5).

53.BluesteinAJDWG.Theatlantajournal-constitution.Availableonlineat: https://www.ajc.com/news/one-month-after-warnings-kemp-puts-georgialockdown/db6Aodv3LzftEV89WA1EOI/(2020,April02).

54.KloppenburgK.GovernorLittleissuesstay-at-homeorderforIdaho. Availableonlineat:https://www.krtv.com/news/coronavirus/stay-at-homeorder-issued-in-idaho(2020,March25).

55.Orecchio-EgresitzRMISH.Georgiaallowedsomebusinessestoreopen today,butmanystoreandrestaurantownersaren’treadytotaketherisk. Availableonlineat:https://www.businessinsider.in/international/news/ georgia-allowed-some-businesses-to-reopen-today-but-many-store-andrestaurant-owners-arent-ready-to-take-the-risk/articleshow/75365048.cms (2020,April24).

56.BrownR,SchollJ.Idahogovernorextendsstay-homeorderthroughApril 30becauseofcoronavirus.Availableonlineat:https://www.idahostatesman. com/news/coronavirus/article242012651.html(2020,April15).

57.CDC.CoronavirusDisease2019(COVID-19).Availableonlineat:https:// www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html(2020, July2).

58.QuinnSC,KumarS.Healthinequalitiesandinfectiousdiseaseepidemics: achallengeforglobalhealthsecurity. BiosecurBioterror.(2014)12:263–73.doi:10.1089/bsp.2014.0032

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Singu,Acharya,ChallagundlaandByrareddy.This isanopen-accessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(CCBY).Theuse,distributionorreproduction inotherforumsispermitted,providedtheoriginalauthor(s)andthe copyrightowner(s)arecreditedandthattheoriginalpublicationinthis journaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

published:04September2020 doi:10.3389/fbuil.2020.00143

Editedby: AkiraMatsumoto, NihonUniversity,Japan

Reviewedby: SerdarDindar, IzmirKâtipÇelebiUniversity,Turkey IgorLinkov, UnitedStatesArmyCorps ofEngineers,UnitedStates

*Correspondence: IzuruTakewaki takewaki@archi.kyoto-u.ac.jp

Specialtysection: Thisarticlewassubmittedto TransportationandTransitSystems, asectionofthejournal FrontiersinBuiltEnvironment

Received: 16June2020 Accepted: 29July2020 Published: 04September2020

Citation: TakewakiI(2020)New ArchitecturalViewpointforEnhancing Society’sResilienceforMultipleRisks IncludingEmergingCOVID-19. Front.BuiltEnviron.6:143. doi:10.3389/fbuil.2020.00143

NewArchitecturalViewpointfor EnhancingSociety’sResiliencefor MultipleRisksIncludingEmerging COVID-19

IzuruTakewaki*

DepartmentofArchitectureandArchitecturalEngineering,KyotoUniversity,Kyoto,Japan

ThespreadofCOVID-19allovertheworldsincethebeginningoftheyear2020 requiresare-thinkingofthemeaningoftheterm“resilience”inthefieldofarchitecture andarchitecturalengineering.Resiliencefromtheviewpointofarchitectureand architecturalengineeringhasbeeninvestigatedprimarilyintermsofconventional naturaldisasterrisks(see,forexample, Bruneauetal.,2003; Cimellaroetal.,2010; ArchitecturalInstituteofJapan[AIJ],2020a).However,COVID-19remindsusofthe needtoinvestigateresiliencealsointermsofinfectionrisks.Theplaceswherepeople becomeinfectedareprincipallywithinbuildingsandtransportationsystems.Especially inbuildings,threefactorsconsideredtobemainrisksforinfection(closedspaces withoutventilation,densegatherings,closeconnection)oftenoccur.Forthisreason, theroleofarchitectureandarchitecturalengineeringisessentialfromtheviewpoint ofreducingtheriskofinfection,usingversatileknowledgeandtechnologiesfromthe fieldsofarchitecturalandregionalplanning.FollowingtheappearanceofCOVID-19, architecturaldesignersandengineershaveanimportantmandatetothinkaboutthe roleofbuildingsandtheirrelatedfields.

Keywords:citiesandurbanization,COVID-19,infrastructure,localandregionaldevelopment,manufacturingand production,resilientbuilding,supplychainandtransport,sustainability

Sincethebeginningof2020,theCOVID-19virushasspreadallovertheworld,requiringusto re-thinkthemeaningof“resilience”inthefieldsofarchitectureandarchitecturalengineering.In architectureandarchitecturalengineering,resiliencehastraditionallybeeninvestigatedprimarily intermsofconventionalnaturaldisasterrisks(see,forexample, Bruneauetal.,2003; Cimellaro etal.,2010; ArchitecturalInstituteofJapan[AIJ],2020a).COVID-19remindsusoftheneedto alsoinvestigateresilienceintermsofinfection,duetothefactthattheplaceswherepeoplebecome infectedareprincipallybuildingsandtransportationsystems.Atpresent,thethreemainfactors thatincreaseriskofinfection(closedspaceswithoutventilation,spacesthatencouragedense gatherings,andenvironmentsthatfosterclosephysicalconnections)oftenoccurinbuildings. Versatileknowledgeandtechnologiesfromthefieldsofarchitecturalandregionalplanning couldplayanessentialroleinreducingtheserisks.FollowingtheappearanceofCOVID-19, architecturaldesignersandengineershaveanimportantmandatetore-thinktheroleofbuildings andotherrelatedfields.

Byfocusingonaspectsofarchitecture,itispossibletoconsider asocietyofresiliencethatencompasseshealth-relatedriskslike COVID-19alongsideconventionalnaturaldisasterrisk.Aspects of“resistingability”and“recoveringability”offerawayof classifyingfactorsatmultiplescalesthatmightenhanceresilience towardbothCOVID-19riskandconventionalnaturaldisaster risk.Theseabilitiesrepresentthetwomainconstitutivefactorsof resilience(see Figure1 and Table1).Resistingabilitydescribes theprocessofbeingableto“planandabsorb”(Linkovand Trump,2019),andrecoveringabilitycorrespondstotheprocess ofbeingableto“recoverandadapt”(LinkovandTrump,2019). Theseabilitiesalsoprovidenewconceptsofmultiplescales, factoringinthehumanscale,buildingscale,regionalscale, andcyberscale,amongothers.Inconventionalnaturaldisaster riskthefactorsrelatedtothehumanscalearenotsignificant toitsexperience,buttheaddeddimensionofCOVID-19risk remindedusoftheimportanceoftakingintoaccounttheseother factors,illustratedin Table1.Thisaspectistheoriginalpointin thisperspectivetobefocused.

Asdiscussedhere,importantpointsinCOVID-19riskare differentfromthoseinconventionalnaturaldisasterrisk.Firstly, atthe humanscale forCOVID-19risk,resistingabilities includetheimprovementofhandhygiene,wearingmasksand faceguards,maintainingsocialdistance,andmaintainingstrong immunity(throughnutritionandexercise).Ontheotherhand, recoveringabilitiesincludeboostingimmunity,digitizationof businessdata,adaptationtoDX(digitaltransformation),and thecreationofcommunicationhubsforpeoplefromvarious fields.Theseresistingandrecoveringabilitiesshouldalsobe consideredforconventionalnaturaldisasterrisks,exceptfor themaintenanceofsocialdistancewhichdrivesthethree

occurrenceprobabilities(closedspaces,densegatherings,close connections),whichincreasetheriskoftransmittingand contractingCOVID-19.

Secondly,atthe buildingscale forCOVID-19risk,resisting abilitiesincludeventilationplanningtopreventaerosol infections,flowlineplanningtopreventunnecessaryhuman contact,equipmentplanning(electricity,watersupply,and drainage),andstructuralengineeringplanningforbuilding spaceusage.Ontheotherhand,recoveringabilitiesinclude theflexibilitytomakechangestobuildingusage(hotels,rental residences,carefacilities),digitizationofdesigndata(DX adaptation),promotionofbuildinginformationmodeling (BIM)technology,andshelterplanninginmaintainingsocial distance.Whilethereductionofvulnerabilitiesinbuildingsis usuallyconsideredtobethemainobjectiveforconventional naturaldisasterrisk;theprimaryfocusforCOVID-19risk isthepreventionofinfectionandanincreaseofflexibilityin howbuildingsareused.Thisisanewanalysis,differentiating betweenthecharacteristicsofconventionalnaturaldisasterrisk andCOVID-19risk.

Thirdly,atthe regionalscale forCOVID-19risk,resisting abilitiesincludechangesincommutingstyle(time-lag commuting,flextime),promotionoftelework(DXadaptation), avoidanceofdensedwellingsandworkplaces,leadingto reductionofconcentration.Inaddition,returntoprovincial areas(pastoralcityplanning)couldalsoleadtoreduction ofconcentration,ascouldtherenovationofoldhousesand buildingsforremoteworking.Furthermore,theplanned relocationofhospitals,schools,andcityhalls,aswellasthe distributedallocationofthemainfunctionsofacompany,could alsoleadtoareductionofconcentration.Ontheotherhand,

TABLE1| ClassificationoffactorsinseveralscalesenhancingresilienceforCOVID-19andnaturaldisasterrisks.

COVID-19risk

Naturaldisasterrisk

HumanscaleBuildingscaleRegionalscaleCyberscaleandothers

Resistingability(“plan,absorb”)Strengtheningofhand hygiene

VentilationplanChangeofcommutestyle (Time-lagcommute,Flex time)

Wearingofmaskand faceguard Flowlineplan(Preventionof unnecessarypeople’s contact)

Onlineabilityofworkingtool anddataincompany(DX adaptation)

Promotionoftelework(DX adaptation) Onlineabilityofeducationaltool (DXadaptation)

KeepofsocialdistanceEquipmentplan(Electricity, watersupplyanddrainage)

Avoidanceofdense dwellingandworking

Strengtheningofglobalanalysis abilityofinformation Keepofstrongimmunity (Foodandexercise)

StructuralengineeringplanReturntolocalarea(Pastral cityplan),Renovation AdvanceduseofAIand roboticstechnologiesfor architecturaldesignand construction

Plannedlocationof hospital,school,cityhall

Distributedallocationof mainfunctionsincompany

Recoveringability(“recover,adapt”)BoostingimmunityFlexibilityforchangeof buildinguse(Hotel,rental residence,carefacility)

DigitizationofbusinessdataDigitizationofdesigndata (DXadaptation)

AdaptationtoDX(Digital transformation) PromotionofBIM technology

Constructionof communicationhubwith peopleinvariousfields

Shelterplanforkeeping socialdistance

Multiplicationofsupply chain Insurance

Strengtheningofdomestic production Keepofinternalreserves

Strengtheningofhome deliveryservice

Onlineofsubsidyfrom governmenttocompanyand people

Duplicationoftransitand transportation Producingabilityofmultiple differentproducts

Strengtheningofintelligence network

AdvanceduseofAIand roboticstechnologiesfor architecturaldesignand re-construction

recoveringabilitiesincludethemultiplicationofsupplychains, strengtheningofdomesticproduction,strengtheningofhome deliveryservices,andduplicationoftransitandtransportation options.ForCOVID-19risk,thepreventionofinfectionand themultiplicationandincreaseddiversityinsocialactivitiesare astrongpointoffocusindifferentiatingthecharacteristicsof conventionalnaturaldisasterriskfromthoseofCOVID-19.

Finally,atthe cyberscaleandothers,resistingabilities includetheonlineabilitiesfacilitatedbyworkingtoolsand datasetswithincompanies(DXadaptation),andtheonline abilityofeducationaltools(DXadaptation).Otherresisting abilitiesincludetheuseofadvancedtechnologiessuchasAI androboticsinarchitecturaldesignandconstruction,andas awayofstrengtheningtheglobalanalysisofinformation. Recoveringabilitiesincludeinsurancecontracts,maintenanceof internalreserves,subsidiesfromthegovernmenttocompanies andpeople,theproductioncapabilityofmultipledifferent products,advanceduseofAIandroboticstechnologiesfor

architecturaldesignandre-construction,andstrengthening intelligencenetworks.Inthepast,mostnaturaldisastershave occurredlocally,makingitunnecessarytorespondtodisastersat anationalorglobalscale.However,nationwideresponses,such asDXadaption,arenecessaryinmanagingCOVID-19risk.It shouldbenotedthatthecyberscaleencompassesallhuman, building,andregionalscales(see Figure1).

Severalpreviousstudiesinthefieldofresiliencescienceare closelyrelatedtothisperspective,whichfactorsinhealthand pandemicrelatedrisk.Fourdomainsofresilience(physical, cyber/information,cognitive,andsocial)wereintroducedin studiesby Linkovetal.(2014,2018),and LinkovandTrump (2019).Eachofthesestudiesdefine“resilience”astheabilityto absorb/respond,recover,andadapt. Linkovetal.(2014) have discussedtheconceptofresiliencefromtheviewpointofthe relationshipbetweenriskandtheresiliencemanagement,by assessingtheresilienceofatownfacingvariousrisksincluding thoseofinfection.Thisstudydiscussedfactorsrelatedtothe

humanscalehistorically,includingthoseeffectingthecityof Veniceduringaplagueinthefourteenthcentury.Theyconclude thatbetteroverallsystemmanagementcanbeachievedinthe faceofunknownorunquantifiablethreatsbyintegratingriskand resiliencemanagementandassessingthesystemovermultiple domains:includingthephysical,thoserelatedtoinformation,the cognitiveandthesocial.Althoughitwasnotaimedatthefieldof architecture,anotionofresiliencedirectlyrelatedtoCOVID-19 wasalsodiscussedby Hynesetal.(2020).Similarly, Kurthetal. (2019) havepresentedacomprehensivereviewmainlyfromthe viewpointofconventionalnaturalhazards,exceptforinfection risks.Theydiscussrelatednotionsoffunctionality,recovery, adaptation,indeterminacy,modelinganduncertainty,regulatory mechanisms,economicchallenges,andsoforth.Itisexpected thatthesenotionsandideaswillinfuturebeappliedtoinfection riskssuchasCOVID-19.

Overthenext100years,thefieldsofarchitectureand architecturalengineeringareexpectedtoplayanimportantrole inrespondingtoandovercominginfectionrisksaswellasnatural disasterrisks.Sinceresilienceenhancingfactorscomprisingthe humanscale,buildingscale,regionalscale,cyberscale,and othershavestrongandcomplexcorrelations,itisnecessaryto

REFERENCES

ArchitecturalInstituteofJapan[AIJ].(2020a).Proposalofevaluationindiceson buildingresilienceandbusinesscontinuityplanforbuildingmaintenance andrecoveryfromnaturaldisasters,Specialcommitteeforinvestigation onbuildingresilienceandbusinesscontinuityplanafternaturaldisasters. [https://www.aij.or.jp/jpn/databox/2020/200309.pdf]

ArchitecturalInstituteofJapan[AIJ].(2020b). ActivityHUBrelatedtoCOVID-19 [https://www.aij.or.jp/covid19_info.html]

Bruneau,M.,Chang,S.E.,Eguchi,R.T.,Lee,G.C.,O’Rourke,T.D.,Reinhorn, A.M.,etal.(2003).Aframeworktoquantitativelyassessandenhancethe seismicresilienceofcommunities. EarthquakeSpectra 19,733–752.doi:10. 1193/1.1623497

Cimellaro,G.P.,Reinhorn,A.M.,andBruneau,M.(2010).Frameworkfor analyticalquantificationofdisasterresilience. Engineer.Struct. 32,3639–3649. doi:10.1016/j.engstruct.2010.08.008

Hynes,W.,Trump,B.D.,Love,P.,andLinkov,I.(2020).Bouncingforward:A ResilienceApproachtodealingwithCOVID-19andfuturesystemicshocks. Environ.Sys.Dec. 40,1–11.

Kurth,M.,Keenan,J.M.,Sasani,M.,andLinkov,I.(2019). DefiningresiliencefortheUSbuildingindustry. Build.

considersystematicchallengesandevolveexaminationofrisk inarchitectureandarchitecturalengineering.Inresponse,the ArchitecturalInstituteofJapanlaunchedtheCOVID-19/HUB (see ArchitecturalInstituteofJapan[AIJ],2020b)inJune2020, aforumonitshomepageforinstitutememberstosubmituseful information.Althoughitisimportanttonotethatcultural circumstancesandtechnologiesaredifferentfromcountryto country(andthattheperspectivespresentedheremaybeaffected inthisway),theessentialpointsunderlyingthisdiscussionmay beofuse.

AUTHORCONTRIBUTIONS

ITwrotethewholeperspective.

ACKNOWLEDGMENTS

IgratefultoDr.ThomasDaniell,ProfessorofArchitecture andArchitecturalEngineering,KyotoUniversity,forproviding valuablecommentsforrevision.

Res.Innovat. 47,480–492.doi:10.1080/09613218.2018.145 2489

Linkov,I.,Fox-Lent,C.,Read,L.,Allen,C.R.,Arnott,J.C.,Bellini,E.,etal. (2018).Tieredapproachtoresilienceassessment. RiskAnaly. 38,1772–1780. doi:10.1111/risa.12991

Linkov,I.,Fox-Lent,K.,Keisler,J.,DellaSala,S.,andSieweke,J.(2014).Risk andresiliencelessonsfromVenice. Environ.Syst.Decis. 34,378–382.doi: 10.1007/s10669-014-9511-8

Linkov,I.,andTrump,B.D.(2019). Thescienceandpracticeofresilience Amsterdam:Springer.

ConflictofInterest: Theauthordeclaresthattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Takewaki.Thisisanopen-accessarticledistributedunderthe termsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distribution orreproductioninotherforumsispermitted,providedtheoriginalauthor(s)and thecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournal iscited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

published:24September2020 doi:10.3389/fpubh.2020.569353

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland

Reviewedby: Jean-FrancoisLegare, DalhousieUniversity,Canada HuiWang, ShanghaiJiaoTongUniversity AffiliatedSixthPeople’s Hospital,China

*Correspondence: AshwaniKumar ashwaniiitd@hotmail.com

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 03June2020

Accepted: 14August2020 Published: 24September2020

Citation: KumarA,MallaMAandDubeyA (2020)WithCoronaOutbreak:Nature

StartedHittingtheResetButton Globally. Front.PublicHealth8:569353. doi:10.3389/fpubh.2020.569353

WithCoronaOutbreak:Nature StartedHittingtheResetButton Globally

AshwaniKumar 1*,MuneerAhmadMalla 2 andAnamikaDubey 1

1 MetagenomicsandSecretomicsResearchLaboratory,DepartmentofBotany,Dr.HarisinghGourUniversity(ACentral University),Sagar,India, 2 DepartmentofZoology,Dr.HarisinghGourUniversity(ACentralUniversity),Sagar,India

ConsideringthepotentialthreatandthecontagiousnatureoftheCovid-19pandemic, lockdownshavebeenimplementedworldwidetostopthespreadofthisnovelvirus.The coronaviruspandemichashittheworldseverely,representingthemostseverethreatto humanhealthinmorethanacentury.Theenvironmentfromlocaltoglobalscaleshas witnessedapparentpositiveandnegativeimpacts.Globallockdownshavedrastically alteredthepatternsofenergydemandandhavecausedaneconomicdownturnbut atthesametime,haveprovidedanupside-cleanerglobalenvironment.Suchimmense unintendedadvantagesofferopportunitiesforunprecedentedinsightsintothedynamics ofournaturalandbuiltenvironmentsthatcanleadtoviablepathsfortheconservationand perpetuationoftherecoveredenvironmentsandthroughsensiblepoliciesandpractices thatcanhelptocreatenewrecoverypathways.Knowledgegainedfromthestudies suggeststhatasubstantialrelationshipexistsbetweenthecontingencymeasuresand environmentalhealth.Hereinthisreview,theauthorsdiscussedtheimpactofcoronavirus pandemiconhumanlife,healthcareorganizations,andtheenvironment.Theparallels betweentheCovid-19andotherdiseasesarementioned.Finally,theimpactofCovid-19 onsocietyandtheglobalenvironmenthasalsobeenhighlighted.

Keywords:SARSvirus,COVID-19,environmentalpollution,pandemic,respiratorydiseases

INTRODUCTION

Coronavirusesbelongtothegroupofviruseswithsubfamily Coronavirinae within Coronaviridae familyandaredeemedaspossibleagentsofrespiratorydiseaseswithsymptomssuchasflu,fever, runnynose,cough,breathingdifficulty,pneumonia,andlunginfection(1).InDecember2019, anovelcoronavirusdisease (Covid-19)originated,inWuhan,Hubeiprovince,China,andsoon sproutedacrosstheglobe(2).ByFebruary2020,thedailynumberofCovid-19casesoutsideChina hadincreased drastically,withItaly,USA,Spain,Germany,SouthKorea,Japan,andIranbeing thenewmajorepicenters.Basedonthealarminglevelsofspreadandseverity,on11March2020, theworldhealthorganization(WHO)characterizedtheCovid-19situationasapandemic,andby theendofMarch2020,Europeemergedasthenewhotspotandwasdeclaredastheworld’smajor epicenter(3).Asof14July,theCovid-19diseasehasspreadtomorethan200countriesandUnion Territories(Figure2),withover13,177,855confirmedcasesandover574,793confirmeddeaths worldwide(2).Asthisglobalpandemichitsmorethan200countries,thevirusbesidestaking ahuge tollonpublichealthhascompletelyhijackedtherhythmofourdailylives,hittheglobaleconomy, andforcedthecountriestoshuttheirborders(2, 5).DatareleasedbyEuropeanSpaceAgency(ESA)

andNationalAeronauticsandSpaceAdministration(NASA) indicatesthat pollutioninsomeoftheepicentersofCovid19suchasWuhan,USA,Spain,andItalyhasdecreasedby upto30%(3).WiththeUSA,Spain,Italy,UK,France,and Germany,amongtheworst-hit countriesintermsofinfections anddeaths,Indiaisalsofacingtheheat,andthefigurestoo arenolessdevastating.Environmentalpollutionhasitsrootsin industrializationandurbanization,whicharethemainsources ofthehugereleaseofgreenhousegases(6).Themajorityofthe studiesconductedinthe recentpasthavefocusedmoreupon fightingagainstthisdeadlyvirusbutveryfewarefocusedonthe indirectbeneficialeffectofthispandemicontheenvironment(3, 6, 7).Climateexpertspredictedthattheemissionofgreenhouse gases(GHGs)couldfallbylargeamounts(nearly8%)since WorldWarII(8).ThisreductioninthelevelofGHGsisa consequenceoflockdownandsocialdistancingpoliciesadopted bygovernmentsindifferentcountriestocombatthecoronavirus spread.Theselockdownmeasuresseverelyaffectthecountry’s maincommercialactivities(9).Asaresult,industrialfacilities andpowerplantsstoppedtheir productionandusesofvehicles decreasedconsiderably.Thisledtoanintensedeclineinthe concentrationsofparticulatematterandnitrogendioxide(NO2) inChinaandthereductionofairpollutioninEurope.Therefore, inthisreview,wediscussedbothdirectorindirectpositiveand negativeeffectsoftheCovid-19pandemicontheenvironment andhumanhealth(Figure1).

CORONAPANDEMICANDHUMANLIFE:A GROWINGMISERY

Thepandemicturn’smessierandeverydaylifesuffers,asthe worldremainsunderlockdown(9).Asmentionedabove,till thiswriting,thenumber ofCovid-19casesworldwidewas 12,977,429,withover570,259fatalities(https://coronavirus.jhu. edu/)andover2.5billionpeoplearoundtheworldunder lockdownandstay-at-homeorders(2).Inthepresentera, inwhichwelivetoday,thedevelopmentisatitspeak,with qualityandsophisticationofthetechnologiesandmedicines attheirbest.Moreover,wearealsowitnessingarapidand efficientcollaborationandcommunicationofnationsatglobal levels,yetthisCovid-19pandemicissweepingthroughout theglobewithhighmortality,groundingmostoftheglobal population,bringingthehealthcaresystemsoftheworld’s developedcountriestoabreakingpoint,andshatteredourviews ofnormalityandpeacefullife(10 12).Itisquiteenoughto say,thatthe combinationofadeadlyandrapidlypropagating virusandtheweakhealthinfrastructures,lessinformationabout thisvirus,andunavailabilityofvaccineandpropermedication, havecreatedtheperfectstormandthepeopleareinapanic. Covid-19pandemichasbeenanurgentwake-upcallformany developedandrichcountries,intermsoftheirfailuretostop thispandemicandsavethelivesoftheircitizens,asaresult, hasbroughtforththeirfragilehealthcaresystems(13).Lack ofeffectivetesting,understaffedhospitals,preciseandscienceorientedguidanceanddirections,crumblinghealthcaresystems, andearlyplanningtoprocurenecessarymedicalequipment

[likepersonalprotectiveequipment(PPE)],despiteincreasing evidencesthattheworldisfacingaglobalhealthemergencyhas beenshockinginmostofthedevelopedcountriesespeciallyin theUSA,EU,andKU(14).Thesecountries,beingsuperiorin termsoftheirunions,quality andstrengthofmedicalexpertsand researchers,economicstrength,andbetterhealthcaresystems, failedenormouslyindealingwiththispandemic(15).Thishave unfortunatelyplacedtheweakandmarginalizedsectionofthe populationatgreaterrisk.

PARALLELSBETWEENCOVID-19 PANDEMICANDOTHERGLOBALCRISIS

ThepresentAnthropoceneiswitnessinganupliftmentofglobal crisessuchasclimatedestabilization,populationexplosion, conflicts,increasinglevelsofinequalityamongthepeople, economicuncertainty,mountingpublichealththreats,andmost recentlytheCovid-19pandemic(3).Alltheseglobalcrisesare slowlytippingthebalance,questioningtheglobaleconomy, financialmarkets,andpublichealththerebyforcingthesociety torethinkthenextsteps.Therearecertaindegreesofparallels thatcanbedrawnbetweentheongoingCovid-19pandemic andsomeothercontemporarycrisestheworldiscurrently facing.Allofthesenecessitatelong-termthinkingandglobal responseguidedbysciencetoaddressthesecrises.Inthisview, theCovid-19pandemicmayprovideanopportunitytothe scientificcommunityandthepoliticalsystemforamuchdeeper understandingoftheglobalcrisesandcouldhelpustotackle thebiggestthreatofthecentury,theclimatecrisis.Accordingto Wyns,amemberoftheclimatechangepanelattheWHO,the worldiswitnessingoverwhelmingconsequencesoftheunderpreparedhealthsystemsbecauseoftheseshocks,withmostof thesehavingaclearclimatechangesignature.Almostallthe healthshockshaveonethingincommon;theyhitthepoor, vulnerable,andmarginalizedthehardest(2).Atleast50%ofthe globalpopulationdoesnot havethemostbasichealthservices, thereforewhenadisasterhits,globalinequalityissustained,and compensatedwiththelivesoftheweakandmarginalizedsectors ofthesociety(11, 13).Thesamestandstrueforclimatechange, e.g.,theburningoffossilfuelsbesidesaddingtoairpollution disproportionatelyimpactsthehealthofpoorandweakerpeople. Secondly,theCovid-19pandemiclikeotherglobalcriseshas crushedtheentireglobaldevelopmentwithrecordsofeconomic recessionandfinancialmeltdowns.Thishasputthefateofnot onlythepoorbutalsotherichcountriesundersuchathreatthat theworldhasneverseen.Withinternationaltradeslowingdown, commoditypricescollapsing,thethird-worldcountriesthatwere alreadyinmiseryareontheedgeoffull-blownsovereigndebt crises(16).

MEASURESTOSLOWDOWNTHE CORONAVIRUS

WiththeworldlockedupinadeadlyfightagainsttheCovid19pandemic,countriesacrosstheglobearesettingstandard measurestoslowthespreadofthisvirus.Withoutenough

testkits,thelow-incomecountriesaremainlyrelyingonthe healthcareworkerstotrace,quarantine,andself-isolatethe peopletoslowdowntherateofinfections.Inthesecountries, peopleonlygettestediftheydevelopsymptoms(15, 16).Experts predictthatthe stakesarehighenoughifthepresentcontainment measuresfailtoslowthespreadofthisdeadlyviraloutbreak. Someofthemainmeasurestakenbythegovernmentstoslow downtheoutbreakarecontracttracing,travelrestrictions,social distancing,temperaturechecks,widespreadtesting,andbanon gathering,closingofeducationalinstitutes,lockdowns,andselfquarantine(15).

COVID-19ANDTHEGLOBALCLIMATE CHANGE

IrrespectiveoftheobviousdeclineinCO2 emissionandair pollutionowingtothelockdownswhichalthoughtemporarily, butmaycontributetomitigatingclimatechange(17, 18),many parallelsindeeddoexistbetween thechallengesinfighting thisglobalclimatechangeandpandemic.Asdiscussed,the mandatorylockdownshaverecordeduptoa5◦Creductionin temperaturethantheprelockdownperiods,indicatingthatthe industrialsectorislikelyresponsiblefortheenergyfootprintsthat

FIGURE1| Thepositiveandnegativeeffects ofCovid-19.

candramaticallyincreasethetemperature.Since,bothclimate changeandpandemicare existentialchallengesthatthehuman raceisfacing.Neitherthecoronaviruspandemicnortheclimate seesthecontinentalborders,asisevidentfromthecurrentCovid19,floodsinmidwestplains,bushfiresinAustralia,droughtsin California,growingdesertsinCentralAsia,retreatingglaciersin theAlps,andthemeltingpolaricecaps,andtheconsequences ofclimatechangewillaffectallofus(humans)insomeform atsomepointandnoonecanescapetheseconsequences(19). Therefore,thereis aneedtoconsideralltheseproblemsas“our problems”anditsurgenttimetothinkandacttogether.The catastrophicconsequencesofclimatechangearequitesevereand candamagetheenvironmentandbiodiversity.However,learning fromthelessonsofCovid-19,wemustactnowtoavoidany furtherglobalcatastropheandbeawareofthesinisterthreats thatmayarisegradually.Similarly,ignoringtheever-growing scientificevidenceofbothclimatechangeandtheCovid-19 pandemiccannotsaveusfromthehazardousconsequences (20, 21).Therefore,theneedofthehouristomakedecisions basedonscientificevidence.Fightinganyglobaldisasterneeds internationalcollaborationsothatscientistscanworktogether andaddressthechallenges.Inthecaseofthepresentcoronavirus pandemic,theglobalcollaborationisimpressive,similarly,the modelingandunderstandingofclimatechangeissuesareaglobal collaborativeeffortbytheIntergovernmentalPanelonClimate Change(IPPC)(17).

POSITIVEANDNEGATIVEIMPACTS OF COVID-19

Withoutaviabletherapyandvaccine,theinternational communityisontenterhookstryingtolimitthespreadof coronavirusandreducethemortalityfromtheCovid-19 pandemic.Thevirushasquicklyimpactedthegovernmentand publichealthsystemsandforcedthegovernmentstodeclarea nationalandinternationalpublichealthemergency.Giventhe restrictionsinpublicmovement,closedborders,reducedpublic transport,haltednon-essentialservices,andshelter-in-place

orders,theplanetiswitnessingboththepositiveandnegative effectsoftheCovid-19pandemic(3).

POSITIVEEFFECTSOFCOVID-19ONTHE ENVIRONMENT

The PlanetEarth:AnUnlikelyBeneficiary

ofCoronaPandemic

Withthegloballockdowninprocess,theInternetisabounded witharticlesandthesocialmediaoutletswithpictures,showing theplanetbeingtheunlikelybeneficiaryofthisCovid-19 pandemic(22).Natureseemstohavehittheresetbutton, reclaimingthespacestohealitselfastheanthropogenicactivities havesloweddown.Amidstallthegloomanddoomthatthe Covid-19pandemicisgiving,thereseemstobeaproverbialsilver liningandsomepositiveconsequencesaswell(22).Someofthese arementionedbelow:

DecreaseinAir PollutionLevel

Aircomprisestheimmediateenvironmentofhumanbeings, whichisvitalfortheirsurvival.With91%oftheglobal populationlivinginplaceswheretheairqualityispoor,with AirQualityIndex(AQI)exceedingthepermissiblelimits(23), thepossiblehealth effectsofthedegradedairqualityhad thelargestfootprintsattributabletothepervasive,pernicious, prolonged,andconstantexposuretopollution.Although,the possiblehealtheffectsofpollutioningeneralandairpollution, inparticular,areconsideredthetipoftheiceberg,however, theconsequencesoftheglobalairpollutionaremanifestedin termsofthesignificantpercentageofdeathsworldwideeach year(24).TheLancetcommissionreportsonpollutionand healthsuggest thatpollutionaccountsformorethan16%of theglobaldeaths,withairpollutionalonecontributingup to8%ofthesedeaths,whichisthreetimesmorethanthe deathsduetotuberculosis,malaria,andAIDSand15%more thanwarfaresandotherglobalviolence(24, 25).Estimates suggestthat morethan90%ofthepollution-relateddeaths occurindevelopingcountries,suchasAsiaandAfrica.The UnitedNations(UN)GeneralAssemblyhasalreadyadopted17

FIGURE2| NO2 dropsdowninthecoronavirusepicenterWuhan, HubeiProvince-China. (A) InDecember2019, (B) February2020(4).

sustainabledevelopmentgoals(SDGs)relatedtoclimatechange. TheUNgeneralassemblyhasadoptedadditionalSDGsonclean air,cleanwater,goodhealth,responsibleproduction,andthe industrializationofcities,marine,andterrestriallife(24, 25).In responsetothecurrent Covid-19pandemicandwithcountries suspendingtransportandmillionsofpeopleputinlockdown toflattenthecurve,globalairpollutionhassignificantlycome down,withcarbonmonoxideemissionreducedbymorethan 50%.Chinawasthefirstcountrytoimplementself-quarantine measuresandstricttrafficrestrictionstocontroltheexpansion ofCovid-19.Thisglobalbanontrafficmobilityandlockdown greatlylimitedtransportationemissionsanddeclinedindustrial andresidentialheating.Theseactionswerefoundtogenerate changes,asreportedbyNASAandESA.ThelevelofNO2 was reducedby12.9and22.8 µg/m3 inChinaandWuhancityin HubeiProvince,respectively[(4), Figure2].Similarly,particulate matter(PM2.5)wasfound toreduceby1.4 µg/m3 inWuhan butshowedasignificantdropdown(18.9 µg/m3)inthemajority (morethan350)ofthecities. Figure3 clearlyillustratesasharp reductioninNO2 concentrationsinotherEuropeancountries suchasGermany,Italy,Spain,andFrance[(26), Figure3].The dramaticincreaseintheairqualitylevelacrossChinaduringthe quarantineperiodwasalsodetectedbytheCopernicusSentinel5Psatellite.Similarly,thedatafromtheCopernicusSentinel-5P satellite,usingthenitrogendioxidetroposphericcolumndensity, revealedasteepdeclineinairpollution,particularlyinthe NO2 emissions,overItaly,post-coronalockdown.Additionally, basedonthereportsofCopernicusAtmosphereMonitoring Service(CAMS),theEuropeanUnionobservedasignificant dropinPM2.5(20–30%approx.)inFebruary2020compared withthemonthlyaverageof2019,2018,and2017(27, 28) (Table1).AccordingtoFeiLiu,anair-qualityscientistatNASA’s GoddardSpaceFlightCenter,suchdramaticdropoffintheair pollutionwasseenforthefirsttimefromJanuary2020.China

alsowitnessedasignificantdropdown(36%)incoal-firedpower from3Februaryto1March2020(28).Coronavirushascut emissionsfasterthanyearsofclimatenegotiations.InIndia, likeintherestoftheworld,withstrictlockdowninplace andwithalessernumberofpeopleventuring,thecountryhas seenadrasticfallinpollutionlevels.TheAQIloweredfrom 500to600inwinters,toaslowas50inApril(Figure4) (https://www.aqi.in/).InChinaalone,alltheinterventionsto containthesevereacuterespiratorysyndromecoronavirus (SARS-CoV)-2outbreakledtoair-qualityimprovementswith prominenthealthbenefitsthatoutnumberedtheconfirmed Covid-19deaths(28).

Asmentioned,thelocking downofcitieshassignificantly improvedtheenvironmentalqualitywithasharpdropinair

TABLE1| Reductioninparticulatematter(PM 2.5). CountriesAveragePM2.5 duringlockdown 2020(µg/m3 )

Reduction comparedwith 2019(%)

Reductioncompared withprior4-year average(%)

LosAngeles,USA5.5 31 51 UK 16.2 9 +6 China 35.1 44 50 Italy 16.7 +30 ND Spain 6.4 11 +2 NewYork,US 4.4 25 29 Brazil 10.1 32 26* SouthKorea 24.1 54 32 India 32.8 60 55 ND,nodata. *dataiscomparedonthebasisofa3-yearaverageratherthana4-yearaverage. Source,https://www.iqair.com/world-air-quality-ranking.

FIGURE3| Satelliteimagesfrom ESAshowingadramaticreductionintheamountofharmfulgreenhousegasemissionsintheatmosphere.Pollutiondropsdownin Europeancountriesamidcoronavirusquarantine (A) AsonMarch2019,and (B) March2020(26).

pollutionlevelsacrossseveralcountries(2, 6, 29 33).Whereas, beforeandafterlockdown comparisonisproblematicbecause itlackspropercounterfacts.However,despiteareturnto normalcy,andeasingofrestrictions,thereisevidenceto suggestthattheairqualityhasconsiderablyimprovedafterthe lockdown(31).Dataanalysisfromdifferentcountriesshows lowNO2 pollutionlevels(30%below thenormallevelat theendofJune)despitetrafficandcommercialoperations beingbacktonormal.Moreover,studiessuggestthatmore

developedcountriescouldbemoresubstantiallyinfluenced bylockdown,asindustrialactivitiesremainlargelysuspended (16).Similarly,thelockdowneffectsarelargerinrichand coldareasandcitieswithmoretrafficvolumesexperience amoresubstantialreductioninairpollutionbecausericher countrieshavehigherelectricitydemandsandcolderareas havehighercoaldemands,respectively(29 33).Datalikethese hintthatmother earthisanunintendedbeneficiaryofthe Covid-19pandemic.

FIGURE4| Pre-andpost-lockdownlevel ofairborneaerosolsoverIndiaSource:NASAandESA,(source,https://earthobservatory.nasa.gov/images/146596/ airborne-particle-levels-plummet-in-northern-india,https://earthobservatory.nasa.gov/.accesseddate:13May2020).

EnvironmentalNoisePollutionReduction

Environmentalnoisepollutioniswell-definedasanundesirable soundgeneratedbyvariousanthropogenic,transport,industrial, andcommercialactivitiesandisthemajorsourceofdiscomfort fortheenvironmentandhumanhealth(3, 29).Prolonged exposuretonoisepollutionhasbeenshowntocausearangeof healthproblemssuchasstress,tinnitus,cognitiveimpairment, cardiovasculardisease,hearingloss,lackofsleep,fatigue,poor concentration,difficultiesincommunication,andproductivity lossesfromworkingplaces.Theworldwideimpositionof quarantinemeasuresbygovernmentshasconfinedthepeople totheirhomes.Thisglobalquarantinehasnotonlydecreased theuseofprivateandpublictransportationbuthasalsoled toasignificantdropdownincommercialactivities(3).All thesechanges havecausedaconsiderabledropinthenoise levelinmostcitiesintheworld.Thereportsshowthatnoise reductionshavegonedeep,withseismologistsreportingless seismicnoise.Forexample,inBrussels,theseismicnoisecaused byanthropogenicactivitiesisreportedtobedownby1/3 comparedwiththeprelockdownlevels(30, 31).Likewise,the decreaseintheuseofpublicandprivatetransportalongwith othercommercialactivitieshascausedasignificantfallinthe levelsofnoisepollution.Withcruisestemporarilybeingon hold,oceansaremoreinastateofcalm.Thiscalmnessand decreaseinoceannoiseislikelytoreducethestressofaquatic creatures.Thoughthecurrentreductionseemstobeashorttermphenomenon,properandalong-termstrategyisneeded tocheckandmaintaintheenvironmentalnoiselevelwithin theWHO’spermissiblelimits.AscommentedbyEulaliaParis, anoiseexpertandaleadingauthoratEEA,transportsources andothercommercialactivitiesarethemaincausesofnoise pollution.Asaresult,asignificantreductioninnoisepollution canonlybeachievedbyalong-termandsustainablestrategyon themobilityandtransportationsystems(32).

ImmaculateBeaches

Incoastalareas,beachesfunctionasimportantnaturalcapital assets(2, 3, 5)andprovideessentialservicessuchastourism, recreation,sand, land,andsourceoflivelihoodtocoastal communities(33).Besidesprovidingvaluableandintrinsic values,thesandy beachesanddunesaresentinel,shielding theheavyimpactsofwavesandpreventingthefuriouswinds fromdestroyingcrops,homes,andotherlivestock.However, thenon-responsibleandimproperusebypeoplehascaused manyoftheglobalbeachestopresentpollutionproblems(33). Theseaggregatedanthropogenicpollutantimpactsarenow destabilizinganddamagingthepotentialabilityofthebeaches andothermarineenvironmentstoprovidekeyecosystem servicessuchascoastallivelihoodandeconomicstability,global climatestability,andbiologicalintegrity(33).Withtheglobal statesundergoinglockdown andtheWHOdeclaringemergency andsocialdistancingmeasurestocombatthenovelcoronavirus pandemic,tourismaroundtheworldbeacheshasbeenaffected. Moreover,thecompleteclosureofvariousindustrialactivities hasalmosthaltedthepollutionfromthesesources.Allthese unintendedmeasureshavecausedaremarkablechangeinthe appearanceofmanybeachesintheworld.Prominentexamples

arethebeachesofSalinas(Ecuador),Barcelona(Spain),and Acapulco(Mexico),allthesebeachesnowlookcleanerandwith clearwaters(2).Similarly,Mandaletal.(30)andSaadatetal. (34)whilestudyingtheeffectofCovid-19lockdownonthe surfacewaterquality, foundthatthewaterqualityofVembanad Lake,Kerala,increasedsignificantly.Theauthorsalsointheir studynoticedasignificantdecrease(34%)inthesuspended particulatematter(SPM)concentrationofthelakewaterduring thelockdownperiod.Allthesestudiessuggestthattheviruscrisis hasbroughtwithittheunintendedbenefitsfortheenvironment andmankind(16).

AnimalsonStreet

Theenvironmentalchangesbroughtbythecoronaviruswere firstvisiblefromspace.Then,asthediseaseandthelockdown spread,theycouldbesensedintheskyaboveourheads,the airinourlungs,andeventhegroundbelowourfeet.While humansarerestrictedtotheirhomesundergloballockdown,the wildanimalsallovertheplanetseemtohavecometoreclaim theirterritory.Themediaoutletsaretweetinganduploading severalimagesandvideosshowinganimalsonthestreets(3). Theemergenceofwildanimals inurbanareasismostlybecause thereispeaceandcalm,whichattractstheseanimalstothe residentialareas(accessibleathttps://climaterealityproject.org/ blog/air-pollution-and-coronavirus-connection-explained).

FeathersFlockTogether

Whilethehomeconfinementrules/lockdownandsocial distancinghavestoppedthemovementofpeoplesoutside,atthe sametime,thisgloballockdownhasallowedbirdsandwildlife toflourishandenjoyallthefreedomofnature.Reportsconfirm thatagrowingflockofthousandsofflamingosbeatingtheirblack andpink-linedwingshasbeenseensplashingovertheglistening waterofNartanLagoon,oftheAdriaticcoast.Accordingtopark authorities,sinceJanuary2020,thenumberofthesebirdshas beenfoundtoincreaseby3-folduptosome3,000.Similarly, thewildlifeseemstohaveregainedalltheirabsoluterightsandis enjoyingthefreedomofnature(AgenceFrance–Presse).Similar caseswerefoundintheIndianbeacheswithflocksofflamingos flyingtothesebeacheswiththenumberincreasingbymorethan 25%comparedwithpreviousyears.

NEGATIVEEFFECTSOFCOVID-19ONTHE ENVIRONMENT

Covid-19andtheGlobalEconomy

Althoughtheterritorialcolonizationendedlongago,thisexisting globalhealthcrisiscanserveasareminderthatthecolonization ofeconomics,medicine,andpoliticsarestillalive.Inaddition toitsimmediateeffectsonthelivesandhealthoutcomes,itis nowclearthatthecoronavirusoutbreakislikelytohavelonglastingeffectsontheglobaleconomy(35, 36).Lossoflivesby anysortofpandemiccausesirretrievabledamagetothesociety; however,theCovid-19pandemicapartfromtakingahugetoll onthegloballiveshasseverelydemobilizedtheglobaleconomy. Tolimitfurthertransmission,governmentsatlocal,regional, national,andgloballevelshavedecidedtoundergocomplete

lockdown.Owingtothecompletelockdownandcross-border closure,alltheflights,railwayservices,trucks,buses,andallother typesofvehiculartransportsaresuspended.NearlyalltheCovid19-traumatizednations,industries,andentirecommercial, educational,religious,andsportsinstitutionsareclosed.Allthese restrictionsarenegativelyaffectingglobaleconomies.Moreover, increasedprices,lostincome,andoverburdenedsocialsafetynets willfurtherpushthemorevulnerablegroupsintopovertyand increasethefinancialbarriers(37).Withtheproductionlevel gonedown,theeconomy ofmanyso-calledpowerfulcountriesis facingthethreatofhighinflation.Especially,thegrossdomestic product(GDP)projectionshavealreadybeenreviseddownwards inmostofthedevelopedcountriesamidthedisruptionin production.Mostbusinesssectorsespeciallythoseintourism, aviation,andhospitalityindustriesarefacingseriouschallenges witharealthreatofsignificantdeclinesininsolvencies,revenue, andjoblosses(38, 39).

EffectofCovid-19onEnergy Resources

Intheglobalenergysystems,coalstandsoneofthemajorfuels accountingforupto40%oftheelectricitygeneration(https:// www.iea.org/reports/coal-2019).Theglobalcoalproductionwas estimatedtohaveincreasedby2.7%in2018withtheannual productionof8.1billiontonsin2019.Theincreasewasmainly drivenbythreemajorcoal-producingcountriessuchasChina, India,andAustralia,whichtogetheraccountsfor70%ofglobal production.Owingtothecoronaviruslockdown,theglobal outputisexpectedtoincreaseby0.5%in2020.However,due tocontinuinglockdownandothergovernmentpoliciesduring theon-goingCovid-19pandemic,theglobalcoalmarketis likelytofallfrom$816.5billionin2019to$722.8billionin 2020.Thissignificantdeclineintheglobaloutputismainly becauseoftheeconomicslowdownacrossthecountriescaused bythegloballockdowntostemthespreadingoftheCovid19pandemic.Similarly,theglobaloildemandwasstronglyhit, showingadecline(5%)inthefirstquarterof2020.Thisdrastic reductionwasmainlybecauseofthecurtailmentsinmobilityand aviationwhichaloneaccountsformorethan60%oftheglobal oildemand.Likewise,theelectricitydemandhasalsoshowna significantreduction(>20%)duetolockdownmeasures,with knock-oneffectsonthepowermix.

ImpactsonBiodiversity

Althoughaffectingallthesectorsofhumanlife,theCovid-19 pandemicpropagatesexponentiallyandimpactsotherglobal resourcesatanacceleratingpace.Thisglobalpandemichas itsrootdeeponhowweinteract,perceive,manage,and conserveglobalbiodiversity.Reportssuggestthatthereis reducedhumanpressureonnaturalecosystemsandwildlife (29).Theprotectedareashavewitnessedasignificantdecline inthenumberofvisitors,causedmainlybythetravelban andparkclosure,reducingthestressonthewildlife.Besides someofthepositiveeffects(allthoughtemporary),itisquite unclearhowtheconservationbiologywillfareinthepandemic aftermath.Atpresent,mostoftheprotectedareasappearto besafe,and,biodiversityseemstobebenefittingfromthe reducedhumanactivities;however,threatspersistespecially

intheareaswheretheenforcementhasweakened.Although greenhousegasemissions,environmentalpollution,andmany otheranthropogenicimpactsonthewildnaturewillricochet, thesupportandfundingforconservationpurposeshaveto competewithawiderangeofprioritiesforfinancialresources. Theforestsectorwithoutanydoubtisthemaincontributor tothedevelopmentofsocietyandforsocialandeconomic recoveryintheaftermathofanycrisis(29).Forestsby-products functionasessential sourcesandsupportthelivelihoodduring thecrisis,bydeliveringnecessaryproducts,suchashygieneand sanitaryitems,respiratorpapers,ethanolforsanitizer,biomass forheating,andpapersforparcelpackaging.Thenegativeeffects oftheCovid-19pandemiconproductionandtradeofforest andforestby-productswillputmanyofthekeylivelihoods andindustrialsectorsatrisk(29, 39).Moreover,theforest sectorhashighruraltourbanmigration;however,theCovid-19 pandemicisleadingtoreversemigration,whichhasthepotential tospreadthediseasetotheremote,distant,andunpreparedareas. Furthermore,theeffectofthisglobalpandemiconforest-based industrieswillhaveinstantconsequencesforforestownersand tradersarisingprimarilyfromthepersistentdeclineinproduct runoffandsales(EuropeanFamilyForestry—sustainabilityin action)(40).

OtherEffectsofCovid-19on the Environment

Sincethedawnofcivilization,humanbeingshavegradually startedmanipulatingnaturefortheirbenefit.Secondly, tosatisfythedemandsfortheever-growingpopulation, urbanization,andindustrializationbecamequiteinevitable andtheobvioussignificancewasprovedtobedetrimentalto theglobalenvironment(41).Sincetheoutbreakofthisnovel viralpneumonia,changes todailylifehavebeenswiftand unprecedented.Asthecasessurgeandthedeathtollescalates, boththehumansandtheenvironmentsufferalot.Besides theabovementionedilleffectsoftheCovid-19outbreak,water bodiesandnaturalandbuiltenvironmentshavealsoexperienced significantimpacts.Forexample,topreventthetransmission ofcoronavirusthroughwastewater,Chinahasdirectedthe wastewatertreatmentplantstostrengthenthedisinfection routines.Incontrast,theexcessiveuseofchlorinetotreatthe watercouldgenerateharmfuleffectsonhumanhealth(42). Anecdotalevidenceindicatesthatquarantinepolicieshave increasedthedemandsforhomedelivery,therebyincreasingthe organicwasteproductiongeneratedbyhouseholds.Similarly, theincreasedconsumptionofmedicalstuffsuchasdiagnostic supplies,disinfectants,ventilators,N95,andPPEkits,has significantlyincreasedputtingthemedicalwasteontherise; forexample,duringthecoronavirusoutbreak,thehospitalsin WuhanChinawerefoundtogenerateanaverageof240metric tonsofmedicalwasteperdaycomparedwiththeirprevious averageoffewerthan50tons(42).Similarly,intheUSA, anincreaseingarbageproductionfrompersonalprotective equipmenthasbeenrecorded.Theproblemgotworse,after manycountriesparticularlytheUSAandtheEuropeannations havestoppedwasterecyclingprogramsinsomeoftheircities,

concerningtheriskofCovid-19spreadingintherecycling centers(3).Lastly,theimpactsofthispandemiconthebehavior andpsychologicalwell-beingare evident.Itiswell-knownthat thecalamitiesandotherdisasters,particularlytheonesrelated toinfectiousdiseasesoftenelicitthewavesofheightenedfear andanxiety,thuscausingmassivedisruptionstothebehavior andpsychologicalwell-beingofthepeople.Thesameisbeing seenwiththisvirulentcreature.Recentstudieshaveshown thatthepeoplewhethersusceptibleornot,aredeveloping severepsychologicalconditionsincludingdepression(50.7%), anxiety(44.7%),andinsomnia[sleepingdisorder(36.1%)]due tolockdown(39, 41).

Covid-19PandemicandtheMentalHealth

Deadlyanddisruptiveasitalreadyis,theterribleandrapid propagationofCovid-19pandemichasalreadyinduceda considerabledegreeofconcern,worry,andfearamongthe populationingeneralandcertaingroupssuchascareproviders, olderadults,andpeoplewithunderlyinghealthconditionsin particular.Withuncertainprognosis,loomingscarcityofmedical resources,growingfinanciallosses,theimpositionofunfamiliar publichealthmeasuresthatinfringeonpersonalfreedoms,and conflictingmessagesonsocialmediaarethemajorstressorsthat certainlywillcontributetothewidespreademotionaldistressand psychiatricillnesses(43, 44).Asmentioned,thepublichealth emergencieshave negativeeffectsonthesafety,health,and well-beingofbothindividualsandcommunities.Thepossible effectsontheindividualsincludestigma,insecurity,confusion, andemotionalisolation,whilethoseonthecommunitylevel includeinadequatemedicalresponsesduetoresourceshortage, economicloss,anddeficientdistributionofnecessities,work,and closureofeducationalinstitutes(44).Alltheseeffectsmayleadto arangeofemotionalreactions, unhealthybehaviors,andnoncompliancewiththepublichealthdirectivesinthepopulation. ThisisinterestingtomentionthatthepreviousSARS-CoV-1 epidemicshadshownpsychiatricsymptoms,monthsafterthe epidemicwascontrolled.Theseindicationssuggestthepossible mentalsymptomsafterSARS-CoV-2areexpected(41).Although thecurrentevidenceregardingthedirecteffectoftheCovid19pandemiconmentalhealthisscarce,fewstudies,however, havebeencarriedoutindicatingthatthepandemichasadirect effectonmentalhealth.Theseauthors,whilestudyingtheeffect ofapandemiconmentalhealthconfirmedthatthesameis affectedinthepost-pandemicera(43 45).Inthepopulation, healthcareworkersareregardedasahighlyexposedgroupwith

REFERENCES

1.RothanHA,ByrareddySN.Theepidemiologyandpathogenesisof coronavirusdisease(COVID-19)outbreak. JAutoimmun. (2020) 109:102433.doi:10.1016/j.jaut.2020.102433

2.WHO.Rollingupdatesoncoronavirusdisease(COVID-19). Eventsas TheyHappen. (2020).Availableonlineat:https://www.who.int/emergencies/ diseases/novel-coronavirus-2019/events-as-they-happen(accessedJuly31, 2020).

amuchhigherriskofpsychiatricsymptoms.Although,the numberofriskfactorsofmentalhealthreportedisalreadywellknown.Examplesofsuchmentalriskfactorsincludepresent orpastmedicalhistory,poorself-relatedhealth,andfemale gender.However,theCovid-19pandemichasaddedtheaspects ofself-isolationandquarantine,anestablishedriskfactorwith psychologicalimpact(46, 47).

CONCLUSION

LikethepreviouscatastrophesontheplanetEarth,thehumans willwinoverthispandemicinduecourseoftime;however, peopleshouldknowthelimitstowhichtheycanthrustnature beforeitistoolate.Environmentalchangesarearguablythemost vitalandseverechallengeofthetwenty-firstcentury.Despite thecontinuouseffortsbygovernmentalandnon-governmental organizationstorestoreandrepairnature,humanscanonly moveafewstepsforwardandyetthereareenormouschallenges. However,beingablessingindisguise,theCovid-19pandemic duringthepastfewmonthshassuccessfullyrecoveredthe environmenttoamuchlargerextentandhasimprovedthe mutuallyeffectivelinkbetweennatureandhumans.While atthesametimethelockdownandsocialdistancinghave contributedpositivelytowardtheenvironment,though,itis essentialtotakeintoaccountthenegativeeffectssuchas mortality,impactsonsocialaspects,andthedramaticeconomic effectsaswell.Theviralpandemichasproducedbothpositive andnegativeindirecteffectsontheenvironment.Atpresent, itisimportanttocontrolthedisease,reducethetransmission, andproactivelysavelives.Althoughthepositiveimpactson theenvironmentmaybetemporary,thegovernmental,nongovernmentalorganizations,andtheindividualsshouldlearn fromthislockdownonhowtoreduceandminimizethepollution onalong-termbasis.

AUTHORCONTRIBUTIONS

Allauthorslistedhavemadeasubstantial,directandintellectual contributiontothework,andapproveditforpublication.

FUNDING

ADhadfinancialsupportthroughtheDSTInspirePh.D. Fellowship(IF160797)fromtheDepartmentofScienceand Technology,NewDelhi,India.

3.Zambrano-MonserrateMA,RuanoMA,Sanchez-AlcaldeL.Indirect effectsofCOVID-19ontheenvironment. SciTotalEnviron.(2020) 728:138813.doi:10.1016/j.scitotenv.2020.138813

4.ESA(2020).Availableonlineat:https://www.esa.int/Applications/Observing_ the_Earth/Copernicus/Sentinel-5P/COVID-19_nitrogen_dioxide_over_ China(accessedJuly14,2020).

5.KraemerMUG,YangCH,GutierrezB,WuCH,KleinB,PigottDM,etal.The effectofhumanmobilityandcontrolmeasuresontheCOVID-19epidemicin China. Science. (2020)368:493–7.doi:10.1126/science.abb4218

6.ChakrabortyI,MaityP.COVID-19outbreak:migration,effectson society,globalenvironmentandprevention. SciTotalEnviron. (2020) 728:138882.doi:10.1016/j.scitotenv.2020.138882

7.MaY,ZhaoY,LiuJ,HeX,WangB,FuS,etal.Effectsoftemperaturevariation andhumidityonthedeathofCOVID-19inWuhan,China. SciTotalEnviron. (2020)724:138226.doi:10.1016/j.scitotenv.2020.138226

8.GlobalCarbonProject(2020).Availableonlineat:https://www. globalcarbonproject.org/carbonbudget/index.htm(accessedAugust08, 2020).

9.TesarikJ.Aftercorona:thereislifeafterthepandemic. ReprodBiomedOnline. (2020)40:760–2.doi:10.1016/j.rbmo.2020.04.002

10.SunP,LuX,XuC,SunW,PanB.UnderstandingofCOVID-19basedon currentevidence. JMedVirol. (2020)92:548–51.doi:10.1002/jmv.25722

11.ShiJ,WenZ,ZhongG,YangH,WangC,HuangB,etal.Susceptibilityof ferrets,cats,dogs,andotherdomesticatedanimalstoSARS–coronavirus2. Science. (2020)29:1016–20.doi:10.1126/science.abb7015

12.ColemanCM,LiuYV,MuH,TaylorJK,MassareM,FlyerDC, etal.Purifiedcoronavirusspikeproteinnanoparticlesinduce coronavirusneutralizingantibodiesinmice. Vaccine. (2014) 32:3169–74.doi:10.1016/j.vaccine.2014.04.016

13.KakodkarP,KakaN,BaigM.Acomprehensiveliteraturereviewontheclinical presentation,andmanagementofthepandemiccoronavirusdisease2019 (COVID-19). Cureus. (2020)12:e7560.doi:10.7759/cureus.7560

14.DuffE.GlobalhealthemergencydeclaredbyWHO. Midwifery.(2020) 83:102668.doi:10.1016/j.midw.2020.102668

15.CowlingBJ,AielloA.Publichealthmeasurestoslowcommunityspreadof COVID-19. JInfectDis. (2020)221:1749–51.doi:10.1093/infdis/jiaa123

16.GhosalS,SinhaB,MajumderM,MisraA.Estimationofeffectsofnationwide lockdownforcontainingcoronavirusinfectiononworseningofglycosylated haemoglobinandincreaseindiabetes-relatedcomplications:asimulation modelusingmultivariateregressionanalysis. DiabetesMetabSyndrClinRes Rev. (2020)14:319–23.doi:10.1016/j.dsx.2020.03.014

17.SchwartzSA.Climatechange,covid-19,preparedness,andconsciousness. Explore. (2020)16:141–4.doi:10.1016/j.explore.2020.02.022

18.GrossM.Findingcomfortinnature. CurrBiol. (2020)30:R329–31.doi:10.1016/j.cub.2020.03.073

19.SubramaniamB.Earthdayreflections:hopeamidthepandemic. ACSSustain ChemEng. (2020)8:5817–8.doi:10.1021/acssuschemeng.0c02596

20.PansiniR,FornaccaD.COVID-19higherinducedmortality inChineseregionswithlowerairquality. medRxiv[Preprint]. (2020).doi:10.1101/2020.05.28.20115832

21.SteffenB,EgliF,PahleM,SchmidtTS.Navigatingthecleanenergytransition inthecovid-19crisis. Joule. (2020)4:1137–41.doi:10.1016/j.joule.2020.04.011

22.LauH,KhosrawipourV,KocbachP,MikolajczykA,SchubertJ,BaniaJ,etal. ThepositiveimpactoflockdowninWuhanoncontainingtheCOVID-19 outbreakinChina. JTravelMed. (2020)27:taaa037.doi:10.1093/jtm/taaa037

23.WorldHealthOrganization. WHO’sUrbanAmbientAirPollution databaseUpdate2016.WHO(2016).p.1–7.Availableonlineat:https://www.who.int/ entity/phe/health_topics/outdoorair/databases/cities/en/index.html

24.DiQ,WangY,ZanobettiA,WangY,KoutrakisP,ChoiratC,etal.Air pollutionandmortalityinthemedicarepopulation. NEnglJMed. (2017) 376:2513–22.doi:10.1056/NEJMoa1702747

25.LandriganPJ,FullerR,AcostaNJR,AdeyiO,ArnoldR,BasuN,etal. Thelancetcommissiononpollutionandhealth. Lancet. (2018)391:462–512.doi:10.1016/S0140-6736(17)32345-0

26.ESA(2020)Availableonlineat:https://www.esa.int/Applications/Observing_ the_Earth/Copernicus/Sentinel-5P/Coronavirus_lockdown_leading_to_ drop_in_pollution_across_Europe(accessedJuly14,2020).

27.ChenY,LiuQ,GuoD.Emergingcoronaviruses:genome structure,replication,andpathogenesis. JMedVirol. (2020) 92:418–23.doi:10.1002/jmv.26234

28.OgenY.Assessingnitrogendioxide(NO2)levelsasacontributing factortocoronavirus(COVID-19)fatality. SciTotalEnviron. (2020) 726:138605.doi:10.1016/j.scitotenv.2020.138605

29.CorlettRT,PrimackRB,DevictorV,MaasB,GoswamiVR,Bates AE,etal.Impactsofthecoronaviruspandemiconbiodiversity

conservation. BiolConserv. (2020)246:108571.doi:10.1016/j.biocon.2020.1 08571

30.MandalI,PalS.COVID-19pandemicpersuadedlockdowneffectson environmentoverstonequarryingandcrushingareas. SciTotalEnviron. (2020)732:139281.doi:10.1016/j.scitotenv.2020.139281

31.AroraS,BhaukhandiKD,MishraPK.Coronaviruslockdown helpedtheenvironmenttobounceback. SciTotalEnviron. (2020) 742:140573.doi:10.1016/j.scitotenv.2020.140573

32.BasnerM,McGuireS.WHOenvironmentalnoiseguidelinesforthe europeanregion:asystematicreviewonenvironmentalnoiseandeffectson sleep. IntJEnvironResPublicHealth.(2018)15:285.doi:10.3390/ijerph15 030519

33.SaadatS,RawtaniD,HussainCM.EnvironmentalperspectiveofCOVID-19. SciTotalEnviron. (2020)728:138870.doi:10.1016/j.scitotenv.2020.138870

34.YunusAP,MasagoY,HijiokaY.COVID-19andsurfacewaterquality: improvedlakewaterqualityduringthelockdown. SciTotalEnviron. (2020) 731:139012.doi:10.1016/j.scitotenv.2020.139012

35.McKibbinWJ,FernandoR.TheglobalmacroeconomicimpactsofCOVID19:sevenscenarios. SSRNElectronJ. (2020).doi:10.2139/ssrn.3547729.[Epub aheadofprint].

36.McAleerM.Preventionisbetterthanthecure:riskmanagementofCOVID19. JRiskFinancManag. (2020)13:46.doi:10.3390/jrfm13030046

37.GoodellJW.COVID-19andfinance:agendasforfutureresearch. FinanceRes Lett. (2020)35:101512.doi:10.1016/j.frl.2020.101512

38.BashirMF,MaB,Bilal,KomalB,BashirMA,TanD,etal.Correlationbetween climateindicatorsandCOVID-19pandemicinNewYork,USA. SciTotal Environ. (2020)728:138835.doi:10.1016/j.scitotenv.2020.138835

39.MuhammadS,LongX,SalmanM.COVID-19pandemicand environmentalpollution:ablessingindisguise? SciTotalEnviron. (2020) 728:138820.doi:10.1016/j.scitotenv.2020.138820

40.CarringtonD.Coronavirus:‘Natureissendingusamessage’,saysUN environmentchief. TheGuardian.(2020).Availableonlineat:https://www. theguardian.com/world/2020/mar/25/coronavirus-nature-is-sending-us-a-m essage-says-un-environment-chief

41.XiangYT,ZhaoYJ,LiuZH,LiXH,ZhaoN,CheungT,etal.The COVID-19outbreakandpsychiatrichospitalsinChina:managingchallenges throughmentalhealthservicereform. IntJBiolSci. (2020)6:1741–4.doi:10.7150/ijbs.45072

42.LiW,YangY,LiuZH,ZhaoYJ,ZhangQ,ZhangL,etal.Progressionofmental healthservicesduringtheCOVID-19outbreakinChina. IntJBiolSci. (2020) 16:1732–8.doi:10.7150/ijbs.45120

43.PfefferbaumB,NorthCS.Mentalhealthandthecovid-19 pandemic. NEnglJMed. (2020)383:510–2.doi:10.1056/NEJMp200 8017

44.RajkumarRP.COVID-19andmentalhealth:areviewoftheexisting literature. AsianJPsychiatr. (2020)52:102066.doi:10.1016/j.ajp.2020.102066

45.WorldHealthOrganization.Mentalhealthandpsychosocialconsiderations duringCOVID-19outbreak.WorldHealOrgan(2020).

46.KannanS,ShaikSyedAliP,SheezaA,HemalathaK.COVID-19(Novel Coronavirus2019)-recenttrends. EurRevMedPharmacolSci. (2020) 24:2006–11.doi:10.26355/eurrev_202002_20378

47.Wilder-SmithA,ChiewCJ,LeeVJ.CanwecontaintheCOVID-19outbreak withthesamemeasuresasforSARS? LancetInfectDis. (2020)20:511–628.doi:10.1016/S1473-3099(20)30129-8

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Kumar,MallaandDubey.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

published:15October2020 doi:10.3389/fpsyg.2020.594837

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: SimonO’Leary, Regent’sUniversityLondon, UnitedKingdom AlbertoAmaral, HigherEducationEvaluation andAccreditationAgency(A3ES), Portugal

*Correspondence: AinoSuomi aino.suomi@anu.edu.au

Specialtysection: Thisarticlewassubmittedto OrganizationalPsychology, asectionofthejournal FrontiersinPsychology

Received: 14August2020 Accepted: 22September2020 Published: 15October2020

Citation: SuomiA,SchofieldTPand ButterworthP(2020)Unemployment, EmployabilityandCOVID19:How theGlobalSocioeconomicShock ChallengedNegativePerceptions TowardtheLessFortunate intheAustralianContext. Front.Psychol.11:594837. doi:10.3389/fpsyg.2020.594837

Unemployment,Employabilityand COVID19:HowtheGlobal SocioeconomicShockChallenged NegativePerceptionsTowardthe LessFortunateintheAustralian Context

AinoSuomi1,2* ,TimothyP.Schofield3 andPeterButterworth1,3

1 ResearchSchoolofPopulationHealth,TheAustralianNationalUniversity,Canberra,ACT,Australia, 2 InstituteofChild ProtectionStudies,TheAustralianCatholicUniversity,Melbourne,VIC,Australia, 3 MelbourneInstituteofAppliedEconomic andSocialResearch,TheUniversityofMelbourne,Melbourne,VIC,Australia

Unemployedbenefitrecipientsarestigmatizedandgenerallyperceivednegativelyin termsoftheirpersonalitycharacteristicsandemployability.TheCOVID19economic shockledtorapidpublicpolicyresponsesacrosstheglobetolessentheimpactof massunemployment,potentiallyshiftingcommunityperceptionsofindividualswhoare outofworkandrelyongovernmentincomesupport.Weusedarepeatedcrosssectionsdesigntostudychangeinstigmatiedtounemploymentandbenefitreceiptin apre-existingpre-COVID19sample(n =260)andasamplecollectedduringCOVID19 pandemic(n =670)byusingavignette-basedexperiment.Participantsratedattributes ofcharacterswhoweredescribedasbeingemployed,workingpoor,unemployed orreceivingunemploymentbenefits.Theresultsshowthatcomparedtoemployed characters,unemployedcharacterswereratedsubstantiallylessfavorablyatbothtime pointsontheiremployabilityandpersonalitytraits.Thedifferenceinperceptionsof theemployedandunemployedwas,however,attenuatedduringCOVID19withbenefit recipientsperceivedasmoreemployableandmoreConscientiousthanpre-pandemic. Theseresultsaddtoknowledgeaboutthedeterminantsofwelfarestigmahighlighting theimpactoftheglobaleconomicandhealthcrisisonperceptionofothers.

Keywords:COVID19,employability,personality,BigFive,publicpolicy,unemployment

INTRODUCTION

TheonsetofCOVID19pandemicsawunemploymentclimbtothehighestratesincethe GreatDepressioninmanyregionsglobally1.Overjustonemonth,fromMarchtoApril2020 unemploymentrateintheUnitedStatesincreasedfrom4.4%toover14.7%andinAustraliathe effectiverateofunemploymentincreasedfrom5.4to11.7%(AustralianBureauofStatistics,2020)2 .

1https://fred.stlouisfed.org/series/UNRATE

2TheAustralianfigureincludesindividualsworkingzerohourswhohad“nowork,notenoughworkavailableorwerestood down.”TheUSBureauofLaborStatisticsnotedthatsomepeopleontemporarylayoffwerenotclassifiedassuchandthe unemploymentratecouldhavebeenalmost5percentagepointshigher.

InAustralia,anumberofeconomicresponseswererapidly introducedincludingawagesubsidyscheme(Jobkeeper)to enableemployeestokeeptheiremployeesconnectedtothe workforce,one-offpaymentstomanywelfarerecipients,and adoublingoftheusualrateoftheunemploymentbenefits (Jobseekerpayment)throughanewCoronavirussupplement payment.AtthetimeofwritinginJuly2020,manycountries, includingAustraliaremaininthedepthsofahealthand economiccrisis.

Arichresearchliteraturefromarangeofdisciplineshas documentedthepervasivenegativecommunityviewstoward thosewhoareunemployedandreceivingunemployment benefits,withtheextentofthis“welfarestigma”beingparticularly pronouncedincountrieswithhighlytargetedbenefitsystems suchastheUnitedStatesandAustralia(Fiskeetal.,2002; Baumberg,2012; ContiniandRichiardi,2012; Schofieldand Butterworth,2015).Thestigmaandpotentialdiscrimination associatedwithunemploymentandbenefitreceiptareknownto havenegativeimpactsonhealth,employabilityandequality(for meta-analyses,see Shahidietal.,2016).Inaddition,thereceipt ofunemploymentbenefitsco-occurswithotherstigmatized characteristicssuchaspovertyandunemployment(Schofield andButterworth,2018a).Thechangingcontextrelatedto theCOVID19crisisprovidesanovelopportunitytobetter understandthedeterminantsofstigmatizingperceptionsof unemploymentandbenefitreceipt.

Negativecommunityattitudesandperceptionsofbenefit recipientsarecommonlyexplainedbytheconceptof “deservingness”(vanOorschotandRoosma,2017).The unemployedaretypicallyseenaslessdeservingofgovernment supportthanothergroupsbecausetheyaremorelikelytobeseen asresponsiblefortheirownplight,ungratefulforsupport,notin genuineneed(Petersenetal.,2011; vanOorschotandRoosma, 2017),andlackingreciprocity(i.e.,seenastakingmorethan theyhavegiven–orwillgive–backtosociety; vanOorschot, 2000; Larsen,2008; Petersenetal.,2011; AarøeandPetersen, 2014).GiventheeconomicshockassociatedwithCOVID19, unemploymentandrelianceonincomesupportarelesslikely toseenasanoutcomewithintheindividualscontrolandmay thereforeamplifyperceptionsofdeservingness.Priorwork hasshownthatexperimentallymanipulatingperceivedcontrol overcircumstancesdoesindeedchangenegativestereotypes (AarøeandPetersen,2014).

Anumberofexperimentalparadigmshavebeenused toinvestigateperceptionsof“welfarerecipients”andthe “unemployed.”Thestereotypecontentmodel(SCM; Fiske etal.,2002),forexample,representsthestereotypesof socialgroupsontwodimensions:warmth,relatingtobeing friendlyandwell–intentioned(ratherthanill–intentioned);and competence,relatingtoone’scapacitytopursueintentions (Fiskeetal.,2002).Usingthismodel,the“unemployed”have beenevaluatedaslowinwarmthandcompetenceacross avarietyofwelfareregimetypes(Fiskeetal.,2002; Bye etal.,2014).Thestructureofstereotypeshasalsobeen studiedusingtheBigFivepersonalitydimensions(Schofield andButterworth,2018b; Schofieldetal.,2019):Openness, Conscientiousness,Extraversion,Agreeableness,andEmotional

Stability(forbackgroundontheBigFivesee: Goldberg,1993; Hoganetal.,1996; SaucierandGoldberg,1996; McCraeand Terracciano,2005; Srivastava,2010; Chanetal.,2012; Löckenhoff etal.,2014).ThereareparallelsbetweentheBigFiveandthe SCM:warmthrelatingtothedimensionofAgreeableness,and competencerelatingtoConscientiousness(Digman,1997; Ward etal.,2006; Cuddyetal.,2008; Abeleetal.,2016)andthese constructshavebeenfoundtopredictemployabilityandcareer success(Barricketal.,2001; CuestaandBudría,2017).Warmth andagreeablenesshavealsobeenlinkedtothewelfare-specific characteristicsofdeservingness(AarøeandPetersen,2014).

Theterm“employability”hasbeenpreviouslydefinedasa setofachievements,skillsandpersonalattributesthatmakea personmorelikelytogainemploymentandleadingtosuccess intheirchosencareerpathway(Peggetal.,2012; O’Leary, 2017,2019).Whiletherearefewstudiesexaminingperceptions ofothers,perceptionsofone’sownemployabilityhavebeen recentlystudiedinuniversitystudents,jobseekers(Atitsogbe etal.,2019)andcurrentlyemployedworkers(Plompetal., 2019; Yevesetal.,2019),consistentlyshowinghigherlevelsof perceivedemployabilitybeinglinkedtopersonalandjob-related wellbeingaswellascareersuccess.Examiningother’sperceptions ofemployabilitymaybemorerelevanttounderstandfactors impactingonactualemploymentoutcomes.Amajorityofstudies examiningother’sperceptionsofemployabilityhavefocusedon jobspecificskillsstudy(Lowdenetal.,2011; Dhiman,2012; SaadandMajid,2014).

Buildingonthispreviouswork,ourownresearchhasfocused ontheeffectsofunemploymentbydrawingonframeworks ofBigFive,SCMandemployabilityinpre-COVID19samples (SchofieldandButterworth,2018b; Schofieldetal.,2019).Our studiesconsistentlyshowthatunemployedindividualsreceiving governmentpaymentsareperceivedaslessemployable(poorer “quality”workersandlessdesirableforemployment)andless Conscientious.Wefoundsimilarbutweakerpatternrelated toAgreeableness,EmotionalStability,andtheextentthata personisperceivedas“uniquelyhuman”(Schofieldetal., 2019).Further,wefoundthatvignettecharactersdescribedas currentlyemployedbutwithahistoryofwelfarereceiptwere indistinguishablefromthosedescribedasemployedandwith noreferencetobenefitreceipt(Schofieldetal.,2019).Findings suchasthisprovideexperimentalevidencethatwelfarestigma ismalleableandcanbechallengedbyinformationinconsistent withnegativestereotype(SchofieldandButterworth,2018b; Schofieldetal.,2019;seealso Petersenetal.,2011).

Thebroadaimofthecurrentstudywastoextendthis previousworkbyexaminingtheimpactofCOVID19on personperceptionstiedtoemploymentandbenefitrecipient status.Itrepeatsapre-COVID19studyofanAustralian generalpopulationsampleintheCOVID19context,drawing onthesamesamplingframe,materialsandstudydesign tomaximizecomparability.Thestudydesignrecognizesthat thenegativeperceptionsofbenefitrecipientsmayreflecta combinationofdifferencesourcesofstigma:poverty,lackof work,andbenefitreceipt.Therefore,theoriginalstudyused fourdifferentconditionstoseektodifferentiatethesedifferent sources:(1) Employed;(2) Workingpoor;(3) Unemployed;and

(4) Unemployedbenefitrecipient.Finally,fortheCOVID19 sampleweaddedanovelfifthcondition:(5) Unemployment benefitrecipientalsoreceivingthe“Coronavirus”supplement.We exceptthatthereferencetoapaymentspecificallyapplicableto theCOVID19contextmayleadtomorefavorableperceptions (moredeserving)thantheotherunemployedandbenefit receiptcharacters.

Thestudycapitalizesonamajorexogenousevent,the COVID19crisis,whichwehypothesizewillalterperceptionsof deservingnessbyfundamentallychallengingsocialidentitiesand perceptionsofone’sownvulnerabilitytounemployment.The studyteststhreehypotheses,andindoingsomakesanimportant empiricalandtheoreticalcontributiontounderstandinghow deservingnessinfluencespersonperception,andunderstanding ofthepotential“realworld”barriersexperiencedbypeople seekingemploymentintheCOVID19context.

Hypothesis1

Thepre-COVID19assessmentusesasubsetofdatafrom apre-registeredstudy,butthisreuseofthedatawasnot preregistered3.Wehypothesizethat,atTime1(pre-COVID19 assessment)wewillfindthatemployedcharacterswillberated morefavorablythancharactersdescribedasunemployedand receivingunemploymentbenefits,particularlyondimensionsof Conscientiousness,WorkerandBosssuitability.Moreover,we expectagradientinperceptionsacrossthefourexperimental conditions,fromemployedtoworkingpoor,tounemployedto unemployedreceivingbenefitsandtoshowasimilartrendfor theotheroutcomemeasuresincludedinthestudy.

Hypothesis2

Wehypothesizethatthecharacterintheunemployed condition(s)wouldberatedlessnegativelyrelativetothe employedcondition(s)atTime2,comparedtoTime1.We predictatwo-wayinteractionbetweentimeandconditionforthe keymeasures(Conscientiousness,WorkerandBosssuitability) andasimilartrendonotheroutcomes.

Hypothesis3

Weexpectthatexplicitreferencetotheunemployedbenefit characterreceivingthe“Coronavirussupplement”payment willincreasethesalienceoftheCOVID19contextandlead tomorepositiveratingsofthischaracterrelativetothe standardunemployedbenefitconditioninthepre-COVID19and COVID19occasions.

MATERIALSANDMETHODS

Participants

Twogeneralpopulationsamples(pre-COVID19andCOVID19) wererecruitedfromthesamesource:TheAustralianOnline ResearchUnit(ORU)panel.TheORUisanonlinesurvey platformthatprovidesaccesstoacohortofmembersofthe generalpublicwhoareinterestedincontributingtoresearch.

https://osf.io/wknb6

TheORUrandomlyselectspotentialparticipantswhomeet studyeligibilitycriteria,andprovidestheparticipantwithan incentivefortheirparticipation.ThesamplefortheTime1(preCOVID19)occasionwaspartofalargerstudy(768participants) collectedinNovember2018.Fromthisinitialdataset,wewere abletousedatafrom260(50.1%female, M Age=42.1[16.7] years,range:18–82)participantswhowerepresentedwiththe onevignettescenariothatwecouldreplicateatthetimeof thesocialrestrictionsapplicableintheCOVID19context(i.e., thevignettecharacterwasnotdescribedasgoingoutandvisiting friends,asthesebehaviorswereillegalatTime2).Thesample forTime2(COVID19)wascollectedinMay–June2020,atthe heightofthelockdownmeasuresinAustraliaandincluded 670participants(40.5%female, M Age=51.0[15.8]years, range:18–85).Thetwosampleswerebroadlysimilar(seebelow), thoughtheproportionofmaleparticipantsatTime2was greaterthanatTime1.

Sampling

Thepre-COVIDassessmentatTime1wasrestrictedtothose participantswhocompletedthesocial-distancingconsistent vignetteinthefirstplacetoavoidpotentialorder/context effects.Thisprovided,onaverage,65respondentsineachof thefourexperimentalconditions.Usingtheresultsfromour previouspublishedstudiesasindicatorsofeffectsize(Schofield andButterworth,2018b; Schofieldetal.,2019).MonteCarlo simulationwasusedtoidentifytheTime2samplesizethatwould provide90%powertodetectaninteractioneffectthatrepresented a50%declineinthedifferencebetweenthetwoemployment andtwounemploymentconditionsonthethree-keymeasures attheCOVIDoccasionrelativetothepre-COVIDdifference. Thissamplesizeof135perconditionalsoprovidedbetween60 and90%powertodetectadifferenceofasimilarmagnitude betweentheemployedandunemploymentbenefitconditions acrossthetwomeasurementoccasions.Givenpreviousevidence thatthedifferencesbetweenemployedandunemployed/welfare conditionsisrobustandlargeforConscientiousnessandWorker suitability(SchofieldandButterworth,2018b),thecurrentstudy isalsoadequatelypoweredtodetectthemostreplicableeffectsof unemploymentandwelfareonperceptionsofaperson’scharacter (evenintheabsenceofthehypothesizedinteractioneffect).

MaterialsandProcedure

Theprocedureswereidenticalonbothstudyoccasions. Participantsreadabriefvignettethatdescribedafictional character,andthenratedthecharacteronmeasuresreflecting personalitydimensions,theirsuitabilityasaworkerorboss, morality,warmth,andcompetence,andtheparticipant’sbeliefs thecharactershouldfeelguiltandshame,orfeelangryand disgusted.AtTime1(pre-COVID19context)participantsthen repeatedthisprocesswithasecondvignette,butwedonot considerdatafromthesecondvignette.

Manipulation

Thekeyexperimentalconditionswereoperationalizedbya singlesentenceembeddedwithinthevignettethatwasrandomly allocatedtodifferentparticipants(employed:“S/heiscurrently

workingasasalesassistantinalargedepartmentstore”; workingpoor:“S/heiscurrentlyworkingasasalesassistant, onaminimum-wage,inalargedepartmentstore”;unemployed: “S/heiscurrentlyunemployed”;andreceiptofunemployment benefits:“S/heiscurrentlyunemployed,andisreceiving governmentbenefitsduetohis/herunemployment”).Thefour experimentalconditionswereidenticalatbothtimepoints. AtTime2,anadditionalCOVID19-specificconditionwas included(tomaximizethesalienceoftheCOVID19context): “S/heiscurrentlyunemployedandisreceivinggovernment benefits,includingtheCoronavirussupplement,duetohis/her unemployment.”

Allthreestudyconditionswillimplypoverty/lowincome. InAustralia,fewminimum-wagejobsaresupplementedby tips,andsoaminimum-wagejobindicatesalevelofrelative poverty.Afull-timeworkerinaminimumwagejobisin thebottomquartileofincomeearners(AustralianBureauof Statistics,2017).PriortotheCOVID19crisisandtheincrease inpaymentlevel,asinglepersonwithnodependentsreceiving unemploymentbenefitsreceivedapproximately75%ofthe minimum-wageincashassistance.DuringCOVID19andat thetimeofthedatacollection,therateofpayexceedsthe minimum-wage.

Severalcharacteristicsofthevignettecharacter,includingage andrelationshipstatus,werebalancedacrossstudyparticipants. Agewasspecifiedaseither27or35years,relationshipstatus waseither“single”or“liveswithhis/herpartner.”Thecharacter’s genderwasalsovariedandnameswerestereotypicallyWhite.

Design

ForTime1,manipulatedcharacteristicsyielded32unique vignettes,comprisedoffourkeyexperimentalconditions

(employed,workingpoor,unemployed,andunemployment benefits) × 2ages × 2genders × 2relationshipstatuses. ForTime2,manipulatedcharacteristicsyielded40unique vignettes,comprisedoffivekeyexperimentalconditions (employed,workingpoor,unemployed,unemploymentbenefits, andunemployed + coronavirussupplement) × 2ages × 2 genders × 2relationshipstatuses.The vignettetemplate constructionispresentedin Figure1 includingeachcomponent ofthevignettethatwasrandomlyvaried.

ComprehensionChecks

Inbothstudies,participantswererequiredtoaffirmconsent afterdebriefingorhadtheirdatadeleted.Participant comprehensionofthevignetteswascheckedviathreefreeresponsecomprehensionquestionsaboutthecharacter’sage andweekendactivities.Participantswhodidnotanswerany questionscorrectlywerenotabletocontinuethestudy.

OutcomeMeasures

Personality,employability(suitabilityasaworkerorboss), communionandagency,cognitiveandemotionalmoral judgments,anddehumanizationwereincludedasthestudy outcomes.Whilenotallpersonalityorcharacterdimension measurescanbeconsideredasnegativeorpositive,higherscores wereusedinthestudytoindicatemore“favorable”perceptions bytheparticipantsofthecharacters.

Personality

TheTenItemPersonalityInventorywasusedtomeasurethe BigFive(Goslingetal.,2003)andadaptedtoother–oriented wording(i.e.,“Ifeltlikethepersoninthestorywas...”) (Schofieldetal.,2019).Twoitemsmeasuredeachtraitviatwo

pairedattributes.Oneitemcontainedpositiveattributesandone containednegativeattributes.Participantsindicatedtheextentto which“Ithink[Name]is[attributes]”from1(stronglydisagree) to7(stronglyagree).Theorderofthese10itemswasrandomized. Agreeableness(α =0.54)wasassessedfrom“sympathetic,warm” and“critical,quarrelsome”(reversed);Extraversion(α =0.50) wasassessedfrom“extraverted,enthusiastic”and“reserved, quiet”(reversed);Conscientiousness(α =0.76)wasassessed from“dependable,self-disciplined”and“disorganized,careless” (reversed);Opennesstoexperience(α =0.36)wasassessed from“opentonewexperiences,complex”and“conventional, uncreative”(reversed);Emotionalstability(α =0.65)wasassessed from“calm,emotionallystable.”and“anxious,easilyupset” (reversed).Theorderofthese10itemswasrandomized.

Employability

Singleitemmeasures:“Ithink[Name]wouldbeagoodworker” (Workersuitability)and“Ithink[Name]wouldbeagoodboss” (Bosssuitability)wereratedonthesamescaleasthepersonality measure.Theorderofthesetwoitemswasrandomized.Higher scoresindicatedbetteremployability.

CommunionandAgency

Communionandagencywasassessedusing Bocianetal. (2018) adaptationof Abeleetal.(2016) scalethatmeasuresthe fundamentaldimensionsofcommunionandagencyusingtwosubscalesforeachdimension.Themoralityandwarmthsubscales areseenasmeasuresofcommunion(referredtoaswarmth inSCM; Fiske,2018);whilethecompetenceandassertiveness subscalesmeasureagency(whatFiskereferstoascompetencein SCM; Fiske,2018).Thissubscalestructurehasbeenidentifiedin multiplesamples.Participantsindicatedtheextenttowhich“I think[Name][attributes]”from1(notatall)to5(verymuch so).Morality(α =0.92)wasmeasuredwithsixitems,e.g.,“is just,”“isfair”;Warmth(α =0.96)withsixitems,e.g.,“iscaring,” “isempathetic”;Competence(α =0.90)withfiveitems,e.g.,“is efficient,”“iscapable”;andAssertiveness(α =0.83)withsixitems, e.g.,“isself-confident,”“standsupwellunderpressure.”These itemswerepresentedinarandomorder.

Dehumanization

Dehumanizationwasmeasuredwithacompositescaleoftwoitemsdrawnfrom Bastianetal.(2013).Basedonpriorresearch, wemeasureddehumanizationwithtwoitems:“Ithink[Name]is mechanicalandcold,likearobot”and“Ithink[Name]lacked self-restraint,likeananimal”orderofthesetwoitemswas randomized.Wereversecodedthetwoitemsfortheanalyses forconsistencyfortheothervariables,sothathigherscoreswere indicativeofmorefavorableperceptions.

MoralEmotions

Moralemotionsweremeasuredbyfouritemsthataskedabout emotionalresponsestothecharacterthatwereframedasselfcondemningorother-condemning(Haidt,2003; Giner-Sorolla andEspinosa,2011).Twoother-condemningitemsaskedthe participantabouttheirownemotionalresponsetothecharacter inthevignette(Anger:“[Name]’sbehaviormakesmeangry”; Disgust:“Ithink[Name]issomeonewhomakesmefeel

disgusted,” α =0.92).Thetwoself-condemningitemsaskedabout thecharacter’semotionalresponse(Guilt:“[Name]shouldfeel guiltyabout[his/her]behavior”;Shame:“Ithink[Name]should feelashamedof[him/her]self”; α =0.95).Wereversecodedthe twoscalestoensureconsistencywithothervariables,withhigher scoresindicativeofmorefavorableperceptions.

AnalyticalStrategy

WiththeexceptionoftheMoralemotion(andCommunionand Agency)scalesthatarenewtothisstudyandthepreviously testedOpennesstoExperience,ourpreviousresearchhas demonstrateddifferencesbetweentheratingsofemployedand unemployedcharactersontheincludedoutcomemeasures (SchofieldandButterworth,2018b; Schofieldetal.,2019). Weundertaketheanalysisusingafour-stepprocess.Weuse mixed-effectsmulti-levelmodels,withthe14outcomemeasures nestedwithinparticipants,andpredictedbyfixed(betweenperson)termsrepresentingtheexperimental“Condition,” “Time”(pre-/COVID19)andtheirinteraction,andcontrolling formeasuredifferencesandallowingforrandomeffectsat theparticipantlevel:i)Weinitiallyassessedtheeffectof conditioninthepre-COVID19occasiontoestablishthebaseline patternofresults;ii)wethenevaluatedtheinteractionterm and,specifically,theextenttowhichthebaselinedifference observedbetweenemploymentandunemploymentconditions isattenuatedatTime2(COVID19occasion);iii)wetested thethree-wayinteractionbetweencondition,occasionand measuretoassesswhetherthistwo-wayinteractionvaries acrosstheoutcomemeasures;andifsignificantiv)repeated themodelingapproachusingseparatelinearregressionmodels foreachoutcomemeasure.Ourinitialmodelcontraststhe twoemployed(employedandworkingpoor)andunemployed (unemployedandbenefitreceipt)conditions.Thesecondmodel examinesthefourseparatevignetteconditionsseparately, differentiatingbetweenunemployedandunemployedbenefit conditions.Finally,wecontrastthethreeunemployment benefitconditions:(1)unemploymentbenefitrecipientsat Time1;(2)unemploymentbenefitrecipientsatTime2;and (3)unemploymentbenefitrecipientsreceivingtheCoronavirus paymentatTime2.Forallmodels,weconsiderunadjustedand adjustedresults(controllingforparticipantdemographics).To addressapotentialbiasfromgenderdifferencesbetweensamples, post-stratificationweightswerecalculatedfortheCOVID19 sampletoreflectingthegenderbyagedistributionofthepreCOVID19sample.Allmodelswereweighted.

RESULTS

ThetwosamplesfromTime1(pre-COVID19)andTime2 (COVID19)werecomparableonalldemographicvariables, exceptforgender(χ2 [1,923]=7.04, p < 0.001)andemployment (χ2 [1,910]=27.66, p < 0.001):Thegenderdistributionwas morebalancedatTime1with49.8%ofmales,comparedto 59.5%ofmalesatTime2.Therewasalsoasignificantincrease inunemploymentwith20.9%ofTime1participantsoutofwork comparedto39.3%oftheTime2participants.Thiswaslikely

reflectiveoftheemploymentratenearlydoublinginAustralia duringCOVID19crisis.Bivariatecorrelationsshowedsignificant positivecorrelationsbetweenall14outcomes(p’s < 0.001), exceptforExtraversionthatwasonlypositivelycorrelatedwith EmotionalStability,bosssuitability,warmth,assertiveness,and competence(p’s < 0.05).

ContrastingEmployedandUnemployed Characters

Theresults,bothadjustedandunadjusted,fromtheinitial overallmultilevelmodelusingabinaryindicatorofwhether vignettecharacterswereemployed(thoseintheemployed orworkingpoorconditions)orunemployed(unemployedor welfare)andtestingtheinteractionbetweenvignetteCondition andTime(pre-COVID19vsCOVID19)arepresentedin the SupplementaryTableS1.Theadjustedresults(holding participantage,gender,employment,andeducationconstant) indicatedthattheunemployedcharacterswereratedlowerthan theemployedcharactersatTime1(b = 0.57).Thisdifferencein theratingsofemployedandunemployedcharacterswasreduced intheCOVID19assessmentatTime2,decliningfrom0.57to 0.26,acrossalltheoutcomemeasures.TheadditionofthethreewayinteractionbetweenCondition,Timeandoutcomemeasure significantlyimprovedoverallmodelfit, χ2 (52)=482.94, p < 0.001,indicatingtheinteractionbetweenConditionand Timevariedovermeasures.

Aseriesofseparateregressionmodelsconsideringeach outcomeseparately(see SupplementaryTableS2)showeda significanteffectofCondition(employmentratedhigherthan unemployment)atTime1(pre-COVID)foralloutcomesexcept OpennessandExtraversion.Thelowerratingsforunemployed relativetoemployedcharactersweresignificantlymoderatedat Time2ontheCompetence,WorkerandBosssuitability,and Guilt/Shameoutcomes(p’s < 0.05).

COVID19andPerceptionsof UnemploymentBenefitRecipients

Thenextsetofanalysesconsiderthefourseparatevignette conditions,differentiatingbetweentheunemployedand unemployedbenefitrecipientconditions.Theoverallmixedeffectsmultilevelmodelincorporatingthefourdistinctvignette conditionsprovidedevidenceofsignificanteffectsforCondition andConditionbyTimeinbothadjustedandunadjustedmodels. Theresultfortheadjustedmodel(Table1),averagedacrossthe variousoutcomes,replicatedthepreviousfindingofadifference inratingsofemployedandunemployedcharactersatTime1 (pre-COVID19):relativetotheemployedcondition,therewas nodifferenceinratingsoftheworkingpoor,buttheunemployed andtheunemployedbenefitrecipientcharacterswereratedless favorably.Therewassomeevidenceofagradientacrossthe unemployedcharacters:theaverageratingoftheunemployed conditionwashigherthantheunemployedbenefitcondition, thoughthisdifferencewasnotstatisticallysignificant.Inthe presenceoftheinteractioneffect,thenon-significanteffectof Timeshowsthat,averagedacrossalltheoutcomemeasures,there wasnodifferenceintheratingofthecharactersintheemployed

TABLE1| Adjustedfixedeffectsestimatesofoutcomesasafunctionof interactionsbetweenconditionandtime.

Coeff.SE(robust) zp [95%CI] Time(refTime1) Time2 0 060.09 0 730.47 0 240 10 Condition(refE) WP 0 020.100 180.86 0 190 22 UE 0 500.11 4 70 <0.001 0 71 0 29 UB 0 610.11 5 84 <0.001 0 81 0 41 Time × Condition Time2WP 0 010.120 110.91 0 230 26 Time2UE 0 220.131 740.08 0 030 47 Time2UB 0 330.132 510.010 070 58

Conditions:E,employed;WP,workingpoor;UE,unemployed;UB, unemploymentbenefits.

conditiononthepre-COVID19andCOVID19occasions.We testedfortheeffectofsociodemographiccharacteristicsas covariatesintheadjustedmodels(employmentandbenefit receiptstatus,education,age,andgender)butfoundnomain effectsofanyofthecovariatesexceptforgender:femalestended toratecharactershigher(b =0.13,95%CI[0.04,0.21])compared tomales.Testingtheheterogeneityofthesepatternsacross outcomesviatheinclusionofathree-wayinteractionbetween vignettecondition,occasionandmeasuresignificantlyimproved overallmodelfit, χ2 (104)=533.40, p < 0.001,prompting analysisofeachoutcomeseparately.

Theseparatelinearregressionsforeachoutcomemeasure (SupplementaryTableS3)showthatratingsofunemployed benefitrecipientsattheTime1(pre-COVID19)weresignificantly lowerthantheemployedcharactersforalloutcomesexcept OpennessandExtraversion.StatisticallysignificantConditionby Timetermsindicatedthattheunemployedbenefiteffectwas moderatedatTime2(COVID19)forthethreekeyoutcome measuresidentifiedinpreviousresearch(Conscientiousness, WorkerandBosssuitability)andforthemeasureofGuilt andShame. Figure2 depictsthisinteractionforthesefour outcomes.Theseoccurredintwoprofiles.ForConscientiousness, WorkerandBosssuitability,COVID19attenuatedthenegative perceptionsofunemployedrelativetoemployedcharacters, providingsupportforHypothesis2.Bycontrast,COVID19 hasinducedanewdifference,suchthatparticipantsthought employedcharactersshouldfeelhigherlevelsGuiltandShame atTime2,comparedtoTime1.Whilethe“workingpoor” conditionwasnotcentraltotheCOVID19hypotheses,wenote thatwefoundnoevidencethatratingsofthesecharacterson anyoutcomedifferedfromthestandardemployedcharacter, orthatthisdifferencewaschangedinassessmentatTime2 (COVID19occasion).

TheImpactofCOVID19onPerceptions ofUnemploymentBenefit-Recipients

TheinclusionofthefifthCOVID19-specificunemployment benefitconditiondidnotgeneratemorepositive(ordifferent) ratingsthanthestandardunemploymentbenefitcondition.

FIGURE2| InteractioneffectofTime(COVID19)byConditionmarginalmeanratingsonfouroutcomes:Conscientiousness,Workersuitability,Bosssuitability,and GuiltandShame(reversed).

Overallmixed-effectsmultilevelmodels,bothadjustedand unadjusted,indicatedthatparticipantsintheCoronavirus supplementcondition(adjustedmodel: b =0.26,95%CI[0.06, 0.45])andthegeneralunemployedbenefitrecipientcondition atTime2(adjustedmodel: b =0.28,95%CI[0.08,0.48])were bothratedmorefavorablyincomparisontounemployedbenefit recipientsatTime1.Therewasnodifferencebetweenthesetwo Time2benefitrecipientgroups(b =0.03,95%CI[ 0.12,0.19]). Theseresultsdidnotsupporthypothesis3.

DISCUSSION

Previousresearchhasdemonstratedthatpeoplewhoare unemployed,andparticularlythosereceivingunemployment benefits,areperceivedmorenegativelyandlessemployable thanthosewhoareemployed.However,theeconomic shockassociatedwiththeCOVID19crisisislikelytohave challengedpeople’ssenseoftheirownvulnerabilityandrisk ofunemployment,andalteredtheirperceptionsofthosewho areunemployedandreceivinggovernmentsupport.Thebroad aimofthecurrentstudywastoexaminethepotentialeffect ofthiscrisisonpersonperceptionstiedtoemploymentand benefitrecipientstatus.Wedidthisbypresentingbriefvignettes

describingfictionalcharacters,manipulatingkeyexperimental conditionsrelatedtoemploymentstatus,andaskingstudy participantstoratethecharacters’personalityandcapability.We contrastedresultsfromtwocross-sectionalgeneralpopulation samplescollectedbeforeandduringtheCOVID19crisis.

Thepre-COVID19assessmentreplicatedourprevious findings(e.g., SchofieldandButterworth,2018b)showingthat employedcharactersareperceivedmorefavorablythanthose whowereunemployedandreceivinggovernmentbenefitson measuresofConscientiousnessandsuitabilityasaworker.These findingssupportedHypothesis1.Incomparison,theassessment conductedduringtheCOVID19crisisshowedthatunemployed andemployedcharacterswereviewedmoresimilarlyonthese samekeymeasures,withasignificantinteractioneffectproviding supportforHypothesis2.Ourthirdhypothesis,suggestingthat nreferencetotheCoronavirusSupplement(anadditionalform ofincomesupportintroducedduringthepandemic)would enhanceratingsofunemployedbenefitrecipientsatthesecond assessmentoccasion,wasnotsupported.Wefoundthatbenefit recipientsatTime2wereratedmorefavorablythanthebenefit groupatTime1,irrespectiveofwhetherthisCOVID19-specific paymentwasreferenced.Thissuggeststhebroadercontext inwhichthestudywasconductedwasresponsibleforthe changeinperceptions.

Wesampledparticipantsfromthesamepopulation,used identicalexperimentalprocedures,andfoundnodifferenceover timeintheratingsofemployedcharactersonthekeyoutcome measuresofemployability(WorkerandBosssuitability)and Conscientiousness.Themorefavorableratingsofunemployed andbenefitreceivingcharactersatTime2islikelytoreflect howtheexogenouseconomicshockbroughtaboutbythe COVID19crisischallengedsocialidentitiesandthestereotypes heldofothers4.Thewidespreadimpactanduncontrollablenature ofthiseventareinconsistentwithpre-COVID19viewsthat attributeill-intenttothosereceivingtounemploymentbenefits (Fiskeetal.,2002; Baumberg,2012; ContiniandRichiardi, 2012; Byeetal.,2014).Wesuggestthechangingcontext alteredperceptionsofthe“deservingness”ofpeoplewhoare unemployedasunemploymentinthecontextofCOVID19 islessindicativepersonalfailingsoraresultofone’s“own doing”(Petersenetal.,2011; vanOorschotandRoosma, 2017).Itisimportanttorecognize,however,thatthenegative perceptionsofunemployedbenefitrecipientswereattenuated intheCOVID19assessment,buttheycontinuedtoberated lessfavorablythanthosewhowereemployedonthekey outcomemeasures.

Incontrasttoourfindingsonthekeymeasuresof employabilityandConscientiousness,thepreviousandcurrent researchislessconclusivefortheotheroutcomemeasures. Thecurrentstudyshowedabroadlyconsistentgradientin theperceptionofemployedandunemployedcharactersfor alloutcomemeasuresapartfromOpennessandExtraversion. Findingsontheseothermeasureshavebeenweakerand inconsistentacrosspreviousstudies(SchofieldandButterworth, 2018b; Schofieldetal.,2019),andthecurrentexperimentwas notdesignedwithsufficientpowertodemonstrateinteraction effectsforthesemeasures.Therewas,however,onemeasure thatshowedsignificantdivergencefromtheexpectedprofile ofresults.Asignificantinteractiontermsuggestedthatstudy participantsattheTime2(COVID19)assessmentreported thattheemployedcharactersshouldfeelgreaterlevelsofGuilt andShamethanthosewhoparticipatedinthepre-COVID19 assessment.Incontrast,therewasconsistencyintheratings ofunemployedcharactersonthismeasureacrossthetwo assessmentoccasions.Whilenotpredicted,theseresultsare alsointerpretableinthecontextofthepervasivejoblossthat accompaniedtheCOVID19crisis. Halleretal.(2020),for example,arguethatthehighlydistressing,morallydifficult, andcumulativenatureofCOVID19relatedstressorspresents aperfectstormtoresultinaguiltandshameresponses.The contextofmassjoblossesmayleave“surviving”workersfeeling increasinglyguilty.

Themainfindingsofthecurrentstudyareconsistentwith previousexperimentalstudiesthatshowthatthestereotypes ofunemployedbenefitrecipientsaremalleable(Aarøe,2011; Schofieldetal.,2019).Thesepreviousstudies,however,have demonstratedmalleabilitybyprovidingadditionalinformation aboutunemployedindividualsthatwasinconsistentwiththe unemployedbenefitrecipientstereotype(e.g.,theexternalcauses

4https://pursuit.unimelb.edu.au/articles/our-changing-identities-under-covid-19

oftheirunemployment).Incontrast,thecurrentstudydid notchangehowthevignettecharacterswerepresentedor theexperimentalprocedures.Rather,weassessedhowthe changingcontextinwhichstudyparticipantswerelivinghad alteredtheirperceptions:suggestingtheexperienceofCOVID19 alteredstereotypicalviewsheldbystudyparticipantsrather thanpresentinginformationaboutthecharacterthatwould challengetheapplicabilityofthebenefitrecipientstereotype inthisinstance.

Perceptionsandstereotypesofbenefitrecipientscanbe reinforced(andpotentiallygenerated)bygovernmentactions andpolicies.Structuralstigmacanbeusedasapolicytoolto stigmatizebenefitreceiptasastrategytoreducedependence onincomesupportandencourageworkforceparticipation (Moffitt,1983; StuberandSchlesinger,2006; Baumberg,2012; ContiniandRichiardi,2012; Garthwaite,2013).Inthecurrent instance,however,theAustraliangovernmentactedquickly toprovidegreatersupporttoAustralianswholosttheirjobs (e.g.,doublingtherateofpayment,removingmandatory reportingtothewelfareservices)andthismayhavereduced thestigmatizingstructuralfeaturesoftheincomesupportsystem andcontributedtothechangedperceptionsofbenefitrecipients identifiedinthisstudy.

Limitations

Thecurrentstudytookadvantageofanaturalexperimental designandreplicatedapre-COVID19studyduringthe COVID19crisis.Thestudyislimitedbytherelativelysmall samplesizeatTime1,whichwasnotdesignedforcurrent purposesbutpartofanotherstudy.Wewerenotabletoinclude mostoftheparticipantsfromtheoriginalTime1studyasmost oftheexperimentalconditionsdescribedactivitiesthatwere illegal/inconsistentwithrecommendactivityatthetimeofthe COVID19lockdownandsocialrestrictionmeasures.Finally,the datacollectionforthecurrentstudyoccurredveryquicklyafter theinitialandsuddenCOVID19lockdownsandeconomicshock, whichisbothastrengthandalimitationforthegeneralizability oftheresults.Thepatternofresultsusingthesamesampling frameofferscompellingsupportforourhypothesisthatthe sharedeconomicshockandincreaseinunemploymentattenuates stigmatizingcommunityattitudestowardthosewhoneedto receivebenefits.Ourcurrentconclusionswouldbefurther strengthenedbyasubsequentreplicationwhenthepublichealth andeconomiccrisesstabilize,totestwhetherpre-COVID perceptionsreturn.

CONCLUSION

Thecurrentstudyprovidesnovelinformationaboutimpact oftheCOVID19healthandeconomiccrisis,andtheimpactof thecorrespondingpolicyresponsesoncommunityperceptions. Thisnovelstudyshowshowcommunityperceptionsof employmentandbenefitrecipientstatushavebeenalteredby theCOVID19pandemic.Theseresultsaddtoknowledgeabout thedeterminantsofwelfarestigma,particularlyrelatingto employability,highlightingsocietallevelcontextualfactors.

DATAAVAILABILITYSTATEMENT

Therawdatasupportingtheconclusionsofthisarticlewillbe madeavailablebytheauthors,withoutunduereservation.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswerereviewedand approvedbyMelbourneUniversityHumanResearchEthics Committee.Thepatients/participantsprovidedtheirwritten informedconsenttoparticipateinthisstudy.

AUTHORCONTRIBUTIONS

ASledthereviewconceptualizedbyTSandPB.ASand PBconductedtheanalysesandwroteupthereview.TSled

REFERENCES

Aarøe,L.(2011).Investigatingframestrength:thecaseofepisodicandthematic frames. Polit.Commun.28,207–226.doi:10.1080/10584609.2011.568041

Aarøe,L.,andPetersen,M.B.(2014).Crowdingoutculture:scandinaviansand Americansagreeonsocialwelfareinthefaceofdeservingnesscues. J.Polit. 76, 684–697.doi:10.1017/S002238161400019X

Abele,A.E.,Hauke,N.,Peters,K.,Louvet,E.,Szymkow,A.,andDuan,Y.(2016). Facetsofthefundamentalcontentdimensions:agencywithcompetenceand assertiveness—Communionwithwarmthandmorality. Front.Psychol. 7:1810. doi:10.3389/fpsyg.2016.01810

Atitsogbe,K.A.,Mama,N.P.,Sovet,L.,Pari,P.,andRossier,J.(2019).Perceived employabilityandentrepreneurialintentionsacrossuniversitystudentsandjob seekersinTogo:theeffectofcareeradaptabilityandself-efficacy. Front.Psychol. 10:180.doi:10.3389/fpsyg.2019.00180

AustralianBureauofStatistics(2017). CharacteristicsofEmployment.Australia: LabourForce.

AustralianBureauofStatistics(2020). Employmentandunemployment: InternationalPerspective.Australia:LabourForce.

Barrick,M.R.,Mount,M.K.,andJudge,T.A.(2001).Personalityandperformance atthebeginningofthenewmillennium:whatdoweknowandwheredowego next? Int.J.Select.Assess. 9,9–30.doi:10.1111/1468-2389.00160

Bastian,B.,Denson,T.F.,andHaslam,N.(2013).Therolesofdehumanizationand moraloutrageinretributivejustice. PLoSOne 8:e61842.doi:10.1371/journal. pone.0061842

Baumberg,B.(2012).ThreewaystodefendwelfareinBritain. J.PovertySoc.Just. 20,149–161.doi:10.1332/175982712X652050

Bocian,K.,Baryla,W.,Kulesza,W.M.,Schnall,S.,andWojciszke,B.(2018).The merelikingeffect:attitudinalinfluencesonattributionsofmoralcharacter. J.Exp.Soc.Psychol. 79,9–20.doi:10.1016/j.jesp.2018.06.007

Bye,H.H.,Herrebrøden,H.,Hjetland,G.J.,Røyset,G.Ø,andWestby,L.L. (2014).Stereotypesofnorwegiansocialgroups. Scand.J.Psychol. 55,469–476. doi:10.1111/sjop.12141

Chan,W.,McCrae,R.R.,DeFruyt,F.,Jussim,L.,Löckenhoff,C.E.,DeBolle,M., etal.(2012).Stereotypesofagedifferencesinpersonalitytraits:universaland accurate? J.Personal.Soc.Psychol. 103,1050–1066.doi:10.1037/a0029712

Contini,D.,andRichiardi,M.G.(2012).Reconsideringtheeffectofwelfarestigma onunemployment. J.Econ.Behav.Organ. 84,229–244.doi:10.1016/j.jebo.2012. 02.010

Cuddy,A.J.,Fiske,S.T.,andGlick,P.(2008).Warmthandcompetenceasuniversal dimensionsofsocialperception:thestereotypecontentmodelandtheBIAS map. Adv.Exp.Soc.Psychol. 40,61–149.doi:10.1016/S0065-2601(07)00002-0

Cuesta,M.B.,andBudría,S.(2017).Unemploymentpersistence:howimportant arenon-cognitiveskills? J.Behav.Exp.Econom. 69,29–37.doi:10.1016/j.socec. 2017.05.006

thedatacollection,reviewedandeditedthemanuscript,and provideddatamanagementsupport.Thismanuscriptisbased onpreviousextensiveworkbyTSandPBonstereotypestoward theunemployedandwelfarebenefitrecipients.Allauthors contributedtothearticleandapprovedthesubmittedversion.

FUNDING

ThisstudywasfundedbytheAustralianResearchCouncil(ARC) grant#DP16014178.

SUPPLEMENTARYMATERIAL

TheSupplementaryMaterialforthisarticlecanbefound onlineat:https://www.frontiersin.org/articles/10.3389/fpsyg. 2020.594837/full#supplementary-material

Dhiman,M.C.(2012).Employers’perceptionsabouttourismmanagement employabilityskills. Anatolia 23,359–372.doi:10.1080/13032917.2012.711249

Digman,J.M.(1997).Higher-orderfactorsofthebigfive. J.Personal.Soc.Psychol. 73:1246.

Fiske,S.T.(2018).Stereotypecontent:warmthandcompetenceendure. Curr. Direct.Psychol.Sci. 27,67–73.doi:10.1177/0963721417738825

Fiske,S.T.,Cuddy,A.J.,Glick,P.,andXu,J.(2002).Amodelof(oftenmixed) stereotypecontent:competenceandwarmthrespectivelyfollowfromperceived statusandcompetition. J.Personal.Soc.Psychol. 82:878.doi:10.1037/00223514.82.6.878

Garthwaite,K.(2013).Fearofthebrownenvelope:exploringwelfarereformwith long-termsicknessbenefitsrecipients. Soc.Pol.Administration. 48,782–798. doi:10.1111/spol.12049

Giner-Sorolla,R.,andEspinosa,P.(2011).Socialcuingofguiltbyangerand ofshamebydisgust. Psychol.Sci. 22,49–53.doi:10.1177/095679761039 2925

Goldberg,L.R.(1993).Thestructureofphenotypicpersonalitytraits. Am.Psychol. 48:26.doi:10.1037/0003-066X.48.1.26

Gosling,S.D.,Rentfrow,P.J.,andSwann,W.B.Jr.(2003).Averybriefmeasure oftheBig-Fivepersonalitydomains. J.Res.Personal. 37,504–528.doi:10.1016/ S0092-6566(03)00046-1

Haidt,J.(2003).Themoralemotions. Handb.Affect.Sci. 11,852–870.

Haller,M.,Norman,S.B.,Davis,B.C.,Capone,C.,Browne,K.,andAllard,C.B. (2020).AmodelfortreatingCOVID-19–relatedguilt,shame,andmoralinjury. Psychol.Trauma 12,S174–S176.

Hogan,R.,Hogan,J.,andRoberts,B.W.(1996).Personalitymeasurementand employmentdecisions:questionsandanswers. Am.Psychol. 51:469.doi:10. 1037/0003-066X.51.5.469

Larsen,K.(2008).Knowledgenetworkhubsandmeasuresofresearch impact,sciencestructure,andpublicationoutputinnanostructured solarcellresearch. Scientometrics 74,123–142.doi:10.1007/s11192-0080107-2

Löckenhoff,C.E.,Chan,W.,McCrae,R.R.,DeFruyt,F.,Jussim,L.,De Bolle,M.,etal.(2014).Genderstereotypesofpersonality:universaland accurate? J.Cross-Cult.Psychol. 45,675–694.doi:10.1177/00220221135 20075

Lowden,K.,Hall,S.,Elliot,D.,andLewin,J.(2011). Employers’Perceptionsofthe EmployabilitySkillsofNewGraduates.London:EdgeFoundation.

McCrae,R.R.,andTerracciano,A.(2005).Universalfeaturesofpersonalitytraits fromtheobserver’sperspective:datafrom50cultures. J.Personal.Soc.Psychol. 88,547–561.doi:10.1037/0022-3514.88.3.547

Moffitt,R.(1983).Aneconomicmodelofwelfarestigma. Am.Econom.Rev. 75, 1023–1035.

O’Leary,S.(2017).Graduates’experiencesof,andattitudestowards,theinclusion ofemployability-relatedsupportinundergraduatedegreeprogrammes;trends

andvariationsbysubjectdisciplineandgender. J.Educ.Work 30,84–105. doi:10.1080/13639080.2015.1122181

O’Leary,S.(2019).Genderandmanagementimplicationsfromclearersignposting ofemployabilityattributesdevelopedacrossgraduatedisciplines. Stud.Higher Educ. 1–20.doi:10.1080/03075079.2019.1640669

Pegg,A.,Waldock,J.,Hendy-Isaac,S.,andLawton,R.(2012). Pedagogyfor Employability.York:HigherEducationAcademy.

Petersen,M.B.,Slothuus,R.,Stubager,R.,andTogeby,L.(2011).Deservingness versusvaluesinpublicopiniononwelfare:theautomaticityofthedeservingness heuristic. Eur.J.PoliticalRes. 50,24–52.doi:10.1111/j.1475-6765.2010.01 923.x

Plomp,J.,Tims,M.,Khapova,S.N.,Jansen,P.G.,andBakker,A.B.(2019). Psychologicalsafety,jobcrafting,andemployability:acomparisonbetween permanentandtemporaryworkers. Front.Psychol. 10:974.

Saad,M.S.M.,andMajid,I.A.(2014).Employers’perceptionsofimportant employabilityskillsrequiredfromMalaysianengineeringandinformation andcommunicationtechnology(ICT)graduates. GlobalJ.Eng.Educ. 16, 110–115.

Saucier,G.,andGoldberg,L.R.(1996).“Thelanguageofpersonality: lexicalperspectives,”in OntheFive-factorModelofPersonality:Theoretical Perspectives,ed.J.S.Wiggins(NewYork,NY:GuilfordPress),21–50.

Schofield,T.P.,andButterworth,P.(2015).Patternsofwelfareattitudesin theAustralianpopulation. PLoSOne 10:0142792.doi:10.1371/journal.pone. 0142792

Schofield,T.P.,andButterworth,P.(2018a).Arenegativecommunityattitudes towardwelfarerecipientsassociatedwithunemployment?evidencefrom anaustraliancross-sectionalsampleandlongitudinalcohort. Soc.Psychol. Personal.Sci. 9,503–515.doi:10.1177/1948550617712031

Schofield,T.P.,andButterworth,P.(2018b).Communityattitudestowardpeople receivingunemploymentbenefits:doesvolunteeringchangeperceptions? BasicAppl.Soc.Psychol. 40,279–292.doi:10.1080/01973533.2018.149 6335

Schofield,T.P.,Haslam,N.,andButterworth,P.(2019).Thepersistenceofwelfare stigma:doesthepassingoftimeandsubsequentemploymentmoderatethe

negativeperceptionsassociatedwithunemploymentbenefitreceipt? J.Appl. Soc.Psychol. 49,563–574.doi:10.1111/jasp.12616

Shahidi,F.,Siddiqi,A.,andMuntaner,C.(2016).Doessocialpolicymoderatethe impactofunemploymentonhealth?amultilevelanalysisof23welfarestates. Eur.J.fPublicHealth 26,1017–1022.doi:10.1093/eurpub/ckw050

Srivastava,S.(2010).Thefive-factormodeldescribesthestructureofsocial perceptions. Psychol.Inquiry 21,69–75.doi:10.1080/10478401003648815

Stuber,J.,andSchlesinger,M.(2006).Sourcesofstigmaformeans-tested governmentprograms. Soc.Sci.Med. 63,933–945.doi:10.1016/j.socscimed. 2006.01.012

vanOorschot,W.(2000).Whoshouldgetwhat,andwhy?ondeservingnesscriteria andtheconditionalityofsolidarityamongthepublic. Pol.Pol. 28,33–48. doi:10.1332/0305573002500811

vanOorschot,W.,andRoosma,F.(2017). TheSocialLegitimacyofTargeted Welfare.Cheltenham:EdwardElgarPublishing.

Ward,L.C.,Thorn,B.E.,Clements,K.L.,Dixon,K.E.,andSanford,S.D.(2006). Measurementofagency,communion,andemotionalvulnerabilitywiththe PersonalAttributesQuestionnaire. J.Pers.Assess.86,206–216.doi:10.1207/ s15327752jpa8602_10

Yeves,J.,Bargsted,M.,Cortes,L.,Merino,C.,andCavada,G.(2019).Ageand perceivedemployabilityasmoderatorsofjobinsecurityandjobsatisfaction:a moderatedmoderationmodel. Front.Psychol. 10:799.doi:10.3389/fpsyg.2019. 00799

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Suomi,SchofieldandButterworth.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.No use,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

CONCEPTUALANALYSIS

published:16October2020 doi:10.3389/fsoc.2020.575791

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland

Reviewedby: AriannaSchianoLomoriello, UniversityofPadua,Italy GordonCooke, MemorialUniversityof Newfoundland,Canada

*Correspondence: VincenzoAuriemma vauriemma@unisa.it

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 24June2020

Accepted: 10September2020 Published: 16October2020

Citation: AuriemmaVandIannacconeC(2020)

COVID-19Pandemic: Socio-EconomicConsequencesof SocialDistancingMeasuresinItaly. Front.Sociol.5:575791. doi:10.3389/fsoc.2020.575791

COVID-19Pandemic: Socio-EconomicConsequencesof SocialDistancingMeasuresinItaly

VincenzoAuriemma* andChiaraIannaccone

DepartmentofPoliticalandSocialStudies,Sociology,UniversityofSalerno,Fisciano,Italy

Thelock-downmeasuresadoptedinallcountriesoftheworldhaveledtofar-reaching socialandeconomicchanges.Thehealthemergencyhadimmediaterepercussionsfirst onthesocialsystemandthenontheeconomicone.Thesocialrepressionmeasures takentolimittheinfectionhavegeneratedadrasticchangeindailylife,detaching ourselvesfromtheotheremotionallyandphysically.ThealreadydifficultsituationthatItaly wasexperiencingfromaneconomicandsocialpointofviewisimmediatelyexposedby thehealthemergency,andthenworsenedandextendedtoallsectors.Inthiscontext,itis importanttostudydifferenttypesofphenomena:thesuspensionofcommercialactivities andtheconsequentrepercussionsontheworksector,smart-workingandinfrastructural andculturaldigitaldivide,thenewformsofinteractionandrelationshipthattransform theemotionsand,finally,theenormousfluctuationofworldmarkets.Tofacesucha far-reachingcrisis,themeasurestakennotonlyatnationallevel,butalsosupranational andinternationalwillbedecisive.

Keywords:coronavirus,digitaldivide,economy,empathy,socialdistance,work

INTRODUCTION

OnJanuary30,2020,ChinareportedtotheworldtheexistenceinthecityofWuhanofa clusterofcasesofpneumoniaofunknownetiology(lateridentifiedasanewcoronavirusSarsCoV-2),thesamedaytheWHO(WorldHealthOrganization)declaredtheinternationalstateof emergency.Thefollowingday,January31,theItaliangovernmentproclaimedastateofemergency andimplementedthefirstmeasurestocontaintheinfectionthroughoutthenationalterritory. OneofthefirstmeasuresadoptedwasthesuspensionofallflightstoandfromChinawiththe implementationofairportcontrols,usingthermoscannersformeasuringbodytemperature,in ordertomonitorthehealthconditionsofpassengersfromChinathroughstopoversintermediate. Theincreaseinhealthcheckswasimmediatelyforeseenalsoinports,involvingnotonlynonEUboatsbutallmerchantandcruiseboatsintransitonthenationalterritory.OnFebruary21, theMinistryofHealthintroducedmandatoryquarantineisolationmeasuresforclosecontacts withacasethattestedpositiveforCovid-19,andorderedactivesurveillancewithfiduciaryhome stayforthosewhowereinriskareasinthelast14days,withtheobligationofreportingby theinterestedpartytothelocalhealthauthorities.On23February,followingtheoutbreaks registeredinLombardyandVeneto,thefirst“redzone”wasestablished,somemunicipalities wereisolated(banonexpulsionandbanonaccess)andweresuspendedinthemalleducational andculturalactivities,economic,commercialandrecreational-recreationalactivitiesguaranteeing citizenshipaccesstoessentialservicesandgoods.OnFebruary25,somemeasurestocontainthe contagion,concerningthesuspensionofsportingevents,schoolactivitiesandhighereducation

(recommendingtheimplementationofdistancelearning), culturalandtourismactivities anddrivingexams,wereextended toallthemunicipalitiesoftheRegions:Emilia-Romagna,Friuli VeneziaGiulia,Lombardy,Veneto,LiguriaandPiedmont.On 1MarchthesameRegionsenteredthe“redzone.”On4 March,educationalactivitiesinschoolsanduniversities,congress activities,culturaleventsandsportingeventsweresuspended throughoutthecountry,recommendingtheuseofagilework. On8March,asinglecontainmentareawascreatedwithmore stringentmeasuresincludingtheterritoryoftheLombardy Regionand14otherProvinces(fivefromEmilia-Romagna,five fromPiedmont,threefromVenetoandonefromMarche).With theDCPM(PresidentialDecreeoftheCouncilofMinisters)8 March,respectfortheinterpersonalsafetydistanceofatleastone meterisintroducedforthefirsttimeasacontainmentmeasure andtheneedtoavoidgatheringsishighlightedseveraltimes, theuseofthemaskisinsteadrecommendedonlytothosewho suspecttobesickandtothosewhocareforsickpeople1.On9 Marchthe“redzone”isextendedtothewholenationalterritory andwillremaininforceuntil4May.

Maintainingsocialdistanceseemstobethemosteffective healthdeviceforpreventingCovid-19contagion.Sincethe coronavirusbeganitsdiffusion,twotypesofdistanceswere recognized:onereferstothedistancebetweenindividuals (gatherings)andtheothertothedistancethateachindividual mustkeepontheother,inordertoavoidcontagion(Bignami, 2020;CDC,2020;Demarais,2020).Socialdistance,sociology andsocialpsychology,mean thewillingnessofmembersofone grouptohavesocialcontactswithpeoplefromanothergroup. Inparticular,itisstudiedinwhichwaypeoplearereadyto excludeoradmitthosewhobelongtoanothergroup(Canavese, 2020).Itisimportant toknowthatthismeasureisnotnew,its firstapplication,even ifnotintheseterms(1.8million),dates backtoSeptember1918,towardtheendoftheFirstWorldWar, whenabadinfluencebegantospreadthroughouttheworld.The virusresponsibleforthedisease,whichbecameknownasSpanish flu,infectedoveraquarteroftheworld’spopulation,withan estimateddeathtollof50to100million,itbecameoneofthe deadliestpandemicsinhumanhistory.Thefirstprohibitionsand thefirst“socialdistances,”althoughtheydidnotusethisterm correctly,beganintheUnitedStates.Atthattime,somecities wereorganizingparadestopromotetiesoffreedom,withtheaim ofhelpingtopayforthewareffortsinEurope.InPhiladelphia, Pennsylvania,where600soldiershadalreadybeeninfectedwith thefluvirus,anever-adoptedrulewasintroduced,quarantine andsocialdistancewithinthefamilysystem(Pottinger,2013; Bourouiba,2020;Carlini,2020; Resnick,2020).

Theobjectiveofthisworkistoinvestigatetheconsequences producedbythemeasuresadoptedbytheItaliangovernment, andsubsequentlybymanyotherEuropeanandnon-European countries,todealwiththeCovid-19pandemicstartingfrom

1Theobligationtowearamaskhasnotbeenintroduceduniformlyonthenational territory.Thisobligationwasmostlyprovidedforina“transversal”way,thatis onlyforcertainpopulationgroups(healthprofessionals,commercialoperatorsof basicnecessitiessuchasfood,pharmacies,etc.)and,inanycase,onlyattheregional level.

ananalysisofthesituationpriortothecrisisandinvestigating someofthepossiblefuturescenarios.Asiswell-known,Italy suffersfromvariousstructuraldeficienciesmadeevenmoreacute inthelastdecadebytheeconomicpolicyrecipesadoptedfor therestructuringoftheexponentialnationalpublicdebt.The Covid-19emergencyhadthemerit,ordemerit,ofunmasking thedeficitsthathaveexistedinItalyforyearsinallsectorsof activity,publicandprivate,andurgentlyimposestheneedto remedydramaticallychronicsituations,theresultofpoliticaland economicactions.Theimportanceofwell-being,theimportance ofincomeandthecriticalissuesraisedbyevermoremarked inequalitieshavebeenrediscovered.

THECONSEQUENCESOFSOCIAL DISTANCES

EconomyandWork

TheIstat(NationalInstituteofStatistics)noteonemployedand unemployedofFebruary2020showsastableemploymentrate at58.9%,theresultofaslightincreaseinemploymentamong women(+12thousandunits),temporaryemployees(+14 thousand)andyoungpeopleaged15age24(+35thousand) andadropinemploymentamongmen( 22thousandunits), permanentemployees( 20thousand),self-employedpersons ( 4thousand),andover35( 44thousand)(IstitutoNazionale diStatistica,2020b). Theinactivityratestandsat34.5%with anincreaseinFebruaryofwomenandpeopleagedatleast35 equalto12thousandunits.Inthesamemonth,womenseeking employment( 39thousandunits)andtheover35sdecreased, whilemen(+22thousandunits)andyoungpeoplebetween15 and24yearsincreased.Unemploymentstoodat9.7%,witha slightdecreaseof0.1%,whileyouthunemploymentremained stableat29.6%.ComparingtheDecember2019–February2020 quarterwiththepreviousone,September–November2019,there isacleardeclineinemployment( 89thousandunits)involving bothgendercomponentsbetween15and49years,permanent employeesandself-employedwhileitseesaslightgrowthamong temporaryemployees.Inthesamequarter,thenumberofpeople seekingemploymentdecreasedandtheinactiveincreased(+51 thousandunits)(IstitutoNazionalediStatistica,2020b).Anotat allrosypre-crisispicturethatsubstantiallyrecordsanincreasein precariouswork,astrongmistrustinthefutureandadramatic youthcondition.Anevenlesscomfortingsituationifyoulookat thelatestdatamadeavailablebythe2019statisticalyearbookon poverty(IstitutoNazionalediStatistica,2019a,b,c).In2018the percentageoffamiliesinabsolutepovertyinItalywas7%(882 thousand)withanalarmingincidenceintheSouthwherethe valuestoodat20.5%(higherthanthenationalaverageof19.4%) (IstitutoNazionalediStatistica,2019a,b,c).Thehighestincidence isrecordedamongfamilieswithfiveandmorecomponents (19.6%),followedbycoupleswiththreeormorechildren(16.6%), single-parentfamilies(11.4%)andfamilieswithfourcomponents (8.9%).Thelowestincidenceisrecordedamongfamiliesof andwiththeelderly(4%)andfurtherdecreasesinfamiliesin whichthereferencepersonisover64yearsold(3.2%).Onan individuallevel8.4%oftheentirepopulationisinconditionsof

absolutepoverty,ofthe5millionand40thousandindividuals inthisconditionover2 millionand300thousandresideinthe South(11.4%)andover2millionand500thousandarewomen (8.3%).Theincidenceofabsolutepovertyishighamongminors (12.6%)andpeopleagedbetween18and34(10.3%),confirming itsminimumamongover74years(4.6%)(Ibid).Theelderly populationinItalyprovestobethemainsocialsafetynet,afigure thatshouldnotbeunderestimatedifweconsiderthatmostofthe deathsfromCovid-19belongtotheagegroupbetween60and 90yearsofageandover,onApril13,2020thenumberofdeaths between60and69yearsis11.5%ofthetotal,between70and 79yearsat31.5%,between80and89yearsat40.4%andamong peopleover90yearsofage11.6%(IlSole24Ore.,2020).

Decisionsonadoptingsocialdistancehaveinevitablyinvolved almostallproductiveactivities.InItaly,accordingtotheISTAT noteontheeconomictrendofthemonthofMarch,theactivities of2.2millioncompanies,49%ofthetotal,havebeensuspended, investingtheexportingcompaniestoagreaterextent,involving 65%ofthetotal.Theblockadeofproductionactivitiesinvolved 44.3%ofemployeesand42.1%ofemployees.Thefirstresponse recordedbytheNationalStatisticalInstituteisasharpcollapse inconsumerandbusinessconfidence(IstitutoNazionaledi Statistica,2020a).In additiontothedirecteffectsconnected withthesuspensionof theworkactivities,theproduction sectoralsosuffersfromtheindirecteffectrelatedtothecrosssectoralrelations.Anexampleisgivenbytheexpensesfor fuelsandlandtransport(forexamplebus)serviceswhich havefallensharplyandtheexpensesfortourismwhichhave beencompletelyeliminated.Thefirstestimateoftheeffects oftheblockadeonISTAT’Seconomicperformanceisnot reassuring.Inthissituation,twotypesofscenarioshavebeen hypothesized.Thefirstoneisrelatedtothepossibilitythat thelimitationofproductionactivitiesislimitedonlyforthe monthsofMarchandApril,areductioninfinalconsumption of4.1%isestimated,withadecreaseinvalueaddedgenerated bytheproductionsystemof1.9%,involving385thousand employees,ofwhich49thousandirregular,foranamountof approximately9billioneurosinsalaries.Themostexpensive priceofthedropinvalueaddedispaidbytheaccommodation andrestaurantservices( 11.3%)andbythecommerce, transportandlogisticssectors( 2.7%),whiletheconsequences onthelessincisivesectorstheyare:producinginvestment goodsandconstruction(lessthanonepercentagepoint) (IstitutoNazionalediStatistica,2020a).

Thesecondoneconcernstheextensionofthemeasurestothe monthsofMayandJune,leadingthereductioninconsumption of9.9%,withanoverallreductioninaddedvalueof4.5%, involving900thousandemployees,ofwhom103thousandnonregular,foratotalof20.8billioneurosinsalaries.Also,inthis casethemostmarkedcontractionsoftheaddedvaluewould involvetherestaurantandrestaurantbusiness( 23.9%),trade, transportandlogistics( 6.9%)withmoremarkedeffectson theproductionofconsumergoods( 3.6%),personalservices ( 3.6%)andprofessionalservices(-3.4%).Inthisscenario, commercialservicesand“socialization”wouldpaythemost expensiveprice,withadropinvalueaddedof 16.4%inthe culturalsector, 12.7%intheentertainmentsectorand 6.7%

intheretailtrade,potentiallyaffecting608thousandemployees, ofwhom72thousandarenotregular(IstitutoNazionaledi Statistica,2020a).

InMarch,therewasaslowdownininflationattributable, accordingtoISTAT,totheslowdowninunregulatedenergy goods( 2.7%)andservices(from + 1%to + 0.6%),thesetrends ofdecreaseswereonlypartiallyoffsetbytheaccelerationinfood prices(from + 0.4%to + 1.2%)andtobaccos(from + 1.5%to + 2.5%)(IstitutoNazionalediStatistica,2020a).

Todateitisstill difficulttoestimatethenumberofpeople who,duetotheCovid-19emergency,couldfindthemselvesout ofajobasitisdifficulttopredictthenumberofsmalland medium-sizedenterprisesthatwillbeabletoresistandgetto phase2,consideringthatmanyofthemarealreadysuffering. Fornow,anumberofworkersatriskof10millionisassumed, basedonthisestimatetheStatehasmade10billionavailable withabonusof600eurosfor5.3millionworkerswhowillreach 800inAprilandMay,whilefortheprecarious,whodemonstrate thattheyhaveworkedatleast4weeksayear,400–500eurosper monthwerepaid(Livelli,2020;Mondani,2020).Aninsufficient measureifweconsider allthoseprecariousworkersofthe informaleconomywhichintheSouthamounttoabout50%.Law DecreeApril8,2020,n.23(Urgentmeasuresregardingaccess tocreditandtaxobligationsforbusinesses,specialpowersin strategicsectors,aswellasinterventionsinthefieldofhealthand work,extensionofadministrativeandproceduralconditions) “Credito”hasdisbursed e 400billioninadditiontothe350 billionalreadyallocatedbythedecree18/2020“CuraItalia”, 200billionwereallocatedtogiveliquiditytocompaniesfor thoseinvolvedintheinternalmarketandforthosededicatedto exports.Again,themeasuresmaybeinsufficient,inadditionto theloans,non-repayableloanshavenotbeendisbursed(Istituto NazionalediStatistica,2020a).

Theeconomicandfinancialcrisis generatedbythishealth emergencycouldhaveevenmoredamagingconsequencesthan therecent2008subprimemortgagecrisis,becauseeverynew coronavirusoutbreakintheworldbreaksthechainsofa productionsystemthatisnowstrictlycloseinterconnected globally.Thisisashockthataffectsbothdemandand supplysimultaneouslyandcouldcausegeneralizeddeclinesin productionandsuppliestogetherwitharecoveryininflation (IstitutoNazionalediStatistica,2020a).Humanityisfacingan unprecedentedglobalcrisiswhich,unlikethebarriersraised bynationalistpolicies,hasnoborders.Accordingtothe InternationalMonetaryFund(2020),3%ofworldGDP(Gross DomesticProduct)willincreasein2020,witheconomiclosses ofabout9,000billiondollars,indiscriminatelyaffectingrich andpoorcountries.Globalsupplychainshavemajorflaws andthefinancialcrisisinvolvesmarketsandrawmaterials; advancedeconomieswillpaythemostexpensivepricewith acontractionof 6%ofGDPwhileforemergingcountries itwillbeequalto1%.TheEurozonewilllose7.5%ofGDP, thetaillight,immediatelyafterGreece,Italyisforwhicha contractionof 9.1%isexpected(IstitutopergliStudidiPolitica Internazionale,2020).Inpresentingthereportsontheworld economyinApril2020,the directorofInternationalMonetary Fund,KristalinaGeorgieva,saidthattheongoingcrisiswill

leadtotheworsteconomicfalloutoftheGreatDepression,if anincreaseinper capitaincomewasexpected3monthsago inover160membercountriesofthenegativegrowthofthe IMFisnowforecastfor170countries(IstitutoNazionaledi Statistica,2020a).AngelGurria, OECDsecretarygeneral,said thatintheeventthatcountriesmanagetorespondpromptlyto theshockandwithappropriatemeasures,therecoverycurvewill resembleaU,withalongperiodofsufferingthatwilllastfor years,otherwiseitcouldbecomeanL(Szu,2020).Thiscrisis presentsseveralpeculiarities,firstofalltheuncertaintyofits durationandintensity,whichisstillimpossibletodefinetoday, andalsotheimpossibilityofgivingimpetustotheeconomywith theusualmeasures,howtostimulateaggregatedemand,where thesetheyareundesirableforthosesectors,mostaffectedin compliancewithcontainmentmeasures(InternationalMonetary Fund,2020).AsstatedbyGitaGopinath,IMFeconomic consultant,thiscrisis mustbefacedintwophases:oneof containmentandstabilizationandtheotherofrecovery.In thefirstphase,blockingandsocialdistancingmeasuresare essentialtoslowdownthetransmissionofthevirusandgivethe healthsystemtimetoexpanditsservicesandtrytodevelopa vaccinethroughtherightflowofresources.Atthesametime, itisessentialthatstatesimplementthefiscal,monetaryand financialmeasuresnecessarytokeepthecompany’seconomic infrastructureintact.Toreducesystemicstress,liquiditymust beintroducedtocounteractlossofconfidenceandstrengthen expectationsforeconomicrecovery.Governmentsandcentral bankswillhavetotakealeadingroleineconomieswith thesupportofinternationalfinancialinstitutionsandbilateral economiccreditors.Economicpolicyactionswilldeterminethe conditionsforrecovery,theprotectionofpeopleandbusinesses willbeessential(InternationalMonetaryFund,2020).

Smart-WorkingandConnectivity

Thetotalblockadeatdifferentlevels-educationalinstitutions, commercialactivities,industrialproduction-hasplacedItaly facinganunprecedentedchallenge.Inacountrythathasbeen tryingtoadapttothedigitalizationprocesshaveemerged stronglyproblemsrelatedtounequaltechnologicaldevelopment, whichtravelsatdifferentspeedsalongthenationalterritory. Theproblemsopenedupbytheneedtoactivateintelligent workingmethods,inallthosesectorsinwhichthereisno urgentneedforphysicalpresenceand/ormanualwork,are manifoldandembracedifferentaspectsrangingfromstructural issuestopersonalproblemsandneeds.Thedigitaldivide essentiallyreferstotwoformsofinequalitythathavemanifested themselvesinaccesstoadequateInternetcoverage(digital infrastructuregap)andintheuseofinformationtechnology (digitalculturaldivide).

DigitalInfrastructureDivide

TheEuropeanCommissiondefinesthedigitalinfrastructure divideasthelackoffixedbroadbandcoverageofatleast2 megabits.AccordingtothelatestDESIreportof2019(The DigitalEconomyandSocietyIndex),99.5%ofItalianfamilies areservedbyfixedbroadband,fastbroadband(NGA-Next GenerationAccess)reaches90%offamilieswhileonly24%itis

obtainedfromultrafastbroadband(100Mbpsandabove)(The DigitalEconomySocietyIndex,2019).DatafromtheMinistry ofEconomicDevelopment, referringtothelastnationalpublic consultationdatingbackto2017,showanevenwidergap, statingthatonly2%ofnationalhousenumbersarereachedby aconnection >100Mbps,30%theyhaveaconnectivityhigher than30Mbps,whilealmost70%ofcitizensarenotcovered bythe“ultra-wide”band(CalendaandBentivogli,2018).The variabilityofthedataisdictatedbythedifferentcalculation systemsusedbut,whatevertheresultsareclosesttothereal, itshouldberememberedthattheactualnavigationspeedis lowerthanthemaximumdeclaredspeedandonwhichthese estimatesaremade.Anemblematicexamplearethevaluesofa speedtestcarriedoutbytheteamofUniversityofSalernoon 17January2020,beforethereforethecoronavirusemergency,in amunicipalityintheprovinceofAvellinolocated725meters abovesealevel,theOspedalettod’Alpinolo.Againstaconnection speeddeclaredbythetelephoneoperatorat20Mbps,theactual downloadspeedwas2.61Mbpswhiletheuploadspeedwas 0.48Mbps.

ThelatestIstatCitizens,BusinessesandICT(Information andCommunicationTechnologies)report(2018)highlightsa muchmoreworryingsituation.Italianfamilieswithinternet accessfromhomeare75.1%,ofwhich73.7%havebroadband connection.InEurope,theaveragerateofbroadbanddiffusion amongresidenthouseholdswithatleastonememberaged16–74 is86%;Italy,witharateof83%,hasagapof3percentagepoints. Despitethegrowthinthenumberofhouseholdsthathavea broadbandconnection,thegapsstillremainwide,24.7%of householdsdonothaveaccesstotheinternet.Morethanonein twofamiliesdeclarethattheydonothaveaccesstotheinternet athomebecausetheydonotknowhowtouseit(58.2%),and morethanonefifth(21.0%)donotconsidertheInternetauseful andinterestingtool.Thereareeconomicreasonsrelatedtothe highcostofconnectionsornecessarytools(15.2%),while8.1% donotsurftheNetfromhomebecauseatleastonememberof thefamilyaccessestheInternetfromanotherplace.Ontheother hand,theshareoffamilieswhoindicateinsecuritywithregardto theprotectionoftheirprivacy(2.9%)andthelackofavailability ofabroadbandconnection(2.0%)amongthereasonsisresidual (IstitutoNazionalediStatistica,2019b).Themainterritorialgaps arefoundonthealreadyknownlinesofinequality:north-south, city-countryside,scatteredhousesofurbanagglomerations, coastalareas-inlandareas,hillyareas-mountainousareas, continentalislands.

ThecontainmentmeasuresadoptedtodealwiththeCovid19emergencyhavehadastrongimpactonthealready inadequatesituationofcountry’sinfrastructuralnetwork,causing anoverloadandafurtherslowdownofthesame.Thetransition todigitaldoesnotonlyconcernworkneedsbutallareasof dailylife,fromrelationshipstovideolessons,fromrecreational activitiestopurchases.JoyMarinodirectorofMilanoInternet Exchange,themainhubofItalianconnectionstoandfrom abroad,saidthatintheweekbetween9and15Marchthere wasanincreaseof112%intermsofuseofvirtualprivate networks(VPN)(Levels,2020).Asisknown,theproblemis notlimitedtoItaly,asofApril9,2020accordingtoWHO

data,216countriesareaffectedbytheepidemicwithatotalof 1,439,013confirmedcases and85,587deaths(WHO,2020),while accordingtowhenreportedbyAFP,theFrenchnewsagency, about4millionpeoplearecurrentlyconfinedtotheirhomes (AFP,2020).

FromlateFebruarytolate March,globalInternettraffic increasedby30%withanincreaseinbytesconsumedofabout 10timescomparedtotheaveragemonthlydata(Ruscono, 2020).InthecountriesaffectedfirstbyCovid-19(China,Korea, Japan,andItaly)there havebeenvariationsinInternettraffic 25%higherthantherestoftheworldinthesameperiodof time,inItalythegrowthinconnectionshasbeenconstant sincebeginningattheendofMarch(Ruscono,2020).The FacebookCEOsaid thatinallthecountriesaffectedbyCovid19averyhighusewasmadenotonlyofWhatsAppbutalso ofFacebookandMessenger(Levels,2020).InItaly,thetime spentonWhatsApp,MessengerandInstagramhasincreasedby 70%sincethestartofthepandemic,thedurationofcallson MessengerandWhatsApphasincreasedbymorethan1,000% whiletheexchangeofmessagesontheseappshasincreasedby 50%.Theeveningbandsarethosethatregisterthemaximum increaseinconnectiontothenetworkupto100%(Levels,2020). Themainrisksforintelligentworkarerelatedtotheoverload oftheso-calledpubliccloudservices,locatedmainlyoutside ItalyandEurope,whichcouldbesloweddownandinterrupted bylimitingorcompletelypreventingaccesstothesharingand communicationportals,byvideoconference(Levels,2020).The mainconcernisrelatedtotheincreaseofpeoplesimultaneously inisolationandtheconsequentexponentialgrowthintheuseof thevariousplatformsdedicatedtorelationships,leisureactivities andworkneeds,ascenariothatcouldleadtoaninclinationofthe server.Theministerfortechnologicalinnovation,PaolaPisano, promptlyreassuredthecountrybydeclaringthatthenetwork willbeabletoresistthisdataoverload,buthasalsoinvited tousetheInternetsparingly,callingita“preciousresource” (SkyTg24,2020).TheItalianstateimmediatelytookstepsto introducethenecessarymeanstoavoidapossiblecollapseof thenetwork,art.82ofthelegislativedecree17March2020, n.18(Measurestostrengthenthenationalhealthserviceand economicsupportforfamilies,workersandbusinessesrelated totheepidemiologicalemergencyfromCovid-19)—“Cura Italia”reads“Measuresintendedforoperatorswhoprovide communicationnetworksandserviceselectronics”inwhich operatorsareaskedtostrengtheninfrastructurestoguarantee thefunctioningofthenetworkandthecontinuityofservices, favoringthefunctioningofthehealthandemergencysector (Levels,2020).TheEuropeanCommissionaskedthemainvideo streamingplatformstoreducethequalityandspeedofvideo playback,measuresreadilyadoptedbyNetflix,Youtubeand Amazon,whileaskinguserstoprivilegethefixednetwork overthemobilenetworkforfileplaybackmultimedia.The InternationalTelecommunicationUnion(ITU)hasinstead implementeda“GlobalNetworkResiliencePlatform”withthe aimofprotectingthenetworksofvariousoperatorsduringthe Covid-19crisisandsupportinggovernmentsinensuring“safer” networksandwithbetterperformance(Levels,2020).Theneed toacceleratethedigitizationprocessasmuchaspossibleandto

paytheutmostattentiontoriskmanagementandoperational continuityofthenetwork,whichisthemainallyintheattempt nottorestorethecountry’sproductivityandtoofferasemblance ofnormalitytoeverydaylifeormaybebuildacompletely differentone.

DigitalCulturalDivide

Thedigitalculturaldividehighlightsthedivisionbetweenthe partofthepopulationwithdigitalskillsfromotherswhodoesnot possesstheseskills.Digitalexclusionseemstofollowthealready knownlinesofsocialdiscrimination,whichaffecttheelderly, unemployedorwomeninparticularconditions,immigrants, peoplewithdisabilities,prisonersandallthosewithlowlevels ofeducationandtraining.The2019DESIreporthighlightsthe sharpgapbetweenItalyandtherestoftheEuropeanUnion countriesintermsofhumancapital.Italyranks26thwithan averageof32.6%comparedtotheEUaverageof48%,only44% ofpeoplebetween16and74havebasicdigitalskillswhilethe percentageisevenlowerthanpeoplewhopossessdigitalskills higherthanthebasiconesequalto19%(TheDigitalEconomy SocietyIndex,2019).Evenmoreworryingisthefigureofthe habitualuseofthe Internetbyyoungpeoplebetween16and 24yearsofage,whichseesItalyinlastplaceamongthe28 EUmembercountrieswithapercentageof92%comparedto 97Average%oftheEU(TheDigitalEconomySocietyIndex, 2019).From9Marchtheactivitiesofeducationalinstitutions weresuspendeduntilalaterdate,theexecutiveimmediately recommendedtheimplementationofdistancelearningtomake itmandatory,withthelawdecreeof8April2020,n.22(Urgent measuresontheregularconclusionandtheorderlystartofthe schoolyearandontheconductofstateexams)approvedbythe CouncilofMinisters,Monday6April.

Thecountryhasrespondedwithdifferenttimesandways startingfromirregularstartingresources.Ashighlightedbythe DESI2019report,theNationalPlanfordigitalschool,launched inItalyin2015,doesnotseemtohaveproducedimportant results,only20%ofteachershaveattendeddigitalliteracycourses and24%ofschoolsdonotyethavecoursesofprogramming (TheDigitalEconomySocietyIndex,2019).Onthesameday thatthegovernmentapproved compulsorydistancelearning, ISTATreleasedanoteentitled“Homespacesandavailabilityof computersforchildrenandadolescents”whichhighlightsthe difficultysituationinacountrywhereinequalitiescontinueto behigh,especiallyalongthenorth-southaxis.Basedonthedata collectedintheyears2018–2019,itappearsthat33.8%offamilies donothaveacomputerortabletathome,apercentagethat dropsto14.3%amongfamilieswithatleastoneminorandstill decreasesreaching7.7%infamilieswhereatleastonecomponent hasadegree,clarifyinghowthelevelofeducationweighsonthe digitalculturaldivide(IstitutoNazionalediStatistica,2020a,b,c). Inthesouththepercentageoffamilieswithoutcomputers exceeds41%comparedto30%inotherareasofthecountry, thesamegapoccursforthenumberofcomputersinhomesin relationtothenumberoffamilymembers,inthesouth26,6% ofHouseholdshasanumberofPCsandtabletsavailableforless thanhalfofthecomponentsandonly14.1%haveatleastonefor eachcomponent(IstitutoNazionalediStatistica,2020a,b,c).Fifty

sevenpercentageofyoungpeopleagedbetween6and17must shareacomputerortabletwiththefamily,thisimpliesthateven incaseswhereInternetaccessispresent(96%offamilies)this doesnotguaranteethepossibilitytocarryoutdistancelearning alsoconsideringthatthisisgenerallythestudentsatthesame timeasadultsareengagedinintelligentwork(IstitutoNazionale diStatistica,2020a,b,c). Inaddition,agoodlevelofconnectionis requiredtofollowtheonline lessons,whichpreventsaudiofrom skippingorblockingthevideo,InfodatahasreworkedISTAT data(Aspectsofdailylife2019)showingthatfamilieswithaband connectionwidefixedaretwooutofthreeinLazio(figure > 62.2%)whiletheydonotexceed41%inCalabriaandBasilicata withagreaterpenaltyforresidentsofsmallmunicipalities (Orlando,2020;Saporiti,2020).Asfordigitalskills,according toISTATdata,only30.2%ofyoungpeoplebetween14and17 yearsofagehavehighdigitalskills,3%donothavedigitalskills whileabouttwothirdshaveloworbase(IstitutoNazionaledi Statistica,2020a,b,c).Thequalityofworkandhomestudyare alsostronglyinfluencedbyanother importantfactor,housing conditions.AccordingtoISTATdatafrom2018,27.8%ofpeople inItalyliveinconditionsofhousingovercrowding,adifficult conditionexperiencedinparticularbyminorswithapercentage of41.9%livinginconditionsofovercrowding.Adiscomfortthat isaggravatedinthepresenceofstructuralhousingproblemssuch ascramped,poorlyventilatedandpoorlylitspaces,whatIstat definesasserioushousingdeprivationconcerns5%ofItalians, alsointhiscaseyoungpeople,7.0%ofminorsand7.9%ofyoung peopleagedbetween18and24liveinconditionsofhousing discomfort(IstitutoNazionalediStatistica,2020a,b,c).

SocialDistancingandEmpathy

TheresponsetotheCovid-19pandemicisinfiltratingevery aspectoflife,socialdistancehasgeneratedseriousconsequences thatarealreadybeingfelt.Thestruggleagainstthisinvisible enemycouldlastformonthsorevenyears.Publichealthexperts believethatsocialdistancingisthebestwaytopreventatruly horriblecrisis,beyondacertainthresholdthenationalhealth systemisunabletoacceptandtreatpeoplewhorequirefans andintensivecareunits.Todate,theonlymeasurethatseems tobeworkingisthestrictSocialDistancepolicy.Theelimination ofthesemeasurescouldnowtriggernewoutbreaksthatwould seriouslyjeopardizepublichealth.Itisnotpossibletopredict whenthevirusdisappearsandrestrictivemeasureswillcontinue foraslongasnecessary,seriouslyaffectingsocialrelationships andinteractions,especiallytheempathicprocess.Empathyrefers totheabilitytoputoneselfinanotherperson’ssituationor, moreprecisely,tounderstandtheotherperson’semotional processesandrespondinacongruentway.Thistermmeans aGermanterminItalian,Einfühlung(Treccani,2019b).This termisplacedatthebaseoftheaesthetictheoryelaborated byVischer(1847–1933)andLipps,accordingtowhomartis theidentificationoffeelinginnaturalforms,thankstoadeep consonanceorsympathybetweensubjectandobject(Vischerand Vischer,1887;Lipps,1903). Theindividualattributesbeautyto theformsinwhichhe managestotransferorprojecthisvital sense.Aestheticenjoymentisthereforeobjectifiedenjoymentof ourselves(Treccani,2019a,b,c).Startingfromtheearly90sthe

problemofunderstanding empathy,understoodasthatform ofidentificationinthepsychologicalstates,whichmoreand moreoftenfallintophysiologicalstates,oftheothertowhich theexplanation,orunderstanding,ofhisbehaviorwouldbe subordinatedatthecenterofameaningfulandlivelydebate inthephilosophyofpsychologyandinthephilosophyofthe mind,whichtodayfallswithinthecognitivesciences(Franks, 2010).Without prejudicetothereferencetothehistoricalmodels ofempathicunderstanding byDilthey(1833–1911),suchas VerstehenbyWeber(1864–1920),Schutz(1899–1959),Simmel (1858–1918)andthere-enactmentofCollingwood(1889–1943), thereneweddebatebeganwithsomedevelopmentsinthe analyticalphilosophyoflanguageandmind,inparticularwith athesisbyQuine(1908–2000).

AccordingtoQuine,theattributionoftheso-called propositionalattitudesorintentionalstates,throughwhichthe psychologyofcommonsensenormallyexplainsthebehaviorof individualsaccordingaccordingtotheclassicmodelofpurpose ofthemeans,isessentiallybasedonanempathicsimulation (Treccani,2019a,b,c).Thisempathicsimulationconstitutes, forQuine,anaturalepistemic modalitywithwhichbeliefs, desiresandperceptionsarecurrently,andoftenunconsciously, attributed(Quine,1990,1992).Tryingtoanalyzethisaspect withinthedynamics oflife,itcanbesaidthata“lowering ofempathylevels”isverylikelytooccur.Although,onthe onehand,theremaybeknowncases,reportedeverydayby newspapersandtelevisionnews,inwhichoneormorepeople identifywiththosewhosuffer,asneighbors,friends,relatives orwiththosewholivecomplexexperiences,situationsand disadvantagesfromthepointofview.Inviewofhealthand finance,theypromoteactivitiessuchasso-called“suspended expenses.”Solidarityactivitiessuchashumanitarianaidofany kindoreventhesimplehomedeliveryoffoodandmedicine forpeoplewhodonothavetheopportunitytogooutand meettheirneedsincrease.However,thereisasliceofthe populationthatdoesasempiricalevidenceinwhichithas beenaddressedthatphysicalandpsychologicaldistancecan modulatetheempathicreactionofapersonwhoisobserving someoneelseinpain.Sobeingfurtherawaymakestheempathic reactionlessstrong.Ithinkthispointiscrucial,asthisblock hasforcedpeopletokeeptheirdistance,creatingascenario wherenoonecanbeclosetoothersand/oryouhavetowear amask,whichpreventsyoufromfeelingthesame“levelof empathy.”However,thereisapartofthepopulationthatsuffers, morethantheother,thecurrentsituation(socialdistance, mask,etc.).Inthisregard,anextremelyinterestingresearch by Lomorielloetal.(2018),throughempiricalevidence,that physicalandpsychological distancecanmodulatetheempathic reactionofapersonwhoisobservingsomeoneelseinpain. Sobeingfurtherawaymakestheempathicreactionlessstrong. Thereferenceisclearlyaddressedtothetechnologythatis used,which,eveninthisphase,depersonalizesrelationshipson theonehand,orratherdistortsthemasforcedtousethem, butbringsuscloser,albeitvirtually,totheother.Humanity findsitselfexperiencingakindofhyperconnectedfeelinginan attempttomitigatetheblowittookwhentheforced“fence” wasdeclared.

“Thisevidenceprovidesanimportantinsightintothe frameworkofknowledgeonfactorscapableofshapingempathy, anditiscertainlyimportantalsoinrelationtotheevidence suggestingastronglinkbetweenrepresentations,alsoinneural terms,ofphysicalandpsychologicaldistance.Althoughit isobviousthatineverydaylifesituationsitisnotpossible toestablishinadvancethephysicaldistancebetweenan observerandsomeonesubjectedtophysicalpain(given theunpredictabilityofsuchsituations),theevidenceonthe importanceofphysicaldistanceinmodulatinganempathic reactioncouldbefundamentalforpsychotherapy,clinicaland medicalcontexts,inwhichpsychotherapists,doctorsandhealth professionalscouldusethisknowledgetofavorornot,as appropriate,anempathicreactioninthemselvesandintheir patients”(Lomorielloetal.,2018,p.11).

Inconclusion,therefore, astrongforcingthatcouldhave theeffectofwithdrawingcompletelyfromtheother,oncethe wholevirussituationisover.Intheworstcase,youcouldsee theintensificationofsomesocialphobias,thesameonesthat hadpreviouslybeenalleviatedthankstoasimplemeetinginthe officeoronthestreet.Inthismoment,eventhe“howareyou”at thebeginningofaphonecall,videocallorconferencecallisno longerjustaformality,asitoncewas.Forexample,intelligent workers,discussedindetailinthepreviousparagraphs,now, whentheycalltheircollaborators,mustexpectaftertheusual question,notasimple“good,”butmuchmorecomplexanswers. Generatinginthosewhoreceivetherequestthefalsebeliefthat theotherisactuallyinterestedintheirsituation.Whilethosewho poseitcouldgenerateanxietyandanguishgiventheobligation tolisten,feelingalmostobliged,totheanswersthattheother personisgiving.Thus,itcanbethoughtthatthesituationof theaforementioned“forcedempathy”mayoccur.Thisisbecause thedistanceandtheemergencysituationmakepeoplewanttobe heardandappreciate“howareyou?”thehooktoexpressfears, emotions,fearsandweakpoints(Pasetti,2020).

DISCUSSIONS

Eachnationis facingtheemergencyfromadifferentstarting conditionthatwillinevitablyaffectthetimingandmethods ofrecovery.

Itisnotyetpossibletopredictif,howandwhenItalywill rise,butwhatisnothopedforisareturntonormality.That normalityinwhicheverydayindividualshavetofighttoimprove theirconditions,oflifeandwork,andtoask,atmost,when

theydonothavetodefendthosewhohavebeenconquered bycenturiesofsocialstruggles,forgreaterrights.Thecrises facedsofarandtherecipesadoptedtoovercomethemdo notleadustohopetobeabletobuildabetter,morejust, morefavorable,lessunequalworld,butonceagaintoseewages decrease,precariousnessincrease,gobackwards,povertyand unemploymentreachhistorichighs.Thistimeitwillnotbethe armythatwillstopthecryofdespairthatrisesfromtheworld, butaninvisiblethreatthatstandsbetweenindividualsandkeeps themseparate,everyonewillbemorecommittedtodefending themselvesfromtheotherandtheydonothavethestrength todefendthemselvestogether.Itisallthathumanitydoesnot hopefor.

CONCLUSION

Toconclude,referringabovealltothelatestdevelopments withtheOpenFiberagreementinItaly,thepoliticalquestion underlyingtheproblemsduetoconnectivityisoflongstanding. EventodaywecanseethedualityofItaly,ontheonehand theonecharacterizedbysuper-speedandhyper-connection,on theothertheonethathasnetworkinfrastructuraldeficiencies (totalabsenceofconnection)andthatstrugglestohaveastable connection.Allthistranslatesintoaneconomicdelayforthe entirecountry,mainlyduetothelackofgrowthopportunities thattoday,moreandmore,passthroughthenetwork.Withthe hopethattheOpenFiberproject,approvedbythegovernment, canreallysolveoneofthebiggestproblemsandthatthiscan slightlyreducethegapwiththewholeofEurope.Furthermore, theCovid-19crisisphasehasbroughtoutwithgreaterforcethe workproblemsalreadypresentinpreviousyears.Inparticular, followingthelockdownphase,itemergedthatthecontinuous cutsmadetofundsdestinedforuniversities,researchand healthcare,haveledtoastructuralandorganicdeficiencythat hasgenerateddeepmicro-criseswithinthecrisisitself.Therefore, thehopeisthatCovid-19willserveasalessonandthatmore fundswillbeallocatedtosectorsthatareobjectivelyfundamental forsociety.

AUTHORCONTRIBUTIONS

VAandCIconceptualizedthecontribution.VAwrotethe paper.CIreviewedthemanuscriptandprovidedthecritical revisionprocessesasPI.Allauthorsapprovedthesubmissionof themanuscript.

REFERENCES

AFP(2020). EntroisMois,laPlanèteaPlongédansunScénarioCatastrophe.Paris: AFP.Availableonlineat:https://www.afp.com/fr/infos/334/en-trois-moisla-planete-plonge-dans-un-scenario-catastrophe-doc-1qf7z82(accessedApril 09,2020).

Bignami,L.(2020). BusinessInsider Qualèla‘DistanzaSociale’Giusta?Perl’Oms 1,8m,maUnaRicercadelMitdicecheNonBasta:leGocciolinePossonoArrivare a8m![WhatistheRight’SocialDistance’?FortheWHO1.8m,aResearchBy MITSaysThatItIsNotEnough:DropletsCanReach8m!]. Availableonline

at:https://it.businessinsider.com/qual-e-la-distanza-sociale-giusta-per-loms18-m-ma-una-ricerca-del-mit-dice-che-non-basta-le-goccioline-possonoarrivare-a-8-m/(accessedMarch04,2020).

Bourouiba,L.(2020).Turbulentgascloudsandrespiratorypathogenemissions: potentialimplicationsforreducingtransmissionof COVID-19. JAMA 323, 1837–1838.doi:10.1001/jama.2020.4756

Calenda,C.,andBentivogli,M.(2018). UnPianoIndustrialeperl’Italiadelle Competenze [AnIndustrialPlanforSkillsinItaly].Roma:MISE.Available onlineat:https://www.mise.gov.it/index.php/it/198-notizie-stampa/2037620un-piano-industriale-per-l-italia-delle-competenze(accessedApril09,2020).

Canavese,P.(2020). Intercultura DistanzaSociale[Interculture.SocialDistance]. Availableonlineat:http://www.pavonerisorse.it/intercultura/distanza.htm (accessedMarch04,2020).

Carlini,R.(2020). ComeAffrontareQuestaCrisiGlobalecheèSanitariaed Economica [HowtoFaceThisGlobalHealthandEconomicCrisis].Roma: Internazionale.Availableonlineat:https://www.internazionale.it/opinione/ roberta-carlini/2020/03/11/affrontare-crisi-sanitaria-economica(accessed April15,2020).

CDC.(2020). CDC.CDC:Availableonlineat:https://www.cdc.gov(accessedApril 09,2020).

Demarais,A.(2020). EIU.EIU:Availableonlineat:https://www.eiu.com/n/ covid-19-to-send-almost-all-g20-countries-into-a-recession/(accessedApril 09,2020).

Franks,D.(2010). NeurosociologytheNexusBetweenNeuroscienceandSocial Psychology. London:Springer.

IlSole24Ore.(2020). CoronavirusinItalia,idatielaMappa [CoronavirusinItaly, DataandMap],Roma-Milano:IlSole24Ore.Availableonlineat:https://lab24. ilsole24ore.com/coronavirus/(accessedApril15,2020).

InternationalMonetaryFund(2020). WorldEconomicOutlookReports Washington,DC:IMF.Availableonlineat:https://www.imf.org/en/ Publications/WEO/Issues/2020/04/14/weo-april-2020(accessedApril15, 2020).

IstitutoNazionalediStatistica(2019a). NoiItalia.100StatisticheperCapireilPaese incuiViviamo[WeItaly.100StatisticstoUnderstandtheCountryweLiveIn], Roma:ISTAT.Availableonlineat:https://www.istat.it/it/files//2019/04/NOTASTAMPA-NOI-ITALIA-EDIZ-2019-PC.pdf(accessedApril15,2020).

IstitutoNazionalediStatistica(2019b). Cittadini,ImpreseeICT [Citizens, BusinessesandICT],Roma:ISTAT.Availableonlineat:https://www.istat.it/it/ files//2019/01/Report-ICT-cittadini-e-imprese_2018_PC.pdf(accessedApril 17,2020).

IstitutoNazionalediStatistica(2019c). AnnuarioStatisticoItaliano2019. CondizioniEconomiche,vitaQuotidianaeConsumiDelleFamiglie[Italian StatisticalYearbook2019.EconomicConditions,DailyLifeandHousehold Consumption].Roma:ISTAT.Availableonlineat:https://www.istat.it/it/files// 2019/12/C09.pdf(accessedApril15,2020).

IstitutoNazionalediStatistica(2020a). NotaMensileSull’andamentoDell’economia Italiana[MonthlyNoteontheTrendoftheItalianEconomy], Roma:ISTAT. Availableonlineat:https://www.istat.it/it/files//2020/04/notamensile_marzo_ def.pdf(accessedApril18,2020).

IstitutoNazionalediStatistica(2020b). OccupatieDisoccupati.Febbraio 2020[EmployedandUnemployed.February2020],Roma:ISTAT.Available onlineat:https://www.istat.it/it/files//2020/04/CS_Occupati-e-disoccupati_ FEBBRAIO_2020.pdf(accessedApril18,2020).

IstitutoNazionalediStatistica(2020c). SpaziinCasaeDisponibilitàdiComputer perBambinieRagazzi[SpacesintheHouseandAvailabilityofComputersfor ChildrenandTeenagers],Roma:ISTAT.Availableonlineat:https://www.istat. it/it/files//2020/04/Spazi-casa-disponibilita-computer-ragazzi.pdf(accessed April18,2020).

IstitutopergliStudidiPoliticaInternazionale(2020). Coronavirus: UnaCrisiEconomicaGlobale [Coronavirus:aGlobalEconomic Crisis].Milano:ISPI.Availableonlineat:https://www.ispionline. it/it/pubblicazione/coronavirus-una-crisi-economica-globale-25789? fbclid=IwAR3MPP4OoRHRmxWoxx6yj3Prqosl35imjooaNWyLWdRJ_ OSHUHTK3oB1dVA(accessedApril15,2020).

Lipps,T.(1903). Ästhetik.PsychologiedesSchönenundderKunst. 2017ed.Berlin: VerlagDerWissenschaften.

Livelli,F.M.(2020). SeilCoronavirusIntasalaRete:QualiMisureperEvitareil Collasso [IftheCoronavirusClogstheNetwork:WhatMeasurestoAvoid Collapse].Milano:AgendaDigitale.Availableonlineat:https://www. agendadigitale.eu/infrastrutture/se-il-coronavirus-intasa-la-rete-qualimisure-per-evitare-il-collasso/(accessedApril08,2020).

Lomoriello,A.,Meconi,F.,Rinaldi,I.andSessa,P.(2018).Outofsightout ofmind:perceivedphysicaldistancebetweentheobserverandsomeone inpainshapesobserversneuralempathicreactions. Front.Psychol. 9:1824. doi:10.3389/fpsyg.2018.01824

Mondani,P.(2020). GliEconomisti [TheEconomists].Roma.Availableonline at:https://www.rai.it/programmi/report/inchieste/Gli-economisti-cf3ca7d9e958-46b2-8637-31d615a5e6e5.html(accessedApril18,2020).

Orlando,L.(2020). CosìilVirusCambiaiConsuminelMondo [Thus theVirusChangesConsumptionintheWorld].Roma-Milano:IlSole24 Ore.Availableonlineat:https://www.ilsole24ore.com/art/cosi-virus-cambiaconsumi-mondo-ADZkWnF(April14,2020).

Pasetti,J.(2020). Smart-Working,CostrettiAll’empatiadaConvenevoliForzati [Smart-Working,ForcedintoEmpathybyForcedPleasantries],Sole24 Ore:Availableonlineat:https://alleyoop.ilsole24ore.com/2020/03/20/covid-19empatia/?refresh_ce=1(accessedMarch20,2020).

Pottinger,P.(2013).Methicillin-resistant Staphylococcusaureus infections. Med. Clin.2,601–619.doi:10.1016/j.mcna.2013.02.005

Quine,W.V.(1990).“ThreeIndeterminacies”in Barrett,RobertandGibson, PerspectivesonQuine,1–16.

Quine,W.V.(1992). PursuitofTruth:RevisedEdition.NewYork,NY:Harvard UniversityPress.

Resnick,B.(2020). Vox.ScientistsWarnWeMayNeedtoLiveWithSocial disTancingforaYearorMore:Availableonlineat:https://www.vox.com/ science-and-health/2020/3/17/21181694/coronavirus-covid-19-lockdownsend-how-long-months-years(accessedMarch17,2020).

Ruscono,G.(2020). EffettoCovid-19:BoomdelTrafficodati,maora(inEuropa) sistaStabilizzando[Covid-19Effect:BoominDataTraffic,butnow(in Europe)itisStabilizing],Milano-Roma:IlSole24Ore.Availableonline at:https://www.ilsole24ore.com/art/effetto-covid-19-boom-traffico-dati-maora-in-europa-si-sta-stabilizzando-ADMbE5I?fromSearch(accessedApril19, 2020).

Saporiti,R.(2020). L’ItaliaèProntaperlaDidatticaaDistanza?AlSUDenei PiccoliComunic’èunProblema[IsItalyReadyforDistanceLearning?In theSouthandinSmallTownsThereisaProblem].Roma-Milano:IlSole 24Ore.Availableonlineat:https://www.infodata.ilsole24ore.com/2020/04/ 08/lezioni-line-al-sud-nei-piccoli-comuni-puo-un-problema/(accessed April10,2020).

SkyTg24(2020). PaolaPisano:“LaretenonRischiailCollasso” [PaolaPisano: “TheNetworkDoesnotRiskCollapse”].Milano:SkyTg24.Available onlineat:https://tg24.sky.it/tecnologia/2020/03/20/rete-collasso-paola-pisano. html(accessedApril10,2020).

Szu,P.(2020). GlobalEconomyWillSufferforYearstoCome,SaysOECD.BBC. Availableonlineat:https://www.bbc.com/news/business-52000219(accessed April16,2020).

TheDigitalEconomyandSocietyIndex(2019). IndicediDigitalizzazione Dell’economiaeDellaSocietà,Italia[IndexofDigitalizationoftheEconomyand Society,Italy].Bruxelles:DESI.https://ec.europa.eu/digital-single-market/en/ scoreboard/italy(accessedApril09,2020).

Treccani(2019a). Einfuhlung.Treccani.Availableonlineat:http://www.treccani. it/enciclopedia/einfuhlung/(accessedApril03,2020).

Treccani(2019b). Empatia [Empathy].Treccani.Availableonlineat:http://www. treccani.it/enciclopedia/empatia/(accessedApril05,2020).

Treccani(2019c). Nilalienum.Treccani.Availableonlineat:http://www. nilalienum.com/gramsci/0_Treccani/FilosofiaT/Empatia.html(accessed January23,2020).

Vischer,F.,andVischer,R.(1887). SimboloeForma[SymbolandShape].2003ed. Torino:Aragno.

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020AuriemmaandIannaccone.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

BRIEFRESEARCHREPORT

published:27October2020 doi:10.3389/fpsyg.2020.556139

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: LinaNovickyte, GovernmentStrategicAnalysis Center,Lithuania MikeTsionas, LancasterUniversity,UnitedKingdom

*Correspondence: TingWu wt198554@163.com BoChen bchen@cufe.edu.cn

Specialtysection: Thisarticlewassubmittedto OrganizationalPsychology, asectionofthejournal FrontiersinPsychology

Received: 05June2020 Accepted: 28September2020 Published: 27October2020

Citation: SunJ,WuTandChenB(2020) FearofVirusorofCompetitors? TheDecisionRationalesofFinancial ManagersUnderCOVID-19. Front.Psychol.11:556139. doi:10.3389/fpsyg.2020.556139

FearofVirusorofCompetitors?The DecisionRationalesofFinancial ManagersUnderCOVID-19

JinluSun1 ,TingWu2* andBoChen3*

1 SchoolofHumanitiesandSocialSciences,BeihangUniversity,Beijing,China, 2 ChongqingVocationalInstitute ofEngineering,Chongqing,China, 3 InstituteforFinanceandEconomics,CentralUniversityofFinanceandEconomics, Beijing,China

Thispapersurveyed422financialmanagersbeforethenumberofnovelcoronavirus (COVID-19)infectionsinChinapeakedandusedpathanalysistostudytheriskdecisionmakingmechanismsoffinancialmanagers.Thestudyfoundthatwhetherfinancial managersdevelopedcopingstrategiesdependsontheirassessmentofpotential businessrevenuelosses.Therearetwotransmissionpaths:thedirecteffectrefers totheriskperceptiondirectlycausedbyCOVID-19,whiletheindirecteffectrefersto managers’fearthattheywillnotmaketimelyadjustmentsorwillmakejudgmenterrors, resultinginthelossofcompetitiveadvantage.Itisworthnotingthattheindirecteffect exceedsthedirecteffect,whichindicatesthatfinancialmanagersaremorerational thanordinarypeopleindealingwithCOVID-19,thattheyarerelativelymoreconcerned aboutcompetitorchanges,andthattheymayevenviewCOVID-19asanimportant opportunitytoobtainabettercompetitiveposition.

Keywords:novelcoronavirus(COVID-19),financialmanagers,decision-making,competitors,China

INTRODUCTION

Thenovelcoronavirus(COVID-19)pandemicbrokeoutattheendof2019andhasshownatrend ofdevelopmentworldwide.Thespreadofinfectiousdiseaserumorsthroughsocialnetworkshas beenshowntocausepublicmoodswings(SmithandChristakis,2008; Hilletal.,2010)andcan evenaffectpeople’sbehavior,suchastheircooperativebehavior(NowakandMay,1992; Ohtsuki etal.,2006).Rumorsaboutinfectiousdiseaseswillforman“emotionalcontagion”(Hatfieldetal., 1994)inashortperiodoftimeandaffectfamilyrelationships(LarsonandAlmeida,1999), roommaterelationships(Howesetal.,1985),andteammaterelationships(Barsade,2002),and evenleadtolarge-scaleemotionalcontagionviasocialnetworks(Krameretal.,2014).This negativeemotionalcontagionhasbeenshowntocausesignificanteconomicdamage.Forexample, overreactionofthegovernmentduringtheSoutheastAsianrespiratorysyndromeledtoadecline intheAsiantourismindustry(Haietal.,2004; McKercherandChon,2004),andfearandpanic sentimentscausedshort-termdamagetotheHongKongeconomy(SiuandWong,2004).During theSoutheastAsiancrisis,somestudiesarguedthattheprimaryreasonforthecrisiswasasudden shiftinmarketexpectationsandconfidence(Feldstein,1998; RadeletandSachs,1998; Stiglitz,1999; ParkandSong,2001).

Emotionalcontagionalsohasadirectimpactonprofessionals’workemotions. Bartel andSaavedra(2000) studiedthemoodsof70workinggroupsandfoundthattheycould bedividedintoeighttypesofemotionsandthatthedifferentiationofworkemotionsis

relatedtotaskandsocialinterdependence,membershipstability, andmoodregulationnorms,aswellasothers.Experiencing positiveemotionalcontagionledtoimprovedcooperation, decreasedconflict,andincreasedperceptionoftaskperformance (Barsade,2002).Emotionalcontagionalsoaffectsaperson’s socialjudgment(Doherty,1998),affectsleadershipandjob output(Johnson,2008),affectsgenderdifferences(Doherty etal.,1995),andinfluencesproductattitudes(Howardand Gengler,2001). Nofsinger(2005) arguedthatthegeneral levelofoptimismorpessimisminsocietyisreflectedinthe emotionsoffinancialdecision-makers.Socialmooddetermines thetypesofdecisionsmadebyconsumers,investors,and corporatemanagersalike.Extremesinsocialmoodsare characterizedbyoptimistic(pessimistic)aggregateinvestment andbusinessactivity.

Mostresearchontheimpactofinfectiousdiseasesonthe emotionsisaimed,forthemostpart,atthepublicleveland littleattentionispaidtothemanagementcommunity,especially financialmanagers.Emotionalcontagionoffinancialmanagers mightbetransmittedtofinancialmarketsandcausevolatility. COVID-19isaphysicalhealththreattofinancialmanagerssoit willalsoimpacttheirinvestmentdecisions,whichmightfurther affectthevolatilityoffinancialmarkets.Financialmanagersare usuallybetterathandlingeventsinvolvingriskthanordinary

people.Theyalsocommunicatethroughtheindustrycommunity tomakethemostreasonablejudgmentsregardingrisks.There aretwopathsinthisdecision-makingprocess:ontheonehand, financialmanagersareworriedabouttheimpactofCOVID-19 ontheirownorganization’sbusiness;ontheotherhand,they arealsoworriedabouttheirownrelativecompetitivenessdueto decision-makingerrors.Byanalyzingtheoccurrencemechanism ofthesetwopaths,itishelpfultounderstandhowtherisk ofCOVID-19influencesfluctuationsinthefinancialmarket throughthedecision-makingmechanismoffinancialmanagers. Thispaperinvestigates422financialmanagersinChinaanduses pathanalysistoexploretheinternallogicoftheaforementioned decision-makingmechanism.

METHOD

ThesurveywasconductedbetweenFebruary23,2020,and February25,2020,whenthenumberofCOVID-19infections inChinahadnotyetpeakedandthediseasehadonlyjust beguntospreadglobally,whichledtoincreasingrisksinthe financialmarkets.Conductingasurveyatthisstageenabledus toobtainamorerealisticperspectiveonfinancialmanagers’ perceptionofrisks.

FIGURE2| Pathanalysisresults.Note: → indicatesthepathinfluencerelationship, ∗p < 0.05,and ∗∗p < 0.01.

Thesurveywasconductedusingaquestionnaire,which featuredeightquestions(see Figure1).Wefirstinterviewed 10managersbyphonetolearnabouttheirjudgmentson theCOVID-19trend,theimpactsonthecompany’sbusiness, andthemeasurestheytook.Basedontheseinterviews,we compiledaninitialquestionnaireandcollected30samples.After analyzingthesamples,weadjustedthequestionsandfinally producedaquestionnairewitheightquestions.Inthefaceof theCOVID-19outbreak,notallfinancialmanagersdeveloped acomprehensiveepidemicresponsestrategy,soQuestion8 wasusedtoinvestigatewhethertheyspecificallydevelopeda COVID-19responseplan(yesorno).Theothersevenquestions wereaskedtoinvestigatetheirriskperception(usingafivepointscale).Basedonthecollecteddata,thispaperused thepathanalysismodeltoanalyzethefinancialmanagers’ decision-makinglogicregardingpandemicriskperceptionand informulatingtheirresponsestrategy. Thepathregressionmodelisdefinedas(Figure2):

than5yearsofexperienceintheindustryandoftenparticipated ineventsorganizedbyindustryassociations.Amongthem, 64.93%ofmanagers(n =274)hadpreviouslyformulatedan outbreakresponseplan.BoththeKolmogorov–Smirnovtestand theShapiro–Wilktestweresignificantata1%level(p < 0.01), indicatingthatthedataconformedtothecharacteristicsofa normaldistribution.Inordertofurtheranalyzethefinancial manager’sdecision-makingmodewhenfacedwithepidemicrelatedrisk,thispaperusedpathanalysismethodologytostudy theinterrelationshipbetweenvariousfactors. Figure2 illustrates thepathanalysischartand Table1 demonstratesthepath coefficientsandfittingindicators.TheMIvaluesarefarbelow20 andthefittingindicatorsarealsogood χ2/df = 2 701, GFI = 0 987, RMSEA = 0 063, RMR = 0.023, CFI = 0.978, NFI = 0.967, NNFI = 0.946 ,

RESULTS

Thequestionnairewasdistributedrandomlythroughout associationsinthefinancialindustry,andatotalof422valid responseswerecollected.Themanagerssurveyedhadmore

whichindicatesthatthepathanalysismodelfeaturesgood explanatorypower.

DISCUSSION

Accordingto Figure2,therearetwosignificantpathsthat affectthemanager’sdecision-makingprocess:thedirectpath andtheindirectpath.FacedwiththeuncertaintyofCOVID19,whetheramanagerdevelopsacopingstrategydepends ontheirindividualassessmentofbusinessrevenueloss potential;theirjudgmentismoderatedbythesedirectand indirecteffects.Thedirecteffectreferstotheriskperception directlycausedbyCOVID-19,whichisusuallyderivedfrom themanager’sdirectobservationsandriskexpectationsof infectiousdisease,byassessingthescopeanddurationof theepidemic’sspread.Theindirecteffectreferstomanagers worryingthattheydidnotmaketimelyadjustmentsor misjudgedthesituation,whichmightresultinthelossof advantageamidfiercecompetition.Anxietyregardingthe aforementionedtworisksisthemainreasonthatfinancial managersmakedecisions.Thedirecteffectmightcausemanagers tounderrecognizeoroverreacttorisks,whiletheindirect effectplaysanintensificationrole,furthercontributingto managers’panic.

Interestingly,thecoefficientofthedirecteffectwas0.0652 (Risk_anticipation → Affected_business → Rate_Revenue), whichwaslessthanthecoefficient(0.0712)oftheindirect effect(Risk_anticipation → Competitiveness → Rate_Revenue), indicatingthattheindirecteffectexceededthedirecteffect. Thismightimplythatfinancialmanagersaremorerational thanordinarypeoplewhendealingwithCOVID-19,that theyaremoreconcernedaboutcompetitordynamics,or thattheymightevenviewCOVID-19asanimportant opportunitytoadjusttheircompetitiveposition.Thispaper’s researchresultsdemonstratethatdifferentcommunities featuresignificantdifferencesintheirperceptionofrisk andbehavioralpatternsintermsofCOVID-19.Evidence fromfinancialmanagerscanenableabetterunderstanding

REFERENCES

Barsade,S.G.(2002).Therippleeffect:emotionalcontagionanditsinfluenceon groupbehavior. Adm.Sci.Q. 47,644–675.doi:10.2307/3094912

Bartel,C.A.,andSaavedra,R.(2000).Thecollectiveconstructionofworkgroup moods. Adm.Sci.Q. 45,197–231.doi:10.2307/2667070

Doherty,R.W.(1998).Emotionalcontagionandsocialjudgment. Motiv.Emot. 22, 187–209.doi:10.1023/A:1022368805803

Doherty,R.W.,Orimoto,L.,Singelis,T.M.,Hatfield,E.,andHebb,J.(1995). Emotionalcontagion:genderandoccupationaldifferences. Psychol.WomenQ. 19,355–371.doi:10.1111/j.1471-6402.1995.tb00080.x

Feldstein,M.(1998).RefocusingtheIMF. ForeignAff. 77,20–33.doi:10.2307/ 20048786

Hai,W.,Zhao,Z.,Wang,J.,andHou,Z.G.(2004).Theshort-termimpactof SARSontheChineseeconomy. AsianEcon.Pap. 3,57–61.doi:10.1162/ 1535351041747905

Hatfield,E.,Cacioppo,J.T.,andRapson,R.L.(1994). EmotionalContagion: CambridgeStudiesinEmotionandSocialInteraction.Cambridge:Cambridge UniversityPress.doi:10.1017/CBO9781139174138

ofthepotentialimpactofinfectiousdiseaseriskon financialmarkets.

DATAAVAILABILITYSTATEMENT

Thedatasetsforthisarticlearenotpubliclyavailablebecause thedataisonlyauthorizedforthisstudy.Requeststoaccessthe datasetsshouldbedirectedtothecorrespondingauthor,BC.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswerereviewedand approvedbyCentralUniversityofFinanceandEconomics. Writteninformedconsenttoparticipateinthisstudywas providedbytheparticipants.

AUTHORCONTRIBUTIONS

JSwasresponsiblefortheoverallresearchideas,modeldesign, andthesiswriting.TWwasresponsiblefordocumentreview writinganddatacollectionandprocessing.BCwasresponsible formodeloptimizationanddiscussionofresearchconclusions. Allauthorscontributedtothearticleandapprovedthe submittedversion.

FUNDING

ThisresearchwasfundedbytheBeijingSocialScience Foundation(No.19JDLJB001).

ACKNOWLEDGMENTS

WethankMs.FengYiforprovidingalotofsupportforthe writingofthismanuscript.

Hill,A.L.,Rand,D.G.,Nowak,M.A.,andChristakis,N.A.(2010).Emotionsas infectiousdiseasesinalargesocialnetwork:theSISamodel. Proc.R.Soc.BBiol. Sci. 277,3827–3835.doi:10.1098/rspb.2010.1217

Howard,D.J.,andGengler,C.(2001).Emotionalcontagioneffectsonproduct attitudes. J.Consum.Res. 28,189–201.doi:10.1086/322897

Howes,M.J.,Hokanson,J.E.,andLoewenstein,D.A.(1985).Inductionof depressiveaffectafterprolongedexposuretoamildlydepressedindividual. J.Pers.Soc.Psychol. 49:1110.doi:10.1037/0022-3514.49.4.1110

Johnson,S.K.(2008).Isecondthatemotion:effectsofemotionalcontagionand affectatworkonleaderandfolloweroutcomes. Leadersh.Q. 19,1–19.doi: 10.1016/j.leaqua.2007.12.001

Kramer,A.D.,Guillory,J.E.,andHancock,J.T.(2014).Experimentalevidenceof massive-scaleemotionalcontagionthroughsocialnetworks. Proc.Natl.Acad. Sci.U.S.A. 111,8788–8790.doi:10.1073/pnas.1320040111

Larson,R.W.,andAlmeida,D.M.(1999).Emotionaltransmissioninthedaily livesoffamilies:anewparadigmforstudyingfamilyprocess. J.MarriageFam. 61,5–20.doi:10.2307/353879

McKercher,B.,andChon,K.(2004).Theover-reactiontoSARSandthecollapseof Asiantourism. Ann.Tour.Res. 31:716.doi:10.1016/j.annals.2003.11.002

Nofsinger,J.R.(2005).Socialmoodandfinancialeconomics. J.Behav.Finance 6, 144–160.doi:10.1207/s15427579jpfm0603_4

Nowak,M.A.,andMay,R.M.(1992).Evolutionarygamesandspatialchaos. Nature 359,826–829.doi:10.1038/359826a0

Ohtsuki,H.,Hauert,C.,Lieberman,E.,andNowak,M.A.(2006).Asimplerule fortheevolutionofcooperationongraphsandsocialnetworks. Nature 441, 502–505.doi:10.1038/nature04605

Park,Y.C.,andSong,C.Y.(2001).“FinancialcontagionintheEastAsiancrisis: withspecialreferencetotherepublicofKorea,”in InternationalFinancial Contagion,edsS.ClaessensandK.J.Forbes(Boston,MA:Springer).doi:10. 1007/978-1-4757-3314-3_10

Radelet,S.,andSachs,J.(1998).TheonsetoftheEastAsianfinancialcrisis. Natl. Bur.Econ.Res. 28,1–74.doi:10.3386/w6680

Siu,A.,andWong,Y.R.(2004).EconomicimpactofSARS:thecaseofHongKong. AsianEcon.Pap. 3,62–83.doi:10.1162/1535351041747996

Smith,K.P.,andChristakis,N.A.(2008).Socialnetworksandhealth. Annu.Rev. Soc. 34,405–429.doi:10.1146/annurev.soc.34.040507.134601

Stiglitz,J.E.(1999).TheWorldBankatthemillennium. Econ.J. 109,F577–F597. doi:10.1111/1468-0297.00473

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Sun,WuandChen.Thisisanopen-accessarticledistributed underthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse, distributionorreproductioninotherforumsispermitted,providedtheoriginal author(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublication inthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

published:09November2020 doi:10.3389/fpsyg.2020.574712

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: MartinThomasFalk, UniversityofSouth-EasternNorway, Norway

MohammadAmiryousefi, UniversityofIsfahan,Iran

*Correspondence: SantoshKumar ksantosh@uthsc.edu

Specialtysection: Thisarticlewassubmittedto OrganizationalPsychology, asectionofthejournal FrontiersinPsychology

Received: 06July2020

Accepted: 16October2020 Published: 09November2020

Citation: KumarS,KodidelaS,KumarA, GerthKandZhiK(2020)Intervention andImprovedWell-BeingofBasic ScienceResearchersDuringthe COVID19Era:ACaseStudy. Front.Psychol.11:574712. doi:10.3389/fpsyg.2020.574712

InterventionandImproved Well-BeingofBasicScience ResearchersDuringtheCOVID19 Era:ACaseStudy

SantoshKumar1* ,SunithaKodidela1 ,AsitKumar1 ,KelliGerth1 andKainingZhi2

1 DepartmentofPharmaceuticalSciences,CollegeofPharmacy,UniversityofTennesseeHealthScienceCenter,Memphis, TN,UnitedStates, 2 ThePloughCenterofDrugDeliverySolutions,UniversityofTennesseeHealthScienceCenter,Memphis, TN,UnitedStates

Thecoronavirusdisease-19(COVID-19)pandemichasaffectedindividualsofall categories,irrespectiveoftheirgeographicallocations,professions,gender,orrace. Asaresultoffullorpartiallock-downandstay-at-homeorders,thewell-being andproductivityofindividualswereseverelyaffected.Sincebasicscienceresearch requireslaboratoryexperiments,thework-from-homestrategyhurttheirproductivity. Inaddition,thecombinationofdecreasedproductivityandstayingathomeislikelyto compromisetheirwell-beingbycausingstressandanxiety.Inthiscasestudy,astrategy wasdevelopedtoengageresearchersthroughlisteningandlearning,motivation,and empowerment,usingregularvirtualsessions.Throughthesevirtualsessions,research workwasprioritizedandcoordinated,fromideaconceptiontowritingresearchpapers andgrantproposals.Perceivedstressscores(PSS)andCOVID-19-relatedstress (COVID-SS)scoresweremeasuredtoevaluategeneralandCOVID-19-inducedstress, respectively,everymonthfromMarchtoJuly2020duringtheCOVID-19era.The resultshowedasignificantimprovementinboththePSSandtheCOVID-SSscores oftheinterventiongroupcomparedtothecontrolgroup.Inaddition,whiletherewas no/minimalchangeinPSSandCOVID-SSscoresfromMarchtosubsequentmonths untilJulyforthecontrolgroup,theinterventiongroupsshowedsignificantandconsistent improvementinbothscoresintheinterventiongroup.Overall,theinterventionstrategy showedimprovedwell-beingforbasicscienceresearchers,whichwasalsoconsistent withtheirimprovedproductivityduringtheCOVID-19era.

Keywords:COVID-19,productivity,perceivedstressscore,laboratoryresearch,well-being

INTRODUCTION

Thecoronavirusdisease-19(COVID-19)pandemicisanongoingworldcrisis.Thispandemichas takenatollonhumanhealthandhasalsoplacedahugeburdenoneconomies,societies,and familiesacrosstheglobe(Carteretal.,2020; Cutler,2020; DonthuandGustafsson,2020; Huaetal., 2020; Jenson,2020; Mclarenetal.,2020; Ornelletal.,2020; Power,2020; Satianietal.,2020).This COVID-19crisisisfurtherdeepenedbecausethefutureofcountries,societies,andindividualsis

uncertainandunpredictableinthemonthsandperhapsyearsto come.ArecentspecialissueonCOVID-19by“TaloyandFrancis” describestheimpactofthispandemicon,“Emergingmarkets financeandtrade,”whichultimatelycausesstressinworld economiesandsocieties(TaylorandFrancis,2020).Inaddition totheimpactonworldeconomies,worldtradehasexperienced amassivecontractionasaresultofadrasticreductionintrade connectivityandcommercialactivitiesamongcountriesduring COVID-19outbreak(VidyaandPrabheesh,2020).Thetrade forecastamongthemajortradingcountriesfurtherShowsa declineuntilDecember2020.However,itisworthmentioning thatamidtheCOVID-19pandemic,thereisasignificant improvementinairquality,thoughtemporarily,andapositive macroeconomicresponsehasbeenseeninsomecountriessuch asChinaandIndiaduringtheCOVID-19outbreak(Mingetal., 2020).Theimpactonglobaleconomiesandlossofmillionsof jobshavebeenoneofthemajorcausesofstressandanxiety amongglobalpopulations.

TheimpactoftheCOVID-19pandemiconhumanhealth, whichcaused ∼38millioninfectionsand >1milliondeaths world-wideasofOctober15,2020,farexceedstheimpactof previousepidemicsorpandemicsinrecenthistory(CoronavirusResources-Center,2020).Althoughover90%ofpeoplerecovered fromtheinfection/disease,manyindividualssufferedfrom multipleorgandamage(lungs,kidney,liver,heart,etc.)(Renu etal.,2020; Spuntarellietal.,2020).Further,alargenumber ofrecoveredpopulationsfromCOVID-19alsosufferedfrom mentalandpsychologicaldiseases/conditionssuchasstress, anxiety,anddepression(Salarietal.,2020; Xiongetal.,2020). Studieshaveshownthat ∼50%ofindividualswhorecovered fromCOVID-19arediagnosedwithdepression,and ∼40% arediagnosedwithanxietyandstress(Rogersetal.,2020). IndividualsassociatedwithCOVID-19patients,andothers, especiallythosewhohavelosttheirjobsandareexperiencing financialcrises,alsoshowsymptomsofdepression,anxiety,and stress(Dubeyetal.,2020; Titovetal.,2020).

Thisisthefirsttimeinmodernhistorythatalmostall countries,eitherfullyorpartially,enterintoalock-downphase andenforcestay-at-homeorders(Asensioetal.,2020).Oneof themajorhealthconcerns,asaresultoflock-downandstayat-homeorders,isthementalhealthofindividualswhostayat orworkfromhome(Killgoreetal.,2020).Stressandanxiety areusualreactionstoanyunpredictablepandemicsituation. AsaresultofstressduetotheCOVID-19pandemic,the generalpopulation,particularlyhealthcareprofessionalsand collegestudents,experiencedchangesinconcentration,anxiety, irritability,andeventuallyreducedproductivity(Tangenetal., 1981; Kecojevicetal.,2020; Ozamiz-Etxebarriaetal.,2020; Stantonetal.,2020; Wuetal.,2020).Thesestudiessuggestaneed todevelopmitigationandpsychologicalinterventionstrategies thatcanimprovethementalhealthofthegeneralpopulation duringtheCOVID-19era,especiallyinvulnerablegroupssuch ashealthprofessionalsandcollegestudents.Tothebestofour knowledge,thereisnostudyconductedamongbasicscience researcherstoexaminetheimpactoftheCOVID-19epidemic onpsychologicalhealthandstressortherelationshipofthese factorstoproductivity.Therefore,weconductedacasestudyon

interventionandwell-beingofbasicscienceresearchersatthe UniversityofTennesseeHealthScienceCenter(UTHSC).

ResearchlaboratoriesatUTHSCwereclosedforallnonemergencyworkinMarch,andtheresearcherswereaskedto workfromhome(UTHSC,2020).Althoughmanuscriptsand grantwritingcouldbedonefromhome,itisverydifficultto stayproductiveifexperimentsinthebasicsciencelaboratoryare completelystalled.Basicscienceexperimentstake1–2weeksto wrapupandequallythesametimetorestart.Thus,untilthe researchlaboratoriespartiallyopenedinthefirstweekofJune, employeeshadlost3monthsofcompletefollowedby2months (June–July)ofpartialbasicscienceresearch.Inadditionto reducedproductivity,thework-from-homeplanforresearchers whonormallyworkinalaboratorysettingcanincreasestress andanxiety.CompoundedbyCOVID-19-relatedstress,thishas thepotentialtofurtherreduceproductivity.Moreover,dueto uncertaintysurroundinglabreopeningdates,researcherswere alsouncertainabouttheircareerprogression.Allthesefactors maycontributetoalackofconcentration,irritability,insomnia, andreducedproductivityamongscholars.

Theobjectiveofthepresentstudyistodesignan interventionalstrategytomitigatestressandmaintainwell-being andproductivityforbasicscienceresearchersduringtheworkfrom-homeorderintheCOVID-19era.Themitigationstrategy istoplanandimplementnecessaryexperimentsduringtheprelock-downperiod,followedbyengaginginideadevelopment, dataanalysis,andmanuscriptwriting,aswellasengagingin listeningandempoweringsessionsviavirtuallabmeetings duringandafterthelock-downperiods.Thehypothesisis thattheinterventionalstrategywillsignificantlyreducestress andimprovethewell-beingofbasicscienceresearcherswhile maintainingtheirproductivity.Toassessthewell-beingof subjects,PerceivedStressScore(PSS)andCOVID-19-related stressscores(COVID-SS)weremeasured.Generally,thestress levelsofhealthcareprofessionalsandcollegestudentsare measuredusingthePSSmethod(Duetal.,2020; Georgiouetal., 2020; Guoetal.,2020; Meiraetal.,2020; Zarghamietal.,2020), whichisthemostwidelyusedmethodtomonitorperceivedstress (NewHampshireDepartmentofAdministrativeServices,2020). However,tomeasurethestress,anxiety,andoverallwell-being ofindividualsspecificallyinducedbyCOVID-19-relatedchanges inlifestyleandalteredproductivity,thePSSmethodmaynot besufficient.Therefore,weusedtheCOVID-19stressrelated score(COVID-SS)toassessthefear,learning,andgrowthin knowledgeofindividualsduringthepandemic(EpilepsySociety, 2020).Thecurrentstudyresultssuggestanimprovedwell-being oftheinterventiongroupcomparedtothecontrolgroup,whichis alsoconsistentwiththereducedstressandimprovedproductivity oftheinterventiongroup.

METHODS

PreparationBeforetheCrisisfor InterventionGroup

WhentheWHOdeclaredCOVID-19aPublicHealthEmergency ofInternationalConcernon30January2020(Pateletal.,2020),

astrategicplanforresearchersinourgroupwasput-together. Thestrategicplanincluded:(1)postponingmanuscriptwriting andotherpaperworkandperformingwet-labexperimentsto obtaindatauntilthelabwasclosedinthesecondweekofMarch, (2)dataanalysisandmanuscriptwritingduringthework-fromhomeordersfrommid-MarchtoMay31anduntilJuly31 duringpartiallab-closure,(3)conceivingnewideasandwriting manuscriptsforreviewpapers,aswellaswritinggrantproposals forthesameperiods.Tomaketheresearchersaccountablefor theirproductivity,a2hvirtuallabmeetingeveryMondayand one-on-onevirtualmeetingsasneededwereimplemented.The demographicsoftheinterventiongroupwas4menand5women thatincluded3students,2post-doctoratefellows,3research staffs,and1faculty.Thestudypopulationwasgenerallyhealthy andtheiragerangedapproximatelyfrom22to50years.Sincethe interventionrequiresacertainsupervisoryrelationshipamong allparticipants,itisnotfeasibletoincreasegroupsize.Inviting researchersfromotherresearchgroupsmayresultinaconflictof interestamongprincipleinvestigatorssincemostresearchgroups areindependent.Hence,wecouldincludeonlyninepeopleinthe interventiongroup.

ImplementationDuringtheCrisis

Amodifiedanonymousstrategywasusedasanintervention. AlmosthalfofeachlabmeetinguntilMay31wasspentin listeningtoeveryone’sconcerns,celebratinganygoodnews,and COVID-19-relatedfactsfromreliablesources.Thefrequencyof thesediscussionswasreducedwhenthelaboratorywaspartially openedfromJune1toJuly31.Ingeneral,thestrategywas tolearnfromeachotherandempowereachother.Duringthe laboratorymeetings,someengaginggameswerealsoplayedto overcomestress.Theempoweringsessionsweredevelopedbased onvastknowledge,emotionalintelligence,andtheexperience ofourdiversegroup,aswellasavailableliteratures(World HealthOrganization,2004; Shultzetal.,2016; Hendriksetal., 2017; Seyedinetal.,2019; Jiménezetal.,2020; Schlesselman etal.,2020).Wecompiledthefollowingdiscussiontopicsto empowereachother.

(1)COVID-DIFFERENTIATOR(COVID-DIFF):Similarto anycrisis,COVIDwoulddifferentiatepeopleintothree categories:(1)Individualswhowerenegativelyimpacted (withnomistakeoftheirs),(2)individualswhostayedthe courseandwereabletohandlewell,and(3)individuals whofoundnewopportunitiesandimprovedperformance. Ingeneral,mostpeople,includingourstudyparticipants, belongtocategories1and2.Ourgoalwastoempower themwiththebelowmentionedstrategies,whichcould helpthemtomovetocategory3.

(2)Faith/dreamsvs.Panic/fear:Theinterventiongroup discussedtheprosandconsofhavingfaith/dreams vs.feelingpanic/fear,withnumerousexamples.These empoweredeachothertohavefaithanddreams.

(3)Facts/realityvs.Opinion/hype:Theinterventiongroupwas advisedtofollowfactsandrealityandeducateotherswith theseratherthanuncorroboratedopinionsandhype.

(4)Safetyvs.Carelessness:Theinterventiongroupwas educatedtoexercisesafetyandcautionbyfollowing theCOVID-19policiesandguidelinesofnationaland localorganizations.

(5)Managingthecrisisvs.Gettingunderthecrisis:The interventiongroupdiscussedvariousaspectsofthecrisis andhowonecanmanagethecrisis,ratherthangetting underthecrisis,inawaythatnegativelyimpactsus.

(6)Thrivingvs.Surviving:Finally,theinterventiongroup discussedhowtothriveduringthecrisisandnotjust survive.AsStanfordeconomistPaulRomeroncestated, “acrisisisaterriblethingtowaste”(Chisholm-Burns, 2010).Theinterventiongroupasawholedecided,“we willnotletthecrisisgotowaste.”Thegroupdiscussed variouswaystoimproveproductivityandmanagestress duringthecrisis.Forexample,waystoimprovegritand mentaltoughnessbyacquiringpositiveattitudesandselfdisciplinewerediscussed.Besides,performingphysical andmentalactivities,suchaswalking/running/exercising, yoga,andmeditationwerepromotedingroupdiscussion.

Inadditiontotheaboveempoweringsessions,the interventiongroupalsodiscussedthefollowingadvantages ofworkingfromhome.

(1)Freedom:freedomtoworkwithachosentime, place,anduniform.

(2)Familytogether:opportunitytospendqualityandquantity timewithfamilies.

(3)Timetothinkcreatively:comparedtolabandoffice environments,work-from-homemaygiveachangein environment,moretime,andquietudetothinkcreatively.

(4)YogaandMeditation:ahomeenvironmentmayempower peopletodoyogaandmeditationtomaintainphysical andmentalhealth.

(5)Opportunitytotakecareofthebacklog,startnewwriting projects,andcontributetosociety:workingfromhome maygivemoretimefordataanalysis,writingmanuscripts, andinitiatingnewprojectsforreviewpapersand/orgrant proposals.Itcanalsomotivateandempowersociety,which isgoingthroughadifficulttime,throughmessagesvia reliablesources.

Finally,asagroupandasindividuals,theinterventiongroup didreflectionexercisesonthefollowingthings.(1)HowhaveI contributedpositivityornegativitytoothers?(2)Doessomeone feelbetterafteraninteractionwithmevs.howtheyfeltbefore? (3)Didsharedinterestriseaboveself-interest?(4)DidIlisten more–ortalkmore?(5)HowmanytimestodaydidIcomplain aboutsomeoneorsomething?(6)HowmanytimesdidIsimply saythankyou?(7)WhatdidIlearnthisweek,especiallythat challengedmythoughtprocesses?(8)WhatdidIdothisweek, especiallythatisuniqueandout-of-norms?

ControlGroup

AcontrolgroupofUTHSCbasicscienceresearchers,which didnotgothroughtheinterventionasdescribedabove,is includedinthisstudy.Thecontrolgroupconsistsof6students,

3post-doctoratefellows,and1researchscientist(5menand5 women).Theparticipantsweregenerallyhealthyandtheirage rangedapproximatelyfrom25to40years.Thecontrolgroupof basicscienceresearchersalsowentthroughsimilarchallengesat UTHSCduetocompletelab-closurefrommid-MarchtoMay31 andpartiallab-closurefromJune1toJuly31.

OUTCOMEMEASURES

Twooutcomesweremeasuredduringthe5-monthperiod. ThePSSandCOVID-SSoutcomesweremeasuredbyusing theirrespectivesurveysuponanInstitutionalReviewBoard (IRB)approvalfromtheUniversityofTennesseeHealth ScienceCenter.

PerceivedStressScore(PSS)

ThePSSofnineparticipantsfromtheinterventiongroupand tenparticipantsfromthecontrolgroupforthemonthsof March–Julyweremeasured,upontheirconsenttodoavolunteer survey.PSSisthemost-widelyusedmethodtomeasurestress levelsinoccupationalhealth,especiallyamongprofessional studentsinhealthscience.Thismethodwasessentiallyused asdescribed(NewHampshireDepartmentofAdministrative Services,2020).Inbrief,PSSwasmeasuredbyself-scoringthe followingquestions.Scoringwasperformed(between0and4; 0beingneverand4beingveryoften),followedbyreversing thescoresofquestions4,5,7,and8,andthenaddingall thescores.Scoreswith0–13,14–26,and27–40aredefinedas low,moderate,andhighstress,respectively.ThegroupPSS scoreswerethenanalyzedlongitudinallyforthemonthsof April–July,usingMarchascontrolmonth,astheintervention beganinApril.COVID-SSscoresfortheinterventiongroup werealsocomparedandanalyzedfromthecontrolgroupfor eachmonth.

COVID-19-RelatedStressScores (COVID-SS)

TheCOVID-SSofnineinterventionparticipantsandtencontrol participantsforthemonthsofMarch–Julywerealsomeasured upontheirconsenttodoavolunteersurvey.COVID-SSisa newmethodthatusedtoassessthestresslevelofparticipants duringtheCOVID-19erausingtheirbehaviorsandactionsin threezones(fear,knowledge,andgrowth).Thismethodwas essentiallyusedasdescribedpreviously(Manch,2020).Inbrief, thequestions/statements,aspresentedin Table1,wereused toself-assessthethreezones:fear,knowledge,andagrowth mindset.Everycorrectstatementforeachzonecarriesone point.Thetotalpointsforeachzonerepresentthemindsets andattitudesofparticipantsintermsofCOVID-19-relatedfear, knowledge,andgrowth.Theinformationobtainedfromthese zonescanthenbecorrelatedwithCOVID-19-inducedstressand overallwell-beingofparticipants.ThegroupCOVID-SSscores werethenanalyzedlongitudinallyforthemonthsofApril-July, usingMarchasthecontrolmonth,astheinterventionbeganin April.TheCOVID-SSscoresfortheinterventiongroupwerealso comparedandanalyzedfromthecontrolgroupforeachmonth.

TABLE1| StatementsusedtoscoreCOVID-SSforeachzone.Eachcorrect statementcarries1point.

Fearzone(total5 points) Knowledgezone(total 7points) Growthzone(total8 points)

Igrabfood,medications, andtoiletpaperthatI don’tneed

Ispreademotionsrelated tofearandanger

IstarttogiveupwhatI can’tcontrol Ithinkofothersandknow howtohelpthem

Istopconsumingwhat hurtsme,fromfoodto news

Imakemytalents availabletothosewho needthem

IcomplainfrequentlyIidentifymyemotionsIliveinthepresentand focusonthefuture

IforwardallmessagesI receiveaboutCOVID-19 Iamawareaboutthe situationsandknowhow toact

Iamempathetictomyself andtoothers

IgetmadeasilyIevaluateinformation beforespreadingfalse Ithankandappreciate others

Irecognizethatweallare tryingtodoourbest Ikeepahappyemotional stateandgivehope Ilookforawaytoadapt tochanges Ipracticequietude, patience,relationships, andcreativity

ResearchProductivity

Ourmitigationandempoweringstrategieswerelikelyto improvetheresearchproductivity.Itwasmeasuredonlyin ourinterventionstudygroupintermsofconceivingideas, dataanalysis,manuscriptwritingandsubmission,manuscript acceptance,andpublication,aswellasgrantsubmission.

StatisticalAnalysis

Mean ± SEMwascalculatedandcomparedtothecontrolgroup. Student’s T-testwasappliedtocomparethescoresbetweenthe interventionandcontrolgroups,aswellasbetweenthecontrol month(April)andindividualinterventionmonths(April–July) forbothcontrolandinterventiongroups.Allthestatistical calculationswereperformedusingGraphPadPrism7. p < 0.05 wasconsideredstatisticallysignificant.

RESULTS

PerceivedStressScore(PSS)

Aninterventiongroupofnineparticipantsandacontrol groupoftenparticipantsvolunteeredtotaketheperceived stresstest,asdescribedintheoutcomesmeasuresection.The Mean ± SD ofthePSSwereevaluated,andtherelativescores oftheinterventiongroupvs.controlgroupwereanalyzed. Comparisonandanalysiswerealsoperformedinalongitudinal manner,inwhichMarchwasacontrolmonthwhenthe interventionbegan(Figure1).Overall,resultsshowedarelatively highPSS(17.4 ± 2.7)fortheinterventiongroupinMarch, whichconsistentlydecreasedinthesubsequentmonths,witha statisticallysignificantdecreaseinJune(13.8 ± 2.3)(Figure1A). However,thePSSscoresdidnotsignificantlychangeinthe

FIGURE1|(A) Mean ± SD ofPerceivedStressScore(PSS)ofcontrol(n =10)andIntervention(n =9)groupsforMarchtoJuly. (B) Mean ± SD ofoverallPSSof control(n =50,10subjectsfor5months)andintervention(n =45,9subjectsfor5months)groups. T-testwasappliedtocomparethescoresbetweenintervention andcontrolgroups. p < 0.05, p < 0.01arerepresentedas“*”and“**”,respectivelywhencomparedthescoresbetweeninterventionandcontrolgroups.“#” represents p < 0.05whencomparedbetweeninterventiongroups(Marchvs.othermonths).“$”represents p < 0.05whencomparedbetweencontrolgroups (Marchvs.othermonths).

controlgroupfromthemonthsMarchtoJuly.Importantly, therewasastatisticallysignificantdecreaseintheoverall PSSscores(March-Julycombined)oftheinterventiongroup comparedtothecontrolgroup(14.7 ± 0.8vs.19.3 ± 0.3) (Figure1B).Ingeneral,theinterventiongroupshowedan increasedstresslevel(moderatestress)inMarch,whichwas subsequentlydecreasedtolowstressinthesubsequentmonths. However,thestresslevelinthecontrolgroupremainedmoderate throughoutthese5months.SincethePSSmethodisused tomeasuregeneralstresslevels,inthefollowingsectionwe usedCOVID-19-relatedstressscoresinourparticipantsand determinedwhetherinterventiongrouphadasignificantly differentstresslevel.

COVID-19-RelatedStressScores (COVID-SS)

COVID-SSmeasuresthreedifferentcomponents(fear, knowledge,andgrowthzones)asdescribedintheoutcomes measuresection.Thismethodwasusedspecificallytomeasure COVID-19-relatedstressandanxiety.COVID-SSexamines whetherparticipantscanchangetheirbehaviorandactions asaresultoftrainingandmovefromthefearzonetothe knowledgezone,andultimatelythegrowthzone,acrossthe5 months.Nineparticipantsfromtheinterventiongroupandten participantsfromthecontrolgrouptooktheCOVID-19-related stresstestsurvey.TheMean ± SD ofCOVID-SSwasevaluated foreachzoneduringthemonthsofMarch–July.Theresults fromnineinterventionparticipantsshowedarelativelyhigh COVID-SSforthefearzone(1.78 ± 0.52)inMarch,which subsequentlydecreasedinApril,withastatisticallysignificant decreaseinMay(0.33 ± 0.23),June(0.55 ± 0.24),andJuly (0.33 ± 0.23)(Figure2A).Ontheotherhand,theCOVID-SS fortheknowledgezonesteadilyincreasedfromMarchtoJuly, withastatisticallysignificantincreaseinMay(5.23 ± 0.23), June(5.33 ± 0.37),andJuly(5.66 ± 0.37)comparedtoMarch

(3.33 ± 0.47)(Figure2C).Similarly,theCOVID-SSforthe growthzonealsosteadilyincreasedfromMarchtoJuly,with astatisticallysignificantincreaseinMay(6.67 ± 0.41),June (7.01 ± 0.16),andJuly(7.10 ± 0.26)comparedtoMarch (4.44 ± 0.62)(Figure2E).Ontheotherhand,comparedto march,COVID-SSscoresofthecontrolgroupinthefear zonedidnotstatisticallychangeinthesubsequentmonths (Figure2A).However,comparedtoMarch,COVID-SSscoresin Julysignificantlyincreasedinbothknowledge(4.80 ± 0.49vs. 1.27 ± 0.42)(Figure2C)andgrowth(6.01 ± 0.75vs.2.26 ± 0.75) zones(Figure2E),perhapsduetopartialopeningofthelab. However,thisincreaseintheknowledgeandgrowthzonesfor thecontrolgroupwasrelativelylowerthanthatoftherespective increaseintheinterventiongroup.

Moreimportantly,COVID-SSscoresoftheintervention groupinthefearzoneweresignificantlylowerthanthecontrol groupinMay(0.33 ± 0.22vs.1.47 ± 0.49)andJuly(0.33 ± 0.33 vs.1.65 ± 0.55)(Figure2A).Ontheotherhand,COVIDSSscoresoftheinterventiongroupinknowledgezonewere significantlyhigherthanthecontrolgroupinMay(5.33 ± 0.23 vs.1.13 ± 0.38)(Figure2C).Similarly,COVID-SSscoresofthe interventiongroupingrowthzonewerealsosignificantlyhigher thanthecontrolgroupinMay(6.67 ± 0.47vs.1.95 ± 0.65) andJune(7.01 ± 0.16vs.1.90 ± 0.63)months(Figure2E). WealsoanalyzedtheoverallCOVID-SSscoresforeachzone forthemonthsofMarch-Julyforbothinterventionandcontrol groups.TheoverallCOVID-SSscoresoftheinterventiongroup inthefearzoneweresignificantlylowerthanthecontrolgroup (0.75 ± 0.26vs.1.74 ± 0.08)(Figure2B).Ontheotherhand, theoverallCOVID-SSscoresoftheinterventiongroupinthe knowledgezoneweresignificantlyhigherthanthecontrolgroup (4.80 ± 0.43vs.4.18 ± 0.21)(Figure2D).Similarly,overall COVID-SSscoresoftheinterventiongroupinthegrowthzone werealsosignificantlyhigherthanthecontrolgroup(6.13 ± 0.51 vs.4.88 ± 0.40)(Figure2F).Takentogether,thesefindings

FIGURE2| TheCOVID-relatedstressscore(COVID-SS)inthefearzone (A,B),knowledgezone (C,D),andgrowthzone (E,F) forMarch,April,May,June,andJuly werecollectedandcomparedbetweencontrol(n =10)andintervention(n =9)groups.ThescoresofinterventionandcontrolgroupsinMarchwerealsocompared totheirrespectivescoresofinterventionandcontrolgroupsinothermonthsineachzone.Thedatain (B,D,F) representMean ± SD ofoverallCOVID-SSscoresof control(n =50,10subjectsfor5months)andintervention(n =45,9subjectsfor5months)groups. T-testwasappliedtocomparethescoresbetweenmonths. p < 0.05, p < 0.01arerepresentedas“*”and“**”or“***”,respectivelywhencomparedthescoresbetweeninterventionandcontrolgroups.“#”represents p < 0.05 whencomparedbetweeninterventiongroups(Marchvs.othermonths).“$”represents p < 0.05whencomparedbetweencontrolgroups(Marchvs.anothermonth).

suggestthatinterventionstrategytodealwithCOVID-related stressandanxietysignificantlyandconsistentlydecreasedthe fearandincreasedtheknowledgeandsubsequentgrowthin theirknowledge.

ProductivityDuringtheCOVID-19Era

Itiswidelyknownthatreducedstressenhancesproductivity, andincreasedproductivityfeedsintolowstressandimproved well-being(AnderzénandArnetz,2005; HeylighenandVidal, 2008).Stressandproductivityworkasaloopthatfeedinto eachother.Therefore,theresearchproductivitywasmeasured intermsofconceivingnewideasforareviewpaper,data analysisfortheoriginalpaper,andmanuscriptwritingandtheir publicationinpeer-reviewedjournals.Sincetheevidenceforonly publishedpaperscanbeprovided,theproductivitymetricsfor onlypublishedpapersarepresentedin Table2.Briefly,thedata fromaproject(Table2)wasanalyzed,whichwaslaterwrittenand published.Twoothermanuscriptsfororiginalarticleswerealso revisedandpublishedduringthesametime-period.Inaddition tooriginalarticles,7reviewpapersand1editorialwerepublished betweenMarchandthefirstweekofSeptember(Table2).Twoof thesereviewpapersarefromthefieldofCOVID-19forwhichwe conceivedtheideaofthepaperduringtheCOVID-19era.

Forthepast5years,theaveragepeer-reviewedpublication rateforthegroupis8peryear.Thus,publishing11papers in6monthscanbeconsideredhigherthantheprevious productivityforthisresearchgroup.Ithasbeenwidelyaccepted thatobtainingdataisthemosttime-consumingstepandrequires significantmanpower.However,intheabsenceofexperiments, optimalprioritiesandtimemanagementwereimplementedto maximizeproductivitywithanoverallexceptionalresult.The productivityisalsoconsideredunique,sincetworeviewarticles werepublishedonthemuch-neededfieldofCOVID-19.

Inadditiontoscientificpapers,twoopinioncolumnson COVID-19werepublishedintheMemphis-based“Commercial Appeal,”the“USAToday”network,onApril13(Kumar,2020b) andonJune11(Kumar,2020a).Theformeropinioncolumn wason,“UniversityofTennesseeHealthSciencesCentermaking stridesintreatingCOVID-19,”inwhich,ascientificopinionon repurposingantiviraldrugswasprovided.Thelatteronewas

on,“ChallengeswithCOVID-19couldbringtransformational change,improvehumanhealth,”inwhich,ascientificopinion onhowCOVID-19couldhelpimprovegeneralimmunityand reducetheprevalenceofchronicdiseaseswasprovided.

DISCUSSION

Thepresentstudywasdesignedtomitigategeneralaswellas COVID-19-inducedstressinbasicscienceresearchers,which subsequentlyhelpstoimprovetheoverallwell-beingand productivityintheinterventiongroup.WeusedbothPSS andCOVID-SSmethodstomeasuretheirstresslevelsand correlatedtheimprovedwell-beingoftheinterventiongroup withtheirproductivity.Overall,findingsstronglysuggestthatthe mitigationstrategyresultedinreducedstresslevelsandincreased researchproductivityamongbasicscienceresearchersduringthe COVID-19pandemic.However,thedatafromthecontrolgroup suggeststhatthecurrentCOVID-19pandemichasasignificant impactonthementalhealthofbasicscienceresearchers,which isconsistentwiththeimpactonmentalhealthinthegeneral population,especiallyinhealthcareprofessionalsandcollege students(Tangenetal.,1981; Kecojevicetal.,2020; OzamizEtxebarriaetal.,2020; Stantonetal.,2020; Wuetal.,2020).

Overall,theinterventiongroupshowedreducedgeneralstress comparedtothecontrolgroup.Ouroutcomeisdifferentfrom theoutcomesderivedfromtheperceivedstressandanxiety inthegeneralpopulation,inwhichthispandemicincreased anxietylevels.Inonestudy,highPSSscoresamongthe generalpopulationwereobservedinwomen,personsunder age30,students,andthosewhobelievedthemselvestobe atagreaterriskofcontractingtheillness(Limcaocoetal., 2020).Additionally,participants’perceptionofsusceptibilityto COVID-19waslikelyaffectedbyseveralfactors.Participants werenotelderlyorinotherhigh-riskgroups.Further,acertain levelofscientificliteracy(undergraduateandabove)mayhave equippedtheresearcherstopracticeappropriateCOVID-related healthmeasuresandmitigateCOVID-relatedfear.Moreover, uponcomparingwiththecontrolgroup,whichwereofsimilar demographics,ages,andeducationlevels,itcanbesaidthatthe

strategytodealwithstressduringtheCOVID-19erahashelped tomanagestresslevelsoftheresearchers.

Interventionstudybasedonthepsychologicalhealth statusofresearchersasbacklineworkerscouldprovidea potentialstatewidemeasurethatcouldbeusedbyother researchersorevenfrontlineworkerstocopewithstress duringthepandemicoutbreak.However,stressassessment andoutcomemeasurementsusedinourstudywillbemore appropriateforstressmanagementandwellbeingofthemental stateamongresearchers.Inconsistentwithourfindings,the frontlinehealthcareprofessionals,whowereworkingin proximitytopatientsadmittedintheICUwithseverelung infections,experiencedmentalhealthproblemswithsubstantial psychologicaldistress(Greenbergetal.,2020).Adescriptive studythatwasperformedonhealthcareprofessionalsduring COVID-19revealedarelativelymoderatelevelofperceived stress(PSSmean=15.71 ± 4.02)onPSS-10,alongwith38% identifiedasdepressedand24%assufferingfromanxiety.Health careprofessionalswhoexperiencehigherperceivedstressthan otherslikelyworkedatintensivecareunits(ICUs)(Maetal., 2020).Findingsofameta-analysisindicatedahighpsychological impact,notonlyonhealthcareworkers(HCW)andpatients, butalsointhegeneralpopulation(Luoetal.,2020; Pappaetal., 2020).Thepsychologicaldistresswasmediatedbyanxietyand depression.However,theexistenceofothervariablescouldbe wronglypredictedasstressassociatedwithCOVID 19.

Inacross-sectionalstudyconductedonfrontlinenurses (n =325),123nurseswerefoundtohaveadysfunctionallevel ofanxietythatinvolvesfear,behavior,andpsychologicaldistress (LabragueandDeLosSantos,2020; Lee,2020).Studiesconducted onthepsychologicalimpactofCOVID-19onfrontlinenurses havefoundanoverallhighprevalenceofanxietyrangedbetween 18and92.3%(Alwanietal.,2020; Luoetal.,2020)that couldbeavertedbyprovidingbetterorganizationalandsocial support,inadditiontotheimplementationofsafetymeasures attheworkplaceandqualitypersonalprotectiveequipment (PPE)(LabragueandDeLosSantos,2020).Overwhelming workloadandlackofsleepmayalsocontributetothemental burdenoffrontlineworkers(Laietal.,2020)thatcouldbe consideredduringtheassessmentoftheirstresslevels.Ingeneral, healthypeoplewerefoundtobelessaffectedbyCOVID19relatedstresscomparedtothosewithanxiety-relatedor mooddisordersinthepopulation-basedstudyconductedinthe USandCanada(Asmundsonetal.,2020).Across-sectional surveybasedonmodifiedPSS-10conductedon406individuals comprisingprofessors,students,andhealthprofessionals,aimed toassesstheprevalenceandvariablesrelatedtoperceived stressassociatedwithCOVID-19(Pedrozo-Pupoetal.,2020). Intotal,15%oftheparticipantsscoredforhighperceived stressassociatedwithCOVID-19.However,theprevalenceof highperceivedstresswasrelativelylowerthanpreviousstudies performedduringotherepidemics,suchasequineinfluenza (Pedrozo-Pupoetal.,2020).However,psychologicalresponsesto epidemicsandoutbreakmanagementrelatetoseveralvariables, suchasmisinformationorinformationoverloadandeducation, althoughfindingsregardingeducationcanbeinconsistentacross differentcountries.Forinstance,lesseducatedyoungpeoplewere

foundmorevulnerabletohighpsychologicaldistressduringthe outbreakofequineinfluenzainAustralia(Tayloretal.,2008), whereasanoppositetrendisseeninChina(Qiuetal.,2020). SincePSSdataisatestforwell-beingingeneralconditions,andit maybebiasedforstressinducedbyCOVID-19,anothermethod thatmeasuredCOVID-SSwasused.

Thepresentstudyfindingssuggestthattheintervention strategytodealwithCOVID-relatedstressandanxiety significantlyandconsistentlydecreasedthefearandincreasedthe knowledgeandsubsequentgrowthintheirknowledge.Thisisa newtestthatusedforthefirsttimetoevaluatefear,knowledge, andgrowthmindsetsinresearchersduringtheCOVID-19era. Thus,itisnotfeasibletodirectlycomparetheseoutcomeswith othersintheliteraturethatuseddifferenttests.Thisoutcome measurementwasusedspecificallyinthecontextasaninnovative strategytohelpmanagestressandincreaseproductivityamong researchers.Recentstudiesevaluatedmentalhealthassociated withCOVID-19-mediatedstressandanxietyinthegeneral population(Liuetal.,2020; Shammietal.,2020),aswellasin healthworkerswhowereinvolvedinthetreatmentofCOVID19patients(Bohlkenetal.,2020; Yinetal.,2020).Theoutcomes fromallthosestudiesshowedasignificantdecreaseintheir mentalhealthasmeasuredbytheprevalenceandpredictors ofpost-traumaticstresssymptoms(PTSS)andothermethods. Theparticipantsinthosestudiesexperiencedhighstressand anxiety,lackofsleep,anduncertaintyintheirfuture.Thus,unlike otherreports,outcomesfromthecurrentstudywithsignificant improvementinmentalhealthsuggestthatthestrategyto managethestressofresearchersappearstobeeffective.However, itisimportanttonotethatparticipantswereatlowriskof becomingunemployedandwerenototherwiseeconomically affectedbythepandemic.Further,noparticipantsinthisstudy weredirectlyaffectedbytheillness;neitherparticipantsnor participants’familymemberscontractedtheillnessorsuffered negativephysicalhealthoutcomesrelatedtothepandemic,and participantswerenotinhigh-riskgroupsforcontractingthe disease.Inaddition,mostparticipantswerenotdirectlyexposed tosickpatients,incontrastwithfrontlineworkers.However,it canalsobenotedthatthestrategyhelpedtomanagethewellbeingoftheinterventiongroupcomparedtothecontrolgroup, whichbelongedtothesamedemography,agegroup,education level,andoverallenvironment.

TheUnitedStateshasbeenexperiencingasurgeincreaseof anxietyprescriptiondrugsinrecentdecades(Rossetal.,2019). TheCOVID-19pandemicmayexaggeratestressandanxiety issuesintheUS.Therationaleofthecurrentintervention studyaimstoprovideaproof-of-principletouseanonymous basedinterventionsasanalternative.BothPSSandCOVID-SS scoresaremarkersofstressmanagement.Ithasbeenreported thatgroupanonymousifperformedproperly,hasthepotential toturnnegativestressintopositivemotivations(Murphy LawrenceandHurrellJoseph,1987).Anonymousisawidely usedtherapymethodfortreatmentinalcohol,smoking,and narcoticdrugabuse(MoosandMoos,2006).Inthisstudy,the interventionemphasizespositivefeedback,encouragement,and mentalsupporttoeliminatethefear,stress,anduncertaintydue toCOVID-19.ImprovementinbothPSSandCOVID-SSscores

fromtheinterventiongroup,aswellasrelativelyimprovedscores comparedtothecontrolgroup,provedthegeneralimprovement instressconditions.

Itiswell-knownthatincreasedstresscansignificantlyimpair theproductivity,andourmitigationstrategyhasimprovedthe mentalhealthandresultedinimprovedresearchproductivity duringthepandemic.Healthandproductivitymanagement (HPM)wasinitiallyintroducedbackinthe1990s(Goetzel andOzminkowski,2000).ThemaingoalofHPMwastotrain employeeswiththecapabilitytohandlecrisesandchallenges. Stressmanagementwasalsointroducedatthebeginningofthe 21stcenturytopromoteproductivity(Razavietal.,2012).The COVID-19pandemicisachallengeforbothbusinessandthe community.Hence,trainingresearcherstodomorewithfew resourceswillbenefittheminboththeshort-termandlongterm.Intheshort-term,researchersareengagedinexpanding theirproductivityportfoliobysubstitutingwet-labresearchto paper/computer-basedresearch.Thepaper/computerresearch conductedduringthisperiod,includingpeer-reviewedarticles andreviewpaperwritingandwhite/technicalpaperpublications, arealsovaluablefortheircareer.Moreimportantly,theseworks, especiallytheprocessofliteratureresearch,mayprovidehints forfuturewet-labexperiments.Ithasbeenwidelyacceptedby scientiststhatsteppingawayfromthewet-laballowsthemtoreset andre-thinktheresearchplantocomeupwithmoresuccessful ideas(Harricketal.,1986; DeBloometal.,2014).

Inthelong-term,afterexperiencingthesechallenges, researchersmaybemoreflexibleandmaturewhenfacing negativesituations.Negativesituationsincludeanotherglobal pandemic,wars,socialconflicts,biasanddiscriminations, negativeresearchresults,andanyothersituationsthatmaybring stress(Zareietal.,2014).

STRENGTHSANDWEAKNESSESOF THESTUDY

Ourstudyisuniqueinthatitisdesignedtomaintainwell-being andimprovetheproductivityofbasicscienceresearchersduring theCOVID-19era.Althoughitisasmallcasestudywithonly 19participants(alimitation),thestudyprovidespreliminary evidencethatthestrategyhasapositiveimpactonparticipants’ well-beingandproductivity.Moreover,thestudydesignusing bothcross-sectionalandlongitudinalstudies,providesrigorto ouranalysisandconclusion.Thisstudydoesnotperformcrosssectionalfindingsforproductivity,ascomparingdatafromother basicscienceresearchgroupsmaybeunfairanddifficult.Our studymaybeutilized,uponoptimization,byaspecificgroup tomanagethewell-beingoftheirresearchgroupandmaintain productivityduringachallengingsituationlikeCOVID-19.

IMPLICATIONSANDFUTURE PROSPECTS

Fromthecorporateperspective,allindustrieshavebeen affectedduringCOVID-19pandemic,includingtheenergy,

tourism,transportation,andretailandmanufacturingsectors (FuandShen,2020; Shenetal.,2020).Forinstance,the performanceofcompaniesbelongingtoenergysectorsis foundtobenegativelyimpactedinastudyperformedon thecorporateperformanceintheenergyindustrybythe paneldataandDifference-in-Differencemodel(FuandShen, 2020).Therefore,thisstudycouldbeimplementedwithor withoutmodificationsineverysectortoimprovethewellbeingofindividualsandenhancetheirproductivity.More specifically,thestrategiesdiscussedinthisstudycouldbehighly beneficialwhenimplementedinhealthcareandhighereducation institutions.

AsavaccineforCOVID-19hasnotyetbeenapproved, andduetotheresurgenceoftheinfectionafuturelimited lock-downmayyettakeplace.Therefore,itisimportant tocontinuetooptimizethecurrentapproachifsimilar circumstancesrecur.Duetocurrentfearsforasecond waveofillnessduringthefluseason,whichmayfurther complicatethediagnosisandtreatmentofCOVID-19,it willbebeneficialtocontinuetomonitorPSSandCOVIDSSregularly.Thus,thisfindingwillprovideapotential measureforotherresearchgroupstotakenecessarysteps inmanagingwell-beingandmaintainingproductivityin casethesecondwaveleadstoeitherfullorpartiallockdownand/orlabclosures.Furthermore,thesecondwaveof illnesswillnecessitateextracautioninpracticingpreventive healthmeasures.Researchgroups,aswellasgroupsin otherprofessions,couldusesimilarempowermentsessionsto encourageeachothertokeephealthydiets,meetexercisegoals, andmaintainregularsleepschedules,totheextentthattheir occupationsallow.

Finally,thestrategydiscussedinthisstudy,uponappropriate modificationtotailorthesituation,couldalsobeimplemented inotherfuturechallengesthatwemayface,e.g.,newemerging orre-emergingepidemicsorpandemics,financialcrises,natural disasters,etc.Basedonhistoricalperspectives,eitherlocallyor globally,wefacefinancialcrisesandepidemicseverydecade, aswellasnaturaldisastersinmultiplecountriesalmostevery year(ArcherandGeyer,1982; Roser,2019; FinancialTimes, 2020).Therefore,itisimportanttohaveastrategyatevery institution,especiallyatresearchandeducationalinstitutions, toeffectivelymitigatethestressandanxietycausedbythese challengesandtoimprovethewell-beingandproductivityof individuals.

DATAAVAILABILITYSTATEMENT

Therawdatasupportingtheconclusionsofthisarticlewillbe madeavailablebytheauthors,withoutunduereservation,toany qualifiedresearcher.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswerereviewed andapprovedbytheInstitutionalReviewBoard, UniversityofTennesseeHealthScienceCenter.The

patients/participantsprovidedtheirwritteninformedconsentto participateinthisstudy.

AUTHORCONTRIBUTIONS

SaKconceivedofthepresentedidea,obtainedandanalyzedthe data,andwrotethefirstdraftofthemanuscript.SuKobtained andanalyzedthedata,andwrotepartofthemanuscript.AK obtaineddata,andwrotepartofthemanuscript.KGobtained data,andwrotepartofthemanuscript.KZObtainedadditional dataandcontributedsignificantlyforrevisionofthemanuscript.

REFERENCES

Alwani,S.S.,Majeed,M.M.,Hirwani,M.Z.,Rauf,S.,Saad,S.M.,Shah,S.H.,etal. (2020).Evaluationofknowledge,practices,attitudeandanxietyofpakistans nursestowardsCOVID-19duringtheCurrentOutbreakinPakistan. medRxiv [Preprint].2020.2006.2005.20123703.

Anderzén,I.,andArnetz,B.B.(2005).Theimpactofaprospectivesurvey-based workplaceinterventionprogramonemployeehealth,biologicstressmarkers, andorganizationalproductivity. J.Occup.Environ.Med. 47,671–682.doi: 10.1097/01.jom.0000167259.03247.1e

Archer,A.W.,andGeyer,R.(1982).Productionofcyanideinasodiumnitrite poisoningcaseusinganaciddistillationscreeningtest. J.Forensic.Sci.Soc. 22, 333–334.doi:10.1016/s0015-7368(82)71506-3

Asensio,C.,Aumond,P.,Can,A.,Gascó,L.,Lercher,P.,Wunderli,J.-M.,etal. (2020).Ataxonomyproposalfortheassessmentofthechangesinsoundscape resultingfromtheCOVID-19lockdown. Int.J.Environ.Res.Pub.Health 17:4205.doi:10.3390/ijerph17124205

Asmundson,G.J.G.,Paluszek,M.M.,Landry,C.A.,Rachor,G.S.,Mckay, D.,andTaylor,S.(2020).Dopre-existinganxiety-relatedandmooddisorders differentiallyimpactCOVID-19stressresponsesandcoping? J.AnxietyDisord. 74:102271.doi:10.1016/j.janxdis.2020.102271

Bohlken,J.,Schömig,F.,Lemke,M.R.,Pumberger,M.,andRiedel-Heller,S.G. (2020).COVID-19pandemic:stressexperienceofhealthcareworkers-ashort currentreview. Psychiatr.Praxis 47,190–197.doi:10.1055/a-1159-5551

Carter,P.,Anderson,M.,andMossialos,E.(2020).Healthsystem,publichealth, andeconomicimplicationsofmanagingCOVID-19fromacardiovascular perspective. Eur.HeartJ. 41,2516–2518.doi:10.1093/eurheartj/ehaa342

Chisholm-Burns,M.A.(2010).Acrisisisareallyterriblethingtowaste. Am.J. Pharmaceut.Educ. 74,19–19.doi:10.5688/aj740219

Coronavirus-Resources-Center(2020). COVID-19DashboardbytheCenterfor SystemsScienceandEngineering(CSSE)atJohnsHopkinsUniversity(JHU) [Online].[Epubaheadofprint].Availableonlineat:https://coronavirus.jhu. edu/map.html[accessedJuly9,2020).

Cutler,D.(2020). HowWillCOVID-19AffecttheHealthCareEconomy [Online].Availableonlineat:https://jamanetwork.com/channels/healthforum/fullarticle/2764547[accessedAugest8,2020).

DeBloom,J.,Ritter,S.,Kühnel,J.,Reinders,J.,andGeurts,S.(2014).Vacationfrom work:A‘tickettocreativity’?:Theeffectsofrecreationaltraveloncognitive flexibilityandoriginality. Tour.Manag. 44,164–171.doi:10.1016/j.tourman. 2014.03.013

Donthu,N.,andGustafsson,A.(2020).EffectsofCOVID-19onbusinessand research. J.Bus.Res. 117,284–289.doi:10.1016/j.jbusres.2020.06.008

Du,J.,Dong,L.,Wang,T.,Yuan,C.,Fu,R.,Zhang,L.,etal.(2020).Psychological symptomsamongfrontlinehealthcareworkersduringCOVID-19outbreak inWuhan. Gen.Hosp.Psychiatry.[Epubaheadofprint].doi:10.1016/j. genhosppsych.2020.03.011

Dubey,S.,Biswas,P.,Ghosh,R.,Chatterjee,S.,Dubey,M.J.,Chatterjee,S.,etal. (2020).PsychosocialimpactofCOVID-19. Diab.Metab.Synd. 14,779–788. doi:10.1016/j.dsx.2020.05.035

EpilepsySociety(2020). EmpoweringYourselfDuringCOVID-19[Online] Availableonlineat:http://bcepilepsy.com/blog/empowering-yourself-duringcovid19(accessedOctober15,2020).

FUNDING

WeacknowledgefinancialsupportfromtheNationalInstitute ofHealthgrant(DA047178)andThePloughCenterfor SterileDrugDeliverySolutions,UniversityofTennesseeHealth ScienceCenter.

ACKNOWLEDGMENTS

Weacknowledgealltheparticipantsfortheirsurvey. Weacknowledgealltheparticipantsfortheirsurvey.

FinancialTimes(2020). FinancialCrisesOccurAboutOnceEveryDecade[Online] Availableonlineat:https://www.ft.com/content/5148cd1e-cf01-11e4-893d00144feab7de,(accessedOctober15,2020).

Fu,M.,andShen,H.(2020).COVID-19andcorporateperformanceintheenergy industry. EnergyRes.Lett. 1:12967.doi:10.46557/001c.12967

Georgiou,N.,Delfabbro,P.,andBalzan,R.(2020).COVID-19-relatedconspiracy beliefsandtheirrelationshipwithperceivedstressandpre-existingconspiracy beliefs. Pers.Individ.Differ. 166:110201.doi:10.1016/j.paid.2020.110201

Goetzel,R.Z.,andOzminkowski,R.J.(2000).Healthandproductivity management:emergingopportunitiesforhealthpromotionprofessionalsfor the21stcentury. Am.J.HealthPromot. 14,211–214.doi:10.4278/0890-117114.4.211

Greenberg,N.,Docherty,M.,Gnanapragasam,S.,andWessely,S.(2020). Managingmentalhealthchallengesfacedbyhealthcareworkersduringcovid19pandemic. BMJ 368:m1211.doi:10.1136/bmj.m1211

Guo,Q.,Zheng,Y.,Shi,J.,Wang,J.,Li,G.,Li,C.,etal.(2020).Immediate psychologicaldistressinquarantinedpatientswithCOVID-19andits associationwithperipheralinflammation:Amixed-methodstudy. Brain BehaviorImmunity 88,17–27.doi:10.1016/j.bbi.2020.05.038

Harrick,E.J.,Vanek,G.R.,andMichlitsch,J.F.(1986).Alternateworkschedules, productivity,leaveusage,andemployeeattitudes:afieldstudy. PublicPers. Manag. 15,159–169.doi:10.1177/009102608601500206

Hendriks,T.,DeJong,J.,andCramer,H.(2017).Theeffectsofyogaonpositive mentalhealthamonghealthyadults:asystematicreviewandmeta-analysis. J.AlternComplementMed. 23,505–517.doi:10.1089/acm.2016.0334

Heylighen,F.,andVidal,C.(2008).Gettingthingsdone:thesciencebehindstressfreeproductivity. LongRangePlanning 41,585–605.doi:10.1016/j.lrp.2008. 09.004

Hua,C.-Z.,Miao,Z.-P.,Zheng,J.-S.,Huang,Q.,Sun,Q.-F.,Lu,H.-P.,etal.(2020). EpidemiologicalfeaturesandviralsheddinginchildrenwithSARS-CoV-2 infection. J.Med.Virol.doi:10.1002/jmv.26180

Jenson,H.B.(2020).Howdid“flattenthecurve”become“flattentheeconomy?”A perspectivefromtheUnitedStatesofAmerica. Asia.J.Psychiatry 51,102165–102165.doi:10.1016/j.ajp.2020.102165

Jiménez,Ó,Sánchez-Sánchez,L.C.,andGarcía-Montes,J.M.(2020).Psychological impactofCOVID-19confinementanditsrelationshipwithmeditation. Int.J. Environ.Res.PublicHealth 17:6642.doi:10.3390/ijerph17186642

Kecojevic,A.,Basch,C.H.,Sullivan,M.,andDavi,N.K.(2020).Theimpact oftheCOVID-19epidemiconmentalhealthofundergraduatestudentsin NewJersey,cross-sectionalstudy. PLoSOne 15:e0239696.doi:10.1371/journal. pone.0239696

Killgore,W.D.S.,Taylor,E.C.,Cloonan,S.A.,andDailey,N.S.(2020). PsychologicalresilienceduringtheCOVID-19lockdown. PsychiatryRes. 291, 113216–113216.doi:10.1016/j.psychres.2020.113216

Kumar,S.(2020a).ChallengeswithCOVID-19couldbringtransformational change,improvehumanhealth.Availableonlineat:https://www. commercialappeal.com/story/opinion/2020/06/11/enhance-your-healthduring-covid-19/5336309002/(accessedOctober26,2020).

Kumar,S.(2020b).UniversityofTennesseeHealthSciencesCenter makingstridesintreatingCOVID-19|Opinion.Availableonlineat: https://www.commercialappeal.com/story/opinion/2020/04/13/progressmade-finding-covid-19-vaccine/2985371001/(accessedOctober26,2020).

Labrague,L.J.,andDeLosSantos,J.(2020).COVID-19anxietyamongfrontline nurses:predictiveroleoforganisationalsupport,personalresilienceandsocial support. J.Nurs.Manag.28,1653–1661.doi:10.1101/2020.07.16.20141069

Lai,J.,Ma,S.,Wang,Y.,Cai,Z.,Hu,J.,Wei,N.,etal.(2020).Factorsassociatedwith mentalhealthoutcomesamonghealthcareworkersexposedtocoronavirus disease2019. JAMANetw.Open 3:e203976.doi:10.1001/jamanetworkopen. 2020.3976

Lee,S.A.(2020).CoronavirusAnxietyScale:abriefmentalhealthscreenerfor COVID-19relatedanxiety. DeathStud. 44,393–401.doi:10.1080/07481187. 2020.1748481

Limcaoco,R.S.G.,Mateos,E.M.,Fernandez,J.M.,andRoncero,C. (2020).Anxiety,worryandperceivedstressintheworldduetothe COVID-19pandemic,March2020.Preliminaryresults. medRxiv [Preprint]. 2020.2004.2003.20043992.

Liu,N.,Zhang,F.,Wei,C.,Jia,Y.,Shang,Z.,Sun,L.,etal.(2020).Prevalence andpredictorsofPTSSduringCOVID-19outbreakinChinahardest-hitareas: genderdifferencesmatter. PsychiatryRes. 287:112921.doi:10.1016/j.psychres. 2020.112921

Luo,M.,Guo,L.,Yu,M.,Jiang,W.,andWang,H.(2020).Thepsychological andmentalimpactofcoronavirusdisease2019(COVID-19)onmedicalstaff andgeneralpublic-Asystematicreviewandmeta-analysis. PsychiatryRes. 291:113190.doi:10.1016/j.psychres.2020.113190

Ma,Y.,Rosenheck,R.,andHe,H.(2020).Psychologicalstressamonghealth careprofessionalsduringthe2019novelcoronavirusdiseaseOutbreak:Cases fromonlineconsultingcustomers. IntensiveCrit.CareNurs. 20:102905.doi: 10.1016/j.iccn.2020.102905

Manch,S.E.(2020). FocusingonResilience.Availableonlineat:https: //www.winston.com/en/thought-leadership/focusing-on-resilience.html (accessedOctober26,2020).

Mclaren,H.J.,Wong,K.R.,Nguyen,K.N.,andMahamadachchi,K.N.D.(2020). Covid-19andWomen’stripleburden:vignettesfromSriLanka,Malaysia, VietnamandAustralia. Soc.Sci. 9:87.doi:10.3390/socsci9050087

Meira,T.M.,Paiva,S.M.,Antelo,O.M.,Guimarães,L.K.,Bastos,S.Q.,and Tanaka,O.M.(2020).Perceivedstressandqualityoflifeamonggraduatedental faculty. J.DentalEduc.84,1099–1107.doi:10.1002/jdd.12241

Ming,W.,Zhou,Z.,Ai,H.,Bi,H.,andZhong,Y.(2020).COVID-19andair quality:evidencefromChina. Emerg.MarketsFinan.Trade 56,2422–2442. doi:10.1080/1540496x.2020.1790353

Moos,R.H.,andMoos,B.S.(2006).ParticipationintreatmentandAlcoholics Anonymous:A16-yearfollow-upofinitiallyuntreatedindividuals. J.Clin. Psychol. 62,735–750.doi:10.1002/jclp.20259

MurphyLawrence,R.,andHurrellJoseph,J.(1987).Stressmanagementinthe processofoccupationalstressreduction. J.Manag.Psychol. 2,18–23.doi: 10.1108/eb043387

NewHampshireDepartmentofAdministrativeServices(2020). PerceivedStress Scale.Concord,NH:NewHampshireDepartmentofAdministrativeServices. Ornell,F.,Schuch,J.B.,Sordi,A.O.,andKessler,F.H.P.(2020).“Pandemicfear” andCOVID-19:mentalhealthburdenandstrategies. Braz.J.Psychiatry 42, 232–235.doi:10.1590/1516-4446-2020-0008

Ozamiz-Etxebarria,N.,Dosil-Santamaria,M.,Picaza-Gorrochategui,M.,and Idoiaga-Mondragon,N.(2020).Stress,anxiety,anddepressionlevelsinthe initialstageoftheCOVID-19outbreakinapopulationsampleinthe northernSpain. CadSaudePub. 36:e00054020.doi:10.1590/0102-311x0005 4020

Pappa,S.,Ntella,V.,Giannakas,T.,Giannakoulis,V.G.,Papoutsi,E.,and Katsaounou,P.(2020).Prevalenceofdepression,anxiety,andinsomniaamong healthcareworkersduringtheCOVID-19pandemic:asystematicreviewand meta-analysis. BrainBehav.Immun. 88,901–907.doi:10.1016/j.bbi.2020. 05.026

Patel,A.,Jernigan,D.B.,andnCoVCDCResponseTeam,(2020).Initial PublicHealthResponseandInterimClinicalGuidanceforthe2019Novel CoronavirusOutbreak-UnitedStates,December31,2019-February4,2020. MMWR Morbid.Mortal.WeeklyRep. 69,140–146.doi:10.15585/mmwr. mm6905e1

Pedrozo-Pupo,J.C.,Pedrozo-Cortés,M.J.,andCampo-Arias,A.(2020).Perceived stressassociatedwithCOVID-19epidemicinColombia:anonlinesurvey. Cad SaudePub. 36:e00090520.doi:10.1590/0102-311x00090520

Power,K.(2020).TheCOVID-19pandemichasincreasedthecareburdenof womenandfamilies. Sustainability 16,67–73.doi:10.1080/15487733.2020. 1776561

Qiu,J.,Shen,B.,Zhao,M.,Wang,Z.,Xie,B.,andXu,Y.(2020).Anationwide surveyofpsychologicaldistressamongChinesepeopleintheCOVID-19 epidemic:implicationsandpolicyrecommendations. GenPsychiatr 33:e100213. doi:10.1136/gpsych-2020-100213

Razavi,R.,Emamgholizadeh,S.,andEmami,M.(2012).Asurveyofthe relationshipbetweenstressmanagementandworkforceproductivityofoneof iran’sindustrialparks. ElixirHumanRes.Mgmt. 48,9371–9378.

Renu,K.,Prasanna,P.L.,andValsalaGopalakrishnan,A.(2020).Coronaviruses pathogenesis,comorbiditiesandmulti-organdamage-Areview. LifeSci. 255:117839.doi:10.1016/j.lfs.2020.117839

Rogers,J.P.,Chesney,E.,Oliver,D.,Pollak,T.A.,Mcguire,P.,Fusar-Poli,P.,etal. (2020).Psychiatricandneuropsychiatricpresentationsassociatedwithsevere coronavirusinfections:asystematicreviewandmeta-analysiswithcomparison totheCOVID-19pandemic. LancetPsychiatry 7,611–627.doi:10.1016/s22150366(20)30203-0

Roser,H.R.A.M.(2019). NaturalDisasters[Online].Availableonlineat:https: //ourworldindata.org/natural-disasters(accessedOctober15,2020).

Ross,E.L.,Vijan,S.,Miller,E.M.,Valenstein,M.,andZivin,K.(2019). Thecost-effectivenessofcognitivebehavioraltherapyversussecondgenerationantidepressantsforinitialtreatmentofmajordepressivedisorder intheUnitedStates. Ann.Int.Med. 171,785–795.doi:10.7326/m181480

Salari,N.,Hosseinian-Far,A.,Jalali,R.,Vaisi-Raygani,A.,Rasoulpoor,S., Mohammadi,M.,etal.(2020).Prevalenceofstress,anxiety,depression amongthegeneralpopulationduringtheCOVID-19pandemic:asystematic reviewandmeta-analysis. GlobalHealth 16:57.doi:10.1186/s12992-02000589-w

Satiani,B.,Zigrang,T.A.,andBailey-Wheaton,J.L.(2020).COVID-19financial resourcesforphysicians. J.Vascul.Surgery 72,1161–1165.doi:10.1016/j.jvs. 2020.04.482

Schlesselman,L.S.,Cain,J.,andDivall,M.(2020).Improvingandrestoringthe well-beingandresilienceofpharmacystudentsduringapandemic. Am.J. PharmEduc. 84:aje8144.doi:10.5688/ajpe8144

Seyedin,H.,Samadipour,E.,andSalmani,I.(2019).Interventionstrategiesfor improvementofdisastersriskperception:family-centeredapproach. J.Educ. HealthPromot 8:63.

Shammi,M.,Bodrud-Doza,M.,TowfiqulIslam,A.R.M.,andRahman,M.M. (2020).COVID-19pandemic,socioeconomiccrisisandhumanstressin resource-limitedsettings:AcasefromBangladesh. Heliyon 6:e04063.doi:10. 1016/j.heliyon.2020.e04063

Shen,H.,Fu,M.,Pan,H.,Yu,Z.,andChen,Y.(2020).TheimpactoftheCOVID19pandemiconfirmperformance. Emerg.MarketsFin.Trade 56,2213–2230. doi:10.1080/1540496x.2020.1785863

Shultz,J.M.,Cooper,J.L.,Baingana,F.,Oquendo,M.A.,Espinel,Z.,Althouse, B.M.,etal.(2016).Theroleoffear-relatedbehaviorsinthe2013-2016west africaebolavirusdiseaseoutbreak. Curr.PsychiatryRep. 18:104.doi:10.1007/ s11920-016-0741-y

Spuntarelli,V.,Luciani,M.,Bentivegna,E.,Marini,V.,Falangone,F.,Conforti, G.,etal.(2020).COVID-19:isitjustalungdisease?Acase-basedreview. SN Compr.Clin.Med. 20,1–6.doi:10.1007/s42399-020-00418-6

Stanton,R.,To,Q.G.,Khalesi,S.,Williams,S.L.,Alley,S.J.,Thwaite,T.L., etal.(2020).Depression,AnxietyandStressduringCOVID-19:associations withchangesinphysicalactivity,sleep,tobaccoandalcoholuseinaustralian adults. Int.J.Environ.Res.PublicHealth 17:7848.doi:10.3390/ijerph1711 4065

Tangen,K.O.,Lindmo,T.,Sobrinho-Simões,M.,andJohannessen,J.V.(1981). CellularDNAcontentinnormalhumanthyroid:aflowcytometricstudybased onfrozenbiopsymaterial. DiagnHistopathol. 4,343–348.

Taylor,M.R.,Agho,K.E.,Stevens,G.J.,andRaphael,B.(2008).Factorsinfluencing psychologicaldistressduringadiseaseepidemic:datafromAustralia’sfirst outbreakofequineinfluenza. BMCPublicHealth 8:347.doi:10.1186/14712458-8-347

TaylorandFrancis(2020).SpecialIssue:researchonpandemics. EmergingMark. FinanceTrade 20:56.

Titov,N.,Staples,L.,Kayrouz,R.,Cross,S.,Karin,E.,Ryan,K.,etal.(2020).Rapid report:Earlydemand,profilesandconcernsofmentalhealthusersduringthe coronavirus(COVID-19)pandemic. Int.Intervent. 21:100327.doi:10.1016/j. invent.2020.100327

UTHSC(2020). UTHSCCOVID-19Update:ShelterinPlace[Online].Available onlineat:https://www.uthsc.edu/coronavirus/campus-updates/update-03-2320-b.php(accessedMarch23,2020).

Vidya,C.T.,andPrabheesh,K.P.(2020).ImplicationsofCOVID-19pandemic ontheglobaltradenetworks. Emerg.Mark.FinanceTrade 56,2408–2421. doi:10.1080/1540496x.2020.1785426

WorldHealthOrganization(2004). PromotingMentalHealth[Online].Available onlineat:https://www.who.int/mental_health/evidence/en/promoting_mhh. pdf(accessedOctober15,2020).

Wu,W.,Zhang,Y.,Wang,P.,Zhang,L.,Wang,G.,Lei,G.,etal.(2020). PsychologicalstressofmedicalstaffsduringoutbreakofCOVID-19and adjustmentstrategy. J.Med.Virol. 21:25914.doi:10.1002/jmv.25914

Xiong,J.,Lipsitz,O.,Nasri,F.,Lui,L.M.W.,Gill,H.,Phan,L.,etal.(2020). ImpactofCOVID-19pandemiconmentalhealthinthegeneralpopulation: asystematicreview. J.Affect.Disord. 277,55–64.doi:10.1016/j.jad.2020.08.001

Yin,Q.,Sun,Z.,Liu,T.,Ni,X.,Deng,X.,Jia,Y.,etal.(2020).Posttraumaticstress symptomsofhealthcareworkersduringthecoronavirusdisease2019. Clin. Psychol.Psychother. 27,384–395.doi:10.1002/cpp.2477

Zarei,M.H.,Razavi,H.R.,andEmamgholizadeh,S.(2014).Isstressmanagement relatedtoworkforceproductivity? IranianJ.Manag.Stud. 7,1–9.

Zarghami,A.,Farjam,M.,Fakhraei,B.,Hashemzadeh,K.,andYazdanpanah,M.H. (2020).AreportofthetelepsychiatricevaluationofSARS-CoV-2patients. Telemed.Health 20:788.doi:10.1089/tmj.2020.0125

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Kumar,Kodidela,Kumar,GerthandZhi.Thisisanopen-access articledistributedunderthetermsoftheCreativeCommonsAttributionLicense (CCBY).Theuse,distributionorreproductioninotherforumsispermitted,provided theoriginalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.No use,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

published:10November2020 doi: 10.3389/fpubh.2020.604394

Editedby: DelaliA.Dovie, UniversityofGhana, Ghana

Reviewedby: ZaferÇaliskan, HacettepeUniversity,Turkey NarimasaKumagai, SeinanGakuinUniversity,Japan

*Correspondence: LaurentMusango musangol@who.int

Specialtysection: Thisarticlewassubmittedto HealLthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 09September2020

Accepted: 21October2020 Published: 10November2020

Citation: MusangoL,NundoochanAand KirigiaJM(2020)TheDiscounted MoneyValueofHumanLifeLosses

AssociatedWithCOVID-19in Mauritius. Front.PublicHealth8:604394. doi:10.3389/fpubh.2020.604394

TheDiscountedMoneyValueof HumanLifeLossesAssociatedWith COVID-19inMauritius

LaurentMusango 1*,AjoyNundoochan 1 andJosesMuthuriKirigia 2

1 WorldHealthOrganization,CountryOfficeforMauritius,PortLouis,Mauritius, 2 AfricanSustainableDevelopmentResearch Consortium(ASDRC),Nairobi,Kenya

Background: Mauritiusalongwithother12countriesintheAfricanRegionwasidentified attheearlystartoftheCOVID-19pandemicasbeingathighriskduetohighvolumeof internationaltravel,highprevalenceofnon-communicablediseasesandco-morbidities, highpopulationdensityandsignificantshareofpopulationover60years(16%).The objectiveofthisstudywastoestimatethetotaldiscountedmoneyvalueofhumanlife losses TDMVCLMAURITIUS associatedwithCOVID-19inMauritius.

Methods: Thehumancapitalapproach(HCA)wasusedtoestimatethe TDMVCLMAURITIUS ofthe10humanlifelosseslinkedwithCOVID-19inMauritius asof16October2020.TheHCAmodelwasestimatedwiththenationallifeexpectancy of75.51yearsandadiscountrateof3%.Asensitivityanalysiswasperformedassuming (a)5and10%discountrates,and(b)theaverageworldlifeexpectancyof73.2years, andtheworldhighestlifeexpectancyof88.17years.

Results: ThemoneyvalueofhumanliveslosttoCOVID-19,atadiscountedrateof3%, hadanestimated TDMVCLMAURITIUS ofInt$3,120,689,andanaverageofInt$312,069 perhumanlifelost.Approximately74%ofthe TDMVCLMAURITIUS accruedtopersons agedbetween20and59years.Reanalysisofthemodelwith5and10%discountrates, holdingnationallifeexpectancyconstant,reducedthe TDMVCLMAURITIUS by19.0and 45.5%,respectively.Applicationoftheaverageworldlifeexpectancyat3%discountrate reduced TDMVCLMAURITIUS by13%;anduseoftheworldhighestlifeexpectancyat3% discountrateincreased TDMVCLMAURITIUS by50%.

Conclusions: Theaveragediscountedmoneyvalueperhumanlifelossassociated withCOVID-19is12-foldthepercapitaGDPforMauritius.Allmeasuresimplementedto preventwidespreadcommunitytransmissionofCOVID-19mayhavesavedthecountry 837humanlivesworthInt$258,080,991.Thisevidence,conjointlywithhumanrights arguments,callsforincreasedinvestmentstobridgetheexistinggapsforachieving universalhealthcoverageby2030.

Keywords:coronavirus,COVID-19,grossdomesticproduct(GDP),humancapitalapproach(HCA),valueof humanlife

INTRODUCTION

Mauritiusisthesecond countryamongthe47WorldHealth Organization[WHO]AfricanRegion[WAFR]memberstates whichgraduatedtoahigh-incomeeconomy.TheGrossNational Income(GNI)percapitafor2019wasUS$12,740,withan estimatedpopulationof1.27million(1).Furthermore,Mauritius hasahumandevelopment indexof0.796andwhichafter adjustingforinequalitydropsto0.688.Inthesamebreath,the countryhasaGiniindexof35.8(2).AsaresultofCoronavirus Disease(COVID-19),the economyisexpectedtoexperience itsfirstcontractionin40years.AccordingtotheInternational MonetaryFund(IMF),therealgrossdomesticproduct(GDP) growthwouldcontractby6.8%in2020(3).

In2017,whichwas beforeCOVID-19pandemic,Mauritius hadatotalof10,332.65deaths,ofwhich88.95%werefromnoncommunicablediseases(NCD),5.28%frominjuries,and5.76% fromcommunicablediseases(CD).Thedeathratesper100,000 populationforvariousCDswere:39.12forchronicrespiratory diseases;25.31forrespiratoryinfectionsandtuberculosis;7.77 formaternalandneonataldisorders;7.63forHIV/AIDSand sexuallytransmittedinfections;2.19forentericinfections;1.08 fornutritionaldeficiencies;0.14forneglectedtropicaldiseases andmalaria;and2.66forotherinfectiousdiseases(4).

TheCOVID-19outbreakcontinuestoacceleratewithatotal of39,175,462confirmedcases,including1,102,941deathsanda casefatalityrateof2.8%,reportedgloballyat16October2020(5). TheAfricancontinenthadatotalof1,621,853cases,including 39,150deathsandacasefatalityrate(2.4%).SouthAfricaisthe hardest-hitcountryintheAfricancontinentandrankseleventh globallyaftertheUnitedStatesofAmerica(USA),India,Brazil, Russia,Spain,Argentina,Colombia,Peru,MexicoandFrance (5).Asof16October2020,therewere415confirmedCOVID-19 casesinMauritius, including10deaths,364recoveredcases,and 41activecases(5).Thecasefatalityratewas2.4%andarecovery rateof87.7%(5, 6).

Notwithstandingthe growinginterestforresearchinthearea ofCOVID-19,thereisadearthofcountryevidenceonthe monetaryvalueofhumanlifelossesassociatedwithCOVID19.Brazil(7),Canada(8),China(9),France(10),Iran(11), Italy(12),Spain (13),Turkey(14),theUnitedKingdom[UK] (15),andtheUSA(16)areexceptions.Quantifyingthereal diseaseburdenofCOVID-19 indollartermsiscriticaltobuilding advocacytoincreaseinvestmentintohealth-relatedsystems. Theobjectivesofthispaperare2-fold.First,toestimatethe discountedmoneyvalueofhumanlifelossesassociatedwith COVID-19inMauritiusasof16October2020.Secondly,to estimatebrieflythepotentialgainsfrompreventiveactionstaken tocontainthespreadofCOVID-19.

MauritiusisamongtheveryfewcountriesintheWAFRwhich hasmanagedtohaltthecommunitytransmissionofCOVID19.Therehavebeennoconfirmedcasesoflocaltransmission since26April2020.Thesuccessmightbeattributedtofour systemicreasons.

First,relativelygoodgovernancecomparedtotherestof Africacontinent.TheIbrahimIndexofAfricanGovernance (IIAG)isatoolfortrackingAfricangovernmentsprogress

inattainingtheUnitedNationsSustainableDevelopment (SDG)Goal16relatingtoeffective,accountableandinclusive institutionsatalllevels(17, 18).In2017,Mauritiushadanoverall IIAGscoreof79.5%,whichconsistedofcategoryscoresof81.3% insafetyandtheruleoflaw(SRL),77.2%inparticipationand humanrights(PHR),74.8%ofsustainableeconomicopportunity (SEO),and84.6%inhumandevelopment(HD)(19).The MauritiusoverallIIAGandthe fourcategoryscoreswerehigher thanAfrica’soverallIIAGscoreof49.9%,andcategorymean scoresof52.6%inSRL,49.2%inPHR,44.8%inSEO,and52.8% inHD(19).

Second,Mauritiushasmoreresourcednationalhealthsystem andothersystemsthataddresssocialdeterminantsofhealththan thoseofmanyothercountriesintheWAFR.Asshownin Table1, thehealthworkforce,medicaldevices,infrastructure,essential healthservicecoverage,percapitacurrenthealthexpenditure, andsafelymanagedwaterandsanitationindicatorsforMauritius aresignificantlyhigherthanthoseoftheWAFR(20 25).

Thepublicandprivatehealthsectoraremannedbyatotal of3,210medicaldoctors(including895specialists),411dentists and4,400nursesandmidwives(27).Thedoctorpopulationratio (25.3per10,000population)andnurseandmidwiferyratio(35.2 per10,000population)inMauritiusare,respectively,8-and 3-foldhigherthanthoseoftheWAFR(20, 22).

In2017,Mauritiuspercapitacurrenthealthexpenditure (CHE)ofUS$600(Int$1,278)was4.4timeshigherthanthe averageofInt$292intheAFR(25).Thepercentageofthe populationwithhouseholdexpendituresonhealthofmorethan 25%ofthetotalhouseholdincomeincreasedslightlyfrom1.2% in2012to1.8%ofthepopulationin2018(24, 28).In2012, 0.34%ofhouseholdswere impoverishedbyOOP(28).Thehealth systemisadequatelyresourced tokeepMauritiusontrackto attainingtheSDG3target3.8onachievinguniversalhealth coverage(UHC)(18, 29, 30).TheMauritiusUHCessentialhealth servicescoverageindex(measuredonascaleof0totargetof 100)of63%in2017washigherthantheaverageof46%forthe WAFR(23).

Third,strongersystemsthatprovideservicesrelatedtosocial determinantsofhealth.Theproportionofthepopulationusingat leastbasicdrinking-waterservicesinMauritiusof99%was3-fold thatoftheWAFR(24, 26).Also,theproportionofthepopulation usingimprovedsanitationservicesinMauritiusof91.0%was three-timesthatofWAFRin2017(24, 26).

Fourth,morerobustdiseasesurveillanceandresponsesystem (DSRS)duetobetterInternationalHealthRegulation(IHR) corecapacitiesasrecommendedbythe58thWorldHealth Assembly(31, 32).In2013,WHOdevelopedanIHRcore capacitymonitoringframeworkconsistingof achecklistand indicatorsthatcountriescanusetomonitorprogressinthe implementationof13IHRcorecapacities(33).

Table2 showsthat,exceptfortheZoonoticandhumananimalinterface,alltheother12IHRcorecapacityscoresfor MauritiuswerehigherthanthosefortheWAFR(34).Theaverage ofthe13IHRcore capacitiesscoreof64washigherthanthe averageforWAFRof44.

Despitethepastrelativesuccess,theMinistryofHealth andWellnessacknowledgestheneedtosustainadvocacyfor

TABLE1| Healthsystemandsocialdeterminants ofhealthindicatorsinMauritius vis-à-vistheWHOAfricanRegion(WAFR).

Valuein Mauritius Averagevalue inWAFR

Healthworkforceindicators(20)

Medicaldoctorsper10,000population (2018)25.33.0

Nursingandmidwiferypersonnelper10,000 population(2017) 35.210.1

Dentistsper10,000population(2018) 32.8

Pharmacistsper10,000population(2018)4.2

Medicaldevicesindicatorsin2013(21)

Computedtomographyunitsper million population 6.4 0.4

Mammographyunitspermillionfemalesaged 50–69years 2.4 7.4

Radiotherapyunitspermillionpopulation49.70.1

Infrastructureindicatorsin2013(22)

Specializedhospitalsper100,000population 0.4

Provincialhospitalsper100,000population0.4

District/ruralhospitalsper100,000population0.16

Hospitalsper100,000population 1.0 0.8

Healthcentersper100,000population 8.84

Healthpostsper100,000population 0.16

Hospitalbedsper10,000population 34

Essentialhealthservicecoverageindicatorsin2017(23)

UHCindexofservicecoverage (SCI) 63 46

UHCSCIcomponents:Reproductive, maternal,newborn,andchildhealth 69 54

UHCSCIcomponents:Infectiousdiseases53 42

UHCSCIcomponents:Non-communicable diseases 52 71

UHCSCIcomponents:Servicecapacityand access 80 30

Healthfinancingandcatastrophicout-of-pockethealthspending(SDG indicator3.8.2)in2017

Populationwithhouseholdexpenditureson health >10%oftotalhouseholdexpenditure orincome(SDG3.8.2)(%)(24)

Populationwithhousehold expenditureson health >25%oftotalhouseholdexpenditure orincome(SDGindicator3.8.2)(%)(24)

8.97.26

TABLE2 | ComparisonofMauritiusandaverageWHOAfricanRegionIHRscore percapacity,2019.

CoreIHRcapacities

MauritiusIHR scores AfricanRegion IHRScores

Legislationandfinancing 60 43 Coordinationandnationalfocalpoint functions 90 51 Laboratory 53 56 Surveillance 70 61 Humanresources 80 49 Nationalhealthemergencyframework67 40 Healthserviceprovision 73 41 Riskcommunication 80 43 Pointsofentry 80 36 Chemicalevents 40 32 Radiationemergencies 40 32 Zoonoticandhuman-animalinterface 20 50 Foodsafety 80 43

Averageofthe13IHRcorecapacities64 44 Source:WorldHealthOrganization[WHO](34).

increasedandefficiently utilizedinvestmentstobridgethealbeit limitedpersistinggapsinUHCandimplementationofsomeof theIHRcorecapacities(35).CardandMooney(36)arguethat giventheresourcesavailableinanyhealthsystemforsavinglife arelimited,rationalallocationofresourcesisneeded,whichcall formonetaryvaluationofhumanlife.AccordingtoRice(37),itis importanttotranslateadverseeffectsofdiseases,suchasCOVID19,intodollartermswhichistheuniversallanguageofdecisionmakersinministriesofeconomicdevelopment,planning,and finance;theprivatesector;andtheinternationaldevelopment policyarena.

MATERIALSANDMETHODS

1.81.78

Current HealthExpenditure(CHE)perCapita inPPP(25) 1,278.01291.9

Domestic GeneralGovernmentHealth Expenditureas%ofCHE(25) 42.8755.52

DomesticPrivate HealthExpenditureas%of CHE(25) 56.3044.48

Out-of-PocketExpenditure(OOPS)as%of CHE(25) 48.8735.82

External healthexpenditureas%ofCHE(25)0.8321.39

CHEas%Gross DomesticProduct(GDP)(25)5.725.65

Domesticgeneralgovernment health expenditureaspercentageofGDP(%)(25) 2.451.91

SocialDeterminantsofHealthin2017

Populationusingsafely-managed drinking-waterservices(%)(24, 26) >99 29

populationusingsafely-managedsanitation services (%) (24, 26) 96 20

StudyAreaandOverviewofInterventions

ImplementedtoCombatCOVID-19

Thecross-sectionalstudyreportedinthispaperwasundertaken amongthetenpersonsdeceasedduetoCOVID-19inMauritius between18March2020(whenthefirstcasewasdiscovered)to16 October2020.

TheRepublicofMauritiusimplementedawidearrayofpublic healthcontainmentmeasuressincetheoutbreakofCOVID19wasreportedinthecountryon18March2020toprevent widespreadcommunitytransmission(6, 38).Theseincluded bansonpublicgatherings,acurfeworder,closingofborders, discontinuationofpublictransportation;closingofschools, universities,shoppingmalls,andtouristsites;suspendingof employeeattendanceatgovernmentandprivateworkplaces (exceptforessentialstaff);andintroductionofmasstestingfor antigenson27April2020.Asthecountryrecordednonewcases fornearly3weeksandnoactivecasessince11May2020,a strategicallyphasedresumptionofeconomicactivitiesbeganon

15May2020.AWorkAccessPermitissuedbytheauthorities, exceptforthoseworking inessentialsectorsbecamemandatory foremployeestoresumetheirduties.

Arrangementsweremadebythepublictransportcompanies tocomplywiththeprescribedhealthmeasuresandtoadhere tothephysicaldistancebetweenpassengers.Schoolchildrenhad tostayathome,whilethecoursescontinuedtobedelivered remotely.Banksandsupermarketsstilloperatedonalphabetical order,andthesameappliedtopostoffices.Twosetsoflegislations wereenactedmid-May2020,namelytheCOVID-19Billand QuarantineBill.Bothlegislationsdelineatedthetransition processfromthecurfewbystrengtheningthesurveillance controlandhealthsystempreparedness.Theseactionsensureda progressivereopeningofeconomicandotheractivitieswithstrict sanitaryrulesandaddedmeasurestoavoidaresurgenceofthe disease(6, 38).

Notwithstandingthe curfewwasliftedfromendofMay2020, physicaldistancingguidelinesremaininplace,aswellasthe mandatorywearingofmasksinpublic.Whileworkingaccess permitsarenolongerrequired,officesarerequiredtoincorporate physicaldistancingrequirements,andencourageworkingfrom home.AllschoolsreopenedinJuly2020whiletheborders remainedcloseduntiltheendofSeptember(6, 38).

EmpiricalFramework

Everyhumanbeingis imbuedwithuniquecapabilitiesthatenable themtoenjoytheirrighttolife(Article3),therighttorestand leisure(Article24)(39),flourishingasahuman(40),andperform expectedsocietalroles (e.g.,spouse,carer,breadwinner/worker, taxpayer,commodityconsumer,investor,innovator,inventor, mentor,learner,educator,religiousworshiper)(41).According totheOECDsuch capabilities(humancapital)include“The knowledge,skills,competenciesandattributes(physical,emotional andmentalhealthplusmotivation,andbehavior)embodiedin individualsthatfacilitatethecreationofpersonal,socialand economicwell-being (p.18)”(42).Theactualizationofsuch capabilitiesduringone’slifetimeenablestheindividual,the family,andthesocietytoflourishorthrive(43).Prematuredeath fromCOVID-19(oranyother cause)annihilatesthestockof thoseembodiedhumancapitalcapabilities(includinghealth), capacitytoenjoyleisureactivities,abilitytoconsumenonhealthgoodsandservices,capabilitytocontributetogovernment revenue(viaservicefeesandtaxes),abilitytosaveandinvest,and abilitytoproducegoodsandservicesfordomesticuseorexport.

Thepotentiallyproductiveyearsoflifelost[YLL]froma COVID-19deathequalstheaveragelifeexpectancyatbirthof Mauritiusminustheageofonsetofdeathofthespecificperson. Jones-Lee(44)andMooney(45)explainsanddiscussesthe strengthsandlimitations ofthethreeapproachesusedtovalue monetarilystatisticalhumanlife,i.e.,thehumancapitalapproach (HCA),therevealedpreferencesapproach(orimpliedvalues), andthewillingness-to-pay(orcontingentvaluation)approach.

ThecurrentstudyemploystheHCAoriginallydevelopedby Petty(46),andafterthat,refinedbyWeisbrod(47)andRice andCooper(48).AccordingtoWeisbrod(47),“Thepresent valueofaman atanygivenagemaybedefinedoperationally ashisdiscountedexpectedfutureearningsstreamnetofhis

consumption.”(p.427).Weisbrod(47),Chisholmetal.(49),and WorldHealthOrganization[WHO](50)recommendsuseofper capitaGDPnetofcurrent healthexpenditureinthevaluation ofYLL.

WhyusenetGDPpercapita,i.e.,thedifferencebetweenGDP percapitaandhealthcareexpenditurepercapita?Economic theoryassumesthateveryrationalindividualstrivestomaximize utility(happinessorpleasureorwelfare).Themaindirect determinantsofutilityaretheconsumptionofhealth,nonhealthgoodsandservices,andleisure(50).Individualsdemand healthbecause itisintrinsicallypleasurable,allowsonetoengage inactivitiesofdailyliving(e.g.,schooling,work),andenables onetoenjoyleisureactivities(e.g.,eatinganddrinkingin restaurants,localandinternationaltourismactivities,sports, socializing,visitingdramaandmovietheaters,sports).People demandhealthgoodsandservices,whichdonotyieldutility, becauseoftheexpectedpositiveimpactonhealth,i.e.,healthrelated-qualityoflifeandlengthoflife.Thus,thedemandfor healthgoodsandservicesisderivedfromthedemandforhealth (51).COVID-19illness(oranyotherillness)compelsindividuals (andhouseholds)topay forhealthgoodsandservices,which reduceshouseholddisposableincome,andhence,enjoymentof leisureactivitiesandnon-healthgoodsandservicesthatdirectly deliverutility(orpleasure)(49).ItisforthisreasonthatWHO (50)recommends:

“...itisimportanttonotethatGDPincludesexpenditureon healthgoodsandservices,sothiscomponentshouldbeomitted, andthefocusofanalysisberedirectedtowardestablishingthe presentvalueofdiscountedaggregateflowsofcurrentandfuture consumptionofnon-health-relatedgoodsandserviceslinkedto disease(p.4)”.

ThecurrentstudyreplicatestheHCAmodeldevelopedby Weisbrod(47),andrecentlyappliedinBrazil(7),Canada(8), China(9),France(10),Iran(11),Italy(12),Spain(13),Turkey (14),theUK(15),andtheUSA(16)toestimatethemonetary valueofhumanliveslost duetoCOVID-19.Thetotaldiscounted moneyvalueofhumanlifelosseslinkedwiththe10COVID19deathsinMauritius (TDMVCLMAURITIUS) equalssumofthe discountedmoneyvalueofeachcasewhoseoutcomewasdeath (DMVCLi).Where‘i’equalsCase1,Case2,Case3,Case4,Case 5,Case6,Case7,Case8,Case9,andCase10.Formulaically:

TDMVCLMAURITIUS = CASE=10 CASE=1 DMVCLi (1)

The DMVCLi foreachith COVID-19casewithdeathoutcome isthesumofthemultiplicationofdiscountfactor,netper capitaGDPforMauritius,andyearsoflifelost(YLL)perith case.Where:

a)Discountfactor (Q1) equals 1 (1+r)t , r isthediscountrate of 3%inthisstudy(7 16, 52),and t isthespecificYLL; b)netpercapita GDPequalsthedifferencebetweenGDPper capita (Q2) minuscurrenthealthexpenditureperperson (Q3) inMauritius;

c)YLLequalstheaveragelifeexpectancyatbirthinMauritius (Q4) minustheaverage ageofonsetofdeathfortheith caseof COVID-19 (Q5 ).

Theformulaforestimating DMVCLi fortheith casecanbe expressedasfollows:

DMVCLi=1,..,10 = T t=1 (Q1) × (Q2 Q3) × (Q4 Q5) (2)

Where: t=j t=1 istheadditionfromthe1st toyear T oflifeforthe ith case,andthemeaningofothervariablesareasdefinedearlier. 2020wastakenasthebaseyearfortheanalysis.

DataandDataSources

Theeconomicmodel(equations1and2)wasestimatedusingthe followingdataanddatasources:

a)Discountrates (Q1) of3%,5%,and10%fromthepublished pastCOVID-19studies(7 16).

b)DataontheGDPpercapita (Q2) ofMauritiusof Int$26,460.581retrievedfromtheIMFWorldEconomic OutlookDatabase(53).

c)Dataonthecurrenthealthexpenditureperperson (Q3) in MauritiusofInt$1,278.012fromtheWHOGlobalHealth ExpenditureDatabase(25).

d)DataonbothsexesaveragelifeexpectancyforMauritiusof 75.51years (Q4),theworldof73.2years,andworldhighest (HongKongFemales)of88.17yearsfromtheWorldometer demographicsdata(5).

e)Dataonthe10COVID-19casesthatdiedfromtheMinistry ofHealthandWellnessCOVID-19website(6),whichis alsoretrievablefrom theWorldometerCoronavirusPandemic Database(5).

f)Dataontheagesofonsetofdeath (Q5) forpersonswhodied ofCOVID-19(i.e.,Case1 = 20years,Case2 = 42years,Case 3 = 51years,Case4 = 59years,Case5 = 59years,Case6 = 63 years,Case7 = 63years,Case8 = 69years,Case9 = 71years, Case10 = 76years)fromtheMinistryofHealthandQuality ofLifeCOVID-19database(6).

g)Dataonthe155personscontaminatedby23positiveCOVID19caseswasfromtheMinistryofHealthandWellness(6).

h)DataonMauritian4,500repatriatedfromforeigncountries, outofthem166testedpositivewasfromtheMinistryof HealthandWellness(6).

DataAnalysis

ExcelSoftware(Microsoft,NewYork)wasusedtoanalysedata followingthestepsbelow:

Step1: Equations1and2insubsectionEmpiricalFramework werebuiltintoanExcelspreadsheet.

Step2: ThenetpercapitaGDPforMauritiuswasestimated bysubtractingcurrenthealthexpenditureperpersonfrom percapitaGDPforMauritius,i.e.,Int$26,460.581minus Int$1,278.012equalsInt$25,182.57.

Step3: TheYLLforeachofthe10COVID-19casesthatdied wascalculatedthroughsubtractionoftheaverageageofonset

ofdeathfromtheaveragelifeexpectancyatbirthinMauritius. ThecalculationofYLLcanbeillustratedusingCase1.The averageageofonsetofdeathforCase1was20years,andthe averagelifeexpectancyforMauritiuswas75.51years.Thus, theundiscountedYLLforCase1equals55.51,i.e.,75.51years minus20years.TheundiscountedYLLforthe10humanlives lostwas187years(See SupplementaryTable1).

Step4: ThediscountingofYLLat3%,5%and10% discountratesyielded124,100,and68years,respectively(See SupplementaryTable2).

Step5: Theeconomicmodelwasestimatedusingadiscount rateof3%,whichiswidelyappliedinhealth-relatedstudies (25 30, 43, 46).Itentailedmultiplicationofthediscounted YLLof124years bythenetGDPpercapita(Int$25,182.57) (See SupplementaryTable3).

Step6: TheaveragemoneyvalueperCOVID-19deathwas calculatedthroughthedivisionofthetotaldiscountedmoney valueofhumanliveslostinMauritiusbythetotalnumberof deaths,i.e.,Int$3,120,689.13dividedby10deaths.

Step7: Theaveragemoneyvalueperpersoninpopulationwas estimatedthroughthedivisionofthetotaldiscountedmoney valueofhumanliveslostbythetotalpopulationin2020for Mauritius,i.e.,Int$3,120,689.13dividedby1,271,766.

Step8: Twounivariatesensitivityanalyseswereconducted totesttheimpactofuncertaintysurroundingtwovariables. First,duetothelackofconsensusinthehealtheconomics literature,uncertaintysurroundsthechoiceofdiscountrate (54, 55).Inordertotesttheimpactofchangesinthediscount rateonthe TDMVCLMAURITIUS,themodelwasrecalculated usingdiscountratesof5%and10%(7 16, 56, 57).Second, thereisnoconsensusregardingwhethertoapplythenational averagelifeexpectancyatbirthortheworldhighestaverage lifeexpectancyatbirthinthecalculationsofYLL(7 16).The economicmodelwasfirst estimatedusingthenationalaverage lifeexpectancyatbirthforMauritius,andsubsequently, reanalysedwiththeglobalaveragelifeexpectancyatbirthand theworldhighestaveragelifeexpectancyatbirth(i.e.,female averagelifeexpectancyinHongKong).

Step9:ThepotentialgainsduetoCOVID-19contacttracing andquarantinewereestimated.Thestepentailedcalculation ofthe:

a)Casefatalityrate = actual10COVID-19deaths dividedbytotalCOVID-19casesof344(1) = 10/344 = 0.0290697674418605.

b)Contaminationsperpatient = 155persons contaminateddividedby23contaminators(5) = 155/23 = 6.73913043478261.

c)Numberprotectedbyquarantine = 166 quarantined casestimescontaminationperpatient(6.73913043478261) = 1,119.

d)NumberofCOVID-19deathsaverted = 1,119protected casestimescasefatalityrate(0.0290697674418605) = 33.

e)Thediscountedmoneyvalueofhumanlivessaved withquarantinewasequalthe33deathsavertedtimes theaveragediscountedmonetaryvalueperhumanlife ofInt$312,069.

TABLE3| Thetotaldiscountedmoneyvalue ofhumanliveslostduetoCOVID-19 inMauritius:assumingnationallifeexpectancyof75.51yearsandadiscountrate of3%.

Casenumberandageat onsetofdeath

Discountedmoneyvalue perhumanlifelost(Int$) Percent

Case1:20years 679,060 21.8

Case2:42years 532,154 17.0

Case3:51years 438,508 14.1

Case4:59years 331,557 10.6

Case5:59years 331,557 10.6

Case6:63years 267,815 8.6

Case7:63years 267,815 8.6

Case8:69years 156,894 5.0

Case9:71years 115,329 3.7 Case10:76years 0 0

Total 3,120,689 100.0

Average 312,069

Step10.Thepotentialgainsfromallmeasures(whichare statedintheMethodssection)takenbytheGovernment andpeopleofMauritiustopreventwidespreadcommunity transmissionofCOVID-19wereestimatedbymultiplyingthe 837predictednumberofdeathsfromCaboreetal.(58)by averagediscountedmoneyvalueperhumanlife.

EthicsApproval

Ethicsapprovalwasnotnecessarysincethestudydidnotinvolve humanoranimalsubjects.Itreliedexclusivelyontheanalysisof secondarydatafromIMF(53),MauritiusMinistryofHealthand Wellness(6), WHO(24, 25),andWorldometer(5)databases.The dataisfreelyaccessibletothepublic.

RESULTS

FindingsofAnalysisWithMauritiusLife Expectancyof75.51Yearsanda3%

DiscountRate

Asdepictedin Table3,the10humanliveslosttoCOVID-19had anestimatedtotaldiscountedmoneyvalueofInt$3,120,689,and anaverageofInt$312,069perhumanlifelost.

Ofthetotaldiscountedmoneyvalueofhumanliveslostdue toCOVID-19(TDMVCL),21.8%accruedtothe20year-oldcase, 17.0%tothe42year-oldcase,14.1%tothe51year-oldcase, 21.2%tothetwo59year-oldcases,17.2%tothetwo63year-old cases,5.0%tothe69year-oldcase,3.7%tothe71year-oldcase, and0.0%tothe76year-oldcase.Thediscountedmoneyvalue perhumanlifediminisheswithincreaseinage.Forinstance,the discountedmoneyvalueofthe20year-oldcasewas6-foldhigher thanthatofthe71year-oldcase.Approximately74.1%ofthe TDMVCLaccruedtopersonsagedbetween20and59years,i.e., themostproductagebracket.

TABLE4| ThetotaldiscountedmoneyvalueofhumanliveslostduetoCOVID-19 inMauritius:assuming5and10%discountrates(in2020Int$).

Casenumberand ageatonset of death

Discountedmoneyvalue perhumanlifelostat5% discountrate(Int$)

Discountedmoneyvalue perhumanlifelostat 10%discountrate(Int$)

Case1:20years 470,877 250,615 Case2:42years 407,779 241,969 Case3:51years 354,922 228,583 Case4:59years 283,910 202,003 Case5:59years 283,910 202,003 Case6:63years 236,554 178,881 Case7:63years 236,554 178,881 Case8:69years 145,716 122,599 Case9:71years 109,027 95,462 Case10:76years 0 0

Total 2,529,250 1,700,996 Average 252,925 170,100

FindingsofReanalysisWith5and10% DiscountRatesWithMauritiusLife Expectancyof 75.51Years Table4 presentstheresultsofsensitivityanalysisofusing5and 10%discountrates.

Reanalysisofthemodelwithadiscountrateof5%,while holdingnationallifeexpectancyconstant,reducedtheTDMVCL byInt$591,439(19.0%),andthevalueperhumanlifeby Int$59,144.Re-estimationofthemodelwitha10%discount rate,holdingthenationallifeexpectancyconstant,decreasedthe TDMVCLbyInt$1,419,693(45.5%),andthevalueperhumanlife byInt$141,969.

FindingsofReanalysisWiththeAverage GlobalLifeExpectancyof73.2Yearsand theWorldHighestLifeExpectancyof88.09 YearsHoldingDiscountRateConstant

at3%

Table5 portraysfindingsofrecalculationoftheeconomicmodel substitutingthenationallifeexpectancywiththeaverageworld lifeexpectancyandtheworldhighestlifeexpectancy.

Applicationoftheaverageworldlifeexpectancyof73.2years, witha3%discountrate,slashedtheTDMVCLbyInt$411,159 (13%),andthevalueperhumanlifebyInt$41,116.Recalculation ofthemodelwiththehighestlifeexpectancyintheworldof 88.09years,holdingdiscountrateconstantat3%,enlargedthe TDMVCLbyInt$1,574,773(50%),andtheaveragediscounted moneyvalueperhumanlifebyInt$157,477.

PotentialGainsFromCOVID-19Contact TracingandQuarantine

Withoutcontacttracingandquarantine,atotalof43persons wouldhavediedduetoCOVID-19withamonetaryvalueof

TABLE5| Thetotaldiscountedmoneyvalue ofhumanliveslostduetoCOVID-19 inMauritius—assumingaverageglobalandworld’shighestlifeexpectancies(in 2020Int$).

Casenumberand ageatonset of death

Discountedmoneyvalueper humanlifelostataverage globallifeexpectancyof73.2 yearsand3%discountrate (Int$)

Discountedmoneyvalue perhumanlifelostat averageworldhighest lifeexpectancyof88.09 yearsand3%discount rate(Int$)

Case1:20years 664,190.0 726,946

Case2:42years 503,662.2 623,909

Case3:51years 401,332.5 558,228

Case4:59years 284,464.2 483,215

Case5:59years 284,464.2 483,215

Case6:63years 214,812.4 438,508

Case7:63years 214,812.4 438,508

Case8:69years 93,606.1 360,710

Case9:71years 48,186.1 331,557

Case10:76years 0 250,667

Total 2,709,530 4,695,463

Average 270,953 469,546

Int$13,269,240,i.e.,Int$10,148,550(valueof33averteddeaths) plusInt$3,120,689(valueof10actualdeadcases).Therefore, quarantinehelpedMauritiustosave33humanliveswitha discountedmonetaryvalueofInt$10,148,550,i.e.,the33deaths avertedtimesaveragediscountedmonetaryvalueofInt$312,069 perhumanlife.

PotentialGainsFromAllMeasuresTaken bytheRepublicofMauritiustoPrevent WidespreadCommunityTransmissionof COVID-19

ThewidespreadcommunitytransmissionofCOVID-19 infectioninMauritius,aspredictedbyCaboreetal.(58)would haveledtoatotalof837lossesinhumanliveswithatotal discountedmonetaryvalueofInt$261,201,681,i.e.,837deaths timesaveragediscountedmoneyvalueofInt$312,069perhuman life.Thus,allmeasuresimplementedintheRepublicofMauritius topreventwidespreadcommunitytransmissionofCOVID-19 mayhavesavedthecountryatotalofInt$258,080,991,i.e., Int$261,201,681minusInt$3,120,689(totalvalueoftheactual 10deaths).

DISCUSSION

KeyFindingsandImplications

• The10humanliveslosttoCOVID-19hadanestimatedtotal discountedmoneyvalueofInt$3,120,689.

• Theaveragediscountedmoneyvalueperhuman lifewasInt$312,069.

• Reanalysisofthemodelwithdiscountratesof5and10% attenuatedtheTDMVCLby19.0and45.5%,respectively.

• Theapplicationoftheaveragegloballifeexpectancyof73.2 yearsslashedtheTDMVCLby13%.

• Theuseofhighestlifeexpectancyintheworldof88.09years enlargedtheTDMVCLby50%.

• Quarantinesaved33humanliveswithadiscountedmonetary valueofInt$10,148,550.

Allmeasuresimplementedtopreventwidespreadcommunity transmissionofCOVID-19mayhavesavedthecountry837 humanlivesworthInt$258,080,991.Theeconomicimpactsof COVID-19,aswellastheimplementationofrelatedcontainment publichealthmeasures,arewell-determined.InApril2020the IMFforecastedthatthenationaleconomywouldcontractby 6.8%in2020.AslongasothercountriesarenotCOVID-19 free,Mauritius,whichisaneconomyheavilydependentonthe tourismindustryremainsvulnerabletotheSpecteroftheglobal pandemic.Inthesamevein,thenationaldebatewhetherto opentheborderstogivesomebreathingspaceandtoallow thetourismindustrytoremainafloatfinanciallyishighonthe agenda.However,asthethreatofthepandemicstilllooms,the economiclossduetopublichealthmeasuresshouldbeweighed againstthepotentialgainsestimatedatInt$261,201,681.While containmentmeasurescomeatacostandstopineconomic activity,beyondeconomics,thepriorityshouldbeontheimpact onlengthandqualityoflifeofpeople.

TheTDMVCLwas0.009%ofthetotalGDP(inPPP)for Mauritiusin2020.Whereas,theaveragediscountedmoneyvalue perhumanlifelossassociatedwithCOVID-19was12-foldthe percapitaGDPforMauritius.

Anincreaseinthediscountratefrom3to10%resultsin adropinTDMVCLfromInt$3,120,689toInt$1,700,996.This representsa46%decrease.Also,a16.7%growthintheaverage lifeexpectancyatbirthleadstoanexpansioninTDMVCLof50%. Thisresultconfirmsthefindingsfrompaststudiesthatindeed, themagnitudemoneyvalueofhumanlifelossesisdependent onboththediscountrateandtheaveragelifeexpectancies used(7 16).

ComparisonWithOtherStudies

Table 6 providesacomparisonofthefindingsfromtheMauritius studywiththoseof10othercountriesthatemployedtheHCAto estimatethemonetaryvalueofhumanlifelossesassociatedwith COVID-19.

Thetotaldiscountedmoneyvalueofhumanlifelossesin Mauritiuswas1,151-foldlowerthanthoseofBrazil(7);653foldofCanada(8);296-foldofChina(9);3,362-foldofFrance (10);1,125-foldofIran(11);4,188-foldofItaly(12);3,086-fold ofSpain(13);352-foldof Turkey(14);3,167-foldoftheUK (15);and6,338-foldoftheUSA(16).Thedifferencescouldbe attributedtosignificantlylowernumber ofCOVID-19deathsin Mauritiuscomparedtothesixothercountries.

Theaveragediscountedmoneyvalueperhumanlifein Mauritiuswashigherthantheothersixcountries(Brazil,Canada, Iran,Turkey,UK,andUSA),whichisrelatedtohighermortality rateintheyoungeragegroupsinMauritius.Astheshareof deathsinCanada,France,Italy,Turkey,UKandUSAintheolder agegroupof60yearsandabovewasconsiderablymuchhigher,

TABLE6| AcomparisonofMauritiusdiscounted moneyvalueofhumanlife lossesassociatedwithCOVID-19tothoseof10othercountries.

Countries Totaldiscounted moneyvalueof humanlifelosses

Theaverage discountedmoney valueperhumanlife

Mauritius* Int$3,120,689 Int$312,069

Brazil(7) Int$3,591,028,164 Int$99,629

Canada(8) Int$2,037,021,173 Int$231,217

China(9) Int$924,346,795 Int$356,203

France (10) Int$10,492,290,194 Int$339,381

Iran (11) Int$3,510,063,043 Int$165,187

Italy(12) Int$13,070,141,190 nt$369,088 Spain(13) Int$9,629,234,112 Int$470,798

Turkey(14) Int$1,098,469,122 Int$228,514

UnitedKingdom[UK](15)Int$9,883,426,226 Int$225,104

UnitedStatesofAmerica [USA](16) Int$19,780,290,991 Int$292,889

Sources: *Estimatesfromthecurrentstudy.Sourcesforothercountriesarereferencedin theTable.

thecomponentofyears’lifelost(lifeexpectancylessageatonset ofdeathduetoCOVID-19)islower.Conversely,aspeopledied fromCOVID-19atrelativelyyoungerageinChinaandSpain,the benefits/returnsforegonehadthesepeoplestayedalivearemuch higherperpersoninChinaandSpaincomparedtoMauritius.

StrengthsoftheStudy

ThisstudyappliedHCA,awell-knowneconomicmethodology, tomonetarilyvaluethehumanlifelossesassociatedwith COVID-19inMauritius.Itisthefirststudyofitskind inMauritius.Theevidencepresentedinthispapercanbe judiciouslyusedbytheMinistryofHealthandWellnessto makeacaseforaugmentinginvestmentstostrengthenhealthrelatedsystemstobridgeextantservicecoveragegaps.Universal coverageofhealthandhealth-relatedserviceswouldcontribute inassuringeverycitizen’srighttolife,andachievementofthe SDG3on“Ensuringhealthylivesandpromotewell-beingforall atallages”andSDG6on“Ensuringavailabilityandsustainable managementofwaterandsanitationforall”[(18),p.14].

LimitationsoftheStudy

Thestudy hadsomeshortcomings.First,thescopeofthestudy waslimitedtotheimpactofCOVID-19onthelifeexpectancy ofthetenpersonswhodied.Therefore,sincethestudydidnot evaluateboththecostsandconsequencesofalternativeCOVID19controlinterventionoptions,thestudyfindingscanonly beusedforadvocacyandnottoinformpolicydevelopment anddecision-making.

Second,thestudydidnotincludethecostofsocietalresources expendedinprevention(water,sanitation,handwashing withsoap,hand-sanitisers,facialmasks,personalprotective equipmentforhealthworkers),quarantine,testing,contacttracing,treatment,andrehabilitationofthe332casesthat recoveredfromCOVID-19infection.Itdidnotalsoincludethe

costofdiagnosis,treatment,post-mortem,mortuarystorage, andintermentofthe10casesthatdied.

Third,Santarpiaetal.(59)conductedastudyamong 13individualswithCOVID-19isolated attheUniversityof NebraskaMedicalCentertoexamineaerosolandsurface contaminationwithSARS-CoV-2.Theauthorsfoundthat “... dataindicatesignificantenvironmentalcontaminationin roomswherepatientsinfectedwithSARS-CoV-2arehousedand caredfor,regardlessofthedegreeofsymptomsoracuityofillness. Contaminationexistsinalltypesofsamples:highandlow-volume airsamples,aswellassurfacesamplesincludingpersonalitems, roomsurfaces,andtoilets”(p.3).Thisimpliesthatsincethere maystillbeaerosolandsurfacecontaminationatquarantine andisolationcenters,wemayhaveoverestimatedtheeffectof quarantine,andhence,thepotentialdiscountedmoneyvalueof humanlivessaved.

Fourth,theHCAapproachusedhasanumberofweaknesses: (a)itusesGDPpercapitatovaluetheYLL,whichignoresnonmarketcontributionstosocietalwelfare,thenegativeimpact ofeconomicproductionprocesses(e.g.,onclimatechange), inequalitiesinthedistributionofwealthandincome,andquality oflife(60);(b)valuestheYLLabovethenationalaverage lifeexpectancyat birthatzero;(c)assumesthattheonly objectiveofimproving(orsustaining)humanhealth(healthrelatedqualityandlengthoflife)istocontributetoeconomic production(61),whichdisregardsotherobjectivessuchas assuringhumanrights(39),andenablinghomosapiensto flourish(40).

CONCLUSION

This studysucceededin estimatingthediscountedmoneyvalue ofhumanlifelossesassociatedwithCOVID-19inMauritiusas of16October2020.Theaveragediscountedmoneyvalueper humanlifelossassociatedwithCOVID-19ofInt$312,069is significant,sinceitis12-foldthepercapitaGDPforMauritius. Asnotedearlier,theRepublicofMauritiuspromptaction inarrestingthespreadofCOVID-19infections,optimizing recoveries,andlimitingthenumberofdeathsislaudable. Allmeasuresimplementedtopreventwidespreadcommunity transmissionofCOVID-19mayhavesavedthecountry837 humanlivesworthInt$258,080,991.Thiseffectivenesshas beenattributedtorelativelygoodpoliticalgovernance,anda highlyperformingnationalhealthsystem,diseasesurveillance andresponsesystem,andothersystemsthataddresssocial determinantsofhealth.

TheMinistryofHealthandWellnesscanusetheevidence containedinthispaper,conjointlywithhumanrights(to life,health,andhealthcare)arguments,tosustainadvocacy forfurtherincreaseinmultisectorinvestmentstobridgethe existinglimitedgapsinUHC,IHRcorecapacities,andsocial determinantsofhealthtomitigateandtorespondtofuturepublic healthemergencies,andtosustainthegoodhealthindicators.

Inordertoguidedecision-makingrelatedtoCOVID19,thereisaneedforstudiesthatestimatebothcosts andconsequencesofalternativeprevention(e.g.,lockdown,

handwashing,physicaldistancing),contact-tracing,quarantine, treatment,andrehabilitationinterventions(62, 63).

DATAAVAILABILITY STATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle/SupplementaryMaterials,furtherinquiriescanbe directedtothecorrespondingauthor/s.

AUTHORCONTRIBUTIONS

LM,AN,andJKdesignedthestudy,extractedthedataonper capitaGDPfromIMFdatabase,currenthealthexpenditureper personfromWHOGlobalHealthExpendituredatabase,number ofCOVID-19deathsinMauritiusfromtheWorldometer database,agesofonsetofdeathfromtheRepublicofMauritius MinistryofHealthandWellnesswebsite,developedthehuman capitalapproachmodelonExcelsoftware,andwrotethe manuscript.Allauthorshavereadandagreedtothepublished versionofthemanuscript.

FUNDING

ThisresearchreceivedfundingfromtheWorldHealth Organization.ThisworkwassupportedbytheWorldHealth Organization[PurchaseOrder202575332,2020].

ACKNOWLEDGMENTS

ThispaperisdedicatedtotheGovernment,health workers,andpeopleofMauritiusfortheexcellentfight againsttheCOVID-19globalpandemic.Thepaper containstheviewsoftheauthorsexclusivelyanddoes notrepresenttheviewsorpoliciesoftheirinstitutions ofaffiliation.

SUPPLEMENTARYMATERIAL

TheSupplementaryMaterialforthisarticlecanbefound onlineat:https://www.frontiersin.org/articles/10.3389/fpubh. 2020.604394/full#supplementary-material

REFERENCES

1.TheWorldBank. MauritiusData. (2019).Availableonlineat:https://data. worldbank.org/country/mauritius(accessedOctober12,2020).

2.UnitedNationsDevelopmentProgramme(UNDP). HumanDevelopment Report2019 BeyondIncome,BeyondAverages,BeyondToday:Inequalitiesin HumanDevelopmentinthe21stCentury.NewYork,NY:UNDP(2019).

3.InternationalMonetaryFund[IMF].G-20surveillancenote.COVID-19— impactandpolicyconsiderations.In: G-20FinanceMinistersandCentral BankGovernors’Meetings,April15,2020VirtualMeeting.Washington,DC: IMF(2020).

4.GlobalBurdenofDiseaseCollaborativeNetwork. GlobalBurdenofDisease Study2017(GBD2017)Results.Seattle,WA:InstituteforHealthMetricsand Evaluation(IHME)(2018).Availableonlineat:http://ghdx.healthdata.org/ gbd-results-tool(accessedOctober12,2020).

5.Worldometer. COVID-19CoronavirusPandemic(Lastupdated:October16, 2020,07:45GMT). (2020).Availableonlineat:https://www.worldometers. info/coronavirus/(accessedOctober16,2020).

6.MinistryofHealthandWellness,RepublicofMauritius. COVID-19 CoronavirusinMauritius. (2020).Availableonlineat:https://health.govmu. org/Pages/default.aspx(accessedOctober16,2020).

7.KirigiaJM,MuthuriRNDK,NkanataLHK,MuthuriNG.Thepecuniaryvalue ofhumanlifelossesassociatedwithCOVID-19inBrazil. IOSRJ. Pharm. (2020)10:45–51.Availableonlineat:http://iosrphr.org/papers/vol10-issue8/ E1008014551.pdf

8.KirigiaJM,MuthuriRNDK.Thedollarvalueofhumanlifelossesassociated withCOVID-19inCanada. PharmBiomedRes.(2020)6.Available onlineat:http://pbr.mazums.ac.ir/article-1-351-en.html&sw=The+Dollar+ Value+of+Human+Life+Losses+Associated+With+Covid-19+in+Cana

9.KirigiaJM,MuthuriRNDK.Thefiscalvalueofhumanliveslost fromcoronavirusdisease(COVID-19)inChina. BMCResNotes. (2020) 13:198.doi:10.1186/s13104-020-05044-y

10.KirigiaJM,MuthuriRNDK,NkanataLHK,MuthuriNG.Thediscounted valueofhumanliveslostduetoCOVID-19inFrance. F1000Research. (2020) 9:1247.doi:10.12688/f1000research.26975.1

11.KirigiaJM,MuthuriRNDK,MuthuriNG.Thepresentvalueofhuman liveslostduetocoronavirusdisease(COVID-19)intheIslamicRepublic ofIran. IOSRJDentMedSci. (2020)19:45–53.doi:10.21203/rs.3.rs-247 11/v1

12.KirigiaJM,MuthuriRNDK,NkanataLHK,MuthuriNG.The discountedfinancialworthofhumanliveslostfromCOVID-19in Italy. IOSRJEconFinanc. (2020)11:15–24.doi:10.9790/5933-1105 051524

13.KirigiaJM,MuthuriRNDK.Thediscountedmoneyvalueofhuman liveslostduetoCOVID-19inSpain. J Health Res. (2020)34:455–60.doi:10.1108/JHR-04-2020-0116

14.KirigiaJM,MuthuriRNDK,NkanataLHK.Themonetaryvalueofhuman lifelossesassociatedwithCOVID-19inTurkey. EmeraldOpenRes. (2020) 22:44.doi:10.35241/emeraldopenres.13822.1

15.KirigiaJM,MuthuriRDKM.Thepresentvalueofhumanliveslostdue toCOVID-19intheUnitedKingdom(UK). PharmBiomedRes.(2020) 19:45–53.

16.KirigiaJM,MuthuriRNDK.Discountedmonetaryvalueofhumanliveslost duetoCOVID-19intheUSAasof3May2020. IOSRJDentMedSci. (2020)19:51–54.doi:10.9790/0853-1905105154

17.MoIbrahimFoundation. Agendas2063&2030:isAfricaonTrack?London: MoIbrahimFoundation(2019).

18.UnitedNations[UN]. TransformingOurWorld:The2030Agendafor SustainableDevelopment.GeneralAssemblyResolutionA/RES/70/1.New York,NY:UN(2015).

19.MoIbrahimFoundation. IbrahimIndexofAfricanGovernance(IIAG). (2019). Availableonlineat:http://iiag.online/(accessedJuly5,2020).

20.WorldHealthOrganization[WHO]. The2018Update:GlobalHealth WorkforceStatistics. (2018).Availableonlineat:https://apps.who.int/gho/ data/node.main-afro.HWFGRP?lang=en(accessedOctober12,2020).

21.WorldHealthOrganization[WHO]. WorldHealthStatistics2015.Geneva: WHO(2015).

22.WorldHealthOrganization[WHO]. GlobalHealthObservatory.Universal HealthCoverage. (2020).Availableonlineat:https://www.who.int/data/gho/ data/major-themes/universal-health-coverage-major(accessedOctober12, 2020).

23.WorldHealthOrganization[WHO]. GlobalHealthObservatory DataRepository.(2020).Availableonlineat:Indexof servicecoverage.https://apps.who.int/gho/data/view.main. INDEXOFESSENTIALSERVICECOVERAGEv?lang=en(accessedOctober 13,2020).

24.WorldHealthOrganization[WHO]. WorldHealthStatistics2020:Monitoring HealthfortheSDGs.Geneva:WHO(2020).

25.WorldHealthOrganization[WHO]. GlobalHealthExpenditureDatabase. (2020).Availableonlineat:https://apps.who.int/nha/database/Select/ Indicators/en(accessedOctober13,2020).

26.UnitedNationsChildren’sFund[UNICEF]WHO. ProgressonHousehold DrinkingWater,SanitationandHygiene2000-2017.SpecialFocuson Inequalities.NewYork,NY:UNICEFandWHO(2019).

27.RepublicofMauritius. HealthStatisticsReport2018:IslandofMauritiusand IslandofRodrigues.PortLouis:MinistryofHealthandWellness(2019).

28.NundoochanA,ThoraballyY,MonohurS,HsuJ.Impactofoutof pocketpaymentsonfinancialriskprotectionindicatorsinasetting withnouserfees:thecaseofMauritius. IntJEquityHealth. (2019) 18:63.doi:10.1186/s12939-019-0959-5

29.UnitedNations[UN]. GlobalHealthandForeignPolicy GeneralAssembly ResolutionA/RES/67/81.NewYork,NY:UN(2012).

30.WorldHealthOrganization[WHO]andTheWorldBank. TrackingUniversal HealthCoverage:2017GlobalMonitoringReport.Geneva;Washington,DC: WHOandTheWorldBank(2017).

31.WorldHealthOrganization[WHO]. RevisionoftheInternationalHealth Regulations.WorldHealthAssemblyResolutionWHA58.3.Geneva: WHO(2005).

32.WorldHealthOrganization[WHO].InternationalHealthRegulations2005 3rded.Geneva:WHO(2005).

33.WorldHealthOrganization[WHO]. InternationalHealthRegulations(2005) -IHRCoreCapacityMonitoringFramework:ChecklistandIndicatorsfor MonitoringProgressintheDevelopmentofIHRCoreCapacitiesinStates Parties.Geneva:WHO(2013).

34.WorldHealthOrganization[WHO]. IHRStatesPartiesAnnualReporting GlobalSubmissionStatusPerYear(Updatedon13-07-2020). (2019).Available onlineat:https://extranet.who.int/e-spar/(accessedJuly17,2020).

35.NundoochanA.Improvingpublichospitalefficiencyandfiscalspace implications:thecaseofMauritius. Int J EquityHealth. (2020) 19:152.doi:10.1186/s12939-020-01262-9

36.CardWI,MooneyGH.Whatisthemonetaryvalueofahumanlife? BrMedJ. (1977)2:1627–9.doi:10.1136/bmj.2.6103.1627

37.RiceDP.Costofillnessstudies:whatisgoodaboutthem? InjPrev. (2000) 6:177–9.doi:10.1136/ip.6.3.177

38.Wikipedia. COVID-19PandemicinMauritius. (2020).Availableonlineat: https://en.wikipedia.org/wiki/COVID-19_pandemic_in_Mauritius(accessed October13,2020).

39.UnitedNations[UN]. InternationalBillofHumanRights:AUniversal DeclarationofHumanRights.GeneralAssemblyResolutionA/RES/217(III)A NewYork:UN(1948).

40.CulyerAJ.Commodities,characteristicsofcommodities,characteristicsof people,utilitiesandthequalityoflife.In:CulyerAJ,CooksonRA,Claxton KP,editors. TheHumbleEconomist:TonyCulyeronHealth,HealthCareand SocialDecisionMaking.York:YorkPublishingServicesLtd.(2012).p.55–66.

41.EaglyA,WoodW.Socialroletheory.In:VanLangePAM,KruglanskiAW, HigginsET,editors. HandbookofTheoriesofSocialPsychology, Thousand Oaks,CA:SagePublicationsInc.(2012).p.458–76.

42.OrganisationforEconomicCo-operationandDevelopment[OECD]. The Well-BeingofNations:TheRoleofHumanandSocialCapital.Paris: OECD(2001).

43.SenA. CommoditiesandCapabilities.Amsterdam:North-Holland(1985).

44.Jones-LeeMW.Thevalueoflifeandsafety:asurveyofrecent developments. GenevaPapRiskInsurIssuesPract. (1985) 10:141–73.doi:10.1057/gpp.1985.13

45.MooneyGH. TheValuationofHumanLife.London:Palgrave(1977).

46.PettyW. PoliticalArithmeticoraDiscourseConcerningthe ExtentandValueofLands,People,Buildings,etc.London:Robert Clavel(1699).

47.WeisbrodBA.Thevaluationofhumancapital. JPoliticalEcon. (1961)69:425–36.doi:10.1086/258535

48.RiceDP,CooperBS.Theeconomicvalueofhumanlife. AmJPublicHealth. (1967)57:1954–66.doi:10.2105/AJPH.57.11.1954

49.ChisholmD,StancioleAE,EdejerTTT,EvansDB.Economicimpactof diseaseandinjury:countingwhatmatters. BrMedJ.(1699)340:583–6.doi:10.1136/bmj.c924

50.WorldHealthOrganization[WHO]. GuidetoIdentifyingtheEconomic ConsequencesofDiseaseandInjury.Geneva:WHO(2019).

51.GrossmanM.Ontheconceptofhealthcapitalandthedemandforhealth. J PoliticEcon. (1972)80:223–55.doi:10.1086/259880

52.GoldMR,SiegelJE,RussellLB,WeinsteinMC. Cost-EffectivenessinHealth andMedicine.Oxford:OxfordUniversityPress(1996).

53.InternationalMonetaryFund[IMF]. WorldEconomicOutlookDatabase. (2020).Availableonlineat:https://www.imf.org/external/pubs/ft/weo/2019/ 02/weodata/index.aspx(accessedJuly20,2020).

54.RobinsonLA,HammittJK.Behavioraleconomicsandtheconductofbenefitcostanalysis:towardsprinciplesandstandards. JBenefitCostAnal. (2011) 2:1–51.doi:10.2202/2152-2812.1059

55.AttemaAE,BrouwerWBF,ClaxtonK.Discountingineconomicevaluations. Pharmacoeconomics. (2018)36:745–58.doi:10.1007/s40273-018-0672-z

56.SinanovicE,RammaL,VassallA,AzevedoV,WilkinsonL,NdjekaN, etal.ImpactofreducedhospitalisationonthecostoftreatmentfordrugresistanttuberculosisinSouthAfrica. IntJTubercLungDis. (2015)19:172–8.doi:10.5588/ijtld.14.0421

57.KirigiaJM. EconomicEvaluationofPublicHealthProblemsinSub-Saharan Africa.Nairobi:UniversityofNairobiPress(2019).

58.CaboreJW,KaramagiHC,KiprutoH,AsamaniJA,DrotiB,SeydiABW,etal. ThepotentialeffectsofwidespreadcommunitytransmissionofSARSCoV2infectionintheWorldHealthOrganizationAfricanRegion:apredictive model. BMJGlobHealth. (2020)5:e002647.doi:10.1136/bmjgh-2020-002647

59.SantarpiaJL,RiveraDN,HerreraVL,MorwitzerMJ,CreagerHM, SantarpiaGW,etal.AerosolandsurfacecontaminationofSARSCoV-2observedinquarantineandisolationcare. SciRep. (2020) 10:12732.doi:10.1038/s41598-020-69286-3

60.StiglitzJE,SenA,FitoussiJP. Mis-measuringOurLives:WhyGDPDoesn’tAdd Up.NewYork,NY:TheNewPress(2010).

61.ShiellA,GerardK,DonaldsonC.Costofillnessstudies:anaidtodecisionmaking? HealthPolicy. (1987)8:317–3.doi:10.1016/0168-8510(87)90007-8

62.MilesD,StedmanM,HealdA.Livingwithcovid-19:balancingcostsagainst benefitsinthefaceofthevirus. NatlInstEconRev. (2020)253:R60–76.doi:10.1017/nie.2020.30

63.PeiS,KandulaS,ShamanJ.Differentialeffectsofinterventiontiming onCOVID-19spreadintheUnitedStates.NewYork,NY:Columbia University(2020).

ConflictofInterest: LMandANarecurrentemployeesoftheWHO.However, theemployerdidnotinfluencetheconductandoutcomeofthestudyinanyway.

Theremainingauthordeclaresthattheresearchwasconductedintheabsenceof anycommercialorfinancialrelationshipsthatcouldbeconstruedasapotential conflictofinterest.

Copyright©2020Musango,NundoochanandKirigia.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

published:11November2020

doi: 10.3389/fpubh.2020.582706

Editedby: DelaliA.Dovie, UniversityofGhana, Ghana

Reviewedby: SalvadorCruzRambaud, UniversityofAlmeria,Spain MarielaDeliverska, MedicalUniversity-Sofia,Bulgaria

*Correspondence: ClaudiaRivera-Rodriguez c.rodriguez@auckland.ac.nz

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 13July2020 Accepted: 08October2020 Published: 11November2020

Citation: Rivera-RodriguezCandUrdinolaBP (2020)PredictingHospitalDemand DuringtheCOVID-19Outbreakin Bogotá,Colombia. Front.PublicHealth8:582706. doi:10.3389/fpubh.2020.582706

PredictingHospitalDemandDuring theCOVID-19OutbreakinBogotá, Colombia

ClaudiaRivera-Rodriguez 1*

andBeatrizPiedadUrdinola 2

1 DepartmentofStatistics,UniversityofAuckland,Auckland,NewZealand, 2 DepartmentofStatistics,NationalUniversityof Colombia,Bogotá,Colombia

Colombia,likemanydevelopingnations,doesnothaveastronghealthsystemableto respondtoapandemicofthemagnitudeofCovid-19.Thereisanincreasingneedto createamodelthatallowsparticularclinicsandhospitalstoestimatethenumberof patientsthatrequireIntensiveCareUnits-ICUcare(critical),andthenumberofpatients thatrequirehospitalcare(severe),butnotICUcare,inordertomanagetheirlimited resources.ThispaperpresentsapredictionofthetotalnumberofICUandregularbeds thatwillbeneededinBogotá,Colombia,duringtheCOVID-19pandemic.Weusean SEIRmodelthatincludesthreedifferentcategoriesofinfection:thosewhocanstay athome,thosewhoneedregularhospitalbeds,andthosewhoneedICUtreatment. Themodelallowsforatimevaryingtransmissionratewhichweusetoincorporatethe measuresintroducedbythegovernmentovertheperiodofonesemester.Themodel predictsthatbymidNovember2020,thecitywillneed1362ICUbedsandmorethan 9000regularhospitalbeds.Thenumberofactivecaseswillbe67,866bythenand thedeathtollwillreach13,268peoplebytheendofDecember.WeprovideaShiny appavailableathttps://claudia-rivera-rodriguez.shinyapps.io/shinyappcovidclinic/.The originalvaluesintheappreproducetheresultsofthispaper,buttheparametersand startingvaluescanbechangedaccordingtotheuser’sneeds.COVID-19hasposed toomanychallengestohealthsystemsaroundtheglobe.Thismodelisausefultoolfor cities,hospitalsandclinicsinColombiathatneedtobepreparedfortheexcessdemand ofservicesthatapandemiclikethisonegenerates.Unfortunately,themodelpredictsthat bymid-NovembertheprojectedcapacityofthesysteminBogotáwillnotbeenough.We expectthelockdownrulestobestrengthenedinfuturedays,sothedeathtollwillnotbe asbadaspredictedbythismodel.

Keywords:COVID-19,SEIR,Bogotá,compartmentalmodel,Colombia

1.BACKGROUND

Thenovelcoronavirusdisease2019(COVID-19)epidemichadspreadfromChinatoalmostallthe countriesintheworldbyApril1,2020.ThefirstofficialcasewasreportedinColombiaonMarch 6,2020,fromanimportedcase,andevolvedtolocalcasesoftransmission.Inordertoreducethe impactoftheCOVID-19outbreakinBogotá,thelargestcityinColombia,alocallockdownwas introducedonMarch15,2020,followedbyanationallockdownonMarch19,2020.Colombia,

likemanydevelopingnations,doesnothaveastronghealth systemabletorespond toapandemicofthemagnitudeof thepresentone.Neitherintermsofinfrastructureandmedical personnel,norintermsoflogisticalpreparednessandthe technicalcapacitytoprovideallmedicallyneededresources. Thelatteristhemainmotivationtocreateamodelthatallows particularclinicsandhospitalstoestimatethenumberofbeds andrespiratorsneededduringthepeakdays.Specifically,we areinterestedinestimatingthenumberofpatientsthatrequire IntensiveCareUnits-ICUcare(critical),andthenumberof patientsthatrequirehospitalcare(severe),butnotICUcare.

AsofApril4,2020,Colombiahadonlycarriedout 460testspermillionpeople(https://infogram.com/, https://ourworldindata.org/covid-testing),whereasother countries,suchasGermanyandSouthKorea,hadcarriedout over1,000testspermillionpeople.Additionally,onMarch26, oneofthetwoavailablemachinesusedtorunthedetectiontests broke,leadingtoareductionoperationsandcausingdelaysin thedetectionofthetotalnumberofcases.Unfortunately,for developingcountrieslikeColombia,ithasbeenanenormous efforttoexpandfacilitiesandtheproductionofbiotechnology inputstorunthenecessarynumberoftestsrequiredtodetectall activecasesofthevirus;thehighestnumberuptodatehasbeen 17,000tests,onJune19,2020.Thus,oneofthebiggestconcerns isthatthedatamaynotbewell-informativeastohowmany hospitalbeds(andICUbeds)willbeneededduringthepeak oftheoutbreak.Infact,oneofthemaincaveatsforthisstudy isthattheofficialdataisverylikelytobeunderestimated,as onlypatientswithatleastonesymptomorthathavehadcontact withanotherdetectedcasearebeingtested(1)(NationalHealth Institutebyitsacronymin Spanish).Moreover,weareemploying anoverallprobabilityofrequiringICUtreatment,althoughsex, age,andco-morbidity(diabetes,hypertension,acuterespiratory diseases,anddepressedimmunesystem)giverisetodifferential probabilities,thatarenottakenintoaccounthere.

WeimplementedanSEIRmodel(Susceptible-Exposed -Infectious-Recovered)toforecastthenumberofcasesin Bogotá,thelargestcityinColombiaandtheonewiththelargest numbersofcasestodate,usingthepublicofficialCOVID-19 informationfromtheHealthSecretariat-Saludataandavailable at(http://saludata.saludcapital.gov.co/osb).Themodelincludes threedifferentcategoriesofinfection:InfectedthatrequireICU care,Infectedthatrequirehospitalcare,butnotICUcare,and InfectedthatonlyrequireHomecare.Themodelaccountsfor theeffectofcontrolstrategiesintroducedbythegovernment bychangingthetransmissionrateovertime.Wedevelopeda Shinyappthatdisplaystheresultsfromthemodel.Itispublicly availableat(https://claudia-rivera-rodriguez.shinyapps.io/ shinyappcovidclinic/).Userscanchangetheinitialparameters accordingtotheirspecificsituation.TheShinyappcanworkas aforecastingtoolforindividualclinicsbyspecifyingthemarket share(percentage)ofthepopulationcorrespondingtotheclinic. Duringtheoutbreak,someclinicsshouldbereadytoseean increaseintheirmarketsharebecausetheymayhavemore

Abbreviations: SEIR,Susceptible-Exposed-Infected-Recovered;ICU,Intensive CareUnit;COVID-19,Coronavirusdisease2019.

resources,suchasICUbeds,andthemodelallowseachclinicto adjustthis.Themodelcanbeusedforspecificcitiesortowns: theuseronlyneedstochangethepopulationsizeandsomeof theparametersofinterest.

2.METHODS

SIRmethods(Susceptible-Infected-Recovered)havebecome widespreadinthepredictionofcommunicablediseasessince theircreationintheearly20thcentury(2).Severalauthorshave providedforecasting models usingthismethod,aspresented in(3),butSIRmodelsrelyheavilyoninitialassumptionsthat arestrong.SEIRmodelsarea variationthatrelaxessomeof thoseassumptions,includingclosedpopulations,andaccount forcommunicablediseasesthattransmitintransitions,starting fromtheentirepopulation(Susceptible)thatincubatethedisease foraperiodoftime(Exposed)makingthepersoninfected butnotinfectious(I)andfinallybecomeRecovered(R)(4). Eachtransitionhasaratebasedonwhatisobservedfrom apopulation,thatis,asusceptiblepersongetsinfectedata transmissionrateonceincontactwithaninfectedindividual, andbecomesexposed.Onceexposed,thetransitiontoinfected happensataratethatcapturestheinverseofthemeanlatent periodofthedisease.Thefinaltransitionisrecoverywith permanentimmunity.Wechosethismodeltoestimatethe demandforbedsforeachinstitutioninColombia,distinguishing betweenregularandICU(IntensiveCareUnits)beds,which allowsdifferenttransitionratesforeachtype.Wealsoestimate therequisitepreparednessandlogisticalneedsforthehealth providers.Similarmethodshavebeenusedtoforecastsimilar needsinEuropeandtheUnitedStatesofAmerica(5 7)andmore recentlytheyhavealsobeenpartofthediscussionindeveloping nations:SIRmodelsarealsousedtoforecastthevirusprogression inColombia.

3.MODEL

WefittedadeterministicSEIRmodelover6months.For practicalpurposes,itisimportanttobearinmindthatpolicies werechangingoverthisperiodoftime,andthereforemodels mustbeupdated.Thepopulationisdividedintocompartments orstatesthatindividualstransitionfromonestatetotheother, correspondingtoSusceptible(S),Exposed(E),Infected(I), recovered(R),anddeath(D).ThoseInfected(I)aresubdivided intothreecompartments: IU, INoU, IH which,respectively,denote infectedindividualsthatrequireICUcare,infectedindividuals thatrequirehospitalcarebutnotICU,andinfectedindividuals thatonlyrequirehomecare.

Oneimplicationofourmodelisthatitdoesnotconsider eventssuchasbirthsormigration,anditonlyconsidersdeaths duetoCOVID-19.Notethatweassumethatpatientstransitfrom EtoICUcaredirectly,thereforeweassumethattheaverage timefrom(E)to(IU)islargerthantheaveragetimefrom (E)to(INoU)andsubsequentlythisislargerthantheaverage timefrom(E)to(IH).Thesetransitionsandconsiderationsare summarizedin Figure1.Wealsoassumethattheonlypatients

thattransitiontodeatharethoseinICU,whilstotherinfected patientsrecover:this assumptionisbasedonthefactthatatthe beginningofthepandemic,whenthisdocumentwaswritten, therewasnocollectedevidencebesidespatientsinclinics,and theobservedratesshowedadisproportionatelylargemortality rateforICUpatientsinWuhanandWashingtonState(8, 9). ThetotalpopulationofBogotáis7.4million,butweassumean initialpopulationsizeof8milliontoaccountforitsmetropolitan areabecausepeoplecommutedailytoworkandstudyfromthe surroundingtownstoBogotá’sCapitalDistrict.

Wedescribetheepidemictransitionsthroughthemodelusing thefollowingequations. dS(t) dt =−β (t)S(t) (IU(t) + INoU(t) + IH)(t) N (1) dE(t) dt = β (t)S (IU(t) + INoU(t) + IH(t)) N (κU + κNoU + κH)E(t) (2) dIU(t) dt = κUE(t) γUIU(t) (3) dINoU(t) dt = κNoUE(t) γNoUINoU(t) (4) dIH(t) dt = κHE(t) γHIH(t) (5) dR(t) dt = (1 d)γUIU(t) + γNoUINoU(t) + γHIH(t)(6) dD(t) dt = dγUIU(t) + γNoUINoU(t) + γHIH(t)(7) N = S(t) + I(t) + R(t) + D(t) (8)

where κNoU = pNoUκ , κU = pUκ and κH = pHκ .Thissetof equationsisthecoremodel,where,attime t,thepopulation isdividedintosusceptible(S(t)),exposed(E(t)),infectedICU (IU(t)),infectedinhospitalbutnotICU(INoU(t)),infectedthat requireonlyhomecare(IH(t)),recovered(R(t))anddeadsubjects (D(t))individuals.Thetotalofinfectedindividualis I(t) = IU(t) + INoU(t) + IH(t),withrespectiveproportions pU, pNoU, and pH.Thetransmissionrate, β (t),controlstherateofspread, i.e.,theprobabilityoftransmittingdiseasebetweenasusceptible andaninfectiousindividual.Weallowthistobeastep-wise functiontoadjustforthemeasurestakenbylocalauthoritiesto controlthespreadofthevirus.Theterm1/κ representsthemean incubationperiodand γU, γNoU, γH arethedailyprobabilities thattherespectivepatientsrecover.Furthermore, d denotesthe probabilityofdeathforICUpatients.Themodel’stransitionsare describedin Figure1.Equation(1)describestherateatwhich newindividualsareexposed,thisrateis β (t)S(t) I(t) N ;Equation(2) describestherateatwhichexposedindividualsbecomeinfected, thisrateis(κU + κNoU + κH)E(t).Infectedindividualsbecome infectedinoneofthethreecategories: IU(t) + INoU(t),and IH(t) withprobabilities pU, pNoU,and pH,respectively.Additionally, Equation(3)describestherateatwhichinfectedindividualsin ICU eitherdieorrecover,thisrateis γUIU(t).Similarly,Equation (4)representstherateatwhichinfectedindividualsinhospital (but,not ICU)eitherdiesorrecover,thisrateis γNoUINoU(t)and

Equation(5)describestherateatwhichinfectedindividualsat homeeitherdieorrecover: γHIH(t).Equation(6)describesthe rateatwhichinfectedindividualsrecover.Notethatthisrateis alwayspositiveandthenumberofrecoveredindividualsnever decreases.Similarly,Equation(7)describestherateatwhich infectedindividualsdie.Notethatonlyindividualsfrom ICU dieandthisrateisalsopositive.Thetotalpopulationis N = S(t) + I(t) + R(t) + D(t)(Equation8).

Weareawarethatothervariables,beyondtotalpopulation counts,suchasageandsexdistributionandhavinganidentified co-morbiditysuchasobesity,diabetes,hypertension,and/or cancer,increasestheprobabilityofdevelopingcomplications duetoCovid-19thatincreasethechancesofdying.However, Colombiandatawasnotavailableatthemicrodatalevelwhenthe pandemicerupted,andstillisnotavailable,notevenintabular form,includinganyoftheseadditionalvariables.Hence,the bestwecoulddowastoimplementthemodelforthegeneral observednumbers.

Tomodeltheimpactoftheinterventionsintroducedbythe government,weallowthetransmissionratetobeastep-wise function β (t),withthreestepsat t0, t1 and t2.Thetime t0 (2020-05-24)correspondstothetimewhenwestartpredicting, t1 (2020-06-16)iswhennewmeasureswereintroduced,and t2 (2020-06-30)isthedatewhenmeasureswererevisedand implemented.Weestimate β (t0)fromthebasicreproduction numbersuchthat R0 = 1.1(10).For t > t0, wechoose β (t) suchthat R(t) ≈ 1.3,for t1 ≤ t < t2 and R(t) ≈ 1.2, for t ≥ t2 (10)(Appendix).

Theterms pU, pNoU and pH denotethe probabilitiesthata caserequiresICUcare,hospitalnon-ICUcare,andonlyhome care,respectively.Notethat pU + pNoU + pH = 1.Toestimate theseprobabilities,weuseinformationfromtheColombian NationalHealthInstitute,finding pU = 0.0168, pNoU = 0.14 and pH = 0.843.Theparameter κ isthedailyprobability ofanexposedindividualbecominginfected,and γU, γNoU, γH arethedailyprobabilitiesthataninfectedindividualrecovers giventhattheyareinICU,Regularbedandhome,respectively. Theprobability d denotestheprobabilitythataninfectedICU individualdies. Table1 displaystheparametersofthemodels, theirinterpretationandsources.Thestartingvaluesforthemodel arebasedonthenumbersfromBogotá,Colombiareportedby May24.Therewhere7,166cases,1,318recovered,and212deaths bytheninthecity.

4.RESULTS

Figure2 showstheresultsthemodelpredictsforeachcategory. Evenwithallthepositivemeasuresassumedinthemodel,we predictthatthepeakoftheepidemiccouldhappenaround November11,2020.Duringthepeakoftheepidemic,the modelpredictsthat1,362ICUswillbeneededforcoronavirus patients,and9,470non-ICUhospitalbeds.Wepredictthatthe maximumnumberofprevalentcaseswillbe67,866(2020-1114)forthe6monthsoftheprediction.Withtheparametersin themodels,thetotalnumberofdeathscouldreach13,268in 6months’time.

FIGURE1| Wedividedthepopulation intosusceptible(S),exposed(E),infectedICU(IU),infectedinhospitalbutnotICU(INoU),infectedthat requireonlyhomecare(IH),recovered(R),anddeadsubjects(D).Infectedsubjectsare IU, INoU or IH withprobabilities pU, pNoU and pH, respectively.Theterm1/κ isthemeanincubationperiodand γU, γNoU, γH arethedailyprobabilitiesthattherespectivepatientsrecover. d isthe probabilityofdeathforICUpatients.

TABLE1| Parametersanddefinitionofmodel(1).

SymbolDefinition Value Source

β (t)Transmissionrate

Stepwisefunction(11, 12)

κ Dailyprobabilityofanexposed individualbecominginfected: κ = 1/α,with α beingthemeanincubationperiod1/5.2 (13)

pU ProbabilityofpatientbeingICU 0.0168 (10)

pNoU Probabilityofpatientbeingin Hospital,butnotICU 0.14 (10)

pH Probabilityofpatientbeingmild/athome 0.843 (10)

γU Dailyprobabilitythataninfected individualinICUrecovers,whenthemeaninfectionperiodis bU, γU = 1/bU 1/6 (13 15) γNoU Dailyprobabilitythataninfected individualinHospital,butnotICU,recovers,whenthemeaninfectionperiodis bNoU, γNoU = 1/bNoU 1/5 (13 16) γH Dailyprobabilitythataninfected individualinHospital,butnotICU,recovers,whenthemeaninfectionperiodis bH, γH = 1/bH 1/5 (13 16)

d Probabilityofdyinggiventhat patientisinICU 0.50 (17)

Figure3 displaysacloserpictureofthoseinfectedandthe totalnumberofdeaths.Wecanseethatthetotalnumberof infectedthatwillneedhospitalcare(ICUandnon-ICU)ishigh enoughforconcern.Additionally, Figure4 showsthoseinfected

thatwillneedhospitalcare,comparedtothecurrentnumberof ICUbedsinthecity.ItshowsthatthenumberofICUsneeded willbe1,362,i.e.,thecityhastoincreaseitscapacityinorderto providecaretoeveryonethatneedsit.Thelocalauthoritiesin

FIGURE2| Progressoftheepidemicusingmodel(1).

Bogotáareplanningtohaveatotalof1,200ICUbedsinthecity, butthecurrentnumberis stilllowerthanthat.Thenumber1,200 willbeoverrunbymid-September,2020,withadeathtollof4,850 peoplebythen.Unfortunately,thetrendkeepsonincreasingover thefollowingmonths,whichreflectsthelackofpreparednessfor acatastrophelikethecurrentoneinBogotá,andprobablyin othersimilardevelopingnations.

WhenweincreasethenumberofdaysthatICUpatientstake torecover,i.e.,1/γU = 14days,ratherthan7,thenumberofICU bedsneededalmostdoubles.IftheprobabilityofbeinganICU patient pU isreduced,thenumberofbedsisreduced,butevena smallincreaseinthisprobabilitywillcausealargeincreaseinthe numberofICUbedsneededduringthepeakoftheepidemic.

5.DISCUSSION

ThispaperpresentsapredictionofthetotalnumberofICUand regularbedsthatwillbeneededduringthepandemicCOVID-19 forBogotá,Colombia.WeuseaSEIRmodelthatdifferentiates betweenthreetypesofinfectedpatients:thosewhocanstayat home,thosewhoneedregularhospitalbeds,andthosewho needICUtreatment.Itemploysameanincubationperiodof 5.2daysandmeaninfectionperiodsof4days(forpatientsat home),5days(forpatientsinregularhospitalbeds),and7days (forpatientsinICU).Theparametersassumedinthemodelare forapositivescenario,wheretheeffectivereproductionnumber duringthelock-downisassumedtobe1.1,and1.3afterthelockdown,and1.2whenothermeasuresareintroduced.Weassume that2.6%ofpatientsrequireICUtreatment,13.4%require regularhospitalbeds,andtherestonlyrequirehomecare.The modelallowsforatimevaryingtransmissionratewhichweuse toincorporatethemeasuresintroducedbythegovernmentover theperiodof1year.Themodelpredictsthatbymid-November,

2020,thecitywillreachthepeakoftheepidemicwithatotal 67,866prevalentcasesand1,362activeICUprevalentcases.

Thenumberofpatientsthatneedhospitalizationcansurpass thecurrentplannedcapacity,setat1,200bedsforICU bedsinthecity,andthedeathtollcanreachatotalof 13,268in6months’time(bytheendofDecember).The unpreparednessofthehealthsystemwillonlyincreaseCOVID19relatedandunrelatedmortality,asalreadyobservedin Italy,theUSA,andothercountries.Measureslikelockdown havebeenusedinmostcountriestodiffusethedemandfor healthservicesduetoCOVID-19overtime,howeveritmay beinsufficientiftherearenotenoughresourcestorampthe healthservicesindevelopingnations,suchasisthecaseof Colombia,wheretheneedforadditionalresourcesisapriority atthispoint.

OtherthantheintrinsiclimitationsofSEIRmodels, thispredictionmodeldoesnottakeintoaccountthe ageandsexdistributionofthepopulation,butweplan tointroducesuchdistinctionsinafutureversionofthe modelwithanadditionalmixingincludingthecontact matrices,astherecentnationalpopulationcensusin Colombiaisavailable.Also,wehavefittedamodel withtwointerventions:alockdownandmitigation measures,butthiscanbemodifiedlaterintime.Neither dowetakeintoaccountregionaldifferences,ina tropicalcontextrelatetoweatherandclimate,because thereisnoevidence,todate,whetherthepatternof spreadofthenovelcoronavirusdependsonweather conditions.

Finally,weprovideaShinyappavailableathttps://claudiarivera-rodriguez.shinyapps.io/shinyappcovidclinic/.Theoriginal valuesintheappreproducetheresultsofthispaper,butthe parametersandstartingvaluescanbechangedaccordingtothe user’sneeds.

FIGURE3| Progressoftheepidemic—infectedanddeaths,resultsfrommodel(1).

FIGURE4| Progressoftheepidemic—infectedthatrequireICUandinfectedthatrequireregularhospitalbeds,resultsfrommodel(1).

6.CONCLUSIONS

COVID-19hasposedtoo manychallengestohealthsystems aroundtheglobe.Itisremarkablethatgovernmentseverywhere haveswiftlyrespondedbyincreasinglaboratorytests,medical personnel,infrastructure,anddataproductionlinkedtothe disease.Itisevenstrikingthatadevelopingnation,such asColombia,haspubliclyavailableinformationupdated dailyontheevolutionofthepandemic,withallthe attendantprosandcons.Dailydataisprobablydefective, andbynowispreliminary,butstillveryhelpfulwhen tryingtofindsolutionstothehardissuesimposedonthe demandforhealthresourcesduetothepandemic.The standardtimeofproductionofmortalitydatais2years

andatrimester,accordingtotheofficialnationalstatistical office(DANE).

Thismodelisausefultoolforcities,hospitalsandclinics inColombiathatneedtopreparefortheexcessdemandof servicesthatasituationlikethisimposes.Themodelpredicts thatbymid-November,thecurrentcapacityofICUsinBogotá willnotbeenoughifnoothermeasuresaretaken.Lockdownrulesinfactwerestrengthened,tracking,surveillance andtestingcapacitiesalsoincreased,andsocialbehaviortilted towardfollowingpreventivemeasures.Asaresult,theobserved reproductivenumbersdramaticallydiminished,andwhenused inthemodelweobtainafairlysimilarnumberofbedsdemanded asthoseactuallyobserved,andaslightlyhighermortalitythan observed.Weexpectallthosemeasuresandpreventivebehavior

willbemaintainedfortheremainderofthepandemic,otherwise therewillbeademand forbedsthatwillsurpassthecurrent capacityinthecity.

DATAAVAILABILITYSTATEMENT

Thematerials(code)usedand/oranalyzedduringthe currentstudyareavailablefromthecorresponding authoronreasonablerequest.Additionally,ashiny appisavailableonlineathttps://claudia-riverarodriguez.shinyapps.io/shinyappcovidclinic/.

REFERENCES

1.InstitutoNacionaldeSalud,INS(2020). CoronavirusColombia.Available onlineat:https://www.ins.gov.co/(accessedApril28,2020).

2.AndersonR.TheKermack-McKendrickepidemicthresholdtheorem. Bull MathBiol. (1991)53:3–32.

3.MurrayC.ForecastingCOVID-19impactonhospitalbed-days,ICU-days, ventilator-daysanddeathsbyUSstateinthenext4months. medRxiv [Preprint].(2020).doi:10.1101/2020.03.27.20043752

4.MartchevaM.Anintroductiontomathematical epidemiology.In TextsinAppliedMathematics.Vol.61. NewYork,NY:Springer(2015).doi:10.1007/978-1-48997612-3

5.LiR,RiversC,TanQ,MurrayM,TonerE,LipsitchM.Thedemandfor inpatientandICUbedsforCOVID-19intheUS:lessonsfromChinesecities. medRxiv[Preprint].(2020).doi:10.1101/2020.03.09.20033241

6.MassonnaudC,RouxJ,CrépeyP.COVID-19:forecastingshort termhospitalneedsinFrance. medRxiv[Preprint].(2020). doi:10.1101/2020.03.16.20036939

7.ZhangT,McFarlaneK,VallonJ,YangL,XieJ,BlanchetJ,etal.Amodel toestimatebeddemandforCOVID-19relatedhospitalization. medRxiv [Preprint].(2020).doi:10.1101/2020.03.24.20042762

8.DuRH,LiuLM,YinW,WangW,GuanLL,YuanML,etal. Hospitalizationandcriticalcareof109decedentswithCOVID-19 PneumoniainWuhan,China. AnnAmThoracSoc. (2020)17:839–46. doi:10.1513/annalsats.202003-225oc

9.PhuaJ,WengL,LingL,EgiM,LimCM,DivatiaJV,etal.Intensive caremanagementofcoronavirusdisease2019(COVID-19):challenges andrecommendations. LancetRespiratMed. (2020)8:506–17. doi:10.1016/s2213-2600(20)30161-2

10.BogotaA. COVID-19enBogota.(2020).Availableonlineat:https://bogota. gov.co/coronavirus-en-bogota/(accessedJune,2020).

11.LiuY,GayleAA,Wilder-SmithA,RocklövJ.Thereproductivenumberof COVID-19ishighercomparedtoSARScoronavirus. JTravelMed.(2020) 27:taaa021.doi:10.1093/jtm/taaa021

12.KucharskiAJ,RussellTW,DiamondC,LiuY,EdmundsJ,Funk S,etal.EarlydynamicsoftransmissionandcontrolofCOVID-19: amathematicalmodellingstudy. LancetInfectDis. (2020)20:553–58. doi:10.1016/S1473-3099(20)30144-4

AUTHORCONTRIBUTIONS

CR-Rcontributedtotheanalysisandcodingofthemodeland theshinyapp.BUcontributedtomodelinterpretationandarticle writing.Allauthorshavereadandapprovedthemanuscript.

ACKNOWLEDGMENTS

Thismanuscripthasbeenreleasedasapre-printathttps:// www.medrxiv.org/content/10.1101/2020.04.14.20065466v2(18). Wethankthe ColombiaresearchgroupCOVIDModelingCG fortheirfeedback.

13.ZhangJ,LitvinovaM,WangW,WangY,DengX,ChenX,etal.Evolving epidemiologyandtransmissiondynamicsofcoronavirusdisease2019outside Hubeiprovince,China:adescriptiveandmodellingstudy. LancetInfectDis. (2020)20:793–802.doi:10.1016/s1473-3099(20)30230-9

14.LiuT,HuJ,XiaoJ,HeG,KangM,RongZ,etal.Time-varyingtransmission dynamicsofNovelCoronavirusPneumoniainChina. bioRxiv[Preprint]. (2020).doi:10.1101/2020.01.25.919787

15.PremK,LiuY,RussellTW,KucharskiAJ,EggoRM,DaviesN,etal.Theeffect ofcontrolstrategiestoreducesocialmixingonoutcomesoftheCOVID-19 epidemicinWuhan,China:amodellingstudy. LancetPublicHealth. (2020) 5:e261–e270.doi:10.1016/S2468-2667(20)30073-6

16.LinQ,ZhaoS,GaoD,LouY,YangS,MusaSS,etal.Aconceptualmodel forthecoronavirusdisease2019(COVID-19)outbreakinWuhan,China withindividualreactionandgovernmentalaction. IntJInfectDis. (2020) 93:211–16.doi:10.1016/j.ijid.2020.02.058

17.WuZ,McGooganJM.Characteristicsofandimportantlessonsfromthe coronavirusdisease2019(COVID-19)outbreakinChina:summaryofa reportof72314casesFromtheChineseCenterforDiseaseControland Prevention. JAMA. (2020)323:1239–242.doi:10.1001/jama.2020.2648

18.Rivera-RodriguezC,UrdinolaBP.Predictinghospitaldemandduringthe COVID-19outbreakinBogota,Colombia. medRxiv[Preprint]. (2020). doi:10.1101/2020.04.14.20065466

19.vandenDriesscheP.Reproductionnumbersofinfectiousdiseasemodels. InfectDisModell.(2017)2:288–303.doi:10.1016/j.idm.2017.06.002

20.DiekmannO,HeesterbeekJAP,RobertsMG.Theconstructionofnextgenerationmatricesforcompartmentalepidemicmodels. JRSocInterface. (2009)7:873–85.doi:10.1098/rsif.2009.0386

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Rivera-RodriguezandUrdinola.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

APPENDIX

REPRODUCTIONNUMBERAND β (T)

Weusethe nextgenerationmatrixapproachtofindthebasic reproductionnumber(19, 20).Weestimate β (t0)fromthebasic reproduction number.Tofind R0,following(4),welet x = [E, IU, INoU, IH ]and y = [S, R, D]. Diseasefreeequilibriumis x0 = [0,0,0,0]and y0 = [N,0,0].Then,

Using this,wefindthat β (t0) = γUγNoUγH(κU + κNoU + κH) γNoUγHκU γUγHκNoU γUγNoUκH R0 (A8)

When R0 = 1.1, β (t0) = 0.22.Ourrationale forchoosing β (t1)and β (t2)isasfollows. Usingtheinitial β0,wecalculate S(t1)/N,andweassumethat R(t) = 1.3for t1 ≤ t ≤ t2,and R(t) = 1.1for t > t2 Tofind β (t),weassumethat R(t) ≈ β (t) ∗ τ S(t)/N.So,we havethat β (t) ≈ R(t) ∗ N/(τ ∗ S(t))So,wehave β (t) = 0.26for t1 ≤ t ≤ t2,and β (t) = 0.24for t > t2.

published:16November2020 doi:10.3389/fbuil.2020.590146

Editedby: DelaliA.Dovie, UniversityofGhana,Ghana

Reviewedby: CheulKyuLee, KoreaRailroadResearchInstitute, SouthKorea RuilinYou, ChinaAcademyofRailwaySciences, China

*Correspondence: SakdiratKaewunruen s.kaewunruen@bham.ac.uk; sakdirat@gmail.com

Specialtysection: Thisarticlewassubmittedto TransportationandTransitSystems, asectionofthejournal

FrontiersinBuiltEnvironment

Received: 31July2020 Accepted: 15October2020 Published: 16November2020

Citation: LiuR,LiDandKaewunruenS (2020)RoleofRailwayTransportation intheSpreadoftheCoronavirus: EvidenceFromWuhan-Beijing RailwayCorridor. Front.BuiltEnviron.6:590146. doi:10.3389/fbuil.2020.590146

RoleofRailwayTransportationinthe SpreadoftheCoronavirus:Evidence FromWuhan-BeijingRailway Corridor

RuchengLiu,DanLiandSakdiratKaewunruen*

SchoolofEngineering,UniversityofBirmingham,Birmingham,UnitedKingdom

ThelastfewmonthshavemarkedanotablesurgeinCOVID-19.Thediseasehas infected10millionpeoplearoundtheworldandhasgainedattentioninthefieldof research.AllegedlyoriginatinginChina,thevirushasspreadtonearlyeverycountry. Thecurrentstudyaimstoanalyzethepotentialspreadofthecoronavirusthroughrail transportbyconsideringthecaseoftheWuhan-BeijingrailwaycorridorinChina.Ithas beenfoundthatapproximately43,000peopletraveldailythroughthisrailwayline,which indicatesahighchanceforthisrailwaylinetospreadthevirus.Thisstudyadoptsa quantitativemethodologytoanalyzethespreadofthediseaseduetoalargenumberof peopletravelingontheWuhan-Beijingrailwayline.Thefindingsofthisstudyestablish thattherailwaylineleavingWuhancarriesapproximately43,000peopledaily.Themore peopletravel,thehigherthechancesareforthespreadofthediseasethroughthis railwayline.Inlinewiththat,thestudyhasalsoanalyzedtheeffectivenessofcontrol measuressuchaslockdown,theuseofmasks,sanitization,andsocialdistancing forrailwayauthoritiesaswellaspassengers.Thisstudyconcludesbyproposingnew practicalrecommendationsforfurthercontrollingthespreadofthediseaseinWuhan.

Keywords:COVID-19,COVID,coronavirus,railway,transportation,corridor

INTRODUCTION

Overthepastfewmonths,theworldhasexperiencedamassiveoutbreakofanovelcoronavirus (COVID-19),whichisbelievedtohaveoriginatedinWuhan,China.Theexactsourceofthevirus is,however,stillunclearbuthealthofficialshaveidentifiedthatthevirusimmediatelyspreads frompersontopersonwhenaninfectedpersoncoughsorsneezesclosetoanotherperson.Since December2019,thevirushascausednearly3,300deathsinChina(Jungetal.,2020).Outside China,thevirushasspreadtoapproximately200countriesaroundtheworldandstudieslike (Luetal.,2013)and(Yangetal.,2020)reportthattheoutbreakhasnowbeendesignatedaglobal pandemic,whichisjustifiedbyitsspreadaroundtheworld.Thepandemichasresultedinmany countriesimposingstrictlockdowns.Thegovernmentsofallcountrieshavebeentakingserious stepstominimizethespreadofthedisease.Hence,itcanbestatedthatresearchersandhealthcare authoritiesareworkinghardtonotonlyidentifythecausesofthevirusbutitscuretoo.

Ithasbeenreportedthatthespreadofthevirushasbeenmost severeinChina.TheBBChasreportedthatthecoronavirusisstill spreadingthroughoutthecountry.Researchersandspecialists havespentagreatamountoftimetryingtoidentifythecauses ofthediseaseinChina,butthisisstillnotclearlyknown. Althoughacarefulassessmentofthediseasehasresultedin recognizingthemethodsresponsibleforthespreadofthedisease. Forinstance,researchers(Cascellaetal.,2020)revealedthatthe diseasespreadsbyalackofdistancebetweenpeople.Similarly, anotherstudyanalyzed(Peerietal.,2020)howthevirustransfers byphysicalcontactbetweenpeople,suchasthroughhandshakes andhugs.Thefindingsofastudyby Ayitteyetal.(2020) identifiedtheobjectsthroughwhichcoronavirusislikelyto spread,suchashandrails,telephones,anddoorhandles.The Guardianalsosupportsthisfindingbystatingthatbanknotes, doorhandles,andhandrailsarethemostsignificantobjects thattransmitthediseasefromonepersontoanother.This impliesthatplaceswhicharedenselypackedhavethehighest probabilityofcontributingtothespreadofthecoronavirus. Amongotherplaces,railwaystationshavebeenignoredinthe literature,whichiswhythisstudyassessesthespreadofthe coronavirusthroughrailtransportbyconsideringtheexampleof theWuhan-Beijingrailwayline.

Background

Withitsmassiveoutbreak,thediseasehasgainedattention inthefieldofresearchtoo.Variousresearcherslike(Balkhair etal.,2017),(Anthonyetal.,2017),and(Wangetal.,2020) havededicatedstudiestoanalyzethecauses,impacts,and controlmeasuresofthecoronavirus.Moreover,scholarsare alsoattemptingtocarefullygaugethespreadpatternsofthe diseasesothattheycanbecontrolled.Buttheexistingresearch failstoacknowledgethespreadofthediseasethroughrailway transportinChina.Thelastdecadehasmarkedamassivegrowth inrailtransportinthecountrywithabout3.4billionpeople travelingbytrainin2018.Itis,therefore,essentialtoidentify thetransmissionofthediseasethroughthisformoftransport. Thisstudyseekstoinvestigatehowincreasingmovementof peoplethroughtherailwayinChinaplaysasignificantrole inthespreadofthecoronavirus.About440millionpeople traveledusingWuhan’srailwaylineforChina’sNewYear festivities,thespreadofthediseasewasevident(Wong,2019). Therefore,thefocusofthisstudyhasbeennarroweddownto evaluatethespreadofthecoronavirusthroughtheWuhanBeijingrailwayline.

ResearchQuestions

Thefindingsofthisstudywilladdressthefollowingresearch questions:

• Howdoeshighdependenceonrailtransportspreadthe coronavirusindifferentcitiesofChina?

• Whatistheeffectivenessofthecurrentpracticesand controlmeasuresforthespreadofthecoronavirus?

• Whatarethestrategiestocontrolthespreadofthe coronavirusthroughrailtransportinWuhanand Beijing?

PREVIOUSSTUDIES

Sincethistopicisgainingincreasingattentionintheresearch frontier,itisessentialtoreviewwhathasalreadybeenreported sofar.Thus,thissectionreviewspreviousstudiesonthetopic.

SpreadPatternsoftheCoronavirusin China

Studiesrecognizethefirstknowncaseofthecoronavirustobe onDecember1,2019,inWuhan,Hubei,afterwhichthecases continuedtoincrease(Zhaoetal.,2020b).Eversince,thevirus hasspreadnotonlythroughtheprovincebutthroughoutthe wholeofChinatoo.Inviewoftheinitialspreadofthedisease inWuhan,thefocusofthisresearchisalsoWuhan.Chinais identifiedasthemostpopulouscountryintheworld.Wang reportsthatthecountryhadapopulationofapproximately1.39 billionin2018withanareaof8,494km2,asshownin Figure1 (Wang,2019).Wuhan,withapopulationof11millionpeople istheseventhmostpopulatedcityinChina.As Figure1 shows, WuhanislocatedinthemiddleofChina,hasaconvenient transportsystem,andsoitispossibletoassumethatthevirus canbespreadtoallofChinafromWuhanasthecenterofthe breakout,asshownin Figure2

Relatingthatwiththecoronavirus,itcanbeseenthatamassive numberofpeoplearelikelytobeinfectedinthecountry.This alsoindicatestheuncontrolledspreadofthediseaseinChina, comparedtoothercountries(see Figure3).Thefigurealso showsthepatternofthediseaseacrossJanuary,March,and May. Figure2 highlightsthemassivenumberofcoronavirus casestobeidentifiedinWuhan(asshownbynumberand dots).ThetotalnumberofcasesconfirmedbytheChinese authoritiesjumpedto4,515onJanuary27,whichshowsan immenseincreasefrom1,680casesfromthepreviousday(BBC China,2020).Thisuncontrolledoutbreakforcedthegovernment andhealthauthoritiesinChinatotakemultiplestepstocontrol thedisease,suchaslockdowns,thebanonmovementofpeople andtransport,andastrictprohibitiononpublicgatherings.Due tothesedrasticmeasures,thespreadoftheviruswascontrolledin thecountry,ultimatelyresultinginnonewreportedcasesinthe middleofMarch.BloombergNewsreportsthatwiththepassage oftime,thecountrywitnessedagradualdecreaseinthenumber ofcasesidentifiedandanincreaseinthenumberofrecovering people(BloombergNews,2020).

RailTransportandtheSpreadofthe Coronavirus

Withanemergingvolumeofresearchbeingdedicatedtothe spreadofthecoronavirus,researchersareattemptingtoidentify thecausesofthediseasetoo.Inthisregard,researchersand officialshavediscussedthevariousobjectswhichcancontribute tothespreadofthedisease,suchasthosestatedbefore.Objects usedbymultiplepeople,forinstance,coffeemachinesinan office,ATMmachines,andbathroomsurfaces,contributetothe spreadofthedisease.Giventhecurrentsituation,governments andauthoritieshaveputastrictbanontransportmechanisms (Ranasingheetal.,2020).Thissituationcanbejustifiedbythe

factthattransportvehicles,specificallytrainsandbuses,spread thediseasetoalargeextent. Otteretal.(2016) explainsthis factbyshowingthat,amongothermaterials,plastic,andsteel contributesignificantlytothespreadofthedisease.TheNew EnglandJournalofMedicinereportedthatthecoronaviruscan surviveonmaterialslikeplasticandsteelforaslongas72h, cardboardforapproximately24h,andcopperforanestimated 4h(Pasley,2020).Thisdoesnotimplythattheseobjectsspread thevirus;instead,thatinteractionwiththeseobjectsandthen touchingthefacedoes.

Byrelatingthesefindingsbacktothetransportmechanism, itcanbestatedthattheinfrastructureoftransportationrelies heavilyonthesematerials.Whenpeopleusetransportservices, suchastherailway,theyarehighlylikelytobecontaminatedwith thevirus.Thiscanbeexplainedbytheincreasinguseofhandrails

andticketmachines,whichiswhyauthoritiesdisinfectthemfrom occasionally. Shenetal.(2016) reportsthatrailtransportarea highlypopularmodeoftransport,withahighdensityofpeople. Sincethevirusspreadsbythecloseproximityofpeople,the chancesforthediseasetoriseareevidentthroughrailtransport (Shenetal.,2016). GoscéandJohansson(2018) addtothese findingsandstatethatpeopletravelingthroughunderground railwaysarepronetoinfluenza-likediseases,whichcanlaterlead tothecoronavirus.Someundergroundrailwaylinesaredensely packedwithpeople,whichalsoindicatestheriseofthevirus duetothelackofdistancebetweenpeople.Apartfrompeople atrailwaystations,peoplelivinginnearbyareasarealsoprone tothevirusbecauseofitscontagiousnature.Thisalsojustifies thestrictlockdownsandbansonrailtransportbygovernments indifferentcountries.Theresearchinthisdimensionconcerning thespreadofthevirusisrare,whichjustifiesthefocusof thecurrentstudy.

Giventhesignificanceofrailtransport,theliteratureneeds topayattentiontothespreadofthecoronavirusthrough transport.Forinstance, Wong(2019) reportedontheincreasing dependenceofpeopleonrailtransportinChina.Otherstudies like(Ranasingheetal.,2020)addtothesefindingsandstatethat peopleinChinafinditfeasibletotravelwithincitiesthrough high-speedrailnetworks.Thesignificanceoftherailwaynetwork inWuhanisspecificallyemphasizedbecauseitisthehubof transportationinHubeiprovince.Whileresearchershighlightthe significanceofrailtransportanddependenceonit,theyareyet toinvestigatethespreadofcoronavirusduetothisdependence. Thisresearchseekstofillthisgapinlightoftheexistingliterature. Thisstudywillbehelpfulforpolicymakersandthemanagement authoritiesofWuhanrailwaystationssinceitwillhighlighthow thespreadofthediseasecanbecontrolled.

FIGURE1| Chinamap(highlightedareashowingWuhan).

METHODOLOGY

Designinganeffectivemethodologyisofcoresignificance togeneratehigh-qualityresearchresults.Thus,thissection highlightsthemethodologicalfoundationsofthecurrentstudy.

ResearchMethod

Thecurrentresearchusesquantitativemethodswhichare assumedtogeneratecredibleandobjectivefindings.Asthe questionathandisofcoreimportance,itisessentialfor theresearchertogenerateundistortedandauthenticfindings. Aqualitativeresearchmethodwasnotusedtogaugethespread ofthecoronavirusthroughtherailwaybecausethismethodtakes timeandislikelytobemisinterpretedbytheresearcher(Tracy, 2019).Thus,aquantitativemethodwasusedtogaugethenumber ofpeopletravelingalongtheWuhan-Beijingrailwaylineandthe consequentspreadofthedisease.Inlinewiththechosenmethod, thisresearchmakesuseofpositivistphilosophy.Throughthis philosophy,thisresearchgeneratescredibleandreliableresults aboutthespreadofthecoronavirusthroughrailtransportin China.Althoughinterpretivismcanalsobeusedforthisresearch, positivismwaschosen,tosavetimefortheresearch.Positivist philosophyisalsopreferredbecauseitkeepstheresearcher detachedfromthefindingsofthisstudy.Carehasbeentaken inordertomakethefindingsregardingthespreadofthe coronavirusthroughrailwaystationsmeaningfulandobjective.

Thismethodologymakesuseofadeductiveapproach.The choiceofapproachcanprimarilybejustifiedbythefactthata largevolumeofdataalreadyexistonthistopic,whichcanbe analyzedtogaugethespreadofthecoronavirusinChina.The inductiveapproachwouldhavebeenpreferrediftheresearch lackedanytheoriesortestablehypothesesregardingthespread

ofthecoronavirusinChina,asalsoanalyzedby Liu(2016).In viewoftheproblemathand,theappropriatenessofthedeductive approachisjustifiedbecauseonlythroughthisapproachisthe researcherabletoempiricallyidentifywhetherthecoronavirus spreadsthroughrailtransportandtowhatextent.

Sampling

Multiplesamplingtechniquescanbeusedtodrawa representativesampleforstudy.Thecurrentstudyrelieson arandomsamplingtechnique.Thistechniquemadeiteasier fortheresearchertoselectthesamplerespondentsasperhis ease.Thesamplerespondentsincluderailwaystationofficials atWuhan,whoareawareoftheWuhan-Beijingrailwayroute aswellasthenumberofpeopletravelingthroughit.Througha randomsamplingtechnique,theresearcherselectedasampleof 50respondentsfromtheadministrativebodyofWuhanrailway station.Theuseofasampleofthissizeisjustifiedby Heydari andMountrakis(2018)

DataCollectionStrategyandMethod

Thecurrentstudyreliesonprimarydatathroughsurvey questionnaires,whichrailwaystationofficialsinWuhan completed.Sincethereislittletonoevidenceaboutthespread ofthecoronavirus,specificallythroughrailtransport,collecting primarydataisessentialandjustified.Differentstrategiesare usedforthecollectionoffreshdata,outofwhichsurveyshave beenusedinthisstudy.Inaccordancewiththequantitative approachandpositivistphilosophy,theresearchrelieson quantitativesurveys(Bramleyetal.,2018).Afive-pointLikert scalequestionnairewasdesignedtocollectdatafromrailway officialsatWuhanrailwaystation.Sincethescopeofthisresearch islimitedtotheWuhan-Beijingrailwaylineonly,questionswill

FIGURE3| SituationofthespreadofthecoronavirusinChina(Self-drawn).

relatetothenumberofpeopletravelingbyrailfromWuhanto Beijingbeforethespreadofthecoronavirus,thenumberofcases reportedasaresultofthattravel,andareaswherethedisease hasspreadasaresult.Theuseofquantitativesurveysisjustified forthisresearchsincethisstrategyhasallowedtheresearcher togainaconsiderableamountofdatainacomparativelyshort time(CliftonandCarrasco,2018).Thiswouldnothavebeen possibleusingotherresearchstrategies,likeinterviewsand observations.Thedatacollectedhasthenbeenanalyzedusing descriptiveanalysistechniques,soastoprovideasummaryof thekeyfindingsregardingthespreadofthecoronavirusthrough railwaysinChina.

EthicalConsiderations

Whencollectingthedata,theresearcherhasbeencautiousabout sustainingtheethicalstandardsforconductingresearch.Inthis regard,theresearcherhastakencarenottouseanyforceful techniquestocollectdata.Moreover,alltherespondentswere giventherighttowithdrawfromthestudyatanypoint.Asper therecommendationof Tourangeau(2018),theresearcherhas takenspecialcaretomaintaintheconfidentialityandanonymity oftherespondents.Besidesthis,carehasbeentakentoavoidthe misuseofdatacollected.Thestudiesusedfortheliteraturereview havebeencitedappropriately.Inthisway,theethicalstandards requiredforthisresearchhavebeenassured.

RESULTSANDDISCUSSION

Thedatacollectedthroughprimarymeanshasbeenanalyzed usingdescriptiveanalysis.Thissectionisdedicatedtoillustrating anddiscussingthekeyfindingsfromtheprimarydata.Inorder toextractusefulmeaningsfromthefindings,thediscussionis builtbyrelatingthefindingsofprimarydatawiththosefromthe existingbodyofknowledge.

ResultsFromPrimaryData

AgeandExperienceofRespondents

Thissectionexaminestheageandexperienceofrespondents toanalyzethecharacteristicsofthesample.Thedemographic analysisofasampleisusefultoensurethatasuitableand respectablesamplehasbeenselected. Figures4A,B highlight thatalloftherespondentsare30yearsorolderandhavea workingexperienceofmorethan3years. Paradisetal.(2016) highlightsthatexperiencedrespondentsarelikelytogivebetter responses,especiallyaboutaglobalissuelikethecoronavirus, hencetheselectionoftheserespondentsisevidenceofthevalidity oftheresponses.

EffectivenessofControlMeasures

InviewofthemassivespreadofthediseaseinChina,authorities atthegovernmentandprivatelevelaretakingeffectivemeasures tocontrolitsspread.Ithasbeenfoundthatthecoronavirus startedinDecember2019inWuhanandspreadrapidlyinthe city(Ayitteyetal.,2020).Withapopulationofapproximately 11.08millionpeople,Wuhanisoneofthemostpopulouscitiesin China.Inadditionthis,thecityisalsoakeytransportationhubin

China.Thisimpliesthatduetothemassivenumberofresidents, alongwiththemovementofpeoplefromnearbycities,the chancesofthespreadofthediseaseareautomaticallyamplified. Giventhesefacts,authoritiesandthemanagementofWuhan railwaystationhavetakenmultiplestepstocontrolthespread ofthedisease.Forexample,theauthoritiescompliedwiththe regulationsregardinglockdownandbannedrailtransportation toandfromWuhan(BBCChina,2020).Assoonasthe epidemicspread,theWuhangovernmentbannedallmodesof transportationtoandfromthecity,includingtherailway,ferries, subways,citybuses,andlong-distanceshuttlebuses.Afterlifting thelockdown,therailwayauthoritiesimposedseveralrestrictions toensurethatthediseaseremainedcontrolledinthecity.These restrictionsincludedwearingmasks,usingsanitizersfrequently, andmaintainingsocialdistance.TheBBCreportedthateven afterliftingthelockdown,onlythosewithhealthclearance certificateswereallowedtousethetrainservice.Accordingto theprimarydatacollectedhere,itcanbestatedthatanotable numberofrespondentsagreewiththefactthatthesepracticesare effectiveincontrollingthespreadofthedisease(see Figure5A). However,someoftherespondentsdisagreedwiththeeconomic burdenthatlockdowncreatedontherailwaytransportsector. WithamassivenumberofpeopledependingontheWuhan railwaynetwork,theeconomichitonthissectorwasnotable. Forinstance,thelockdownresultedinanabruptdropinthe profitstoWuhanrailwaystation.Studiesrefertothelossof jobsinChinaasaresultofthecoronavirusandthatimplication isevidentinWuhantoo.Bycombiningthesefindings,itcan bestatedthatalthoughthemeasurestakenbytherailway authoritiesaredeemedasimpracticalbysomepeople,theyare effectiveinthelongrununtilthecityisdeclaredcompletely freefromthevirus.

Similarly,theprimarydatacollectedforthisstudyhasgauged theeffectivenessofthesecontrolmeasuresforthecustomers.As evidentin Figure5B,themajorityofrespondentsagreewith thefactthatcontrolmeasureslikelockdown,theuseofmasks, sanitization,andsocialdistancingareeffectiveforthesafetyof passengersinthispandemic.Theresistanceofpeopletothese controlmeasurescanbejustifiedbythefactthatlockdownhas hinderedanumberoflifeeventsandday-to-dayactivitiesand peopleareforcedtostayintheirhomes.However,themajorityof therespondentsagreethatthesecontrolmeasuresareeffectivein controllingthemassivespreadofthedisease.PeopleinWuhan havebeenpsychologicallydisturbedbythepandemic,whichis whytheyarewillingtocomplywiththeregulationsimposedby thegovernmentandrailwayauthorities.Itisonlyduetothis compliancethatthenumberofcoronaviruscasesinWuhanhas reducedsignificantlyinthepastfewdays.Newsreportsshow thatinJuly,onlyfournewcaseswerediagnosed,whichwereall importedfromothercountries.Hence,itcanbededucedthat controlmeasureshavebeeneffectiveincontrollingthespreadof thediseaseinChina.

Figures6A,B showtheamountofacknowledgmentofthe coronavirusbythepeopleinWuhanandthereducedpassenger flowtoandfromthecity.Withreferenceto Figure6A,it canbestatedthatalmostalltherespondentsacknowledgethe rapidspreadofthecoronavirus.Asstatedearlier,peoplein

Acknowledgement of the rapid spread of corona virus Dependence of people on WuhanBeijing railway. Awareness of the phenomenon of coronavirus

FIGURE6|(A) Acknowledgmentoftherespondentsand (B) passengerflowontheWuhan-Beijingrailwayline.

Wuhansignificantlydependonrailtransport,whichiswhy railwaytransportheavilycontributestothespreadofthedisease. Giventheincreasingnumberofcasesandconsequentdeaths, theflowofrailwaypassengershasbeenreducedtoanotable

Spread of coronavirus by massive travel of people through Wuhan-Beijing railway line Decrease in the number of passengers travelling from Wuhan to Beijing dependence of people on WuhanBeijing railway

degree(see Figure6B).Thelockdownandcontrolmeasures imposedbytherailwayauthoritieshavebeeneffective.Further, peopleinWuhanalsorealizethenegativeconnotationsofthe diseaseandthuscomplywiththebanontransport.Itisdueto

thisacknowledgmentthatthenumberofcoronaviruscasesand deathsinWuhanhasgraduallydecreased.

Discussion

Thefindings,inrelationtotheexistingliterature,show thattheWuhan-BeijingrailwaylinestartsfromWuhanand passesthroughBeijing,Guangzhou,Shenzhen,andHongKong (Huetal.,2017).Apartfromthat,respondentsrevealthat approximately43,000passengersnormallytravelthroughthis railwaylineeveryday.Thisisfoundtobeinaccordancewiththe findingsof LiandSheng(2016),whoalsostatethatthisrailway lineisthebusiestinChina.Byrelatingthefindingsfromprimary andsecondarysources,itcanbeestablishedthatthemassive numberofpeopletravelingdailythroughthebusiestrailwayline inChinamaybecomecarriersofthediseaseinalltheconnecting cities.TheWuhan-Beijingrailwaylinepassesthroughfourcities. Theintermixingofpeopleacrossthesecitiessuggestsarapid transmissionofthisdisease,whichiswhythecasescontinuedto increasefromDecember2019toFebruary2020(Figure1).Thus, itcanbestatedthatrailwaysplayaconsiderableroleintherapid transmissionofthedisease.

BeforethegovernmentofChinaandtherailwayauthority ofWuhanimposedrestrictionsontravel,thenumberofcases continuedtorise.ExtantstudiesreportthatWuhanisknown forthehighnumberofpassengersenteringandleavingthe city.ItisduetothisthatthegovernmentofHubeiimposeda lockdowninWuhanonJanuary232020,therebypreventair andrailtransportuntilfurthernotice(Mizumotoetal.,2020). Findingsfromtheprimarydatacanberelatedtothefactthatthe transmissionofthediseasecouldbeaccreditedtoanincreased flowofpeoplefromWuhantoBeijing.Thefindingsregarding theeffectivenessoflockdownforrailwayofficialsandpassengers canalsobeexplainedbythisdiscussion.Whenthelockdownwas imposedandtravelfromWuhantoBeijingwasbanned,therewas agradualdropinthenumberofcasesreportedinChina.Itcan bededucedthataftertheimpositionofthestrictlockdown,China experiencedabreakfromthemassivespreadofthecoronavirus. Bycombiningallthesefindings,itcanbededucedthatrail transportinChinahasbeenanotablecontributortothefarreachingspreadofthecoronavirus.Lookingatthecaseofthe Wuhan-Beijingrailwayline,itcanunarguablybeestablishedthat theimmenseflowofpeoplefromWuhantoBeijingandother connectingcitiesalongthisrailwaylinecreatedasurgeinthe numberofcasesreported.

Inviewofthisdiscussion,theeffectivenessofthecontrol measurestakenbygovernmentofficialsforthegeneralpublic canalsobeestablished.Primarydatareportsthatalthougha largenumberofpeoplefindpracticessuchaslockdown,wearing masks,sanitizinghands,andsocialdistancingeffective,somestill disagreewiththissetofrestrictions,holdingthatfindingacureis keytobattlingthispandemic.Whatneedstobeunderstoodhere istheideathatpracticeslikesocialdistancingandquarantineare effectiveincontrollingthemassivetransmissionofthedisease (Katzetal.,2019).ThegovernmentofChinaandtherailway authoritiesofWuhanhaverestrictedrailtravelsothatthespread ofthecoronaviruscanbecontrolledandthewellbeingofthe generalpublicisconsequentlyguaranteed.Giventhecurrent

situationwhereinthecasesofthecoronavirushavereducedin China,thegovernmentofChinaliftedthelockdowninWuhan andothercities. Figure2 highlightsthecasesofthecoronavirus indifferentcitiesinChina.Bycomparingthismapwiththeone shownin Figure3,itcanbeseenthatthecasesofthecoronavirus inMayconsiderablyreduced.

However,theimpactofthisepidemicislong-lasting.In accordancewiththefindingsof Maetal.(2020),itcanbededuced thatWuhanisnolongeratransportationhubsincetheglobal epidemichasleftanenduringwaveoffearandsocialisolation amongpeople.Thisindicatesaneedforseveralpolicymeasures thatthegovernmentofWuhanshouldconsidersoastorestore thecitytoitspreviousstate.Giventhisfact,thegovernment ofChina,andespeciallyWuhan,shouldexecuteawareness programsforcitizens.Intheseprograms,healthexpertsshould guidethepeoplerecoveringfromthevirusregardingtheirmental andpsychologicalstability.Healthexpertsshouldemphasizethe positiveelementsofthepandemicsothatanxiety,depression, andothermentalhealthissuesarereduced.Inaddition,the governmentshouldalsodevisepoliciestorestoretheeconomyof China(Jiaoetal.,2017; Changetal.,2020; Laietal.,2020; Nature, 2020; Zhaoetal.,2020a).Inthisregard,thegovernmentshould specificallypromoteonlinebusinessesinthecountry.Thereason behindthisisthefactthatpeopleareextremelyscaredtogoout forprofessionalorleisurepurposes,evensincetheepidemichas diminished(VOANews,2020).Inordertosatisfytheshopping needsofthecitizens,thegovernmentofChinashouldstimulate businessestotransfertheirsetupstodigitalsettings.Thiswill createawin-winsituation,whereinbusinesseswillbeableto overcomethelosstheyhavebeenbearingandconsumerswillbe abletoobtaintheproductsandservicestheyneedonline.

DistanceandtheSpreadoftheCoronavirus

Oneofthemostimportantaspectstonoteinthistopicisthe spreadofcoronavirusduetodistance.Ithasbeenseenthatitis duetorailtransportthataconsiderablenumberofCOVIDcases emergedinWuhan.Buttheexistingresearchfailstoacknowledge theroleofdistanceinthespreadofcoronavirusdiseaseinChina. VOANews(2020) reportsthatthedistrictsthatarecloserto theWuhanrailwaystationhavemorecoronaviruscasesthanthe onesthatarefartherfromit(see Figure1).Byanalyzingthe matterindeeperdetail,itcanbestatedthatsincerailwaystations, especiallytheoneinWuhan,aremassivelycrowded,travelersare morelikelytobeinfectedbythevirus.Whentheytravelfromthe railwaystationintothecity,theycantransmitthevirustopeople whoareinclosevicinitytotherailwaystation.

Findingsfromtheprimarydatashownin Tables1 3 reveal thatthespreadofcoronaviruscanbegreatlyaccreditedtopeople travelingfromWuhantoothercities.Byrelatingthefindings withtheexistingstudies,itcanbeevaluatedthatamassive movementofpeoplefromandtoWuhananditsoutskirts resultedinanotablespreadofthedisease.Xinhuanews(Xinhua, 2020)reportsaprominentnumberofcasesintheWuchang, Jianghan,andQiaokoudistricts,whichareincloseproximity toWuhanrailwaystation.Thisisowingtothefactthatthe railwaylinepassingthroughWuhanendsatZhangzhou,which is980kmfromWuhan.Studiesreportthatapproximately43,000

TABLE1| Summaryofdatacollectionprocedure(Self-drawn).

DatacollectionDetails

DataCollectionthroughquestionnairesfromrailwaystation officialsinWuhan

ProcedureAdministeringthequestionnairesthroughemailto managers

DatauseDescriptivedataanalysisthroughfrequencytables Dataalignmentwith researchquestions Linkingbacktheresultswithexistingstudiesand researchquestions

TABLE2| Viewsoftherespondentsregardingthespreadofthedisease.

Accordingto Shenetal.(2020),thevirusspreadsthrough sneezing,coughing,nasaldischarge,andthetouchofaninfected person.Thisimpliesthatwhenalargenumberofinfectedpeople passthroughthenearbydistrictsofWuhanrailwaystation, suchasWuchang,Jianghan,andQiaokou,theyarelikelyto infectthepeopleinthosedistricts.Thespreadofthediseasein thethreestateddistrictsisquitehighbecausepeopleflowinto Wuhantopassthroughthesedistricts.Evenifincomingpeople donotstayintheseareas,thefactthatthesethreedistrictsare veryclosetoWuhanjustifiesthatthesedistrictsreflectamore criticalspreadpatternofthecoronavirusthandistrictsthatare fartherfromWuhan.

ExperienceAwarenessof the phenomenonof thecoronavirus

Dependenceof peopleonthe Wuhan-Beijing railway.

Acknowledgments oftherapid spreadofthe coronavirus 10years222 3years888 4years999 5years121212 6years444 7years333 8years777 9years555 Grandtotal505050

TABLE3| PassengerflowontheWuhan-Beijingrailwaylineandthespreadofthe coronavirus.

ExperienceDependenceof peopleonthe Wuhan-Beijing railway

Decreaseinthe numberof passengers travelingfrom WuhantoBeijing

Spreadofthe coronavirusbymassive travelofpeopleonthe Wuhan-Beijing railwayline 10years222 3years888 4years999 5years121212 6years444 7years333 8years777 9years555 Grandtotal505050

passengerstraveldailythroughtherailwaylinesinWuhan.Every trainthatdepartsfromWuhanstationpassesthroughitsnearby districts,particularlyWuchang,Jianghan,andQiaokou.Ithas beenobservedthattravelersreachingWuhanrailwaystation taketaxistotraveltotheirdesiredlocations.Whenthesetaxis passthroughnearbydistricts,chancesforthespreadofthe diseaseautomaticallyincrease.Thisimpliesthatthespreadof thecoronavirusisalsodependentuponthedistancebetween cities(see Figure7).Byrelatingthediscussionwiththeresearch questions,itcanbededucedthatrailwaytraffic,passingthrough differentlocationsnearWuhan,playsasignificantroleinthe spreadofthecoronavirus.

Apartfromthat,thedistanceofdifferentcitiesfrom Wuhanalsoplaysaroleinspreadingthediseasetomultiple locations.Thiscanbedemonstratedbyusingtheexamples oftwocitiesthatarelocatedalongsidetheWuhan-Beijing railwayline:XinyangandAnyang.Itcanbeobservedthat thesituationofthecoronavirusinXinyangisworsethan thatinAnyang.ThecasesreportedinXinyangarealmost equaltothosereportedintheWuhanprovince,whichis evenmorepopulatedthanXinyang.Thismassivespreadin XinyangcanbeaccreditedtothecloserproximityofXinyang toWuhan. Singhal(2020) showsthatthevirusspreadsthrough thecloseproximityofpeople.Whenamassivenumberof peoplegatherinWuhan,thereareincreasedchancesofthem infectingpeoplelivinginthenearbydistrictofXinyang.This discussionfurtheraffirmsthatthecoronavirusislikelyto spreadovertheshortdistancebetweencitiesanddistricts. Further,thespreadofdiseaseduetotheshortdistance canalsobeexplainedbytherapidmovementofpeople inXinyangtoWuhan.Thedistancebetweenthetwocities isamere216kmandWuhanisknownasthemost developedcenterinChina.PeopledrivetoWuhanfrom Xinyangonadailybasis.Thechancesforthediseaseto spreadbetweenthetwocitiesareevidentbecauseanyinfected populationinWuhan,havinginteractedwithanyonefrom Xinyang,cantransmitthediseasetoXinyang.Theargument, therefore,showsthattheshortdistancebetweenWuhan andXinyangisoneofthereasonsforthespreadofthe coronavirusinXinyang.

SummaryofFindings

Tosummarize,itcanbededucedfromthefindingsthatrailway platformsplayanimportantroleinthespreadofthecoronavirus. Thisstudyshowsthatamongotherreasons,thespreadofthe virusinChinaisduetothedistancebetweenthecitiesandpeople travelingamongdifferentcitiesthroughtherailway.Wuhanis knowntobethemostpopulatedprovinceofChinaandHubei isidentifiedasahuboftravelingandtransportinthecountry. TherailwaylineleavingWuhancarriesapproximately43,000 passengersdailytodifferentcities.Thelargeamountofpeople travelingfromWuhantonearbycitiesresultsinthespreadof thediseasetothesecitiesandnearbyareastoo.However,the findingsalsoreportontheeffectivenessofcontrolmeasures takenbytherailwayauthorities.Itcanbededucedfromthe findingsofthisstudythatmeasuressuchaslockdown,theuse ofmasks,sanitization,andsocialdistancinghavebeenproven

FIGURE7| Demonstrationofareaswithhighprevalenceofthecoronavirus (TravelChinaGuide,2020).

tobebeneficialforcontrollingthespreadofthecoronavirus inChina.Inlinewiththis,thenextsectionhighlightspractical recommendationssothatthediseasecouldbecontrolledfurther.

CONCLUSIONAND RECOMMENDATIONS

IthasbeenshowninthisstudythatWuhanislocatedinone ofthemostpopulousprovinces,whichisanindicatorofthe quickspreadofthediseaseinthiscity.Althoughthetopicof thecoronavirusisgainingincreasingsignificanceinthebodyof research,thereliesagapinanalyzingthespreadofthedisease throughrailtransportinChina.Thisiswhythecurrentstudyhas adoptedacase-studyapproachtoevaluatethetopic,considering thecaseoftheWuhan-Beijingrailwayline.Findingsfromthe literaturerevealanotableconcentrationofcoronaviruscasesin Wuhan(Ranasingheetal.,2020).Apartfromitslargepopulation, thenotableinflowandoutflowofpeopleinWuhanareabig reasonforthespreadofthedisease.Inadditiontothat,the currentstudyhascollecteddatathroughprimarysourcesfrom experiencedrailwayofficials.Findingsfromtheprimarydata arefoundtosupporttheextantstudies,exceptatparticular points.IthasbeenshownthattransportthroughtheWuhanBeijingrailwaylinehascontributedsignificantlytothespread ofthedisease.Theimpositionoflockdownsandtheemphasis onpracticessuchassocialdistancingandwearingsafetymasks arefoundtobeeffectiveinprotectingpeoplefromthedisease. However,findingsrevealanevidentabnormalityinWuhaneven afterliftingthelockdown,andsoauthoritiesshouldconsider thefollowingrecommendations,sothatthephysicalandmental wellbeingofthepeopleisguaranteed.

• Afterthelockdown,animmenseoutflowofpeoplefrom Wuhanisexpected.Studies(Saadatetal.,2020)report thataround55,000peoplewereexpectedtoleaveWuhan oncethelockdownwaslifted.Inordertosustainthelow figuresofthecoronavirus,therailwayauthoritiesshould stillkeepinconsiderationthepracticesofsocialdistancing. Theauthoritiesshouldbecautiousofthetimeswhenthe railwaystationsarelikelytobepackedandexpandtheir infrastructureinawaythattheexpectedoutflowofpeople canbehandledwhilemaintainingasafedistancebetween passengers.Ithasalsobeenshownthatevenafterthe cancellationoflockdown,therailwayauthoritiesshould continuetakingprotectivemeasures(Khanetal.,2020).

• Therailwayofficialsshouldeasethefearsofthepeople bypostingmotivatingsignboardsatdifferentplacesin railwaystations.Giventhemostunexpectedoutcomes ofthepandemic,peoplewillbescaredtomoveacross differentcities.Thus,therailwayauthoritiesshouldfollow therecommendationof FineandRajput(2020) andspread smilesforpeoplewhohavesurvivedthecrisis.

• Therailwayauthoritiesshouldinstallasystemoftesting forcomingtorailwaystations.Althoughthegovernment mandatedmeasuringtemperaturesofpeoplemoving duringthelockdown,atestshouldbedonesothat anypersonwithsymptomsofthecoronaviruscouldbe deterredfromenteringthepremisesortravelingthrough therailway.Besidesthis,theauthoritiesshouldmakesure thatpeoplewearmasksandsanitizethemselvesregularly. Theauthoritiesshouldbeconsiderateaboutinstallinghand

sanitizerandfreemasksatdifferentspotsintherailway station,aswellasintrains.Thisway,thechancesforthe coronavirustospreadagainwillbeminimized.

• AlthoughthelockdownhasbeenliftedinWuhan,thereare onlyafewpeopleonroadsandonpublictransport.This canbeaccreditedtothewaveoffearthatthispandemic hasleftamongpeople.Inordertocomfortpassengers,the railwayauthoritiesshouldsharepublicservicemessages usingthemostpopularmedialikeTVadsandWeChat. Asalsorecommendedbyresearchers(Hunteretal.,2016), sharingencouragingmessageswiththepeoplesurvivingthe crisiswillhelpbuildpositivityamongthem.Thecitywhich wasonceametropolitanhubisnowdesertedanddestitute. Whiletheeconomicshockisharsh,societalwellbeinghas alsobeenharmed,andneedstoberestored.

Byactingupontheserecommendations,thegovernmentof Wuhanandtherailwayauthoritieswillgraduallyovercomethe shockthatthecoronavirushascaused.Theultimateaimofthe railwayauthoritiesshouldbetosustainnotonlytheireconomic profitsbutthewellbeingandbettermentoftheirsocietytoo.

StrengthsandLimitationsoftheStudy

Thestudyhasquantitativelyemphasizedtheroleofrailway platformsinthespreadofthecoronavirusinChina.Thekey strengthsofthisstudyincludetherelianceonprimarydata,the useofaquantitativemethodology,andtheproductionofcredible findings.Havingusedthequantitativemethod,thefindingsof thisstudyaregeneralizabletoo.Moreover,thestudyhastaken intoaccountaratheruntappedareaofresearch.Giventheextant literature,itisevidentthattheresearchisscarceontherole ofrailwayplatformsinthespreadofthecoronavirusinChina. Thus,thisstudyhasattemptedtobridgethisgapwhilefurther extendingtheliteraturetoo.Therecommendationsproposed inthisstudyalsoplayapartincontrollingthespreadofthis diseaseinChina.However,therearealsoseverallimitations. Forinstance,thereareseveralobjectiveandunavoidableerrors inthemethodologicalchoicesofthestudy.Giventheethical considerations,theresearchercouldnotforceanyrespondentto participateinthestudy.Thisresultedinsomemissinganswers fromtherespondents.Moreover,thesamplerespondents,who werethemanagersatWuhanrailwaystation,submittedtheir responsesinarushduetotheirbusyschedules.Duetotheevident situationofthepandemic,theresearchercouldnotmeetthe respondentsinperson,whichindicatesachancefortheresponses tobeinaccurate.Inadditiontothis,thesamplesizetakenforthe studyisnotanaccurateandrealisticrepresentativeoftheentire population.Althoughthedatacollectedfromthissamplesizehas resultedinthesupportoftheobjectives,thefindingsarenotas comprehensiveastheycouldhavebeeninthecaseofalarger samplesize.Apartfromthemethodologicalchoices,anotherkey limitationwasthelimitedscopeofthestudy.Theresearcher centeredthefindingsonWuhanrailwaystationonly.However,

thestudycouldhavecoveredothernearbyrailwaystations andtheflowofpeoplefromthoseareastoo.Nonetheless,the researcherhastriedtodeducehigh-qualityfindingsbyrespecting alltheethicalstandards.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle/supplementarymaterial,furtherinquiriescanbe directedtothecorrespondingauthor.

ETHICSSTATEMENT

Ethicalreviewandapprovalwasnotrequiredforthestudy onhumanparticipantsinaccordancewiththelocallegislation andinstitutionalrequirements.Writteninformedconsent fromtheparticipantswasnotrequiredtoparticipateinthis studyinaccordancewiththenationallegislationandthe institutionalrequirements.

AUTHORCONTRIBUTIONS

RLandDL:datacollection,conceptualization,investigation, methodology,simulation,andwriting–originaldraft preparation.SK:supervision,projectadministration,funding acquisition,conceptualization,methodology,andwriting–reviewandediting.Allauthorscontributedtothearticleand approvedthesubmittedversion.

FUNDING

ThisresearchwasfundedbytheEuropeanCommissionforthe financialsponsorshipoftheH2020-RISEProjectNo.691135.The APCiskindlysponsoredbyFrontiers’COVID19OpenScience Initiative.

ACKNOWLEDGMENTS

TheauthorsaresincerelygratefultotheEuropeanCommission forthefinancialsponsorshipoftheH2020-RISEProject No.691135“RISEN:RailInfrastructureSystemsEngineering Network,”whichenablesaglobalresearchnetworkthattackles thegrandchallengeofrailwayinfrastructureresilienceand advancedsensinginextremeenvironments(www.risen2rail.eu) (Hunteretal.,2016).SKwishestothanktheAustralianAcademy ofScienceandtheJapanSocietyforthePromotionofScience forhisInvitationResearchFellowship(Long-term),GrantNo. JSPS-L15701attheRailwayTechnicalResearchInstituteandthe UniversityofTokyo,Japan.

REFERENCES

Anthony,S.J.,Johnson,C.K.,Greig,D.J.,Kramer,S.,Che,X.,Wells,H.,etal. (2017).Globalpatternsincoronavirusdiversity. VirusEvol. 3,89–99.doi: 10.1093/ve/vex012

Ayittey,F.K.,Dzuvor,C.,Ayittey,M.K.,Chiwero,N.B.,andHabib,A.(2020). UpdatesonWuhan2019novelcoronavirusepidemic. J.Med.Virol. 92:403. doi:10.1002/jmv.25695

Balkhair,A.,AlMaamari,K.,andAlawi,F.B.(2017).Thestruggleagainst MERS-CoV(thenovelcoronavirus). OmanMed.J. 28:226.doi:10.5001/omj. 2013.66

BBCChina(2020). DeathTollClimbsto106asChinatightensMeasures. [Online].Availableonlineat:https://www.bbc.com/news/world-asia-china51275896(accessedMay4,2020).

BloombergNews(2020). CoronavirusSpreadinChinaSlowsSharplybut DoubtRemains.[Online].Availableonlineat:https://www.bloomberg.com/ news/articles/2020-03-04/coronavirus-spread-in-china-slows-drastically-butdoubt-remains(accessedMay4,2020).

Bramley,I.,Goode,A.,Anderson,L.,andMary,E.(2018).Researchingin-store,at home:usingvirtualrealitywithinquantitativesurveys. Int.J.MarketRes. 60, 344–351.doi:10.1177/1470785318767287

Cascella,M.,Rajnik,M.,Cuomo,A.,Dulebohn,S.C.,andDiNapoli,R.(2020). “Features,evaluationandtreatmentcoronavirus(COVID-19),”in Statpearls [internet],(TreasureIsland,FL:StatPearlsPublishing).Availableonlineat: https://www.ncbi.nlm.nih.gov/books/NBK554776/(accessedOctober4,2020).

Chang,D.,Xu,H.,Rebaza,A.,Sharma,L.,andCruz,C.S.D. (2020).Protectinghealth-careworkersfromsubclinicalcoronavirus infection. LancetRespir.Med. 8:e13.doi:10.1016/s2213-2600(20) 30066-7

Clifton,K.,andCarrasco,J.A.(2018).Workshopsynthesis:measuringattitudes andperceptionsinquantitativesurveys. TransportationRes.Proc. 32,495–500. doi:10.1016/j.trpro.2018.10.040

Fine,L.,andRajput,V.(2020).Thesmileisstrongerthanthehandshake. MedEdPublish 9,2–3.doi:10.15694/mep.2020.000068.1

Goscé,L.,andJohansson,A.(2018).Analysingthelinkbetweenpublic transportuseandairbornetransmission:mobilityandcontagioninthe Londonunderground. Environ.Health 17:84.doi:10.1186/s12940-0180427-5

Heydari,S.S.,andMountrakis,G.(2018).Effectofclassifierselection,reference samplesize,referenceclassdistributionandsceneheterogeneityinper-pixel classificationaccuracyusing26Landsatsites. RemoteSensingEnviron. 204, 648–658.doi:10.1016/j.rse.2017.09.035

Hu,X.,Zhao,S.,Shi,F.,Huang,J.,andShan,X.(2017).Circuityanalysesof HSRnetworkandhigh-speedtrainpathsinChina. PLoSOne 12:89–99.doi: 10.1371/journal.pone.0176005

Hunter,M.L.,VanWassenhove,L.N.,andBesiou,M.(2016).Thenewrulesfor crisismanagement. MITSloanManage.Rev. 57:71.

Jiao,J.,Wang,J.,andJin,F.(2017).Impactsofhigh-speedraillinesonthecity networkinChina. J.TransportGeogr. 60,257–266.doi:10.1016/j.jtrangeo. 2017.03.010

Jung,S.M.,Akhmetzhanov,A.R.,Hayashi,K.,Linton,N.M.,Yang,Y.,Yuan,B., etal.(2020).Real-timeestimationoftheriskofdeathfromnovelcoronavirus (COVID-19)infection:inferenceusingexportedcases. J.Clin.Med. 9:523. doi:10.3390/jcm9020523

Katz,R.,Vaught,A.,andSimmens,S.J.(2019).Localdecisionmakingfor implementingsocialdistancinginresponsetooutbreaks. PublicHealthReports 134,150–154.doi:10.1177/0033354918819755

Khan,S.,Ali,A.,Siddique,R.,andNabi,G.(2020).Novelcoronavirusisputting thewholeworldonalert. J.Hosp.Infect. 104,252–253.doi:10.1016/j.jhin.2020. 01.019

Lai,T.H.,Tang,E.W.,Chau,S.K.,Fung,K.S.,andLi,K.K.(2020).Stepping upinfectioncontrolmeasuresinophthalmologyduringthenovelcoronavirus outbreak:anexperiencefromHongKong. GraefesArch.Clin.Exp.Ophthalmol. 258,1049–1055.doi:10.1007/s00417-020-04641-8

Li,Z.C.,andSheng,D.(2016).Forecastingpassengertraveldemandforairand high-speedrailintegrationservice:acasestudyofBeijing-Guangzhoucorridor, China. TransportationRes.APolicyPract. 94,397–410.doi:10.1016/j.tra.2016. 10.002

Liu,L.(2016).Usinggenericinductiveapproachinqualitativeeducational research:acasestudyanalysis. J.Educ.Learn. 5,129–135.doi:10.5539/jel. v5n2p129

Lu,L.,Liu,Q.,Du,L.,andJiang,S.(2013).MiddleEastrespiratorysyndrome coronavirus(MERS-CoV):challengesinidentifyingitssourceandcontrolling itsspread. MicrobesInfect. 15,625–629.doi:10.1016/j.micinf.2013.06.003

Ma,X.,Hu,X.,andSchramm,D.(2020).“Effectsofschoolactivitiesontrafficflow ontheexampleoftrafficscenariofromthecityWuhan,”in NeueDimensionen derMobilität,ed.H.Proff(Wiesbaden:SpringerGabler),153–163.doi:10.1007/ 978-3-658-29746-6_14

Mizumoto,K.,Kagaya,K.,andChowell,G.(2020).Earlyepidemiological assessmentofthetransmissionpotentialandvirulenceofcoronavirusdisease 2019(COVID-19)inWuhanCity:China,January-February,2020. medRxiv [Preprint].doi:10.1186/s12916-020-01691-x

Nature(2020). Coronavirus:theFirstthreeMonthsasitHappened.[Online] Availableonlineat:https://www.nature.com/articles/d41586-020-00154-w (accessedMay4,2020).

Otter,J.A.,Donskey,C.,Yezli,S.,Douthwaite,S.,Goldenberg,S.D.,andWeber, D.J.(2016).TransmissionofSARSandMERScoronavirusesandinfluenza virusinhealthcaresettings:thepossibleroleofdrysurfacecontamination. J.Hosp.Infect. 92,235–250.doi:10.1016/j.jhin.2015.08.027

Paradis,E.,O’Brien,B.,Nimmon,L.,Bandiera,G.,andMartimianakis,M.A.T. (2016).Design:selectionofdatacollectionmethods. J.GraduateMed.Educ. 8:263.doi:10.4300/jgme-d-16-00098.1

Pasley,J.(2020). ThesearetheEverydayObjectstobeWaryofTouching astheCoronavirusSpreads,andhowtoAdapt.[Online].Availableonline at:https://www.businessinsider.com/photos-objects-wary-what-to-do-corona virus-spreads-2020-3(accessedMay4,2020).

Peeri,N.C.,Shrestha,N.,Rahman,M.S.,Zaki,R.,Tan,Z.,Bibi,S.,etal.(2020).The SARS,MERSandnovelcoronavirus(COVID-19)epidemics,thenewestand biggestglobalhealththreats:whatlessonshavewelearned? Int.J.Epidemiol. 49,717–726.doi:10.1093/ije/dyaa033

Ranasinghe,R.,Damunupola,A.,Wijesundara,S.,Karunarathna,C.,Nawarathna, D.,Gamage,S.,etal.(2020).TourismafterCorona:impactsofCovid19 pandemicandwayforwardfortourism,hotelandmiceindustryinSriLanka. HotelMiceIndustrySriLanka 158,4–10.doi:10.2139/ssrn.3587170

Saadat,S.,Rawtani,D.,andHussain,C.M.(2020).Environmentalperspective ofCOVID-19. Sci.TotalEnviron. 728:138870.doi:10.1016/j.scitotenv.2020. 138870

Shen,K.,Yang,Y.,Wang,T.,Zhao,D.,Jiang,Y.,Jin,R.,etal.(2020).Diagnosis, treatment,andpreventionof2019novelcoronavirusinfectioninchildren: experts’consensusstatement. WorldJ.Pediatr. 16,223–231.doi:10.1007/ s12519-020-00343-7

Shen,Q.,Chen,P.,andPan,H.(2016).Factorsaffectingcarownershipand modechoiceinrailtransit-supportedsuburbsofalargeChinesecity. TransportationRes.APolicyPract. 94,31–44.doi:10.1016/j.tra.2016. 08.027

Singhal,T.(2020).Areviewofcoronavirusdisease-2019(COVID-19). IndianJ. Pediatr. 87,281–286.doi:10.1007/s12098-020-03263-6

Tourangeau,R.(2018).“Maintainingrespondenttrustandprotectingtheir data,”in ThePalgraveHandbookofSurveyResearch,edsD.VannetteandJ. Krosnick(Cham:PalgraveMacmillan),135–141.doi:10.1007/978-3-319-543 95-6_18

Tracy,S.J.(2019). QualitativeResearchMethods:CollectingEvidence,Crafting Analysis,CommunicatingImpact.Hoboken,NJ:JohnWiley&Sons.

TravelChinaGuide(2020). Guangzhou–ShijiazhuangTrain.[Online].Available onlineat:https://www.travelchinaguide.com/china-trains/guangzhou-shijia zhuang.htm(accessedMay28,2020).

VOANews(2020). China’sVirusPandemicEpicenterWuhanEnds76-Day Lockdown.[Online].Availableonlineat:https://www.voanews.com/sciencehealth/coronavirus-outbreak/chinas-virus-pandemic-epicenter-wuhan-ends76-day-lockdown(accessedMay28,2020).

Wang,C.,Horby,P.W.,Hayden,F.G.,andGao,G.F.(2020).Anovelcoronavirus outbreakofglobalhealthconcern. Lancet 395,470–473.doi:10.1016/s01406736(20)30185-9

Wang,M.(2019).Aretrospectiveandpredictivestudyoffertilityratesin Chinafrom2003to2018. Heliyon 5:e01460.doi:10.1016/j.heliyon.2019. e01460

Wong,S.(2019). NumberofTrainPassengersinChinafrom2008to 2018.[Online].Availableonlineat:https://www.statista.com/statistics/ 276054/number-of-train-passengers-in-china/.(accessedApril27, 2020).

Xinhua(2020). ChinaFocus:WuhanUrgesFollow-upSupervisionforover30,000 RecoveredPatients.[Online].Availableonlineat:http://www.xinhuanet.com/ english/2020-03/12/c_138870542.htm(accessedMay28,2020).

Yang,Y.,Peng,F.,Wang,R.,Guan,K.,Jiang,T.,Xu,G.,etal.(2020).The deadlycoronaviruses:the2003SARSpandemicandthe2020novelcoronavirus epidemicinChina. J.Autoimmunity 109:102434.doi:10.1016/j.jaut.2020. 102434

Zhao,S.,Musa,S.S.,Lin,Q.,Ran,J.,Yang,G.,Wang,W.,etal.(2020a).Estimating theunreportednumberofnovelcoronavirus(2019-nCoV)casesinChinainthe firsthalfofJanuary2020:adata-drivenmodellinganalysisoftheearlyoutbreak. J.Clin.Med. 9:388.doi:10.3390/jcm9020388

Zhao,S.,Zhuang,Z.,Ran,J.,Lin,J.,Yang,G.,Yang,L.,etal.(2020b).The associationbetweendomestictraintransportationandnovelcoronavirus (2019-nCoV)outbreakinChinafrom2019to2020:adata-drivencorrelational report. TravelMed.Infect.Dis. 33:101568.doi:10.1016/j.tmaid.2020.101568

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Liu,LiandKaewunruen.Thisisanopen-accessarticledistributed underthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse, distributionorreproductioninotherforumsispermitted,providedtheoriginal author(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublication inthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

published:17November2020

doi: 10.3389/fpubh.2020.606371

Editedby: MagdalenaKlimczuk-Kochanska, UniversityofWarsaw,Poland

Reviewedby: DiegoMarcondes, UniversidadedeSãoPaulo,Brazil SimonGrima, UniversityofMalta,Malta ZhangQingling, GuangzhouInstituteofRespiratory Health,China

*Correspondence: AhmedFerchiou ahmed.ferchiou@envt.fr

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 14September2020 Accepted: 19October2020 Published: 17November2020

Citation: FerchiouA,BornetR,LhermieGand RaboissonD(2020)Individual BehaviorsandCOVID-19Lockdown

ExitStrategy:AMid-Term MultidimensionalBio-economic ModelingApproach. Front.PublicHealth8:606371. doi:10.3389/fpubh.2020.606371

IndividualBehaviorsandCOVID-19 LockdownExitStrategy:AMid-Term MultidimensionalBio-economic ModelingApproach

AhmedFerchiou*,RemyBornet,GuillaumeLhermieandDidierRaboisson

UniversitédeToulouse,INRA,ENVT,Toulouse,France

Asofmid-2020,eradicatingCOVID-19seemsnottobeanoption,atleastintheshort term.Thechallengeforpolicymakersconsistsofimplementingasuitableapproachto containtheoutbreakandlimitextradeathswithoutexhaustinghealthcareforceswhile mitigatingtheimpactonthecountry’seconomyandonindividuals’well-being.Tobetter describethetrade-offbetweentheeconomic,societalandpublichealthdimensions, wedevelopedanintegratedbioeconomicoptimizationapproach.Webuiltadiscrete age-structuredmodelconsideringthreemainpopulations(youth,adultsandseniors) and8socio-professionalcharacteristicsfortheadults.Fifteenlockdownexitstrategies weresimulatedforseveraloptions:abruptorprogressive(4or8weeks)lockdownlift followedbytotaldefinitivetransitoryfinalunlocking.Threevaluesoftransmissionrate(Tr) wereconsideredtorepresentindividuals’barriergesturecompliance.Optimizationunder constrainttofindthebestcombinationofscenariosandoptionswasperformedonthe minimaltotalcostforproductionlossesduetocontractedactivitiesandhospitalization intheshortandmid-term,with3criteria:mortality,person-dayslockedandhospital saturation.Theresultsclearlyshowlittledifferencebetweenthescenariosbasedon theeconomicimpactorthe3criteria.Thismeansthatpolicymakersshouldfocuson individuals’behaviors(representedbytheTrvalue)morethanontryingtooptimizethe lockdownstrategy(definingwhoisunlockedandwhoislocked).ForagivenTr,the choicesofscenariospermitthemanagementofthehospitalsaturationlevelwithregardto bothitsintensityanditsduration,whichremainsakeypointforpublichealth.Theresults highlighttheneedforbehavioralorexperimentaleconomicstoaddressCOVID-19issues throughabetterunderstandingofindividualbehaviormotivationsandtheidentification ofwaystoimprovebiosecuritycompliance.

Keywords:bioeconomicmodel,publichealth,SIR,COVID-19,policysimulation

INTRODUCTION

Coronavirusdisease2019(COVID-19)representsachangeinparadigmforoursocietyandthe healthcaresystem.Inrecentdecades,outbreakshavebeenmaintainedlocallyandhavebeenlimited overtime,whichmakesCOVID-19anovelentity(1).Asofmid-2020,eradicatingadiseasesuch asCOVID-19seemsnotto be anoption,atleastintheshortterm.Thechallengeforpolicy makersconsistsofimplementingasuitableapproachthatcontainstheoutbreak,limitsextra

deaths,andavoidstheexhaustionofhealthcareforceswhile mitigatingtheimpact onthecountry’seconomyandon individuals’well-being(2).Thismeansconsideringseveral competingobjectivesat thesametimeandcontinuously adaptingthestrategyandrules.Thesituationrepresentsan economicdynamicoptimizationproblemunderconstraintin anuncertainenvironment.Bioeconomicsequentialoptimization mayhelptofindthebestmiddle-termsolutionsthatintegrate thecompromisesbetweencompetingcriteria.Epidemiologic andbioeconomicmodelingprovideascientificbackground forevidence-basedpolicytobeimplementedinthesocietal, economic,andpublichealthdimensions.

TheconstraintslinkedtoCOVID-19arisebothfrom thecharacteristicsoftheoutbreak(epidemiologicparameters, severityofinfection)andfromthestructureofthehealthcare system(numberofavailablehospitalbeds,testingfacilities, personnel)(3 7).Economicconstraintsovertakebiological constraintsasthecrisis extends,especiallywhenthedisease becomesendemic.Businessresumptionanddiminishedsocial welfarecallintoquestionboththecost-effectivenessofthepolicy anditsacceptabilityforindividualsinacompromisebetween theresumptionofactivitiesandpublichealth(8 10).Inaddition tothesestandardconstraintsfordecision-making,policymakers mustaddressthebiologicaluncertaintyofanewvirus(i.e., treatment,vaccineavailability,immunityduration,relapse)and economicuncertainty(lockdownimpactwithlarge-scaleshock andresilienceofthesocial-ecologicalsystem).However,neither citizensnorpolicymakersliketodealwithuncertainty.This situationjustifiesleanmanagementthatisadjustableintheshort, middleandlongterm.

Thelockdownandlockdownliftstrategiesdifferbycountry, regardlessofthecountry’ssociodemographiccharacteristics.Up tomid-2020,theshort-andmiddle-termstrategiesadopted prioritizedpublichealthoutcomeswhileconsideringeconomic andsocietal(well-being)constraints.Themiddle-andlong-term strategieswilllikelydifferfromtheshort-termstrategiesfor countriesthatinitiallyhighlightedsafety-first(strictlockdown), whichmaylimittheeconomicandpsychologicalconsequences ofthepreviousstrategies,orforothercountrieswithverylight initiallockdown,whichmaynowincreasepopulationprotection andfacehighpoliticalrisk.

Arecentreviewhighlightedthe5keyfactorsthathaveled tocontractionsinactivity(andeconomy):directlossesdueto deathandinfections,lossesduetogovernmentpoliciessuchas lockdownandrestrictions,declinesinhouseholdconsumption, localinteractionswithinsupplychainsandtrade,andpossible hysteriaeffectsthatpreventareturntopre-crisiseconomic equilibrium(11).Gollier(12)notedthatalimitationofmany studiesfocusedonCOVID-19liesinthewayuncertaintyis accountedforandthedecreaseinthestudies’relevancewithtime. Macroeconomicstudiesfocusingoninternationalornational issuestendtoassesspastand/orfutureimpactsofpandemics (13 16).Theymayormaynotincludesolutionsandsuggestions tomitigatefutureimpacts (17).Othereconomicstudiesfocus onfirms’strategies tolimitthecrisisimpact;todate,these studieshaveunderestimatedimpactssuchasmentalhealth(18). Observationalor simulation-basedstudiesbasedonsociology,

psychologyandeconomicapproachesemphasizetheefficiencyof measurestochangeindividuals’behaviorandmodulateoutbreak dynamics(19 21).

Somebioeconomicstudies dealwiththetrade-offbetween alternativestocontrolCOVID-19,suchaswaitingfora vaccine,developingherdimmunity,contactrestrictionsand, morebroadly,allnon-pharmaceuticalinterventions(22, 23). Interestingly,fewbioeconomicoptimization approaches thatcombineepidemiologicandeconomicapproachesand accountingformulti-criteriadecisionsareavailableforCOVID19.OptimizinglockdownpoliciesinIndiahasbeenproposed usingreinforcementlearning(24).

Atargetedlockdownliftstrategymayhelptoachievemultiple objectivessimultaneouslyandtofindthetrade-offbetween societal,economic,andpublichealthcriteria(2).Wepropose anempiricalapplicationof suchanintegratedbioeconomic optimizationapproach.Withtheexampleofthefourthlargest Frenchcity,wemodelthelockdownliftunderdifferentscenarios andevaluatethebestlong-termstrategiestohighlightwhich politicalleversshouldpreferentiallyfocusonminimizinglongtermimpact.

MATERIALSANDMETHODS

AbioeconomicmodelwasdevelopedtosupportthelongtermlockdownliftstrategyforToulouse,aFrenchcitywith 475,000inhabitants.Themodelconsistsofanepidemiologic compartmentalmodelthatmimicsepidemicdynamicsandan economicoptimizationmodelthataccountsforbothmonetary impact(localgrossdomesticproduct(GDP)andmedicalcare costs)andmedicalstaffandcitizenwelfare.Thebio-economic approachconsidersbothdemographicandsocio-professional profilesoftheinhabitantsandisfocusedonthetrade-offs betweeneconomicimpactlimitationsandthewelfareofdifferent groupsofcitizens.

EpidemiologicCompartmentalModel

Webuiltadeterministicdiscreteage-structuredmodel, consideringthedemographicandageprofileshareofthe population(youngerthan18yearsold,adults,andseniors) basedontheworkperformedbyDiDomenicoetal.(25). Thecompartmentalmodelisdescribedin Figure1.Inbrief, individualsaredividedintosusceptible,exposed,infectious, hospitalized,inintensivecareunits(ICUs),recovered,and deceased.Aprodromicphaseisconsideredbeforetheappearance ofsymptoms.Duringthisphase,individualshaveasmaller transmissionrate(Tr)withrespecttosymptomaticindividuals. Duringthesecondstepoftheinfectiousphase,individualsmay remainasymptomatic(Ia)ordevelopdifferentdegreesofseverity ofsymptoms.Individualsmayremainpaucisymptomatic(Ips) orfacemild(Ims)orsevere(Iss)symptoms.Asymptomatic individuals(includingchildren)haveasmallertransmission rate(Tr)thansymptomaticindividuals.Childrenareassumed tobecomeeitherasymptomaticorpaucisymptomaticonlyand areconsideredtobeassusceptibleasadults.Therecoverystage hasbeendividedintorecoveryfromanepidemiologicpoint ofview(REp),meaningstayingathomeafterthedisease,and

FIGURE1| Compartmentalmodel.S, susceptible;E,exposed;Ip,infectiousintheprodromicphase;Ia,asymptomaticinfectious;Ips,paucisymptomaticinfectious; Ims,symptomaticinfectiouswithmildsymptoms;Iss,symptomaticinfectiouswithseveresymptoms;ICU,severecaseadmittedtoICU;H,severecaseadmittedto thehospitalbutnotinintensivecare;Rep,recoveredwithouteconomicactivity;Rep,recoveredwitheconomicactivity;D,deceased.

ClassofepidemiologicriskcategoryChildAdultAdultSeniorsAdultAdultAdultAdultAdult Adult Inhabitantsnumber 80,50075,00043,50064,50026,77526,77533,50041,65041,65041,650 ActReleasePopi,Lj L03%3%3% 3%100%100%3%3%3% 3%

L13%3%3% 3%100%100%50%50%50%50% L23%3%3% 3%100%100%75%75%75%75% L33%3%3% 3%100%100%100%50%50%50% L43%3%3% 3%100%100%50%100%100%50% L53%3%3% 3%100%100%50%50%50%100%

L6100%3%25%20%100%100%50%50%50%50% L7100%3%25%20%100%100%75%75%75%75% L8100%3%25%20%100%100%100%50%50%50%

L9100%3%25%20%100%100%50%100%100%50%

L10100%3%25%20%100%100%50%50%50%100%

L11100%3%25%wc25%wc100%100%40%wc40%wc40%wc40%wc

L12100%3%25%wc25%wc100%100%75%hwc75%hwc75%hwc75%hwc

L13100%3%25%wc25%wc100%100%75%hwc40%wc40%wc40%wc

L14100%3%25%wc25%wc100%100%40%wc75%hwc75%hwc40%wc

L15100%3%25%wc25%wc100%100%40%wc40%wc40%wc75%hwc

L99100%100%100%100%100%100%100%100%100%100%

ActReleasePopi,Lj isthepercentageofactivityreleasedforscenarioLjandpopulationi.ForL11toL16,wc,andhwcrepresentcontainmentofcontactswithincategories(wc)orhalf containmentofcontactswithincategories(hwc).

fromaneconomicpointofview(REc),meaningreturningto work(withthesamecurrentrulesatthistime).Afterinfection, asmallpartofthepopulation(Ps = 10%)isconsideredtobe susceptibleagain.

Threemainpopulationswereconsideredforthe epidemiologicapproach(young,adults,andseniors),and themodelwasrefinedbyaddingthesocio-professional characteristicsoftheadultstoaccountfordifferentiallockdown exitstrategiesonthissubpopulation(Table1).Thecategories “medical”and“essential”workerswerecreated,representing 30%ofthewholeactivepopulation.Studentsandunemployed subpopulationswerealsocreatedsincetheirmovementand contactswereexpectedtodifferfromotheradultpopulations

duringthelockdownandlockdownlift(26, 27).Fourother socio-professionalcategorieswerecreated(26)basedon (i)theimpossibilityof havingatleastpartialremotework (denoted Fixed)andasimplificationoftheofficialsocioprofessionalclassification:lowersupervisoryandtechnical occupations(denotedLower),intermediateoccupations (denoted Intermediate),andhighermanagerial,administrative, andprofessionaloccupations(denoted Higher).Smallemployers andindividualentrepreneurswerenotaspecificcategorysince theyfallintoeitherthefixedortheintermediarycategory. Similarly,lowermanagerial,administrativeandprofessional occupationswerenotdistinguishedfromotherloweroccupation profilesandwereincludedintheLowercategory.

Thebiologicalmodelisbasedontheprinciplethatcontacts withinandbetweenthe subpopulationsaremodulatedduringthe lockdownandthereafterdependonthelockdownliftscenarios. Thelikelihoodofbecoming Exposed (Figure1)consequently dependsonthecontactmatrixandthetransmissionrate(i.e., probabilityofbecoming Exposed ifincontactwithan Infectious person).Thenumberofsimulatedcontactsduringlockdown andforeachlockdownscenarioweredefinedinrelationtothe percentageoractivityreleased,asindicatedinEquation(1):

ContactsPopi∗ Popi′ ,Lj = CoefContact ∗ ContactPopi∗ Popi′ ,Init ∗ ActReleasePopi,Lj (1)

where

ContactsPopi∗ Popi′ ,Lj:contactmatrixforthescenarioL j andthe populations i and i’ CoefContact:ponderationoftheinitialcontactmatrixdueto changeinbehaviorwithtime

ContactPopi∗ Popi′ ,Init:initialcontactmatrixforthepopulations i and i’

ActReleasePopi,Lj:percentageofactivityreleasedforscenarioLj andpopulation i.

LockdownandLockdownLiftScenarios

Inthelockdownscenario(L0, Table1),allsubpopulations arelocked(3%ofreleasedactivityintermsofcontacts) exceptmedicalandessentialworkers.Thisrepresentsthepolicy implementedinFranceinphase1,fromMarch18thtoMay11th, 2020(28).Schoolswereclosed,and70%ofnon-essentialworkers workedremotely.

Inphase2, startingMay11th,threesetsofmonitored lockdownliftstrategies(L1-L5,L5-L10,andL11-15)were simulated(Table1)andapplied.Forallscenarios,medical, andessentialworkersremainedunlocked.InscenariosL1to L5,allnon-activesubpopulationsremainedlocked,andthe4 populationswitheconomicactivitiesexperiencedpartialortotal lockdownlift.ScenariosL6toL10weredefinedsimilarlytoL1 toL5withallschoolsopenandpartialunlockingofunemployed andseniors.L11toL15representthesamesituationasL6toL10 withcontainmentofcontactswithincategories(wc)orpartial (half)containmentofcontactswithincategories(hwc).This meansthatlockdownliftisadjustedtoallowactivitiesforspecific daysoftheweekdependingonthesubpopulation,leadingto strictlylimitedinter-sub-populationcontacts.Amixedstrategy wasadoptedwithhalfwithincategorycontacts,limitinghalfof thecontactbetweensubpopulationsthankstoapopulation-week regulationsystem(preciserulesdefiningthecombinationsof exitauthorizationsdependingonsocio-professionalcategory).In additiontothemonitoredscenariosL0-L15,atotallockdownexit atthestartofphase2(scenarioL99)wasconsidered.

Tobettermatchtheobservedmeasuresinthefield,the monitoredlockdownliftofphase2wascombinedwithvarious options.ThelockdownliftwasimplementedabruptlyonMay 11th(O1)orprogressivelyat4or8weeks(O2andO3).Because scenariosL1toL15cannotbeappliedindefinitelyduetotheir economicandsocietalimpacts,athirdphasewascreated,and2

otheroptionsweredefined(basedonO3rules)tocapturethe long-termdynamics.OptionO34plannedatotallockdown2 weeksaftertheendofhospitalsaturationorafterthepeakof hospitalizationifnosaturationoccurred.Thetotallockdownexit wasdefinitiveforO34andwastransitoryforO35(mixedstrategy oflockdownliftandre-lockdown).Thestartingdateofphase3 consequentlydependsonthelockdownliftscenario.

Figure2 summarizesthe3phasesoftheFrenchsituationand thecorrespondingsimulatedlockdownexitstrategies.

EconomicOptimizationModel

Sixeconomicscenarios(denotedE0toE5)wereconsidered (Table2)forthe4studiedactivepopulationslockeddown (Active_fixed,Active_lower,Active_intermediate,and Active_higher).Duringlockdown,thepercentageofproductivity comparedtothepre-lockdownperiodisconsideredtovary dependingonthesocio-professionalcategory(E0).Thisdecrease inproductivityisanaverageforthewholelockdownperiod (phase1)andthesubpopulationandshouldnotbecompared toproductivityofworkerswithpartialhomeworkingbefore lockdown.Duringthemonitoredlockdownlift(phase2),the percentageofproductivitycomparedtothepre-lockdown periodwasconsideredtodependonthepercentageofactivity released,inaccordancewiththelockdownliftscenariofora givensubpopulation,asindicatedinEquation(2):

100 ∗ ActEcoPopi,Ek ∗ GDPPopi,Pl, ifk = 0

ProdPopi,Ek =

where:

ActEcoPopi,E0 + 100 ActEcoPopi,E0 ActEcoPopi,Ek; Max100 ∗ GDPPopi, ifk > 0 (2)

ProdPopi,Ek istheproductivitypermittedbythe activepopulationPop i (Active_fixed,Active_lower, Active_intermediate,andActive_higher)fortheeconomic scenarioEk andthelockdownliftscenarioLl ActEcoPopi,Ek isthepercentageofeconomicactivityforthe economicscenarioEk GDPPopi isthedailyGDPforthepopulationPopi

Equation(2)aimstoreproducethefactthatpartiallockdown mayhelptoimproveeconomicactivitycomparedtostrict lockdownandthatverygoodperformancecanbeachievedwith partiallockdownforsomesocio-professionalcategories.

Optimizationunderconstraintwasperformedontheminimal totalcostforCostEk,Lj, andhospitalizationforthewhole 300or600dperiod.Economicriskwasnotaccountedfor.To combinethemainkeydimensionswithinthedecision-making, theoptimalsolutionthatminimizestheoveralleconomicimpact foragivenTrwasplottedconsidering3mainconstraints.Three levelsofconstraintwereconsideredbasedonthequartileand medianmortalityrateobservedbetweenallthescenariosfora givenoptionandagivenTr.Themortalitycriteriahigh,medium andlowusedforoptimizationcorrespondtonoconstraints onmortality,withinthebesthalfofthesituation(lowesthalf mortalityrate)andwithinthebestquarter(lowestquartile mortalityrate),respectively.Thesametypeofrulewasapplied forthewelfarecriteria.Thewelfarecriteriahigh,mediumand

FIGURE2| Flowchartofobservedeventsandsimulatedoptionsandscenariosforthe3phasesoftheCOVID-19outbreakinthestudiedarea.

TABLE2| Economicscenariosandglobalproductionforthe4activepopulations. Active_lowerActive_fixedActive_ Intermediate Active_higher

ECONOMICSCENARIOActEcoPopi,Ek

E025% 0% 66% 66%

E1 ActReleasePopi,Lj

E2 ActReleasePopi,Lj ActReleasePopi,Lj + 25% ActReleasePopi,Lj E3 ActReleasePopi,Lj ActReleasePopi,Lj + 25% E4 ActReleasePopi,Lj + 15% E5 ActReleasePopi,Lj –5% INDIVIDUALGLOBALPRODUCTIONGDPPopi (e PERDAY) 326 326 423 571

lowusedforoptimizationcorrespondtowithinthebesthalfor 75%ofthenumberof person-daysunlockedornoconstraints onperson-daysunlocked,respectively.Thecriteriarelatedto hospitalsaturationweredefinedbythedurationofhospital saturationnottoexceedortothenumberofday-bedslackingfor thewholeperiod,withthecriteriahighmeaningnoconstraints. Thecalculationofthetotalcostforeachscenarioandoption allowedustocalculatetheopportunitycostofchoosingany combinationofscenarioandoptioncomparedtothescenario andoptionwiththeminimalcostforthewholeperiodand givenTr.

ModelParameterization

Thenumberofcontactsperpersonwasdefinedwithinand betweenthe8subpopulations,meaning defacto thatcontacts withinandbetweenthe3epidemiologicpopulations(young, adults,andseniors)wereconsidered.Hospitalizationand admissiontotheICUforseverecaseswereidentifiedfrom Toulousehospitaldata(29)andadjustedfortheanalyzed population.HospitalizationandICUbed occupationswereused toevaluatethecapacitytowelcomepatientsrequiringtheselevels ofcare.Thecalibrationofthecompartmentalmodel(Table3) wasperformedsimilarlytoDiDomenicoetal.(25).Atthe beginningofthelockdown, otherFrenchareaswereclosetothe hospitalsaturationlevel,andcommunicationbythemediaraised peoples’awarenessofhealthrisks.Weconsequentlyconsider thatpeoplechangedtheirbehaviordramaticallyforboththe numberofcontactsduringlockdownandTr.Asaconsequence, thenumberofcontactswithinandbetweenthesubpopulations (Table4)wasbasedonpreviouspublications(25, 30)and adjustedforthenumber ofhospitalizedandICUpatientsduring lockdownfortheconsideredarea.Thesimulatedincidenceof clinicalcaseswascomparedwiththeobservedlocalincidenceto appropriatelyadjustthenumberofcontacts(Table4).Thevalue ofTrwaslikelytochangewithtimeduringthestudiedperiod duetochangesinrules,behaviorsandprotectionsavailability, includingmasks.Itwaskeptconstantforagivensimulation,and thevaluesof0.06,0.10,0.125,0.20,and0.25wereretained.

Theassumptionsonsocialdistancinginterventionmadeby (25)werekept.A75%decreaseinthenumberofcontactsis expectedifsevere symptoms areobservedinoneindividual.

TABLE3| Parameters,values,andsources todefinethebioeconomicmodel.

YoungStudentsUn-employedSeniorMedicalEssentialsActive_ lower Active_ fixed Active_ Intermediate Active_ higher

Young 12.001.44 3.121.201.081.083.60 3.12 2.40 1.20 Students 4.323.36 2.641.680.450.692.04 2.64 2.64 2.52 Unemployed 4.323.36 2.641.680.660.452.04 2.64 2.64 2.64 Senior 0.300.60 3.128.400.420.422.40 2.40 1.68 0.12 Medical 4.323.36 2.641.680.660.452.04 2.64 2.64 2.64 Essentials 4.323.36 2.641.680.450.692.04 2.64 2.64 2.52

Active_lower 3.602.40 3.602.400.510.512.88 2.52 2.52 2.40

Active_fixed 3.122.4 4.442.400.660.662.52 4.56 1.20 0.48

Active_Intermediate2.402.4 0.841.680.660.662.52 1.20 6.00 4.08

Active_higher1.204.44 0.120.120.660.632.40 0.48 4.08 8.40

TABLE4| Matrixcontact(valueofContactPopi*Popi′ ,Init )forthedifferentpopulations.

VariableDescription Value Source

1 Incubationperiod 5.2d 1

µ 1 p Durationofprodromal phase 1.5d,computedasthe fractionof pre-symptomatic transmissioneventsout ofpre-symptomaticplus symptomatic transmissionevents

ǫ 1 Latencyperiod 1 µ 1 p

2

pa Probabilityofbeing asymptomatic 0.2,05 3 pps Ifsymptomatic,probability ofbeingpaucisymptomatic 1forchildren 0.2foradults,seniors 4 pms Ifsymptomatic,probability ofdevelopingmild symptoms

0forchildren 0.7foradults 0.6forseniors 4 pss Ifsymptomatic,probability ofdevelopingsevere symptoms

0forchildren 0.1foradults 0.2forseniors 4–6

sSerialinterval 7.5d 7

µ 1 InfectiousperiodforIa ,Ips , Ims ,Iss

rβ RelativeinfectiousnessofIp, Ia ,Ips

S- 1

0.51 8

p ICU Ifseveresymptoms, probabilityofgoinginICU 0forchildren 0.36foradults 0.2forseniors 9

λ H,R Ifhospitalized,dailyrate enteringinR 0forchildren 0.072foradults 0.022forseniors 9

λ H,D

λ ICU,R

λ ICU,D

Ifhospitalized,dailyrateinD0forchildren 0.0042foradults 0.014forseniors 9

IfinICU,dailyrateentering inR 0forchildren 0.05foradults 0.036forseniors 9

IfinICU,dailyrateentering inD 0forchildren 0.0074foradults 0.029forseniors 9

Fivepercentofadultsstayedathomeinthecaseofschool closures,withtheexceptionofthemedicalandessential activitiessubpopulations.Workingfromhomewasadopted by6%oftheactiveadultpopulationbeforethelockdown. Theisolationofpositivecaseswhenreturninghomewasnot consideredaspossibleforphase1,inaccordancewiththemain observationsduringthisphase.Thenumberofbedsavailablefor hospitalizationandICUwas1,000and300,respectively(29).A highernumberofpatientshospitalizedorintheICUonagiven daydefinedthesaturationsituation,whichwasassociatedwitha three-foldhighermortalityriskforpeopleabovethethreshold. Thepriceperday-bedwasfixedto500 e and1,500 e for hospitalizationandICU,respectively(31).

Theparametersofthe sixeconomicscenariosarereported in Table2.Therangeofactivityduringlockdowncompared tothepre-lockdownperiodwasconsideredtovarybetween0 (fixed)and66%.Thismeans,forinstance,thattheproductivity ofahomeworkeris66%ofhisorherformerproductivity. AsensitivityanalysisispermittedwithscenariosE2toE4, whichattributeafixedextrapercentageofproductivity,andin scenarioE5(limitedproductivityevenifthereisahighrateof lockdownlift).

DailyGDPwasobtainedastheyearlyGDPperworker [e77,212in2018fortheOccitaniearea(32)]andadjusted foreachsubpopulation duetovariationintheofficial estimationofsocioprofessionalstandardlivingincomes (27).Thelocalstandardlivingincomeswereofficially assessedas e18,870, e18,870, e24,520, and e33,090for thesocio-professionalcategoriesActive_low,Active_fixed, Active_intermediate,andActive_high,respectively.The yearlyGDPperworkerforeachsocio-professional categorywasthendividedby200daysworkedyearly (Table2).

Wecalibratedourmodelwithdemographicand socioeconomicdatadescribingToulouseareai.e.,aFrench metropolywitharelativelyhighlevelofeconomicactivity andseveraluniversitiesandhighereducationstructures. Ourfindingsmaynotbeextrapolatedtoothercities,asthe

parametersmayvarybetweencities.However,manyofthe citieswithsimilarsizesinEuropewouldlikelyhaveclose levelsofhealthcareanduniversityfacilities.Tosomeextent, ourresultsprovidevaluableinformationforscientistsand

policy-makersbeyondToulousearea.Atleastwelaiddown inthisempiricalapplicationtherationaleandtheelements requiredtoimplementatailoredandadaptiveapproachof COVID-19management.

FIGURE3| Epidemiologicvalidationofthemodel. (A) Comparisonbetweenthepredicted(solidline)andobserved(dashedline)numberofday-bedsused. (B–F) Numberofdailybedsusedinhospital(CIUexcluded).Thereddashedlinerepresentsthehospitalcapacity.Tr,transmissionrate;Option1,abruptmonitored lockdownliftearlyinphase2;Option3,progressivemonitoredlockdownlifton8weeks;OptionO34,progressivetotallockdownlift(phase3).

RESULTS

Theresultsarepresented fora300-and600-dayperiod simulationtorepresenttheshort-andmid-termimpacts. Thelockdownstartsonday10ofthesimulation(18th March2020),andthelockdownliftstartsonday64 (11thMay2020).Day100correspondstomid-June

2020,andday150correspondstolateAugust2020 (Figure2).

ValidationandSensitivityofthe BioeconomicModel

Thevalidationoftheepidemiologicalpartofthemodelwasbased onthecomparisonbetweenthesimulatedandobservednumber

FIGURE4| Numberofdailybeds used inthehospital(ICUexcluded)forthedifferentscenarios(L1toL15).Tr,transmissionrate;thereddashedlinerepresentsthe hospitalcapacity.OptionO34(left),progressivetotallockdownlift(phase3);OptionO34(right),abrupttotallockdownlift(phase3).

ofday-bedsused,withahighmatchobserved(Figure3A).The results werehighlysensitivetoTr,asillustratedforoptionO1 in Figures3B–D:thenumberofday-bedsusedwasverylow foraTrof0.06andincreaseddramaticallywhenTrincreased to0.125and0.25.BecausethechangeinTrrepresentsthe averagepopulationbehavioraroundvirustransmissioninour model,theresultsarepresentedforthese3valuesofTr.The resultsalsohighlightthecapabilityofthescenariostorepresent varioussituationsintermsofoutbreakdynamicsforthedifferent phases(Figures3B–D).Forinstance,hospitalsaturationmaybe preventedbysomecombinationofTrandscenarios,whereas othercombinationsleadtolongandintensehospitalsaturation.

ForagivenTr(Figures3C,E forTr = 0.125),extendingthe lockdownliftby8weeks,asoccurredinFranceformostactivities, postponedthepeak(toagreaterdegreewhenthepeakwaslow) butfailedtoreducethepeakintensity.Theadoptionofatotal lockdownleadstoasecondwave.Foralockdownsimulatedat8 weeksandTr = 0.125(Figure3F,O34),thesecondwavestartson day250.Thisclearlyshowstheneedforlong-termconsideration toimprovemulti-criteriadecisions.

OptionsO34andO35wereconsequentlymodeledupto 600days(Figure4).Ontheonehand,thegreatertheTr(top todownforagivencolumn),theearlierandthehigherthe peakforboththestrategyoflockdownliftandre-lockdown (O34,left)orthetotaldefinitivelockdownstrategy(O35,right). HospitalsaturationwasonlyavoidedwhenTrremainedverylow (Tr = 0.06)andwithlockdownliftandre-lockdownstrategies (O34).Theseresultsdemonstratethatindividualbehavior(i.e., theTrvalue)ismoreimportantthanpoliticalstrategy(scenario choices)forthelong-termoverallimpact.Ontheotherhand, foragivenTr(i.e.,givenanaveragebehavior),scenariochoices permittedthemanagementofthehospitalsaturationlevel, includingintensityandduration.

MultidimensionalLong-TermOptimization

Theoptimalsolutionsunderdifferentlevelsofconstraints arereportedin Figures5, 6, SupplementaryFigures1, 2.The solutionthatminimizestheoveralleconomicimpactislocated intheforegroundof Figures5, 6, SupplementaryFigures1, 2 (highwelfare,lowmortalityandlowsaturation).Theresults indicatethenameofthescenarioandoptionaswellas thecorrespondingdirecttotalcostcomparedtothereference (opportunitycostvalue = 0).Thetotalcostoflockdown strategiesforO34andthe300-dayperiodwas e2.15billionfor L99andvariedfrom e3to e6billionforscenariosL1-L15.

Short-termoptimization(Figure5)showsthatimprovingone criterionnecessarilyleadstodeteriorationofanothercriterion. CombiningL4orL14andO3representsthebeststrategyinmost ofthesituationforlowTr,withanopportunitycostof e1.29–e1.88billionforthe300dperiod.ForhigherTr,optionsO1,O3, andO34andscenariosL3,L4,L5,L12,L13,andL14appearto beoptimalprovidingthatconstraintsarereleasedonatleast2 criteria.Thedirectcostofoptimalscenariostoimprovewelfare ortodecreasemortalityandhospitalsaturationvarybetween e1.2and e2.7billion(L99excluded).

Consideringthelong-termimpact(Figure6)leadsto dramaticallydifferentresults,withOptionO34asthebest

solutionexceptforveryfewsituations.Thelockdownliftandrelockdownstrategiesfulfillthe3constraintcriteriaforatleastTr = 0.06and0.125.ForTr = 0.25,neitherwelfarenorsaturation constraintsmaybecompleted.Thebestscenariosforlong-term optimizationareL4forTr=0.06(similartoshort-termanalysis), L4andL13forTR = 0.25andL2,L4,L7,L9,andL12forTR = 0.125.Theopportunitycostis e1.28billionforTr = 0.06, e0.68–e1.44billionforTr = 0.125and e0.51–e2.42billionfor Tr = 0.25.Verysimilarresultsareobservedwhenformulating thesaturationconstraintsintermsofsaturationdurationwithout theconditionofsaturationintensity(SupplementaryFigure1) insteadofperpatient-saturatednumbers(Figure6).

Thesecondorthirdbestoptimalstrategy (SupplementaryFigure2)isconsistentlyfoundtobeoption O34combinedwithscenariosL2,L3,L4,L5,L7,L8,L9,and L12.Theopportunitycostcomparedtothefirstbestsolutions foreachsetofconstraintsissmalltoverysmall,showinglittle differencelinkedtothechoiceofthescenariowithinthisrange ofscenarios.

DISCUSSION

Thepresentworkisthefirstlong-termbioeconomicmulticriteria optimizationapproachappliedtoCOVID-19atalocalscale andwasconceivedtosupportdecision-makingregardingpublic healthpolicy.Variouscriteriawereconsideredwithinthe economicpartofthemodel,andtheepidemiologiccomplexity ofthesituationwassimplified.Thepresentapproachallowsus toconsider8socio-professionalcategoriesand3epidemiologic populationsataglance.

Unlikeotherstudies,thepresentworkfocusesonapopulation withverylimitedviruscirculationbeforelockdown.The situationinParisandEasternFranceinFebruaryandMarch 2020aswellasthesituationsinotherplacesinEuropeor worldwideclearlyhighlightthemedicalconsequencesofthe virus,spontaneouslyleadingtoamoderatetohighlevelof barrierroutinesindailyactivitiesforbothprofessionaland non-professionals.Thecontactmatricesandthecontamination probabilitywereadjustedaccordinglyinthepresentsimulation. Becauselockdownfrozeallprofessionalandprivateactivities ofthemajorityofthepopulation,thesimplifiedversionof theSIRmodelingprovidedherewaspreciseenoughtopredict thenumberofcasesobservedinhospitals.ThevalueofTr toberetainedwithinthebioeconomicmodelisakeypoint, andalltheresultsdemonstratethatidentificationofthebest solutionishighlysensitivetothisparameter.Itrepresents individualbehaviorsrelatedtobarriergesturesandindividuals’ compliancewithbiosecurityandsocialdistancingrules.Itstrue valueisconsequentlyverydifficulttoappraiseandmayeven changebetweensocio-professionalcategories(e.g.,education, informationasymmetry).ThefixedTrvalueforagivenset ofscenariosandoptionsisanimportantsimplificationofthe presentstudysinceTrislikelytochangeovertime.Theoptions offeredtopeopletoprotectthemselves(disinfectantgel,masks, etc.)andtherulesorrecommendationsprovidedbyauthorities mayinfluencethevalueofTr.Forinstance,inFrance,masks

FIGURE5| Graphicalrepresentationofthe optimalsolutiondependingonthestrengthoftheconstraintforawholeperiodof300days.Theresultsintheright columnareexpressedasdirectcost(inbillioneuros);Tr,transmissionrate.Theoptimalsolutionthatminimizestheoveralleconomicimpactunderasetofconstraints isfoundintheforeground(lowmortality,highwelfare,andlowsaturation).

FIGURE6| Graphicalrepresentationofthe optimalsolutiondependingonthestrengthoftheconstraintforawholeperiodof600days.Theresultsintheright columnareexpressedasdirectcost(inbillioneuros);Tr,transmissionrate.Theoptimalsolutionthatminimizestheoveralleconomicimpactunderasetofconstraints isfoundintheforeground(lowmortality,highwelfare,andlowsaturation).

wereavailableforeveryoneatthebeginningofphase2,and therecommendationofmaskwearinghaschangedovertime (firstonavoluntarybasisandinmid-summer,mandatoryinall closedpublicroomsandoutsideinsomecrowdedtouristtowns). Moreover,thesensitivityofpeoplewaslimitedwhenprevalence waslowinFranceandEuropebutthenincreasedduringsummer 2020,whenthesecondwavewasobservedinotherEuropean countriesandmovementbansreappeared.

Theprogressivelockdownlift,assimulatedfor8weeksin optionO3,isveryclosetothefieldsituation.Whenphase2 started,thepracticalapplicationofthelockdownlifttook1–2monthsasmanyoffices,schoolsanddaycareswerenotina situationtohostpeople.Highschoolsanduniversitiesremained closeduptoSeptember2020.Mostsocialactivities(museums, restaurants,pubsandcinemas)openedprogressivelyfromMay toAugust2020.Travelingwasfirstauthorizedwithin100kmof home,andthenfreecirculationwasauthorized.Theabilityofthe presentmodeltocloselyrepresentthelockdownliftstrategycan beconsideredhigh.Alimitationofourmodelisthatitdoesnot accountforsummerbreaksandthehigherrateofmovementand contactthatmaytakeplaceduringthisspecificperiod.

Thepresentworkusedasimplifiedvisionofeconomic dynamicsbysummarizingthecreationofvaluebyeachactor tohisorherdailycontributiontotheGDPbeforelockdown. Aglobalanddynamicapproachoftheindustrialandeconomic activitiesthatcouldbepermittedbyeconomicglobal(or partial)equilibriummodelingortheequivalentmayprovide apreciseapproachtoguidedecisionmaking.Itmayhelpto betterconsidertheinterrelationshipbetweensectorsandthe dependencybetweenactorsandpost-disasterrecoverydynamics. Itisdifficulttotrulyappreciatetherelationshipbetweenthe sectorsandalltheinformationrequiredtoparametrizethe modelsduringtherecoveryphaseduetothepaucityofupdated information.Thismeansthatmostofthecalibrationwouldbe basedonanassumptionofbusinessasusual.UsingGDPper socio-professionalcategoryisastrongassumption,andGDPis clearlyaveryrawproxyofthestateoftheeconomy.However,it allowsthecombinationofSIRoutbreakmodelingandeconomic societalconsiderationswithinauniquedecision-makingprocess, whichclearlyaddsvaluecomparedtopreviousstudies.

Themainresultsofthepresentworkarethatpolicymakers shouldfocusmoreonindividualbehaviors(representedby theTrvalue)thanontryingtooptimizelockdownstrategy (definingwhoisunlockedandwhoislocked).Socialdistancing isrecognizedasakeyparametertolimitthespreadofdiseases butisoftenassociatedwithhigheconomicimpact(17).The mainchallengeisthereforetomaintainsocialdistancingby appropriateindividualbehaviorswithoutexcessivecoercive government-enforcedsocialdistancing,whichisveryoften associatedwithhigheconomicimpact.Incountrieswithpoor socioeconomicconditions,stringentsocialdistancingmeasures andgenerousincomesupportprogrammeshavebeenshown tolowercasesanddeaths(33).Thesefindingssuggestthat evaluatingtheglobal impactofCOVID-19oroptimizationto definethebeststrategymayrepresentapriorityandthatresearch

incompartmentaleconomicsorexperimentaleconomicsmaybe neededtoaddressCOVID-19issues.Abetterunderstandingof individualbehavioralmotivationsandtheidentificationofways toimprovebiosecuritycomplianceforeveryoneshouldbecome theshort-termpriority.

Theresultsclearlyshowthatnomajordifferencesinthe economicimpactorinthe3criteriaretainedcanbeseenbetween thescenarios.ScenariosL4andL13appeartobethebest,and scenariosL2,L3,L5,L7,L14,andL12canalsobeconsidered asmulti-criteriaequivalents.TheL1,L6L10,L11,L15,orL15 scenariosshouldnotberecommended.Thescenariosthatlimit interactionsbetweensocio-professionalcategories,whichcanbe seenasprecisionlockdownliftscenarios(L11toL15),were expectedtorepresentthebesttrade-offbetweentheconstraints, buttheyfailedtoensuresatisfactorywelfarecriteria,withthe overalloutdooraccesslimitedcomparedtootherscenarios.

Inallthepotentiallyrecommendedscenarios,thehospital saturationlevelwashandledwithregardtobothintensityand duration.Althoughwedemonstrateherethatseveralcriteria maybeconsideredsimultaneouslyfordecision-makingandthat hospitalsaturationandtheassociatedmortalityincreasedrisk cannotjustifyanendlessstrictlockdown,publichealthremains themostimportantcriterionintheshortterm,andthescenarios contributetoitsoptimization.Hospitalsaturationisnotonlya publichealthissuebutalsoakeypoliticalriskoflockdownpolicy rejection(2).

Inconclusion,ourresultsdemonstrate thatpolicymakers shouldfocusonindividuals’behavioralchangesratherthan ontryingtooptimizelockdownstrategies(definingwhois unlockedandwhoislocked).Theresultshighlighttheneed forcompartmentalorexperimentaleconomicstoaddress COVID-19issuesthroughabetterunderstandingofindividual behavioralmotivationsandtheidentificationofwaystoimprove biosecuritycompliance.

DATAAVAILABILITYSTATEMENT

Publiclyavailabledatasetswereanalyzedinthisstudy.Thisdata canbefoundat:https://www.data.gouv.fr/fr/datasets/?q=covid& page=1.

AUTHORCONTRIBUTIONS

AF,GL,andDRdesignedthestudy.AFandDRperformedthe modeling(modelcalibration,andPythonandGamscode).AF andRBperformedthesimulations.AF,RB,GL,andDRanalyzed theresults.GLandDRwrotethemanuscript.Allauthors contributedtothearticleandapprovedthesubmittedversion.

SUPPLEMENTARYMATERIAL

TheSupplementaryMaterialforthisarticlecanbefound onlineat:https://www.frontiersin.org/articles/10.3389/fpubh. 2020.606371/full#supplementary-material

REFERENCES

1.WorldHealth Organization. CoronavirusDisease(COVID-19)Pandemic (2019).Availableonlineat:https://www.who.int/emergencies/diseases/novelcoronavirus-2019(accessedAugust5,2020).

2.RaboissonD,LhermieG.LivingwithCOVID-19:asystemicandmulticriteriaapproachtoenactevidence-basedhealthpolicy. FrontPublicHealth. (2020)8:294.doi:10.3389/fpubh.2020.00294

3.FergusonNM,LaydonD,Nedjati-GilaniG,ImaiN,AinslieK,BaguelinM, etal. ImpactofNon-PharmaceuticalInterventions(NPIs)toReduceCOVID19MortalityandHealthcareDemand. London:ImperialCollegeCOVID-19 ResponseTeam(2020).

4.AlvarezMM,Gonzalez-GonzalezE,Trujillo-deSantiagoG.Modeling COVID-19epidemicsinanExcelspreadsheet:democratizingtheaccessto first-handaccuratepredictionsofepidemicoutbreaks. medRxiv[Preprint]. (2020).doi:10.1101/2020.03.23.20041590

5.IHMECOVID-19HealthServiceUtilizationForecastingTeam,Murray CJL.ForecastingtheimpactofthefirstwaveoftheCOVID-19 pandemiconhospitaldemandanddeathsfortheUSAandEuropean EconomicAreacountries. medRxiv. (2020).doi:10.1101/2020.04.21.200 74732

6.KisslerSM,TedijantoC,GoldsteinE,GradYH,LipsitchM.Projectingthe transmissiondynamicsofSARS-CoV-2throughthepostpandemicperiod. Science. (2020)368:860–8.doi:10.1126/science.abb5793

7.VelavanTP,MeyerCG.TheCOVID-19epidemic. TropMedIntHealth. (2020)25:278–80.doi:10.1111/tmi.13383

8.HardinG.Thetragedyofthecommons.Thepopulationproblemhasno technicalsolution;itrequiresafundamentalextensioninmorality. Science. (1968)162:1243–8.doi:10.1126/science.162.3859.1243

9.GlazerJ,McGuireTG.Multiplepayers,commonalityandfree-ridingin healthcare:medicareandprivatepayers. JHealthEcon. (2002)21:1049–69. doi:10.1016/S0167-6296(02)00078-4

10.HennessyDA,WolfCA.Asymmetricinformation,externalitiesandincentives inanimaldiseasepreventionandcontrol. JAgricEcon. (2018)69:226–42. doi:10.1111/1477-9552.12113

11.CaraccioloG,CinganoF,ErcolaniV,FerreroG,HassanF,PapettiA,etal. Covid-19andEconomicAnalysis:AReviewoftheDebate.(2020).Available at:https://st.ilfattoquotidiano.it/wp-content/uploads/2020/08/07/Covid-19and-Economic-Analysis-Bank-of-Italy-covid_literature_newsletter_it.pdf (accessedAugust15,2020).

12.GollierC.Pandemiceconomics:optimaldynamicconfinementunder uncertaintyandlearning. GenevaRiskInsurRev.(2020)45:80–93. doi:10.1057/s10713-020-00052-1

13.Gómez-PinedaJG.GrowthforecastsandtheCovid-19recessiontheyconvey. CovidEconomics. (2020)40:196–213.

14.McKibbinW,FernandoR. GlobalMacroeconomicScenariosoftheCOVID-19 Pandemic.(2020).CAMAWorkingPaperNo.62/2020.Availableonlineat: https://ssrn.com/abstract=3635103(accessedJuly17,2020).

15.MamayskyH. FinancialMarketsandNewsabouttheCoronavirus.SSRN’s eLibrary(2020).doi:10.2139/ssrn.3565597Availableat:https://ssrn.com/ abstract=3565597

16.BorelliL,SandolasGóesG.Macroeconomicsofepidemics:interstate heterogeneityinBrazil. CovidEcon. (2020)30:83–119.

17.GetachewYY.OptimalsocialdistancinginSIRbasedmacroeconomic models.In: MERITWorkingPapers2020-034,UnitedNationsUniversity -MaastrichtEconomicandSocialResearchInstituteonInnovationand Technology(MERIT). (2020).

18.BanksJ,XuX.Thementalhealtheffectsofthefirsttwomonthsoflockdown andsocialdistancingduringtheCOVID-19pandemicintheUK. IFSWorking PaperW20/16.IFS(2020).doi:10.1920/wp.ifs.2020.1620

19.PapageorgeNW,ZahnMV,BelotM,vandenBroek-AltenburgE,ChoiS, JamisonJC,etal.Socio-demographicfactorsassociatedwithself-protecting

behaviorduringtheCOVID-19pandemic. IZADiscussionPapers13333, Bonn:InstituteofLaborEconomics(IZA).(2020).

20.LaliotisI,MinosD. SpreadingtheDisease:TheRoleofCulture (2020). doi:10.31235/osf.io/z4ndc

21.KikuchiS,KitaoS,MikoshibaM.WhosuffersfromtheCOVID-19shocks? LabormarketheterogeneityandwelfareconsequencesinJapan. CARFFSeriesCARF-F-490 TheCentreforEconomicPolicyResearch(CEPR);Center forAdvancedResearchinFinance,FacultyofEconomics,TheUniversityof Tokyo.(2020).

22.GapenM,MillarJ,BlerinaU,SriramP.Assessingtheeffectivenessof alternativemeasurestoslowthespreadofCOVID-19intheUnitedStates. CovidEcon. (2020)40:46–75.

23.ThunströmL,AshworthM,FinnoffD,NewboldSC. HesitancyTowardsa COVID-19VaccineandProspectsforHerdImmunity. CenterforAdvanced ResearchinFinance,FacultyofEconomics,TheUniversityofTokyo(2020). p.40.doi:10.2139/ssrn.3593098

24.KhadilkarH,GanuT,SeetharamDP.Optimisinglockdownpoliciesfor epidemiccontrolusingreinforcementlearning. PhysQ-BioStat[Preprint] (2020).doi:10.1007/s41403-020-00129-3

25.DiDomenicoL,PullanoG,SabbatiniCE,BoëllePY,ColizzaV.Impact oflockdownonCOVID-19epidemicinÎle-de-Franceandpossibleexit strategies. BMCMed. (2020)18:240.doi:10.1186/s12916-020-01698-4

26.Insee. Dossiercomplet–communedetoulouse(31555).(2020).Availableonline at:https://www.insee.fr/fr/statistiques/2011101?geo=COM-31555(accessed August5,2020).

27.Insee. Comparateurdeterritoire–départementdelahaute-garonne(31) (2020).Availableonlineat:https://www.insee.fr/fr/statistiques/1405599?geo= DEP-31(accessedAugust5,2020).

28.FrenchGovernment. InformationsCoronavirus.(2020).Availableonline at:https://www.gouvernement.fr/info-coronavirus(accessedSeptember11, 2020).

29.data.gouv.fr. SantépubliqueFrance.(2020).Availableonlineat:https:// www.data.gouv.fr/fr/organizations/sante-publique-france/#(accessedAugust 5,2020).

30.BéraudG,KazmercziakS,BeutelsP,Levy-BruhlD,LenneX,MielcarekN, etal.TheFrenchconnection:thefirstlargepopulation-basedcontactsurvey inFrancerelevantforthespreadofinfectiousdiseases. PLoSONE. (2015) 10:e0133203.doi:10.1371/journal.pone.0133203

31.Atih. Lescoutsdesprisesenchargeàl’hopitalenmédecine,chirurgieet obstétrique.(2020).Availableonlineat:https://www.atih.sante.fr/sites/ default/files/public/content/2563/rapport_couts_de_prise_en_charge_2012. pdf(accessedAugust5,2020).

32.Wikipédial’encyclopédielibre. Listedesdépartementsfrançaisclasséspar produitintérieurbrutparhabitant.(2020).Availableonlineat:https://fr. wikipedia.org/w/index.php?title=Liste_des_d%C3%A9partements_fran%C3 %A7ais_class%C3%A9s_par_produit_int%C3%A9rieur_brut_par_habitant& oldid=173139855(accessedAugust5,2020).

33.NadeemAB.Socioeconomicconditions,governmentinterventions andhealthoutcomesduringCOVID19. CovidEconomics. (2020)37:141–62.

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Ferchiou,Bornet,LhermieandRaboisson.Thisisanopen-access articledistributedunderthetermsoftheCreativeCommonsAttributionLicense(CC BY).Theuse,distributionorreproductioninotherforumsispermitted,provided theoriginalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

STUDYPROTOCOL

published:19November2020

doi: 10.3389/fsoc.2020.574811

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland

Reviewedby: AndreasIhle, UniversitédeGenève,Switzerland HamdiChtourou, UniversityofSfax,Tunisia *Correspondence: HannahR.Marston hannah.marston@open.ac.uk

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 21June2020 Accepted: 05October2020 Published: 19November2020

Citation: MarstonHR,IvanL, Fernández-ArdèvolM,Rosales ClimentA,Gómez-LeónM, Blanche-TD,EarleS,KoP-C, ColasS,BilirB,ÖztürkÇalikogluH, ArslanH,KanoziaR,KrieberneggU, GroßschädlF,ReerF,QuandtT, ButtigiegSC,SilvaPA,GallistlVand RohnerR(2020)COVID-19: Technology,SocialConnections, Loneliness,andLeisureActivities:An InternationalStudyProtocol. Front.Sociol.5:574811. doi:10.3389/fsoc.2020.574811

COVID-19:Technology,Social Connections,Loneliness,andLeisure Activities:AnInternationalStudy Protocol

HannahR.Marston 1*,LoredanaIvan 2,MireiaFernández-Ardèvol 3 , AndreaRosalesCliment 3,MadelinGómez-León 3,DanielBlanche-T 3,SarahEarle 1 , Pei-ChunKo 4 ,SophieColas 5,6,BurcuBilir 7 ,HalimeÖztürkÇalikoglu 7 ,HasanArslan 7 , RubalKanozia 8 ,UllaKriebernegg 9,FranziskaGroßschädl 10,FelixReer 11 , ThorstenQuandt 11,SandraC.Buttigieg 12,PaulaAlexandraSilva 13,VeraGallistl 14 and RebekkaRohner 14

1 HealthandWellbeingStrategicResearchArea,TheOpenUniversity,MiltonKeynes,UnitedKingdom, 2 Communication Department,TheNationalUniversityofPoliticalStudiesandPublicAdministration(SNSPA),Bucharest,Romania, 3 CommunicationNetworks&SocialChange(CNSC)ResearchGroup,InternetInterdisciplinaryInstitute(IN3)Research Institute,UniversitatObertadeCatalunya,Catalonia,Spain, 4 CentreforUniversityCore,SingaporeUniversityofSocial Science,Singapore,Singapore, 5 LeCentredeRecherchesIndividus,Épreuves,Sociétés(CeRIES),UniversityofLille,Lille, France, 6 InstituteforAnthropologicalResearchinAfrica(IARA),KULeuven,Belgium, 7 GraduateSchoolofEducational Sciences,CanakkaleOnsekizMartUniversity,Canakkale,Turkey, 8 DepartmentofMassCommunicationandMediaStudies, CentralUniversityofPunjab,Bathinda,India, 9 AgeandCareResearchGroupGraz,UniversityofGraz,Graz,Austria, 10 InstituteofNursingScienceandAgeandCareResearchGroup,MedicalUniversityGraz,Graz,Austria, 11 Departmentof Communication,UniversityofMunster,Munster,Germany, 12 DepartmentofHealthSciencesManagement,FacultyofHealth Sciences,UniversityofMalta,Msida,Malta, 13 DepartmentofInformaticsEngineering(DEI),CentreforInformaticsand Systems(CISUC),FacultyofScienceandTechnology,UniversityofCoimbra,Coimbra,Portugal, 14 Ageing,Generations, Life-CourseResearchGroup,DepartmentofSociology,UniversityofVienna,Vienna,Austria

Drawnfromthestressprocessmodel,thepandemichasimposedsubstantialstressto individualeconomicandmentalwell-beingandhasbroughtunprecedenteddisruptions tosociallife.Inlightofsocialdistancingmeasures,andinparticularphysicaldistancing becauseoflockdownpolicies,theuseofdigitaltechnologieshasbeenregardedas thealternativetomaintaineconomicandsocialactivities.Thispaperaimstodescribe thedesignandimplementationofanonlinesurveycreatedasanurgent,international responsetotheCOVID-19pandemic.Theonlinesurveydescribedhererespondstothe needofunderstandingtheeffectsofthepandemiconsocialinteractions/relationsand toprovidefindingsontheextenttowhichdigitaltechnologyisbeingutilizedbycitizens acrossdifferentcommunitiesandcountriesaroundtheworld.Italsoaimstoanalyze theassociationofuseofdigitaltechnologieswithpsychologicalwell-beingandlevelsof loneliness.Thedatawillbebasedontheongoingsurvey(comprisedofseveralexisting andvalidatedinstrumentsondigitaluse,psychologicalwell-beingandloneliness),open for3monthsafterrollout(endsSeptember)across11countries(Austria,France, Germany,India,Malta,Portugal,Romania,Spain,Turkey,andUK).Participantsinclude residentsaged18yearsandolderinthecountriesandsnowballsamplingisemployed viasocialmediaplatforms.Weanticipatethatthefindingsofthesurveywillprovide usefulandmuchneededinformationontheprevalenceofuseandintensitiesof digitaltechnologiesamongdifferentagegroups,gender,socioeconomicgroupsina comparativeperspective.Moreover,weexpectthatthefutureanalysisofthedata

collectedwillshowthatdifferenttypesofdigitaltechnologiesandintensitiesofuseare associatedwithpsychologicalwell-beingandloneliness.Toconclude,thesefindingsfrom thestudyareexpectedtobringinourunderstandingtheroleofdigitaltechnologiesin affectingindividualsocialandemotionalconnectionsduringacrisis.

Keywords:gerontology,pandemic(COVID-19),internationalrapidresponse,quantitativedata,socialmedia, gerontechnology,socialscienceresearch

INTRODUCTION

TheongoingCOVID-19pandemic,isoneoftheworst pandemicsinhumanhistoryandinthelast100years,ona globalscaleandhasresultedin ∼21,294,845(267,291—inthe last24h)infectedcases,and761,799deaths(5,985—inthelast 24h)(WorldHealthOrganization,2020)withthestatisticsstill ontherise.The pandemichascauseddisruptionsacrossthe usualsocialandeconomicactivities.Reducingphysicalcontact, socialgatheringsandthecompletelockdownhaveindirectly redefinedthecommonpracticeofwork,caregiving,supportand socialinteraction.

Todate,thereisagrowingbodyofscholarlyresearchrelating totheimpactofCOVID-19andcitizensacrossdifferentcountries andcontinents.Thisincludes Ammaretal.(2020a,b,c) who deployedanonlinesurveyin sevenlanguagestounderstand howthispandemicwasimpactingonthedailylivingandlives ofcitizensinrelationtosocialdistancing,isolationandhome confinement.Furthermore, Bentlageetal.(2020) and Chtourou etal.(2020) whoaremembers ofthesameprojecthaveexplored andprovidedpracticalrecommendationsformaintainingan activelifestyleandphysicalactivityduringthepandemic.Such recommendationsincludeexergaming,yoga,andhome-based exercise,withappropriateamountsofintensityconductedfor bothadultsandchildren.

Scholarlyresearchsurroundingtheuse,benefitsandimpacts ofdigitaltechnologyinthelivesofoldercitizens,aswell asthoseofyoungercitizens(Itoetal.,2010;Cottenetal., 2014;Marston,2019) hasbeengrowingoverthelast30+ years(CzajaandBarr,1989).Theapplicationofdigital technologiesininfluencing socialandpsychologicalwell-being havebeenwidelystudiedwiththefocusofthetypesofdigital connectionsandtheintensitiesofusingdigitaltechnologies amonggeneralpopulation(RosenfeldandThomas,2012;Hofstra etal.,2017;Verduynetal., 2017;Rafalow,2018;Henwoodand Marent,2019;Shahetal.,2019).Thedemographicprofilesof theusers,suchasage,genderandeducationareimportant factorstounderstandtheaccessibility,frequenciesandtypes ofdigitaluseincreatingandenhancingsocialconnections andsupport.

Whenfocusingonsocialisolation,lonelinessandthedigital divide,thereisamyriadofscholarlyresearchsurroundingolder adultsandincludesexploringolderadults’attitudestoward technologyadoptionanduse(Mitzneretal.,2010;Marston, 2012;O’brienetal.,2012;Fernández-ArdèvolandIvan,2015; Marstonetal.,2016,2019;RosalesandFernández-Ardèvol, 2016a,b; Fernández-Ardèvoletal.,2017;Rosalesetal.,2018; Fernández-Ardèvol,2020),leisure activities(Genoeetal.,2018),

supportingindependence,socialsupportand connectedness whilereducingloneliness(Boumaetal.,2004;Cottenetal., 2013;Czajaet al.,2018;Schlomannetal.,2020),thedigital divideandinequalities(Cotten etal.,2009;Gilleardetal.,2015; Lagacéetal., 2015;Friemel,2016;HargittaiandDobransky,2017; Balletal.,2019;Fernández-Ardèvol,2019),telemedicineand emergingtechnologies forhealthcare(SixsmithandSixsmith, 2000;Mitzneretal.,2012; Czajaetal.,2013;Sharitetal.,2019), andtosupportage-in-place (Mynattetal.,2000,2004;Beeretal., 2012;MarstonandvanHoof,2019;Whiteetal.,2020).

Basedonthegrowing literaturehighlightedaboveandin thenextsection,coupledwiththeriseofdigitaltechnologies intermsofsocialnetworkingsites,virtualconferencing,etc. thereisalternativethoughtsandapproachestomaintaining socialconnectionsandactivitiesduringthecrisis.Ingeneral, thisgrowthinscholarlyresearchillustratesafast-movingarena withinthefieldsofsociology,generalsocialsciences,computer scienceandgerontechnology.Inadditiontoaseriesofnational andinternationalresearchprojectsfocusingonthevarious impactsandrolesthattechnologycanplaywithinsociety(Ivan etal.,Accepted;IvanandHebblethwaite,2016;Loosetal.,2018, 2019;Marstonetal.,2019;Nimrod,2019;NimrodandIvan,2019; GallistlandNimrod,2020).

Thepurposeandrationaleofthispaperistodescribea studyprotocolwhichincludesadescriptionoftheConsortium members,theonlineinstrumentusedfordatacollection,coupled withfutureworkanddisseminationactivities.Thisstudy protocoldetailstheurgencyandtheinternationalresponseto theCOVID-19pandemic.Weanticipatethepreliminaryfindings willprovideaninsightintotheuseofdigitaltechnologiesandthe impactsofusingdigitaltechnologiesonpsychologicalwell-being andloneliness.

BACKGROUNDANDLITERATUREREVIEW

InterdisciplinaryResearchProjects

Inwhatfollowswesummarizepreviousprojectsthathave targetedindividualsthroughusingonlinetoolstocollectdata acrossdifferentcountriesandindividual’sage-groups.

TheACT(aging + communication + technologies)project (ACTproject,2014–2021)isaCanadian-fundedpartnership thatbringsmorethan45internationalresearchers,community partnersandinstitutionstogether.Bymeansofdifferentpilot projectsandcasestudies,ACTaimstoexploreandunderstand thetransformationalexperiencesofagingthroughvarious mediumsofcommunication.Itdevelopsresearchinthree mainareas.

First,“AgencyinAging”encompassesaprogramofresearch thatinvolvesindividualsand communitiesinthedevelopmentof participatoryactionresearchprojectsinthefieldofthedigitalarts thathavebothscholarlyandcreativeoutcomes.Second,“Critical Mediations”examinestheeverydaylifepractices,thevarious mediatedexperiencesofadultsinlaterlife,andtheexisting culturesofaging.Finally,“TelecommunicationTechnologies” investigatesaginginthecontextofnetworkedsocieties.Of interesttothispaperaretwocross-countryprojects,onewhich consistsofanonlinelongitudinalstudyaboutolderaudiences inthedigitalmediaenvironmentsandanother,Grannieson theNet,abouttheroleofinformationandcommunication technologies(ICTs)ingrandmothers’interactionswithcloseand distantsocialties.

Theonlinelongitudinalresearchaboutolderaudiencesin thedigitalmediaenvironments(2016–2020)(Loosetal.,2018, 2019)hasrevealedtheratherdiversemediapractices(bothdigital andanalog)andtheheterogeneity ofolderonlinetechnology usersamongthesixcountrieswhicharepartoftheproject. Thisprojectunderlinestheimportanceofcross-nationalanalysis whenwetalkaboutinformationcommunicationtechnology (ICT)usebydifferentgenerations.Inanalyzingdata,researchers notonlyfocusedontherelationbetweenwell-beingandmediabasedleisureofolderadults(GallistlandNimrod,2020)andon technologyusebydifferent generationsofolderadults(Ivanetal., Accepted),butalsoon media-displacement(Nimrod,2019)–a processbywhich traditionalmediahasbeenreplacedtoamoreor lesserextentbythenewmedia,inthewaypeoplecommunicate, getinformation,andsolveeverydaytasks.

TheresultsoftheGranniesontheNetproject,which examinestheroleofICTsingrandmothers’interactionswith closeanddistantsocialties,uncoveredthevaryingmotives andusestrategiesgrandmothersdeploytocommunicatewith adiversityofactorswhilerevealingcommonalitiesinthe challengestheyfaceindifferentculturalcontexts.Wetackled theroleofICTinreducinggrandmothers’feelingofloneliness andtheirneedtoshareeverydayexperienceswithlovedones (IvanandHebblethwaite,2016).Also,weanalyzedtheroleICT playsinolderwomen’sleisure (NimrodandIvan,2019).Onthe onehand,ithelps olderwomentoremainactiveandsocially engagedbysavingtimethatcouldbeusedfortheirleisure, facilitatingparticipationinvariousactivitiesandallowingfora moremeaningfulleisureexperiencesbothonlineandoffline.On theotherhand,ICTcanoftenentailwastedtimeanddisrupted involvement,orsimplyservedasa“timefiller.”Theauthorsof thisrespectivestudyconcludehowtheimpactofICTmayvary acrossvariousagecohortsandgender,whichinturnmayimpact thevariousleisureactivitiesbytherespectiveparticipants.

The TechnologyInLaterLife(TILL)project(2015–2017) isa multi-centered,internationalstudycomprisingof twocountries (UKandCanada)andfoursites:tworural(SouthWales,UK McBride,BC)andtwourban(MiltonKeynes,UKandRegina, SK).TheTILLstudyaimedtoexploretheuse,perceptionsand impactsoftechnologyonadultsaged70+ yearsresidinginthese fourgeographiclocations.ThefindingsfromtheTILLstudy ascertainedtwomainoverarchingthemes.Thefirstis“facilitators oftechnology”,whichrelatestothesharingofinformationby

therespectiveparticipants,andforthoseparticipantswhodo usetechnology,theextenttowhichthisaffordedthemasense ofsecurity.Thesecondthemeis“detractorsoftechnology”, whichidentifiedasenseofapprehensionofusingtechnology. RecommendationsfromtheTILLstudyproposedthenotion ofpromotingtechnologybasedonthestrengthsandpositive opportunitiestofacilitatehealthandwell-being.Secondly,apeer supportnetwork(s)shouldbeconsideredandcreatedtoassist noviceusersinunderstandinghowtouseICTsfacilitatedby experiencedpeerusers.

Thenotionofexploringandunderstandinghow intergenerationalrelationshipscanbeenhancedandmaintained viatechnologyusewasalsosuggested(Marstonetal.,2019). Fromaleisurestandpoint, Genoe etal.(2018) identified technologyasa primarymeansofaccessingleisureactivities suchasgames,hobbiesandmaintainingsocialconnections. However,thoseparticipantsdidnotechallengesincluding, difficultyinusingandupdatingsoftware,concernssurrounding privacyandsecurityandtheiroveralllackofconfidenceand interest.Althoughtechnologymayfacilitateleisureactivitiesand engagementfromtheserespectiveparticipants,toovercomethe issuesanddrawbacksidentifiedbytheseparticipantsmaybe affordedthrougheducational/communityopportunities.

Finally,intergenerationalexperienceswerenotedthrough datacollectionintheTILLstudyandwerepivotalincontinuing socialconnectionswithfamilyandfriends(Freemanetal., 2020).Forexample, findingsshowedolderadultsleveraged existingfriendshipsandfamilialrelationshipswhenlearning andadjustingtonewdigitaldevicesandtechnologies.Thisis particularlythecasewhengeographicdistanceisplayingan integralroleintheserespectiveintergenerationalrelationships. Thenotionofa“digitalgatheringplace”ismotivatedand implementedbyallfamilialrelationshipsandfriendstoensure communicationiscontinued.

TheTechnology4YoungAdults(Technology4YoungAdults (T4YA)Project,2017) wasapilotstudytounderstandthe perception,useandimpact technologyhasonyoungadultsaged 18–34years—theMillennials—intheUK.Findingsfromthe T4YAinitialstudyidentifiedseveralprimarythemesincluding privacyissuesandconcerns,activitiesrelatingtocontentand sharingofinformationconfidence,usability,andfunctionalityof usingtechnologyandassociatedplatformscoupledwithvarious day-to-dayactivities(Marston,2019).

Theinterdisciplinaryresearchproject“InternetandMental Health”(2016–2019)aimedtoinvestigatethepsychosocialeffects ofusingonlinemedia.InGermany,anationallyrepresentative surveyof1,929adolescentsandyoungeradults(aged14–39 years)focusedontopicssuchassocialmediaandgaming disorder(Reeretal.,2020;Tangetal.,2020a),thefearof missingout(Reeret al.,2019),orsexualharassmentinonline contexts(Tanget al.,2020b).Aprimarygoalofthisproject wastoexaminehow theuseofICTsisassociatedwith differentindicatorsofmentalhealth,loneliness,depression,and anxiety.Findingsfromthisprojectunderlinethecentralrole oftheInternetinthedailylivesoftheyoungergeneration andemphasizeitsrelevanceforyoungeruser’spsychosocial well-being.

The“BeingConnectedatHome-Makinguseofdigital devicesinlaterlife”project(BCONNECTHOME,2018–2020)investigatesfundamentalchangesinthecontemporary experienceoflaterlife,attheintersectionofdigital infrastructures,placeandtheexperienceof“beingconnected” (Fernández-Ardèvoletal.,2019).Itaddressesaresearchgap byexploringandtheorizing theroleofdigitalcommunication devices—suchassmartphones(thathavebeentracked),tablets, PCs,apps,fitnesstrackers,pedometers,or“braingames” —inrelationtothemodernlifecourse.Itcombinesthis theoreticalapproachwithapracticalgoalthroughco-designby involvingdiverseolderpeopleandotherrelevantstakeholdersin “AcademicWorkPlaces”intheNetherlands,Spain,Swedenand Canada.Theprojectiscontextualizedbydebatesaroundagein place,lonelinessandsocialisolation,andtheideathattheseare age-relatedchallengesthatrequireinterventions.

TheACCESSProject(SupportingDigitalLiteracyand AppropriationofICTbyolderpeople,2018–2021)aimsto provideandevaluatesociallyembeddedlearningopportunities forolderadultswhoaredigitallyexcluded.Theaimoftheproject istosupportolderadultstolearnandappropriatenewdigital technologieslaterinlifeinAustria,Germany,Italy,Finland andJapan.Itaddressesaresearchgapbyexploringinformal, non-formalandformallearningsettingsinlaterlifeandfurther developingitthroughcombinationofsuchapproacheswith differentformsoflearning(courses,senior-to-seniorapproaches, praxlabs)(Gallistletal.,2020).

Theproject“App-SoluteNews:IntergenerationalLearning, DigitalisationandtheMedia”(2020–2022)looksatthedaily routineofnewspaperreadinginthecontextofthetransition fromanalog(printedpaper)todigital(e-paperandapp). Intergenerationalteamsofstudentsandadults60+ intheregion ofStyriainAustriawillcomparetheirreadinghabits,workwith printedpapersande-paperapps,andcreatedigitalstoriesabout theirexperiences.Theaimistoinvestigatethenarrativesthat areformedintheseintergenerationalencounterswithregard tothetransitionfromanalogtodigital.Theprojectaimsat understandingtheroleofageandage-relatedstereotypesin digitalisationprocesses.

Buildingupontheextensiveprojectsconductedbefore, thisstudyisexpectedtobringinasociologicallensto lookintotheinfluenceofusingdigitaltechnologies.The ongoingCOVID-19pandemicasahealthcrisishasresulted inthedisruptionofwork,familysupport,educationand socialinteraction.Thesechangesmayhaveformedheath, socialandeconomicstressorstoone’spsychologicalwellbeinginthetimesofongoingcrisis.Thestress-process modelillustrateshoweconomicstrainsandchangingsocial circumstancesbecomelong-termstressorsthatimpactindividual healthandwell-beingandhowvarioussociodemographicgroups mayhavedifferentdegreesofimpacts(Pearlinetal.,2005). Thisframeworkprovidesanew perspectivetolookintothe prevalenceofhowindividualsfromdifferentsociodemographic backgroundschangetousethedigitaltechnologiesand alsoprovidesexplanationsontheextentdigitaltechnologies influenceindividualwell-beingandlonelinesstocopewiththe externalpandemic.

Whiletheaforementionedprojectsaddressissuesrelatedto theuseandimpactandappropriationofdigitaltechnology inpeople’slives,thispaperreportsonastudythat,although addressingadjacentgoalstothoseoftheprojectsabove,emerges inthecontextofthecurrentCOVID-19pandemicscenario. Freemanetal.(2020) continuetonotetheimportanceof intergenerationalsupportandcommunication, ishavingandhas beenpivotalsincethestartofthepandemic.Whereby,theuse ofvariousformsofdigitaltechnologies(e.g.,communication toolsandsocialmediaplatforms)asaprimarymethodof maintainingintergenerationalsocialconnectednessandsupport hasbeenkey.Forexample,forthoseolderadultswhodonot haveinternetaccess,whiletheirchildrenorgrandchildrenwho dohaveinternet,hasaffordedtheolderpersontobeableto receivegroceriesduringthestrictlockdown(s)period.During thelockdownperiodofthepandemicandespeciallyforthose citizensinsocietycategorizedasvulnerableandwhoneeded toshield,havingaccesstotheinternetwaskeytoensuring day-to-day/monthlysuppliesofgroceriesaswellasmaintaining communicationandleisureactivities.Thesurveydeployedinthis studyhasandwillcapturethevariousactivitiesofindividual respondentsandtheircommunitiesduringthepandemic.We anticipatewewillbeabletoreportfindingssurroundingwhat typeofleisureactivitieshavebeenconducted,thevarious communityeffortsemployed(especiallyaimedatthevulnerable populations),andthehealthandwell-beingofrespondents relatingtosocialconnectionandloneliness.

METHODS

Theproject- COVID-19:Technology,SocialConnections, LonelinessandLeisureActivities(2020a) hasemployedtwo theoreticaltheories,firstlyalifecourseperspective(Elder, 1985;Green,2017;Hutchinson, 2018).Takingalifecourse perspectivewillafford theConsortiumtoanalysethecollected datatospecificpersonal,andhistoricallifeevents,forming a“personalbiography”(Elder,1985).Thisprojectisnot primarilyaimedatolderadultsbut adultswhoare18years orolderandgiventhisunprecedentedpandemichasimpacted thelivesofallcitizensglobally.Furthermore,takingalife courseperspectivewillprovideaquantifiableunderstanding ofhowdigitaltechnologieshavebeenusedbycitizensand theirrespectiveexperiencesprepandemicaswellasduring thepandemic.

Secondly,ecologytheorywillaffordtheConsortiumto examine,exploreanddiscusstheroleplayedbydigital technologiesduringthepandemic,asthemediumtoimprove citizens’socialconnections,whichinturnenablescitizens socialresourcesandsupporttoreducefeelingofloneliness. Additionally,theecologytheorywillfacilitateapplication associatedto1.thelevelsofloneliness,2.thedecompositionof theuserprofileand,3.toascertainthetypesofdigitaltechnology usedbycitizensduringthepandemicacrossfourareas:1. Individual,2.Relationship(e.g.,family,peers,andfriends),3. Community(e.g.,groups,networks,workplace,neighborhoods), and4.Societal(BerkesandFolke,1998;Foxonetal.,2009;

SmithandStirling,2010;Anderies,2014;McPhearsonetal.,2016; Ahlborgetal.,2019).

AimsandObjectives

Theaimof thispaperistodescribetheonlineinstrumentof the COVID-19:Technology,SocialConnections,Lonelinessand LeisureActivities(2020a,b) Thisonlinesurveyexploreshow digitaltechnologywasused,accessed,perceivedandimpacted thelivesofcitizensacross11countries(UK,Malta,France, Germany,Austria,Romania,India,Singapore,Portugal,Spain, andTurkey)and10languages(English,German,French,Hindi, Mandarin,Portuguese,Romanian,Turkish,Spanish,Catalan). Thiswillprovideusefulinsightsontheuseofdigitaltechnologies andtheimpactofuseonlonelinessfromthesurveysacross 11countries.

Thesurveysacross11countriesundertheproject: COVID19:Technology,SocialConnections,LonelinessandLeisure Activities(2020a) havethefollowingoverarchingobjectives:

• explorethebehavioranduseoftechnologybycitizensduring theCOVID-19pandemic

• explorehowcitizensusetechnologytoconnectwithCOVID19supportgroups

• explorehowcitizensusetechnologytoshareinformation duringtheCOVID-19pandemic

• explorethehealthandwell-beingofcitizensduringCOVID19relatingtolonelinessanddigitalhealthliteracy

• exploretheperceptionandnotionofanationalemergency alertsystembycitizens

• explorethebehaviorandnarrativesofuserswhoare usingtechnologytomaintainfamilialandfriendshipsocial connectionsandbuildnewconnectionsduringtheCOVID19pandemic.

Ascanbeseen,theseaimsareincorporatedintotheonline surveyandwillprovideimportantdataonhowpeoplehave beenusingdigitaltechnologiesandthedifferentiationsofdigital technologiesduringthepandemic.Moreover,thesurveyalso coveredhealth-relatedquestions,whichenableresearchersto lookintothehealthandwell-beingoftherespondents.

Ethics

Ethicalapprovalforconductingtheonlinesurveywasinitially grantedbytheleadandrespectiveUniversity,TheOpen University(HREC/3551/MARSTON)locatedintheUK.

Subsequentethicalapprovalhasbeenprocessedand approvedbytheNationalUniversityofPoliticalStudiesand PublicAdministration(SNSPA–Romania),OpenUniversity ofCatalonia(Spain),SingaporeUniversityofSocialSciences (Singapore),DepartmentofHealthSciencesManagement, UniversityofMalta–(Malta),theDepartmentofInformatics Engineering(DEI)/CenterforInformaticsandSystems(CISUC) attheUniversityofCoimbra(Portugal),theDepartmentofMass CommunicationandMediaStudiesattheCentralUniversity ofPunjab(India),NursingScience,AgeandCareResearch GroupattheMedicalUniversityGraz(Austria),Departmentof SociologyattheUniversityofVienna,theDepartmentofAge andCareResearchGroupattheUniversityofGraz(Austria),

theDepartmentofCommunicationattheUniversityofMünster (Germany),andCanakkaleOnsekizMartUniversityinTurkey.

Allversionsofthesurvey,studyinformationsheetand certificationfromrespectiveUniversitieshavebeenshared withTheOpenUniversityHumanResearchEthicsCommittee (HREC)toensurethoserespectiverecordsaremaintainedand keptuptodate.

Alldocumentationliststheethicalapprovalgrantedbythe leadUniversityandtherespectiveUniversityethicalcommittee orboard.Informedconsentwasobtainedbyallparticipants takingpartinthisonlinesurvey.

PartnerRecruitment

UponcompletionanddeploymentoftheEnglishversionof thesurvey,theprojectlead(HRM)contactedcolleaguesina bidtoexpandthesurveyandincreaseparticipantrecruitment. ThisresultedintheleadforRomania(RO)requestingtheword documentstobetranslatedandrolledoutacrossRomania.

This,inturn,ledtotheUKandROleadsutilizingtheir existingnetworksandinvitingtheirrespectivecolleaguesto jointheproject.HRMprovidedadescriptionofthestudy, responsibilities,andexpectationstoprospectivepartners,and onceapartnerconfirmedtheirinvolvement,theEnglishsurvey andstudyinformationsheetwasprovidedtotherespective partnertoallowforback/translationtocommence.Acopyofthe ethicsapplicationbyHRMatTheOpenUniversitywasshared withtherespectivepartnertofacilitatetherespectivepartnerto expeditetheirownethicalapprovalprocess.

ParticipantRecruitment

Giventhefocusofthisworkandtherestrictionsimposedbythe respectiveUniversitiesandCountries,participantrecruitmentis beingconductedthroughmultiplechannelsinwhatconstitutes a non-probabilistic samplingprocess,usualinonlineresearch (Ayhan,2011).Thisincludessocialmediachannels(e.g., Facebook,LinkedIn,Twitter, WhatsApp),existingmailinglists, stakeholderorganizations(e.g.,AgeNorthernIreland).Subjects aged18yearsandolderareallowedtotakepartinthe onlinesurvey.

ToobtaininsightsintothecurrentCOVID-19health crisisduringthelockdownperiod,avirtual snowballsampling technique isappliedthroughtheprojectteam’snetworkstobuild asamplequicklyandacrossdifferentcountries.Thistechniqueis increasinglyappliedgiventhefacilitiesthattheInternetopens toinvestigatephenomenaincurrentsocieties(Benfieldand Szlemko,2006;Baltarand Brunet,2012).Thisapproachhas advantages suchasreachingindividualsfaster(henceminimizing theperiodofcollectingandprocessingdata),expandingthe samplesizeandthescopeofthestudyacrossdifferentsettings (e.g.,differentcountries)giventheflexibilitytoapplythemin differentformatsandlanguages.Nevertheless,thisapproachalso hassomeshortcomings,suchas selectionbias relatedtothe onlinepopulationreachedandthenon-representativenessof thesampletothegeneralpopulation,aspectsthatshouldbe consideredwhenanalyzingthedata.Additionally,Indiachose torecruitparticipantsusinganalternativeapproachtotheother countries,andincludesusingadirectWhatsApplink,followedby

TABLE1| Demographiccharacteristicsofthecountries includedinthisstudy(UnitedNations,(2019);TheWorldBankGroup,(n.d.);Worldometer,(n.d.-a), (n.d.-b)).

Country TotalpopulationPopulation density/Km2

MedianageLifeexpectancy atbirth

Worldshareof population Economicgroup

Austria 9,006,398 109 43 82.05 0.12% High-Income

France 65,273,511 119 42 83.13 0.84% High-Income

Germany 83,783,942 240 46 81.88 1.07% High-Income

India 1,380,004,385 464 28 70.42 17.70% Lower-MiddleIncome

Malta 441,543 1380 43 83.06 0.01% High-Income

Portugal 10,196,709 111 46 82.65 0.13% High-Income

Romania 19,237,691 84 43 76.50 0.25% High-Income

Singapore 5,850,342 8358 42 86.15 0.08% High-Income

Spain 46,754,778 94 45 83.99 0.60% High-Income

Turkey 84,339,067 110 32 78.45 1.08% Upper-Middle-Income

UnitedKingdom67,886,011 281 40 81.77 0.87% High-Income

frequentfollow-ups.Theapproachwasdeemedbytherespective partnerasameans ofencouragingprospectiveparticipantsto participateinthissurvey.Furthermore,thisapproachprovides amorepersonalizedapproachinhelpingtogetgoodnumbersof responseswithinanIndiancontext.

Currently,somesurveysarestillongoing,anditisnotpossible toprovideacompleteoverviewofparticipantdemographics ofthisstudy.However,the11studysitesinvolvedinthe projectincludeaninterestingsubsetofcountries,representing differentsocio-economicgroupsandpopulationcharacteristics (Table1).Thiswilllendtheprojectandthecollecteddata toincludeandreportdiversity.Furthermore,thiswillprovide insightconcerningcountriesofhigh,middle,andlow-income, surroundingdifferentdemographiccharacteristics,forexample populationdensities,medianage,lifeexpectancy,etc.Overall, thecountriesinvolvedinthisstudyrepresent ∼22%oftheworld shareofthepopulation.

OnlineSurvey

TheonlinesurveyrolledoutforthestudyusestheQualtrics platformasthesolemethodofdeploymentacrossdifferent networks.TheEnglishversionofthesurveyisbasedonprevious iterationsandstudiesconductedbytheleadauthor(Marston, 2012,2019;Marstonet al.,2016,2019).Duringthedesignofthe Englishversionofthesurvey,revisionswereconductedtothe instrumenttomeettheaimsandobjectivesofthestudy.

ForanewsurveytobeaddedtotheQualtricsplatform,a copyismadewithintheplatformandtheleadauthortransfers (manually,copyandpaste)thetranslatedversionofthesurvey intothenewproject.Theprojectisnamedinthatrespective language.Oncethetranslationistransferred,thesurveyis exportedintoMicrosoftWord,saved,andsharedwiththe partner(s)toreviewforanyerrors,changesinquestionsto reflecttheculturalcontextandresentforamendmentswithinthe Qualtricsplatform.InsomeinstancesbacktoHRM,thesurvey mayhaveseveralcolleaguesfromoneinstitutionreviewingthe documentationandsuggestingrevisions.Oncetherespective partnershaveagreedthatthedocumentationiscorrect,the respectiveonlinemeasuringinstrumentgoesthroughsome

usabilitytesting,onvarioushardwaredevices,andchangesare suggested.Oncethisstagehasbeenagreed,theinstrumentis copiedagain,andrepublished,inpreparationforrollout.

SurveyLanguagesandTranslatedVersions

Table2 presentstheversionsofthesurvey,translatedlanguages andtheleadforeachcountry.Atpresentthereare10countries whichcurrentlyhavethesurveydeployedandstaggeredrollout datesbecauseofethicalapproval.Surveyversionsbyadditional partnerswillbeopenfor3monthsrespectivelyuponethical approvalandrollout.

Measures

ThesurveysbuildonpreviousiterationsfromtheTechnology4 YoungerAdults(T4YA)study(Marston,2019),theiStoppFalls EUproject(Marstonetal.,2016),theTechnologyInLaterLife (TILL)project(Genoeet al.,2018;Marstonetal.,2019;Freeman etal.,2020),andthedoctoralworkofHRM(Marston,2012).

Intotaltherehavebeensevenscholarlyworkspublishedusing earlieriterationsofthissurvey(Marston,2012,2019;Marston etal.,2016,2019;Genoeet al.,2018;Freemanetal.,2020).An earlieriterationofasurvey deployedintheTILLstudyisavailable fordownload(Marstonetal.,2019).Thepreviousversionofthe surveydeployedinthe TILLstudycomprisedan80-itemsurvey.

ThisnewiterationoftheEnglishversionofthe surveycomprises65-items(Table3).Forsomeofthe languages/countriestherehavebeensomeminoralterations tothesurveytorepresenteachcountry’srespectiveculture, laws,andeducationalsystems.Forexample,theSingaporearm requestedthequestionsrelatingtosexualityshouldbedeleted forboththeEnglishandMandarinversionswhichwouldbe rolledoutacrosstherespectivenetworks.Theconsideration isduetothefactthatSingaporestillretainsthesection377A ofthePenalCode(SingaporeStatuesOnline,2020).Though thelawisnotenforced (Chen,2013),thepartnerforthe Singaporearmdecidedto revisethequestionaboutthesexuality toaconventionalquestionoftheparticipants’genderwith anoptionwhereparticipantscanfillouttheidentityfreely. TheFrenchpartneralsorequestedthequestionsonsexual

TABLE2| Displaysthesurveyiterations.

#Lead CountryLanguage CountriesdeployedSurveydeploymentEthicalapproval

1HannahR.Marston,Sarah Earle UK English USA,Canada, Singapore,Australia 03.04.2020Approved

2LoredanaIvan Romania(RO)Romanian Romania 20.04.2020Approved

3MireiaFernández-Ardèvo,D. BlancheTarragó,A.Rosales Climent,M.GomezLeon

Spain CatalanSpanishSpainandHispanic America 04.05.2020Approved

4SophieColas France French France,Switzerland, Belgium,Quebec(CA) 12.05.2020ApprovedviaThe OpenUniversity

5Pei-ChunKo SingaporeMandarin Singapore 12.05.2020Approved

6HalimeÖztürkÇaliko ˇ glu, HasanArslan,BurcuBilir Turkey Turkish Turkey 26.06.2020Approved

7RubalKanozia India Hindi India 31.05.2020Approved

8VeraGallistl,UllaKriebernegg, FranziskaGroβ schädl, GerhildeSchüttengruber, RebekkaRohner,HannaKottl

Austria German Germany,Switzerland 05.06.2020Approved

9FelizReer,ThorstenQuandtGermanyGerman Austria/Switzerland 04.06.2020Approved

10SandraC.Buttigieg Malta BritishEnglish Malta 19.05.2020Approved

11PaulaAlexandraSilva PortugalEuropeanPortuguesePortugal 29.05.2020Approved

orientationandtransgenderidentitytoberemovedduetoitstoo intimatenature.

Furthermore,aslightchangeinwordingforquestions relatingtothenationalemergencyalertsystemwererenamed to“PublicWarningSystem”inSingapore.Bothversions inIndia(EnglishandHindi)aswellastheversionin EuropeanPortuguese,FrenchandGermandonotinclude thequestionrelatingtoethnicity.Insomeinstances,the typesofeducationalqualificationwerealteredtorepresent therespectiveculturalcontexts.Thisoccurredfortranslations inCatalanandSpanish,EuropeanPortuguese,andGerman. TheSpanishversionwasalsoaimedatrollingoutin extendednetworksacrossHispanicAmerica.Additionally,in boththeCatalanandSpanishversionsthequestionsrelating toanationalemergencyalertsystemweredeleted,and thiswasontheguidanceofthepartnersintheproject, becausetheyfeltthatintheirtargetedcountriestherewere eithernosuchsystemsinplace,ornopublicdiscussion onthematter,makingthequestiondifficulttoanswerin mostinstances.

Procedure

TheprojectleadfortheUKsharesacopyofthestudy informationsheetandacopyoftheEnglishsurveywiththe newconsortiumpartner.Ifapartnerhasadditionalcolleagues, communicationislimitedtoreducetheriskofinformationbeing misunderstoodandtoensureallcommunicationbetweenthetwo coordinatorsiscorrect.Thisisapracticalapproachduringthe surveytranslation(s)andtestingphases.

Eachnewcountry/partnerappliesforethicalapproval throughtheirrespectiveUniversityethicscommittee.Additional documentationfromtheUKpartnerissharedbasedon thefavorableopiniongrantedbytheOpenUniversity (HREC/3551/MARSTON).Acopyoftheethicsapplication

isalsosharedtoassisttherespectivepartnerincompletingtheir ethicsapplication.Furthermore,eachpartnerhastheoption toattachthisdocumentandthefavorableopiniontotheir respectiveapplication.

TheQualtricsplatformisusedtocreateanddeploythesurvey toadheretotheOpenUniversitypolicies.Alltranslatedsurveys fromeachstudypartneraretransferredintoanewprojectwithin theplatformandexportedtoMicrosoftWordforchecking bytheConsortiumpartner.Eachrevisionwithintheplatform ispublishedandallowstheconsortiumpartnertotesttheir respectivesurveyforuserexperience(UX)/usabilityissuesand formatting.Ateachrevision,theconsortiumpartnerreceivesan updatedversionofthesurveyviaaWorddocumentandisable toreviewthesurveyonline.

SurveyDeployment

Onceethicalapprovalisgranted,thesurveywas“published” viatheQualtricsplatform,whichcreatedanindependentlink thatissharedviavariouschannels(specificemail(s),anonymous linketc.).The COVID-19:Technology,SocialConnections, LonelinessandLeisureActivities(2020b) projectwebsiteisthe portalforallparticipantsto reviewthestudy,downloadthe respectivestudyinformationsheet,andaccesstheonlinesurvey.

Toassistprospectiveparticipantstoidentifythecorrectsurvey tocomplete,aseriesofflagsareplacedatthesideofeach translatedsection(Figures1 4).Toensureaccesstothestudy informationsheetandtherespectiveonlinesurvey—thereare linksintherespectivelanguagewhichhighlightsthelinks— “StudyInformationSheet”and“CompleteOnlineSurveyHere”. Thesizeoftheflagshelpsidentifythedesiredversionof thesurvey.However,anissuethatmightpreventparticipants toreachtheirsurveyisthatthewebpageisonlyavailable inEnglish.

TABLE3| Presentsanoverviewofthe measuringvariablesincludedintheCOVID-19technology,self-isolation,health,well-being,andleisureactivitiesstudy.

SurveysectionSurveyitems

ParticipantConsent Q1

SectionA

Q2–Q16

Participantconsent

Computerownership,purposeofusinga computer,lengthandfrequencyofuse,video gameconsoleownership,favoritetypeof gametoplay.Howtheinternetisaccessed, frequencyofusingtheinternet,purposeof usingtheinternet.Typeofsocialmedia platformsused,frequencyandpurposeof usingsocialmediaplatforms.

Exampleofquestion(s) Source

NA NA

•Haveyouusedacomputer?(selectanswer)

•Howlonghaveyouusedacomputerfor?(selectanswer)

•Doyouusesocialnetworkingsites

•Whydoyouusesocialmediasites

SectionB Q17–35

COVID-19relatedquestions:purposeof usingtechnology/internet/socialmedia platformstoshareinformation,communicate withsupportgroups,challengesfacedduring COVID-19.

•SinceCOVID-19,haveyoubecomeamemberofacommunity supportgrouponsocialmedia(e.g.,Facebookorsimilar)?

•SinceCOVID-19,haveyousigneduptoreceivecommunity deliveries/assistance(e.g.,groceriesfromalocalnewsagents /communityshop/butcher’s/farmer’smarket)?

•PleasedescribewhyyouWOULDsignuptoreceivecommunity deliveriesand/orassistance.Ifyouchoosenottoanswerpleasewrite N/A

•PleasedescribewhyyouareunsureoryouWOULDNOTsignupto receivecommunitydeliveriesand/orassistance.Ifyouchoosenotto answerpleasewriteN/A

•SinceCOVID-19,howhaveyoubeenspendingyourtime?Selectall thatapply

•Mydeathandthatofpeopleclosetome(e.g.,familymembers)

•Limitedsocialcontactwithfriendsandfamily

•Nothavingajobtogobackto

•Iamonmyown.Ihavenosupport(e.g.,nochildrenetc.)

•Educationformychild/children

•OnyourdigitaldevicedoyoushareinformationaboutCOVID-19?

•WhydoyoushareinformationsurroundingCOVID-19–selectall thatapply

(Marston,2012,2019; Marstonetal.,2016, 2019;Genoe etal.,2018; Freemanetal.,2020)

Q17-25-newitems addedaimedspecifically atCovid-19experiences. Q26-35-adaptedfrom (Genoeetal.,2018; Marston,2019;Marston etal., 2019;Freeman etal.,2020)

SectionC Q36–Q40

13-items,1–7 ptLikertCOVID-19 relatedquestions

•Makingnewsocialconnections/friendships

•Spendingmoretimewithspouse/familymembers

•Beingakeyworkerandhelpinginthispandemic

•Beingisolatedmore

•Givingsomethingback

•Pleasedescribehowyourcommunicationbehavior(s)haschanged sinceCOVID-19.IfyouchoosenottoanswerpleasewriteN/A

•SinceCOVID-19,hasthewayyouuseyourdigitaldeviceschanged yourwayofcommunication?

Newitemsaddedrelating toCovid-19

SectionD Q41 18-itemmeasure,1–7ptLikertPsychological well-being

•“Iamgoodatmanagingtheresponsibilitiesofdailylife.”

•“IthinkitisimportanttohavenewexperiencesthatchallengehowI thinkaboutmyselfandtheworld.”

•“IjudgemyselfbywhatIthinkisimportant,notbythevaluesofwhat othersthinkisimportant.”

•IknowwheretofindhelpfulhealthresourcesontheInternet

•IknowhowtousethehealthinformationIfindontheInternettohelp me

•IfeelconfidentinusinginformationfromtheInternettomake healthdecisions

RyffandKeyes,1995; RyffandSinger,1998

NormanandSkinner, 2006

SectionF Q43

•Howoftendoyoufeelthatyouare“intune”withthepeoplearound you?

•Howoftendoyoufeelpartofagroupoffriends?

•Howoftendoyoufeelthatyourinterestsandideasarenotsharedby thosearoundyou?

•Howoftendoyoufeelthatnoonereallyknowsyouwell?

•DuringtheCOVID-19pandemic,howfrequentlyhaveyou communicatedwithmembersofyoursocialnetwork?Pleaserate youranswersbelowoneachofthesliders

•DoesyourcountryhaveaNationalEmergencyAlertSystem(e.g., mobileapporSMS)?

Russell,1996

TABLE3| Continued

SurveysectionSurveyitems

Exampleofquestion(s)

•PleasedescribewhatyourthoughtsarerelatingtoaNational EmergencyAlertSystem(e.g.,mobileapporSMS)?Ifyouchoose nottoanswerpleasewriteN/A

•VirtualAssistantssuchasAlexa,GoogleHome,Sirihavevarious features.Pleasedescribewhetheryouthinksuchdevicesorsimilar wouldbesuitableasawayofsharingNationalEmergencyAlert Systems.IfyouchoosenottoanswerpleasewriteN/A

Source

Newitemsaddedtothe survey.

SectionH Q50–Q65

Demographicquestions:gender,age, country,ethnicity,geographiclocation, education,sexuality,maritalstatus,#of peoplelivingyourhome,#ofchildrenliving yourhome,employmentstatus,disability, self-isolation

•Doyoumeetthecriteriaforbeingvulnerableorextremelyvulnerable?

•Haveyouhadtoself-isolatebecauseofCOVID-19?

(UKGovernment,(n.d.); Marston,2012,2019; Patten,2015;Marston et al.,2016,2019;Genoe etal.,2018;Settlement Hierarchy,2019;Thrive, 2019;Educationinthe UnitedStates,2020; Freemanetal.,2020)

FIGURE1| Figuredisplaysthreepartners involvedinthestudyandtheirrespectiveflags,studyinformation,contactinformation.Foreachpartner/country,therewere additionallinkstotheonlinesurvey,studyinformationsheet,andconsentform.

Foreachcountry/consortiumpartner,thereisacontactemail addressavailableonthestudywebsiteandthestudyinformation sheet.Thisfacilitatestheparticipant(s)tocontacttheresearcher inchargeofthesurveyineachparticularlanguage(Figures1 4).

DataAnalysis

Inthissectionofthestudyprotocol,weoutlinehowthe collecteddataandsubsequentanalysiswilldrivetheresults forward.Eachsurveytranslationclosesatvarioustimes andatpresentbetween4thJulyand29thSeptember2020. Thedataanalysiswilltaketheformofdescriptivestatistics withcrosstabulationsandmultivariateregressionmodels toprovidepreliminarydescriptivefindings.Thisinturn willdrivetheresultstoaffordtheConsortiummembers toexploreandunderstandthecollecteddatafromthe standpointof(a)age,(b)gender,(c)education,and(d) country. T-testswillbeemployedtotestthedifferencesinthe levelsofwell-beingandlonelinessfeelingsamongdifferent socialgroupsbasedonsociodemographiccharacteristics. Lastly,inferentialstatisticalanalysiswillbeconductedto

examinetherelationshipsbetweendigitaluseandwellbeingand/orlonelinessfeelings,withtheconsiderations ofdifferentsociodemographic,familystructure,and countrysettings(especiallyrelatedtoCOVID-19measures) ofrespondents.

Oursampleisaconveniencesampleinallcountries includedinthestudyandwedonotclaimtohave statisticalandnationalrepresentativeatthecountry level.Still,wewillconductfurtheranalysisifthe structureofoursampleineachcountryiscomparable withthestructureoftheadultpopulationwith Internetaccess(age,gender,educationleveland economicstatus).

Toconsiderthedifferencesacrossthecountriesand culturesincludedinthestudy,thisprojectreliesona researchteamthatconsistsofnativespeakersandlocal researchers,whoareandwillplayanimportantrolein contextualizingtherespectivedata.Additionally,members oftheresearchteamhavetheroleincomparingthedata acrossthemainsocio-demographics(age,gender,levelof

FIGURE2| Figuredisplaysthreepartners involvedinthestudyandtheirrespectiveflags,studyinformation,contactinformation.Foreachpartner/country,therewere additionallinkstotheonlinesurvey,studyinformationsheet,andconsentform.

FIGURE3| Figuredisplaysthreepartners involvedinthestudyandtheirrespectiveflags,studyinformation,contactinformation.Foreachpartner/country,therewere additionallinkstotheonlinesurvey,studyinformationsheet,andconsentform.

education,economicstatus)andtoprovidevaluableinformation regardingthecomparabilityofthesampleinthecurrent proposalwiththestructureofthetotaladultpopulationinthe respectivecountries.

Weanticipatethecollecteddatawillprovideaninsightinto theprevalenceofdifferenttypesofdigitaltechnologieswith thecrosstabulationsofvarioussociodemographiccharacteristics. Whileeachstudysitewillbeconductingtheirowndata analysis,wewillalsobemergingthedifferentdatasetsinto STATAtofacilitategreaterstatisticalanalysisviamultivariate analysestounderstandtheimpact(s)ofdigitaltechnologieson well-beingandloneliness.Allsurveyswillbeclosedbytheend ofSeptember.

OnlineRepository

AspartoftheethicalprocessatTheOpenUniversityanonline repositoryisused—OpenResearchDataOnline(ORDO).A separateprojecthasbeencreatedbythelead,andallpartners havebeeninvitedtojointheproject.ORDOwillbeusedtostore allfinaldocuments,dataandassociatedinformationrelating tothisstudy.Eachcountry/regionhasitsindividualfolderto facilitateeaseoforganization,accessandfollowingthepolicies ofTheOpenUniversity.

TheConsortium

Thisisacooperativeprojectthatrespondstotheneedof urgentinformationduringtheunexpectedCOVID-19pandemic.

FIGURE4| Figuredisplaysthreepartners involvedinthestudyandtheirrespectiveflags,studyinformation,contactinformation.Foreachpartner/country,therewere additionallinkstotheonlinesurvey,studyinformationsheet,andconsentform.

Theprojectleadhasalreadydefinedtheoperationaldynamics ofthestudytogrant fastandsustainableoutputs(academic journals,policyrecommendations)aswellasotherdynamics insearchoftheestablishmentofaconsortiumabletocreate anintellectualcommunityaroundthegathereddata.Each studysitehasworkedwiththeprojectleadtoensurethe translatedsurveyhasconductedbackwardstranslationofthe onlinesurveyandtoensurethemeaning(s)ofthesurvey questionsarenotlost.Eachsiteleadwasresponsiblefortheirown participantrecruitment—viamailinglists,varioussocialmedia channels(e.g.,TwitterandFacebook)andwillberesponsiblefor dataanalysis.

DISCUSSIONANDFUTUREWORK

Inthisstudyprotocolwearedescribinghowthisinternational, multi-centeredprojecthasbeendesignedtoexploreand

understandhowdigitaltechnologyandassociatedplatformsare beingusedbycitizensandhowdigitaltechnologyimpactson theirday-to-daylivesduringtheCOVID-19pandemic,across differentcountries,regionsandcultures.Withthisinmind, participantsofthestudyarewelcometocompleteasurveyifthey areover18yearsold.Giventheunprecedentedcrisisonaglobal scale,citizensinsocietyarelivingandexperiencinglifedifferently towhatsocietywaspriortothepandemicandalsodifferently dependingonthecountrytheylivein.Therefore,itisimportant toexplorehowtechnologyishavinganimpactoncitizensfrom theageof18+ years,ratherthanjustfocusingonolderadultsas thiswillallowforcomparisonsbetweengenerations.

Inparticular,itisessentialtocapturethepossibilities thatdigitaltechnologyaffordscitizensduringthispandemic aaswayofgarneringinsightswiththeviewtoworking towardrespectivepathwaystoimpact,whichinturnhasthe abilitytoinformpolicyanddecisionmakersatlocal,regional,

nationalandinternationallevels.Thefactthatthissurveyis beingdeployedacrossseveraldifferentlanguages,affordsthe Consortiummemberstoreachoutandunderstanddifferent culturesanddemographics.Furthermore,thisprojectlendsitself tounderstandingthenecessarymultidimensionalperspective requiredtodevelopeffectiveandmeaningfulpathwaysassociated tosocialscienceandbehavioralresearch,publicengagement, knowledgetranslationandpathwaystoimpactinthefuture. Moreover,thisinternationalprojectaffordstheConsortium partnerstounderstandhowdigitaltechnologyisusedand impactssocietyatatimewhensocialdistancingmeasureswere variedandmayaffordtheresearchteamtounderstandand explorepossiblesuggestionsandsolutionstofeedintopolicy.

ThisstudyprotocoldescribestheCOVID-19:Technology, SocialConnection,LonelinessandLeisureActivitiesprojectand weanticipatethefindingsdrivenfromthecollecteddatawill contributetothefieldsofgerontechnology,HumanComputer Interaction(HCI),gerontology,andsocialsciencesbythe creationofaMasterdatasetandindividualdatasetsfromeach site.Furthermore,thisresearchwillcontributetotheexisting scholarlyresearch(Morrisetal.,2014;Bakeretal.,2018;Barbosa Nevesetal.,2019; Ammaretal.,2020a,b,c;Fakoyaetal., 2020;MarstonandMorgan,2020;Marstonetal.,2020;Seifert etal.,2020).TheConsortiumanticipatesthefindingsfromthe collecteddatawill indicatehowdigitaltechnologyandassociated platformsimpactthelivesofcitizensacrossvarioussitesduring thepandemic.Thiswillaffordresearchers,stakeholdersand policymakerstheopportunityinthefuturetolearnand understandhowcitizensintherespectivecountriesutilized digitaltechnologiesduringunprecedentedtimes.Additionally, theConsortiumwillbeundertakingawidevarietyofpublic engagementandknowledgetranslationactivities,inadditionto ensuringtraditionalacademicoutputsareachieved.Membersof theConsortiumwillseekoutopportunitiestosharefindingswith respectivecountriesatlocal,regionalandnationallevelsofpolicy inabidtoofferinsightsandsolutionsinthefuture.

Currently,existingscholarlyresearchdemonstratesthe growinginterestincontemporaryacademesurroundingtheuse ofdigitaltechnologyasabridgetomaintainsocialconnections andinteractionswhilereducingloneliness;withtheaimof understandinghowtechnologyhasimpactedthelivesofmany citizensworldwide.Thisstudyprotocoldescribeshowthis particularstudy,totheknowledgeoftheConsortium,isthe firsttotakeaninternational,interdisciplinaryrapidresponse totheCOVID-19pandemic,whilecontributingtoexisting respectivedisciplines.

Thesocialimpactsofthepandemiccanbeunderstood throughthelensofthedigitaldividewiththeintersectionality ofeducation,genderandage.Theprojectisexpectedtobring

REFERENCES

Ahlborg,H.,Ruiz-Mercado,I.,Molander,S.,andMasera,O.(2019). Bringingtechnologyintosocial-ecologicalsystemsresearch—motivations forasocio-technical-ecologicalsystemsapproach. Sustainability 11. doi:10.3390/su11072009

infirst-handdatatounderstandtheprevalenceoftechnology associatedtothedifferentsocio-demographicgroups.Thisin turnwillaffordustounderstandwhethertheCOVID-19 pandemicnarrowsthedigitalgaporwidensit.Incorporatedwith thelonelinessscaleandthequestionsoftheactivities,researchers canexaminetheextenttowhichdigitaltechnologyuseinfluences individuals’mentalwell-beingandsocialconnections,andthe heterogeneityamongsocialgroups.

FutureworksurroundingtheConsortiummembersand thecollecteddatawillexplorefundingopportunitiesto enablethenextphaseofthisproject—pathwaystoimpact anddisseminationactivities.Theformermayincludean OpenEducationalResource(OER)developedandaccessible viaTheOpenUniversitywhichwillincludeinputfrom allprojectpartnersandwillincludecontentrelatedtothe findings.Thisinturnwillenablecitizens,policymakers, stakeholders,andresearchersonaglobalscaletoaccess, learn,andunderstandhowdigitaltechnologiesplayeda roleandimpactedthelivesofcitizensacross11countries. Disseminationactivitieswillincludetraditionalacademic outputs(e.g.,journalpapersandconferencepresentations), seminars,booklets/reportsandwhereappropriatecontributing topolicy.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswere reviewedandapprovedbyTheOpenUniversity(UK) HREC/3551/MARSTON.Writteninformedconsentto participateinthisstudywasprovidedbytheparticipants’ legalguardian/nextofkin.Allstudysitesreceivedethical approvalpriortosurveydeployment.TheFrenchversionofthe onlinesurveywasapprovedviatheOpenUniversity.

AUTHORCONTRIBUTIONS

HM:conceptualization.HM,LI,MF-A,AR,MG-L,DB-T,SE,PCK,SC,BB,HÖ,HA,RK,UK,FG,FR,TQ,SB,PS,VG,RR,and theCOVID19TechnologyConsortiumGroup:writing–original draftpreparation,review,andediting.Allauthorscontributedto thearticleandapprovedthesubmittedversion.

ACKNOWLEDGMENTS

Thankyoutoallauthor/siteledforconductingsurvey translation(s)inpreparationforsurveydeployment.Wewould alsoliketothankallparticipantswhocompletedtheonline surveyviathevarioussocialmediachannels,mailinglists,and snowballapproaches.

Ammar,A.,Brach,M.,Trabelsi,K.,Chtourou,H.,Boukhris,O.,Masmoudi,L., etal.(2020b).EffectsofCOVID-19homeconfinementoneatingbehaviourand physicalactivity:resultsoftheECLB-COVID19internationalonlinesurvey. Nutrients 12:1583.doi:10.1101/2020.05.04.20072447

Ammar,A.,Chtourou,H.,Boukhris,O.,Trabelsi,K.,Masmoudi,L.,Brach, M.,etal.(2020a).COVID-19homeconfinementnegativelyimpactssocial

participationandlifesatisfaction:aworldwidemulticenterstudy. Int.J. Environ.Res. PublicHealth 17:6237.doi:10.3390/ijerph17176237

Ammar,A.,Trabelsi,K.,Brach,M.,Chtourou,H.,Boukhris,O.,andMasmoudi, L.,etal.(2020c).Effectsofhomeconfinementonmentalhealthandlifestyle behavioursduringtheCOVID-19outbreak:insightfromtheECLB-COVID19 multicenterstudy. Biol.Sport 38,9–21.doi:10.1101/2020.05.04.20091017

Anderies,J.M.(2014).Embeddingbuiltenvironmentsinsocial–ecological systems:resilience-baseddesignprinciples. Build.Res.Inform. 42,130–142. doi:10.1080/09613218.2013.857455

Ayhan,H.Ö.(2011).“Non-probabilitysamplingsurveymethods,”in International EncyclopediaofStatisticalScience,edM.Lovric(Berlin:Springer). doi:10.1007/978-3-642-04898-2_41

Baker,S.,Warburton,J.,Waycott,J.,Batchelor,F.,Hoang,F.,Dow,B.,etal. (2018).Combattingsocialisolationandincreasingsocialparticipationofolder adultsthroughtheuseoftechnology:asystematicreviewofexistingevidence. Australas.J.Ageing 37,184–193.doi:10.1111/ajag.12572

Ball,F.J.,Kadylak,C.T.,andCotten,S.R.(2019).“Aginginthedigitalage: conceptualizingtechnologyadoptionanddigitalinequalities,”in Ageingand DigitalTechnology,edsB.B.Neves,andF.Vetere(Singapore:Springer),35–49. doi:10.1007/978-981-13-3693-5_3

Baltar,F.,andBrunet,I.(2012).Socialresearch2.0:virtualsnowballsampling methodusingFacebook. Int.Res. 22,57–74doi:10.1108/10662241211199960

BarbosaNeves,B.,Franz,R.,Judges,R.,Beermann,C.,andBaecker,R.(2019). Candigitaltechnologyenhancesocialconnectednessamongolderadults?a feasibilitystudy. J.Appl.Gerontol. 38,49–72.doi:10.1177/0733464817741369

Beer,J.M.,Smarr,C.A.,Chen,T.L.,Prakash,A.,Mitzner,T.L.,Kemp,C.C.,etal. (2012).“Thedomesticatedrobot:designguidelinesforassistingolderadultsto ageinplace,”in ProceedingsoftheSeventhAnnualACM/IEEEInternational ConferenceonHuman-RobotInteraction (Boston,MA:Associationfor ComputingMachinery),335–342.doi:10.1145/2157689.2157806

Benfield,J.A.,andSzlemko,W.J.(2006).Internet-baseddatacollection:promises andrealities. J.Res.Prac.2:2006.http://jrp.icaap.org/index.php/jrp/article/ view/30/51(accessedOctober28,2020).

Bentlage,E.,Ammar,A.,How,D.,Ahmed,M.,Trabelsi,K.,Chtourou,H.,etal. (2020).Practicalrecommendationsformaintainingactivelifestyleduringthe COVID-19pandemic:asystematicliteraturereview. Int.J.Environ.Res.Public Health 17:6265.doi:10.3390/ijerph17176265

Berkes,F.,andFolke,C.(1998).“Linkingsocialandecologicalsystemsfor resilienceandSustainability,”in LinkingSocialandEcologicalSystems: ManagementPracticesandSocialMechanismsforBuildingResilience,edsF. Berkes,andC.Folke(Cambridge:CambridgeUniversityPress),1–26.

Bouma,H.,Czaja,S.J.,Umemuro,H.,Rogers,W.A.,Schulz,R.,andHastutiKurniawan,S.(2004).“Technology:ameansforenhancingtheindependence andconnectivityofolderpeople,”in ProceedingsontheHumanFactors inComputingSystems (Vienna:AssociationforComputingMachinery), 1580–1581.doi:10.1145/985921.986154

Chen,J.(2013).Singapore’sculturewaroversection377A:throughthelens ofpublicchoiceandMultilingualresearch. LawSoc.Inquiry 38,106–137. doi:10.1111/j.1747-4469.2012.01297.x

Chtourou,H.,Trabelsi,K.,H’mida,C.,Boukhris,O.,Glenn,J.M.,Brach,M.,etal. (2020).Stayingphysicallyactiveduringthequarantineandself-isolationperiod forcontrollingandmitigatingtheCOVID-19pandemic:asystematicoverview oftheliterature. Front.Psychol.11:1708.doi:10.3389/fpsyg.2020.01708

Cotten,S.R.,Anderson,W.,andTufekci,Z.(2009).Oldwineinanew technologyoradifferenttypeofdigitaldivide? NewMediaSoc.11,1163–1186. doi:10.1177/1461444809342056

Cotten,S.R.,Anderson,W.A.,andMcCullough,B.M.(2013).ImpactofInternet useonlonelinessandcontactwithothersamongolderadults:cross-sectional analysis. J.Med.InternetRes.15:e39.doi:10.2196/jmir.2306

Cotten,S.R.,Shank,D.,andAnderson,W.(2014).Gender,technologyuse andownership,andmedia-basedmultitaskingamongmiddleschoolstudents. Comput.HumanBehav.35,99–106.doi:10.1016/j.chb.2014.02.041

COVID-19:Technology,SocialConnections,LonelinessandLeisureActivities (2020a).Availableonlineat:https://healthwellbeing.kmi.open.ac.uk/covid19/technology-social-connections-loneliness-leisure-activities/(accessed October1,2020).

COVID-19:Technology,SocialConnections,LonelinessandLeisureActivities (2020b). OnlineSurveys.Availableonlineat:https://healthwellbeing.kmi.open. ac.uk/covid-19/(accessedOctober1,2020).

Czaja,S.,Beach,S.,Charness,N.,andSchulz,R.(2013).“Olderadultsand theadoptionofhealthcaretechnology:opportunitiesandchallenges,” in TechnologiesforActiveAging.InternationalPerspectivesonAging, edsA.Sixsmith,andG.Gutman(Boston,MA:Springer),27–46. doi:10.1007/978-1-4419-8348-0_3

Czaja,S.J.,andBarr,R.A.(1989).Technologyandtheeverydaylifeofolderadults. Ann.Am.Acad.Pol.Soc.Sci.503,127–137.doi:10.1177/0002716289503001010

Czaja,S.J.,Boot,W.R.,Charness,N.,Rogers,W.A.,andSharit,J.(2018). Improvingsocialsupportforolderadultsthroughtechnology:findings fromthePRISMrandomizedcontrolledtrial. Gerontologist 58,467–477. doi:10.1093/geront/gnw249

EducationintheUnitedStates(2020). Wikipedia.Retrievedfrom:https:// en.wikipedia.org/wiki/Education_in_the_United_States(accessedMarch28, 2020).

Elder,G.H.(1985).“Perspectivesonthefifecourse,”in LifeCourseDynamics: TrajectoriesandTransitions,edGlenH.Elder,Jr.(Ithaca,NY:Cornell UniversityPress),23–49.

Fakoya,O.A.,McCorry,N.K.,andDonnelly,M.(2020).Lonelinessandsocial isolationinterventionsforolderadults:ascopingreviewofreviews. BMCPublic Health 20:129.doi:10.1186/s12889-020-8251-6

Fernández-Ardèvol,M.(2019).“Onephone,twophones,fourphones:older womenandmobiletelephonyinLima,Peru,”in GenderedPowerandMobile Technology:IntersectionsintheGlobalSouth,edsC.W.Larsson,andL.Stark, (London:Routledge)93–107.doi:10.4324/9781315175904-5

Fernández-Ardèvol,M.(2020).“Olderpeoplegomobile,”in TheOxford HandbookofMobileCommunicationandSociety,edsR.Ling,L.Fortunati, G.Goggin,S.S.Lim,andY.Li,(Oxford:OxfordUniversityPress)186–199. doi:10.1093/oxfordhb/9780190864385.013.13

Fernández-Ardèvol,M.,andIvan,L.(2015).“Whyageisnotthatimportant? anageingperspectiveoncomputeranxiety,”in HumanAspectsofIT fortheAgedPopulation.DesignforAging. ITAP2015.LectureNotesin ComputerScience,Vol.9193,edsJ.ZhouandG.Salvendy(Cham:Springer). doi:10.1007/978-3-319-20892-3_19

Fernández-Ardèvol,M.,Rosales,A.,Loos,E.,Peine,A.,Beneito-Montagut,R., Blanche,D.,etal.(2019).“Methodologicalstrategiestounderstandsmartphone practicesforsocialconnectednessinlaterlife,”in HumanAspectsofITforthe AgedPopulation.SocialMedia,GamesandAssistiveEnvironments.HCII2019. LectureNotesinComputerScience,Vol.11593,edsJ.Zhou,andG.Salvendy (Cham:Springer).doi:10.1007/978-3-030-22015-0_4

Fernández-Ardèvol,M.,Sawchuk,K.,andGrenier,L.(2017).Maintaining connections:octo-andnonagenariansondigital‘useandnon-use’. Nordicom Rev.38,39–51.doi:10.1515/nor-2017-0396

Foxon,T.J.,Reed,M.S.,andStringer,L.C.(2009).Governinglong-term social–ecologicalchange:whatcantheadaptivemanagementandtransition managementapproacheslearnfromeachother? Environ.Pol.Govern.19,3–20. doi:10.1002/eet.496

Freeman,S.,Marston,H.R.,Olynick,J.,Musselwhite,C.,Kulczycki,C.,Genoe,R., etal.(2020).Intergenerationaleffectsontheimpactsoftechnologyuseinlater life:insightsfromaninternational,multi-sitestudy. Int.J.Environ.Res.Public Health. 17:5711.doi:10.3390/ijerph17165711

Friemel,T.N.(2016).Thedigitaldividehasgrownold:determinants ofadigitaldivideamongseniors. NewMediaSoc.18,313–331. doi:10.1177/1461444814538648

Gallistl,V.,andNimrod,G.(2020).Media-basedleisureand wellbeing:astudyofolderInternetusers. Leis.Stud.39,251–265. doi:10.1080/02614367.2019.1694568

Gallistl,V.,Rohner,R.,Seifert,A.,andWanka,A.(2020).Configuringtheolder non-user:betweenresearch,policyandpracticeofdigitalexclusion. Soc.Incl. 8, 233–243.doi:10.17645/si.v8i2.2607

Genoe,M.R.,Kulczycki,C.,Marston,H.,Freeman,S.,Musselwhite, C.,andRutherford,H.(2018).E-leisureandolderadults:findings fromaninternationalexploratorystudy. Ther.RecreationJ. 52,1–18. doi:10.18666/TRJ-2018-V52-I1-8417

Gilleard,C.,Jones,I.,andHiggs,P.(2015).Connectivityinlaterlife:the decliningagedivideinmobilecellphoneownership. Soc.Res.Online 20:3. doi:10.5153/sro.3552

Green,L.(2017). UnderstandingtheFifeCourse:SociologicalandPsychological Perspectives,2ndEdn.Cambridge:PolityPress.

Hargittai,E.,andDobransky,K.(2017).Olddogs,newclicks:digitalinequality inskillsandusesamongolderadults. Can.J.Commun.42,1–18 doi:10.22230/cjc.2017v42n2a3176

Henwood,F.,andMarent,B.(2019).Understandingdigitalhealth:productive tensionsattheintersectionofsociologyofhealthandscienceandtechnology studies. Soc.HealthIll.41,1–15.doi:10.1111/1467-9566.12898

Hofstra,B.,Corten,R.,vanTubergen,F.,andEllison,N.B.(2017).Sourcesof segregationinsocialnetworks:anovelapproachusingFacebook. Am.Sociol. Rev.82,625–656.doi:10.1177/0003122417705656

Hutchinson,E.D.(2018). DimensionsofHumanBehavior:TheChangingLife Course.London:Sage.

Ito,M.,Baumer,S.,Bittanti,M.,Boyd,D.,Cody,R.,Herr-Stephenson, B.,etal.(2010). HangingOut,MessingAround,andGeekingOut:Kids LivingandLearningwithNewMedia.Cambridge,MA:TheMITPress. doi:10.7551/mitpress/8402.001.0001

Ivan,L.,andHebblethwaite,S.(2016).Granniesonthenet:grandmothers’ experiencesofFacebookinfamilycommunication. Roman.J.Commun.Public Relat.18,11–25.doi:10.21018/rjcpr.2016.1.199

Ivan,L.,Loos,E.F.,andBird,I.(Accepted).Theimpactoftechnologygenerations onolderadults’mediause:reviewofpreviousempiricalresearchandaseven countrycomparison. Gerontechnology.

Lagacé,M.,Charmarkeh,H.,Laplante,J.,andTanguay,A.(2015).Howageism contributestothesecondleveldigitaldivide:thecaseofCanadianseniors. J. Technol.HumanUsabil.11,1–13.doi:10.18848/2381-9227/CGP/v11i04/56439

Loos,E.,Nimrod,G.,andFernández-Ardèvol,M.(Coords.).(2018). Older AudiencesintheDigitalMediaEnvironment:ACross-NationalLongitudinal Study.Wave1Report1.0.Montreal,Canada:ACTproject.Availableonlineat: spectrum.library.concordia.ca/983866(accessedApril26,2020)

Loos,E.,Nimrod,G.,andFernández-Ardèvol,M.(Coords.).(2019). Older AudiencesintheDigitalMediaEnvironment:ACross-NationalLongitudinal Study.Wave2.Reportv1.0.Montreal,Canada:ACTproject.Availableonline at:spectrum.library.concordia.ca/986444/(accessedApril26,2020)

Marston,H.R.(2012).Olderadultsas21stcenturygamedesigners. Int.J.Comput. GamesTechnol. 1,90–102.doi:10.1007/BF03392330

Marston,H.R.(2019).MillennialsandICT.FindingsfromtheTechnology 4YoungAdults(T4YA)project:anexploratorystudy. Societies 9:80. doi:10.3390/soc9040080

Marston,H.R.,Genoe,R.,Freeman,S.,Kulczycki,C.,andMusselwhite,C.(2019). Olderadult’sperceptionsofICT:mainfindingsfromtheTechnologyinLater Life(TILL)study. Healthcare 7:86.doi:10.3390/healthcare7030086

Marston,H.R.,Kroll,M.,Fink,D.,deRosario,H.,andGschwind,Y. J.(2016).Technologyuse,adoptionandbehaviourinolderadults: resultsfromtheiStoppFallsProject. Educ.Gerontol. 42,371–387. doi:10.1080/03601277.2015.1125178

Marston,H.R.,andMorgan,D.J.(2020).Technologyandsocialmedia duringCOVID-19pandemic.Specialissue:COVID-19andgeriatricmental healthWorldwide. IPABull.3.Availableonlineat:https://www.ipa-online. org/publications/ipa-bulletin/featured-articles/covid-19-bulletin-articles/ technology-social-media-during-covid19(accessedOctober28,2020).

Marston,H.R.,Musselwhite,C.,andHadley,R.A.(2020). COVID-19vs SocialIsolation:TheImpactTechnologycanHaveonCommunities,Social ConnectionsandCitizens.AgeingIssues,18thMarch2020.TheBritishSociety ofGerontology.Availableonlineat:https://ageingissues.wordpress.com/ 2020/03/18/covid-19-vs-social-isolation-the-impact-technology-can-haveon-communities-social-connections-and-citizens/?fbclid=IwAR1sUsffKNd_ G5u6d_oc0Z56u4Es7HyoCJYKr0qSnqFxX68pD3PY5JaSl7g(accessedOctober 28,2020).

Marston,H.R.,andvanHoof,J.(2019).“Whodoesn’tthinkabouttechnology whendesigningurbanenvironmentsforolderpeople?”Acasestudy approachtoaproposedextensionoftheWHO’Sage-friendlycities model.Int.J.Environ.Res.PublicHealth 16:3525doi:10.3390/ijerph161 93525

McPhearson,T.,Pickett,S.T.A.,Grimm,N.B.,Niemelä,J.,Alberti,M.,Elmqvist, T.,etal.(2016).Advancingurbanecologytowardascienceofcities. Bioscience 66,198–212.doi:10.1093/biosci/biw002

Mitzner,T.,O’Brien,M.,andRogers,W.(2012).“Emergingtechnologiesfor healthcareandaging,”in ProceedingsontheHumanFactorsinComputing Systems (Austin,TX:AssociationforComputingMachinery),2699–2702. doi:10.1145/2212776.2212699

Mitzner,T.L.,Boron,J.B.,Fausset,C.B.,Adams,A.E.,Charness,N.,Czaja,S. J.,etal.(2010).Olderadultstalktechnology:technologyusageandattitudes. Comput.HumanBehav.26,1710–1721.doi:10.1016/j.chb.2010.06.020

Morris,M.E.,Adair,B.,Ozanne,E.,Kurowski,W.,Miller,K.J.,Pearce,A.J.,etal. (2014).Smarttechnologiestoenhancesocialconnectednessinolderpeople wholiveathome. Australas.J.Ageing 33,142–152.doi:10.1111/ajag.12154

Mynatt,E.D.,Essa,I.,andRogers,W.(2000).“Increasingtheopportunities foraginginplace,”in ProceedingsontheConferenceonUniversal Usability (Arlington,VA:AssociationforComputingMachinery),65–71. doi:10.1145/355460.355475

Mynatt,E.D.,Melenhorst,A.S.,Fisk,A.D.,andRogers,W.A.(2004).Aware technologiesforaginginplace:understandinguserneedsandattitudes. IEEE PervasiveComput.3,36–41.doi:10.1109/MPRV.2004.1316816

Nimrod,G.(2019).Selectivemotion:mediadisplacementamong olderInternetusers. Inform.Commun.Soc.22,1269–1280. doi:10.1080/1369118X.2017.1414865

Nimrod,G.,andIvan,L.(2019).Thedualrolestechnologyplaysin leisure:insightsfromastudyofgrandmothers. Leis.Sci.8,1–18. doi:10.1080/01490400.2019.1656123

Norman,C.D.,andSkinner,H.A.(2006).‘eHEALS:theeHealthliteracyscale correspondingauthor. J.Med.Int.Res.8,1–7.doi:10.2196/jmir.8.4.e27

O’brien,M.A.,Rogers,W.A.,andFisk,A.D.(2012).Understanding ageandtechnologyexperiencedifferencesinuseofpriorknowledgefor everydaytechnologyinteractions. ACMTrans.Access.Comput. 4,1–27. doi:10.1145/2141943.2141947

Patten(2015). Chapter1:EstimatesofMultiracialAdultsandOtherRacialand EthnicGroupsAcrossVariousQuestionFormats.PewResearchCenter,Social &DemographicTrends.Retrievedfrom:https://www.pewsocialtrends.org/ 2015/11/06/chapter-1-estimates-of-multiracial-adults-and-other-racial-andethnic-groups-across-various-question-formats/(accessedMarch28,2020).

Pearlin,L.I.,Schieman,S.,Fazio,E.M.,andMeersman,S.C.(2005).Stress,health, andthelifecourse:someconceptualperspectives. J.HealthSoc.Behav.46, 205–219.doi:10.1177/002214650504600206

Rafalow,M.H.(2018).Discipliningplay:digitalyouthcultureascapitalatschool. Am.J.Sociol. 123,1416–1452.doi:10.1086/695766

Reer,F.,Festl,R.,andQuandt,T.(2020).Investigatingproblematicsocialmedia andgameuseinanationallyrepresentativesampleofadolescentsandyounger adults. Behav.Inform.Technol. doi:10.1080/0144929X.2020.1724333

Reer,F.,Tang,W.Y.,andQuandt,T.(2019).Psychosocialwell-being andsocialmediaengagement:themediatingrolesofsocialcomparison orientationandfearofmissingout. NewMediaSoc.21,1486–1505. doi:10.1177/1461444818823719

Rosales,A.,andFernández-Ardèvol,M.(2016a).BeyondWhatsApp:older peopleandsmartphones. Roman.J.Commun.PublicRelat.18,27–47. doi:10.21018/rjcpr.2016.1.200

Rosales,A.,andFernández-Ardèvol,M.(2016b).“Smartphones,appsandolder people’sinterests:fromagenerationalperspective,”in Proceedingsofthe18th InternationalConferenceonHuman-ComputerInteractionwithMobileDevices andServices,MobileHCI (Florence),491–503.doi:10.1145/2935334.2935363

Rosales,A.,Fernández-Ardèvol,M.,andFerran-Ferrer,N.(2018).“Long-term appropriationofsmartwatchesamongagroupofolderpeople,”in Human AspectsofITfortheAgedPopulation.Acceptance,Communicationand Participation.ITAP2018.LectureNotesinComputerScience,Vol.10926,edsJ. ZhouandG.Salvendy(Cham:Springer).doi:10.1007/978-3-319-92034-4_11

Rosenfeld,M.J.,andThomas,R.J.(2012).Searchingforamate:the riseoftheInternetasasocialintermediary. Am.Sociol.Rev.77:523. doi:10.1177/0003122412448050

Russell,D.W.(1996).UCLAlonelinessscale,(version3):reliability,validity andfactorstructure. J.Pers.Assess.66,20–40.doi:10.1207/s15327752jpa6 601_2

Ryff,C.D.,andKeyes,C.L.(1995).Thestructureofpsychologicalwell-being revisited. J.Pers.Soc.Psychol. 69,719–727.doi:10.1037/0022-3514.69.4.719

Ryff,C.D.,andSinger,B.(1998).Thecontoursofpositivehuman health. Int.J.Adv.Psychol.Theory 9,1–28.doi:10.1207/s15327965pli0 901_1

Schlomann,A.,Seifert,A.,Zank,S.,Woopen,C.,andRietz,C.(2020). UseofInformationandCommunicationTechnology(ICT)devicesamong theoldest-old:loneliness,anomie,andautonomy. Innov.Aging 4:igz050. doi:10.1093/geroni/igz050

Seifert,A.,Cotten,S.R.,andXie,B.(2020).Adoubleburdenofexclusion?digital andsocialexclusionofolderadultsintimesofCOVID-19. J.Gerontol.B gbaa098.doi:10.1093/geronb/gbaa098

SettlementHierarchy(2019). Wikipedia.Retrievedfrom:https://en.wikipedia.org/ wiki/Settlement_hierarchy(accessedMarch28,2020).

Shah,S.G.S.,Nogueras,D.,Woerden,H.van,andKiparoglou,V.(2019). Effectivenessofdigitaltechnologyinterventionstoreducelonelinessinadults: aprotocolforasystematicreviewandmeta-analysis. BMJOpen 9:e032455. doi:10.1136/bmjopen-2019-032455

Sharit,J.,Moxley,J.H.,Boot,W.R.,Charness,N.,Rogers,W.A.,andCzaja, S.J.(2019).Effectsofextendeduseofanage-friendlycomputersystem onassessmentsofcomputerproficiency,attitudes,andusabilitybyolder non-computerusers. ACMTrans.Access.Comput. 12,1–28.doi:10.1145/33 25290

SingaporeStatuesOnline(2020). OutragesonDecency377A.Availableonlineat: sso.agc.gov.sg/Act/PC1871?ProvIds=pr377A(accessedJune7,2020).

Sixsmith,A.,andSixsmith,J.(2000).Smartcaretechnologies:meeting whoseneeds? J.Telemed.Telecare 6,190–192.doi:10.1258/13576330019 34636

Smith,A.,andStirling,A.(2010).Thepoliticsofsocial-ecologicalresilience andsustainablesocio-technicaltransitions. Ecol.Soc.15:11.Availableonline at:http://www.ecologyandsociety.org/vol15/iss1/art11/(accessedOctober28, 2020).doi:10.5751/ES-03218-150111

Tang,W.Y.,Reer,F.,andQuandt,T.(2020a).Theinterplayofgaming disorder,gamingmotivations,andthedarktriad. J.Behav.Addict.9,491–496. doi:10.1556/2006.2020.00013

Tang,W.Y.,Reer,F.,andQuandt,T.(2020b).Investigatingsexualharassment inonlinevideogames:howpersonalityandcontextfactorsarerelatedto toxicsexualbehavioursagainstfellowplayers. Aggress.Behav.46,127–135. doi:10.1002/ab.21873

Technology4YoungAdults(T4YA)Project(2017). ProjectWebsite.Available onlineat:https://healthwellbeing.kmi.open.ac.uk/related-projects/t4yaproject/(accessedOctober1,2020).

TechnologyInLaterLife(TILL)project(2015–2017).Availableonlineat:https:// healthwellbeing.kmi.open.ac.uk/related-projects/technology-in-later-life-tillproject/(accessedOctober1,2020).

TheWorldBankGroup(n.d.). WorldBankCountryandLendingGroups–World BankDataHelpDesk.Availableonlineat:https://datahelpdesk.worldbank. org/knowledgebase/articles/906519-world-bank-country-and-lending-groups (accessedAugust31,2020).

Thrive(2019). HowtoAskaboutGenderandSexualityinSurveys. Retrieved from:https://wewillthrive.co.uk/resources/blogs/how-to-ask-about-genderor-sexuality-in-surveys

UKGovernment(n.d.). ListofEthnicGroups. Retrievedfrom:https://www. ethnicity-facts-figures.service.gov.uk/ethnic-groups(accessedMarch28,2020 UnitedNations(2019). WorldPopulationProspects—PopulationDivision— UnitedNations.Availableonlineat:https://population.un.org/wpp/DataQuery/ (accessedAugust31,2020).

Verduyn,P.,Ybarra,O.,Résibois,M.,Jonides,J.,andKross,E.(2017). Dosocialnetworksitesenhanceorunderminesubjectivewell-being?A criticalreview.Soc.IssuesPolicyRev.11,274–302.doi:10.1111/sipr. 12033

White,P.J.,Marston,H.R.,Shore,L.,andTurner,R.(2020).Learningfrom COVID-19:design,age-friendlytechnology,hackingandmentalmodels [version1;peerreview:awaitingpeerreview]. EmeraldOpenRes. 2:21. doi:10.35241/emeraldopenres.13599.1

WorldHealthOrganization(2020). Coronavirusdisease(COVID-19),Situation Report–209.16thAugust.Availableonlineat:https://www.who.int/docs/ default-source/coronaviruse/situation-reports/20200816-covid-19-sitrep-209. pdf?sfvrsn=5dde1ca2_2(accessedSeptember2,2020).

Worldometer(n.d.-a). LifeExpectancybyCountryandintheWorld (2020)—Worldometer.Availableonlineat:https://www.worldometers. info/demographics/life-expectancy/#countries-ranked-by-life-expectancy (accessedAugust31,2020).

Worldometer(n.d.-b). PopulationbyCountry(2020)—Worldometer.Available onlineat:https://www.worldometers.info/world-population/population-bycountry/(accessedAugust31,2020).

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Marston,Ivan,Fernández-Ardèvol,RosalesCliment,GómezLeón,Blanche-T,Earle,Ko,Colas,Bilir,ÖztürkÇalikoglu,Arslan,Kanozia, Kriebernegg,Großschädl,Reer,Quandt,Buttigieg,Silva,GallistlandRohner.This isanopen-accessarticledistributedunderthetermsoftheCreativeCommons AttributionLicense(CCBY).Theuse,distributionorreproductioninotherforums ispermitted,providedtheoriginalauthor(s)andthecopyrightowner(s)arecredited andthattheoriginalpublicationinthisjournaliscited,inaccordancewithaccepted academicpractice.Nouse,distributionorreproductionispermittedwhichdoesnot complywiththeseterms.

published:08December2020 doi:10.3389/fpubh.2020.585850

Editedby: MagdalenaKlimczuk-Kocha ´ nska, UniversityofWarsaw,Poland

Reviewedby: IndikaVarunaMallawaarachchi, UniversityofVirginia,UnitedStates JidapaKraisangka, MahidolUniversity,Thailand

*Correspondence: AmitTak dramittak@gmail.com

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 21July2020 Accepted: 02November2020 Published: 08December2020

Citation: BhandariS,TakA,SinghalS, ShuklaJ,ShaktawatAS,GuptaJ, PatelB,KakkarS,DubeA,DiaS, DiaMandWehnerTC(2020)Patient FlowDynamicsinHospitalSystems DuringTimesofCOVID-19:Cox ProportionalHazardRegression Analysis. Front.PublicHealth8:585850. doi:10.3389/fpubh.2020.585850

PatientFlowDynamicsinHospital SystemsDuringTimesofCOVID-19: CoxProportionalHazardRegression Analysis

SudhirBhandari 1 ,AmitTak 2*,SanjaySinghal 2 ,JyotsnaShukla 2 ,AjitSinghShaktawat 1 , JitendraGupta 2 ,BhoopendraPatel 3 ,ShivankanKakkar 4 ,AmitabhDube 2 ,SunitaDia 5 , MahendraDia 6 andToddC.Wehner 6

1 DepartmentofMedicine,S.M.S.MedicalCollege&AttachedHospitals,Jaipur,India, 2 DepartmentofPhysiology,S.M.S. MedicalCollege&AttachedHospitals,Jaipur,India, 3 DepartmentofPhysiology,GovernmentMedicalCollege,Barmer,India, 4 DepartmentofPharmacology,S.M.S.MedicalCollege&AttachedHospitals,Jaipur,India, 5 DepartmentofRheumatology, MedstarWashingtonHospitalCenter,Washington,DC,UnitedStates, 6 DepartmentofHorticulturalScience,NorthCarolina StateUniversity,Raleigh,NC,UnitedStates

Objectives: Thepresentstudyisaimedatestimatingpatientflowdynamicparameters andrequirementforhospitalbeds.Second,theeffectsofageandgenderonparameters wereevaluated.

PatientsandMethods: Inthisretrospectivecohortstudy,987COVID-19patients wereenrolledfromSMSMedicalCollege,Jaipur(Rajasthan,India).Thesurvivalanalysis wascarriedoutfromFebruary29throughMay19,2020,fortwohazards:Hazard1 washospitaldischarge,andHazard2washospitaldeath.Thestartingpointforsurvival analysisofthetwohazardswasconsideredtobehospitaladmission.Thesurvivalcurves wereestimatedandadditionaleffectsofageandgenderwereevaluatedusingCox proportionalhazardregressionanalysis.

Results: TheKaplanMeierestimatesoflengthsofhospitalstay(median = 10days, IQR = 5–15days)andmediansurvivalrate(morethan60daysduetoalargeamount ofcensoreddata)wereobtained.TheCoxmodelforHazard1showednosignificant effectofageandgenderondurationofhospitalstay.Similarly,theCoxmodel2showed nosignificantdifferenceofageandgenderonsurvivalrate.Thecasefatalityrateof 8.1%,recoveryrateof78.8%,mortalityrateof0.10per100person-days,andhospital admissionrateof0.35per100,000person-dayswereestimated.

Conclusion: Thestudyestimateshospitalbedrequirementsbasedonmedianlength ofhospitalstayandhospitaladmissionrate.Furthermore,thestudyconcludesthereare noeffectsofageandgenderonaveragelengthofhospitalstayandnoeffectsofage andgenderonsurvivaltimeinabove-60agegroups.

Keywords:COVID-19,coxproportionhazardsmodels,evidencebaseddecisionmaking,hospitalbeds,public health,hospitalmanagement

KEYMESSAGES

-Patientflowdynamicmodelsare usefulinmanagementofthe COVID-19pandemic.

-Hospitaldataonadmissionanddischargecanbeusedto estimateparametersofthemodel,suchashospitaladmission rates,recoveryrates(inverseofmedianlengthofhospitalstay).

-Real-timedemandofhospitalbedscanbefoundbasedon estimatedparameters.

-Evidence-baseddecisionmakingisthebestwaytocombat thispandemic.

-Theintensityofpublichealthmeasuresimplementedshould bebasedonparametervalues.

INTRODUCTION

AccordingtotheWorldHealthOrganization,onJune22,2020, therewere8,860,331confirmedcasesand465,7440deathsdue toCOVID-19(1).ThedynamicsandcourseofCOVID-19 areuncertain,anditis notmerelypossiblebutlikelythatthe patientloadwilloverwhelmthemedicalinfrastructure,including hospitalbedsandmedicalequipment.Theemergenceofa pandemicleadstoextraordinarydemandsonthepublichealth system.Thenumberofhospitalbedsoccupiedisafunction ofmedianlengthofhospitalstayandadmissionrate(2).The publichealthmeasuresduringthemanagementofadisease pandemicshouldbeaimedatincreasinghospitalbedcapacity anddecreasingadmissionratesaswellasthelengthofthemedian hospitalstay.Currently,nopharmaceuticalinterventionsaresafe andeffective;however,bestpracticesfordiseasemanagement arebasedprimarilyonnon-pharmaceuticalmeasures,including abanonpublicgatherings,compulsoryhomestays,closureof religiousandeducationalinstitutions,closureofnon-essential businesses,facemaskordinances,quarantine,and cordon sanitaire (thatis,adefinedquarantineareafromwhichthose insidearenotallowedtoleave)(3).Anumberofmathematical modelshavebeenproposed toestimatethehospitalbedcapacity duringthepandemic(4 6).Theestimationofparametersis requiredforfurtheranalysisby suchmodels.

Thepresentstudyisanefforttoestimatethedynamic parametersoftheCOVID-19pandemic,includingmedianlength ofhospitalstay,mediansurvivaltime,mortalityrate,recovery rate,hospitaladmissionrate,andcasefatalityrateinatertiary carehospital.Furthercomparisonofsurvivaldataacrossgender andagegroupswasperformedusingCoxproportionalhazard analysis.Againstthebackgroundofgivenparameters,the outcomesofpublichealthpolicymakingcanbeevaluated.The rationaleofevidence-baseddecisionmakingcanbefulfilled.

MATERIALSANDMETHODS

Inthishospital-basedretrospectivecohortstudy,987COVID-19 patients(confirmedwithreal-timeRT-PCR)wereenrolledfrom

Abbreviations: cdf,cumulative probabilitydistributionfunction;CI,confidence interval;COVID-19,coronavirusdisease-19;K-M,KaplanMeier;HR,hazard ratio; p, p-value;SARSCoV-2,severeacuterespiratorycoronavirus2;SR1,survival rate1;SR2,survivalrate2;ST1,survivaltime1;ST2,survivaltime2.

February29toMay19,2020,fromSMSMedicalCollegeand Hospital,Jaipur,Rajasthan,India.Survivalanalysiswascarried outtoestimatemedianhospitalstayandmediansurvivaltime. Theeffectsofageandgenderonsurvivalpatternswereevaluated usingCoxproportionalhazardregressionanalysis.Furthermore, casefatality,mortality,recovery,andhospitaladmissionrates werealsoestimated.Thedurationofthestudywas81days.

DataCollection

Theage,gender,anddatesofhospitaladmissionanddischarge wererecordedfromcasesheetsofpatients.Thehospitaloutcome, i.e.,recovered,died,oradmitted,wasalsorecorded.Hazard1 wasconsideredtobehospitaldischargeordeath.Survivaltime1 (ST1)wascalculatedfromastartingpointasthedateofhospital admissionandanendpointasthedateofhospitaldischargeor death(Hazard1).Thecasesadmittedonthelastdayofthestudy werestillconsideredundercensoredobservations(censoring1).

Similarly,Hazard2wasconsideredtobedeathinthehospitalof patientsover60yearsofage.Survivaltime2(ST2)wascalculated astheperiodbetweenthedateofhospitaladmission(asall patientstestedRT-PCRpositivewerehospitalized)anddateof death(Hazard2).Thecasesthatwerestilladmittedorrecovered wereconsideredundercensoredobservations(censoring2).

DataAnalysis

Asthedatawascontinuouslyobservable,thesurvivalanalysis wasdonewiththehelpoftheKaplanMeier(K-M)method.The survivalratewasdefinedasacumulativeprobabilitydistribution function(cdf)ofsurvivaltime(P[ST ≥ t],where t istime). Survivalrates1(SR1)and2(SR2)forHazards1and2 werecalculated.

Inordertoevaluatetheeffectsofageandsexonsurvival patterns,twoCoxproportionalhazardmodels(Coxmodels1and 2)werefittedforHazards1and2,respectively.Thecovariates usedinbothmodelswereageandgender.Beforeanalyzingdata intheCoxmodel,wecheckedtomakesurecensoringdidnot varysignificantlyfordifferentvaluesofcovariates.Thehazard ratioswerecalculatedforbothmodels(7).

Thecasefatality,mortality,recovery,andhospitaladmission rateswerecalculatedasbelow(8):

Fortheestimation

FIGURE1| Stackedbarplotsshowingdistribution ofageofCOVID-19casesalongwithdistributionofgender(maleandfemale)withineachagegroup.

TABLE1| Descriptivestatisticsofageandsex alongwithcomparisonofageandgenderacrossrecoveredanddeathcasesinCOVID-19patients.

Variables Total(N = 987)Recoveredcases (N = 778) Deathcases(N = 80)Statistics*df# p

Age 34(25,50) 33(24,47.75) 55 (35,65) 6.09 91 < 0.001 Male 62.11% 55.94% 5.94% Sex 0.13 1 0.72 Female 37.89% 34.73% 33.79%

*Welchtestwasusedtocompareageinrecoveredanddeathcasesandchi-squaredtestwasusedtofindassociationbetweensexandcases.

# df:degreesof freedom;Medianageand1stand3rdquartileisexpressedinparenthesis.

StatisticalAnalysis

Thequantitativevariableswereexpressedasmedian survivaltimeand95%confidenceintervalswithKMbasedstandarderrorsfortheestimatesoftheCox proportionalhazardregressionmodel.Thestatisticallevel ofsignificancewasconsideredat5%.Forthestatistical analysis,weusedJASPversion0.11softwareandMATLAB 2016a(10, 11).

RESULTS

ThemeanageofCOVID-19caseswas37.08years(SD = 17.87).Men(62.11%)hadahigherproportionofCOVID-19than women(37.89%).Thedistributionofageandgenderindicated thatyoungermenweremostaffected(Figure1).Thedistribution ofageandoutcomeshowedahigherproportionofdeathsinthe elderly(Tables1, 2).

SurvivalCurves

ThesurvivalcurveandK-MestimatesforHazard1wereobtained (Figure2, SupplementalTable1).ThemedianST1(median hospitalstay)was10days.

ThesurvivalcurveandK-MestimatesforHazard2were obtained(Figure3, SupplementaryTable2).ThemedianST2 wasmorethan60daysbecausemostofthedatawascensored.

CoxProportionalHazardAnalysis

ThecensoredanduncensoreddataforHazard1didnotdiffer significantlyinmeanage(t = 0.19, p = 0.85)andgender(χ 2 = 0.13, p = 0.71).Therefore,Coxmodel1wasrunwithage andgenderascovariates.Similarly,forHazard2,therewasno significantdifferencefoundinmeanage(t = 0.71, p = 0.48)and gender(χ2 = 0.26, p = 0.61).Therefore,Coxmodel2wasalso runwithageandgenderasacovariate.

TheCoxModel1forSR1showednosignificanteffectofage (HR = 1.00, p = 0.05)orgender(HR = 0.98, p = 0.88).Similarly,

TABLE2| Associationofmortalityandvarious agegroupsinCOVID-19patients.

Agegroup(Years) Mortalitystatus

Death Recovered Total

0-4 3 17 20

5–9 0 17 17

10–14 1 31 32 15–19 1 52 53 20–24 8 82 90 25–29 2 113 115 30–34 4 100 104 35–39 4 66 70 40–44 3 79 82 45–49 5 43 48 50–54 8 43 51 55–59 7 42 49

60–64 13 45 58

65–69 10 20 30

70–74 3 13 16 75–79 5 5 10 80 3 10 13

Total 80 778 858

Thepresentstudyestimatedvariablesontherightsideofthe inequality.Inordertomaintaintheinequality,hospitalcapacity shouldbeincreasedormedianhospitalstayshouldbedecreased oradmissionrateshouldbedecreased.Thehospitalcapacityof Jaipurwasfoundtobe6,280,andtherightsideoftheinequality was108.5,whichislessthanhospitalcapacity(14).Therateof evolutionforCOVID-19inRajasthanwasamongthetopeight states(15, 16).

Asofnow,nopharmaceuticalagentsareproventobe safeandeffectivefordecreasingmedianhospitalstay.The primarystrategyisfocusedonnon-pharmaceuticalinterventions (NPI)todecreaseadmissionrates.Currentcontrolmeasures aimtoreducediseasetransmissionthroughbansonpublic gatherings,compulsoryhomestays,closureofreligiousand educationalinstitutions,closureofnon-essentialbusinesses,face maskordinances,quarantine,andcordonsanitaire(thatis,a definedquarantineareafromwhichthoseinsidearenotallowed toleave)(3).Ravaghietal.reviewedmethodsfordetermining optimumhospitalcapacity. Themainfactorswereaveragelength ofhospitalstay,admissionrate,dischargerate,andtargetbed occupancyrate(2).

forSR2,theCoxmodel2showednosignificanteffectsofage(HR = 1.01, p = 0.62)orgender(HR = 1.15, p = 0.69).

EstimatedRates

The casefatalityratewasestimatedtobe8.1%(95%CI:6.4–9.8%).Theestimationofrecoveryratewas78.8%(95%CI:76.2–81.3%).Themortalityratewas0.10(95%CI:0.08–0.12)per100 person-days,andthehospitaladmissionratewas0.35(95%CI: 0.33–0.37)per100,000person-days.

DISCUSSION

Theairwebreathe,thefoodweeat,thehouseinwhichwelive, thevirusestowhichweareexposed,thehealthservicestowhich wehaveaccess,andtheenvironmentinwhichwelivedecide theoutcomeofapandemic.TheCOVID-19diseasepatternsare linkedtomigration,populationmovement,anddiseasediffusion (12).ThemaincauseofvaryingratesofevolutionofCOVID-19 hasresultedfromdifferent publichealthpoliciesinvariousstates (13).Theprimaryobjectiveformanagementofapandemicisto keeptherateofevolutionofcaseslowersuchthatthediseasewill notoverwhelmthehospitalbedcapacityofanystate.Theaim ofthemanagementistomaintainthegiveninequality(2)(see SupplementaryFile fordetails):

Hospitalcapacityofthesystem ≥ medianLOS × HAR × N

whereLOSislengthofhospitalstay,HARishospitaladmission rate(in105 person-days)andNisthepopulation(105 persons) dependentonthehospitals.

Anumberofmathematicalmodels havebeenusedin thepredictionofhospitalbedsduringthepandemic.Some aredata-drivenmodelsasusedbyMancaetal.forthe predictionofICUbeds(6).Othersareempiricalmodels, includingSIR,SIRD,SEIR andSEIRD,andSIDARTHE(4). Anumberofmodelswereproposedfor estimatinghospital bedcapacitybasedonqueuingtheory.Patientdemandfor bedswasmodeledwithPoissondistributionwithrate λ Theservicedurationhasanexponentialdistribution1/µ (5). Furtheranalysisofthe modelrequiresparameterslike λ and µ Thepresentstudyestimatesparametersforfurtheranalysisof suchmodels.

Oneapproachtodecreasethemedianlengthofhospital staysistotriagepatientsbasedonrequirementofspecialized carewithbedsallottedaccordingly.TheNationalInstitute ofHealthandCareExcellence(NICE)haspublishedan algorithmtoensureappropriateadmissionstotheICUfor thosemostinneed(17).Inastudyofthepredictionoflength ofhospitalstaywithliverbloodtestresults,livercondition (HBsAbpositive,HBcAbpositive,andfattyliverdisease)was carriedout.Themedianlengthofhospitalstaywas6days (18).Bhandarimentioneddifferentialneutrophilcountand randombloodsugaras predictorsofmortalityriskofCOVID19(19).OnestudyreportedthatBMI,age,andCRPwere allrelatedtoprolongationof lengthofhospitalstay(20). Factorsresponsiblefor prolongedLOSinwhichthemedian was11days(IQR,5–15days)showedthemostimportant werelowerneutrophilcounts,higherpartialthrombintime (PT),lowerD-Dimerassociatedwithprolongedlengthofstay athospital(21).Anovelstrategytomanagepatientsisto triagebasedon diseaseseveritywithmanagementofmild patientsinshelterhomes.Theshelterhomesarelarge-scale, temporaryhospitals,assembledrapidlybyconvertingexisting publicplacessuchasstadiumsandexhibitioncentersinto healthcarefacilities.Theimportantcharacteristicsofshelter homesarerapidconstruction,largescale,andlowcost.

FIGURE2| Survivalcurve(redstaircase plot)forHazard1showsKaplanMeierestimatesforallagegroups.TheCoxmodelwasbasedontheWeibullfunctioncurve (bluelineplot).

FIGURE3| Survivalcurve(redstaircase plot)forHazard2showsKaplanMeierestimatesforpatientsover60yearsofage.TheCoxmodelwasbasedontheWeibull functioncurve(bluelineplot).

Theyservefunctionsofisolation,basicmedicalcare,triage, frequentmonitoringandreferral, essentialliving,andsocial engagement(22).

Finally,theWHOScientific andTechnicalAdvisory GroupforInfectiousHazards(STAG-IH)reviewed availableinformationaboutCOVID-19andfocusedon closuremonitoringofepidemiology,communication strategies,intensivesourcecontrol,continuedcontainment activities,intensifiedactivesurveillance,resilienceof healthsystems,mitigationactivitiesduringcommunity transmission,developmentofserologicaltests,andcontinued research(23).

Conclusion

Thepresentstudywill helpfacilitateanevidence-based decision-makingprocessformanagementoftheCOVID-19 pandemic.Theestimationofdynamicparametersofpatient flowinahospitalhelpsinhospitalmanagement.Further,the parameterscanbeusedbyvariousmathematicalmodelsto predictfuturerequirements.

LimitationsoftheStudy

Thestudyincludesonlyageandgenderascovariatestorunthe model.Theclinicalcovariates,suchasseverity,symptoms,and CTscoresmayprovidemorepreciseinformationaboutsurvival timeandlengthofhospitalstay.

DATAAVAILABILITYSTATEMENT

Thedataanalyzedinthisstudyissubjecttothefollowing licenses/restrictions:Dataisavailableonreasonablerequestto correspondingauthor.Requeststoaccessthesedatasetsshould bedirectedtoAmitTak,dramittak@gmail.com.

REFERENCES

1.WorldHealthOrganization. CoronavirusDisease-2019. (2020).Availabe onlineat:https://www.who.int/emergencies/diseases/novel-coronavirus2019(accessedJune18,2020).

2.RavaghiH,AlidoostS,MannionR,BélorgeotVD.Modelsand methodsfordeterminingtheoptimalnumberofbedsinhospitals andregions:asystematicscopingreview. BMCHealthServRes. (2020) 20:186.doi:10.1186/s12913-020-5023-z

3.HartleyDM,PerencevichEN.PublichealthinterventionsforCOVID-19. JAMA. (2020)323:1908.doi:10.1001/jama.2020.5910

4.GiordanoG,BlanchiniF,BrunoR,ColaneriP,DiFilippoA,Di MatteoA,etal.ModellingtheCOVID-19epidemicandimplementation ofpopulation-wideinterventionsinItaly. NatMed. (2020)26:855–60.doi:10.1038/s41591-020-0883-7

5.GreenLV.Howmanyhospitalbeds? INQUIRY. (2002)39:400–12.doi:10.5034/inquiryjrnl_39.4.400

6.MancaD,CaldiroliD,StortiE.Asimplifiedmathapproach topredictICUbedsandmortalityrateforhospitalemergency planningunderCovid-19pandemic. ComputChemEng. (2020) 140:106945.doi:10.1016/j.compchemeng.2020.106945

7.IndrayanAMalhotraRK. MedicalBiostatistics.inSurvivalAnalysis. 4thed. BocaRaton,FL:CRCPress,Taylor&FrancisGroup(2018).p.513–23.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswerereviewedand approvedbyEthicsCommittee,SMSMedicalCollege,Jaipur (LetterNo.524/MC/EC/2020dated7July2020).Written informedconsentforparticipationwasnotprovidedby theparticipants’legalguardians/nextofkinbecause:Ethics Committeesaid,aspertheNationalEthicalGuidelinesfor BiomedicalandHealthResearchinvolvingHumanParticipants byIndianCouncilofMedicalResearch,2017(section5:Informed ConsentProcess-Box5.2,PageNo53and54),thestudy beingretrospectivewhereparticipantshavebeendeidentified,the waiverofinformedconsentisherebygranted.

AUTHORCONTRIBUTIONS

SB,AD,andJSprovidedadministrativesupport,AT,SD,MD,and TWdidconcept,design,anddataanalysisandinterpretation. AShelpedinprovisionofpatients.SKhelpedincollectionand assemblyofdata.BP,SS,andJGhelpedinmanuscriptwriting. Allauthorscommentedandfinallyapprovedthemanuscript.

ACKNOWLEDGMENTS

Thecontributorstothearticleacknowledgetheinvaluable inputsofthedepartmentsofmedicineandmicrobiologyof SMSMedicalCollegeandAttachedHospitals,Jaipur,andthe GovernmentofRajasthanfortheirongoingsupportagainstthe menaceoftheglobalpandemicofCOVID-19.

SUPPLEMENTARYMATERIAL

TheSupplementaryMaterialforthisarticlecanbefound onlineat:https://www.frontiersin.org/articles/10.3389/fpubh. 2020.585850/full#supplementary-material

8.EpidemiologyWorkingGroupforNCIPEpidemicResponse,Chinese CenterforDiseaseControlandPrevention.[Theepidemiological characteristicsofanoutbreakof2019novelcoronavirusdiseases (COVID-19)inChina]. ZhonghuaLiuXingBingXueZaZhi.(2020). 41:145–51.doi:10.3760/cma.j.issn.0254-6450.2020.02.003

9.JaipurRajasthanOfficial. Population. (2020).Availableonlineat:https:// jaipur.rajasthan.gov.in/content/raj/jaipur/en/about-jaipur/population.html# (accessedJune25,2020).

10.JASPTeam. JASPversion0.12.2[Computersoftware].Amsterdam:University ofAmsterdam,Copyright2013-2019

11.MATLABTeam. StatisticsMachineLearningToolbox10.2,Classification LearnerApp.MATLAB.version9.0.0.341360(R2016a).Natick,MA:The MathworksInc.(2016).

12.DummerTJB.Healthgeography:supportingpublichealthpolicyand planning. CanadMedAssocJ. (2008)178:1177–80.doi:10.1503/cmaj. 071783

13.BhandariS,ShaktawatAS,TakA,PatelB,GuptaK,GuptaJ,etal.Amultistate ecologicalstudycomparingevolutionofcumulativecases(trends)intop eightCOVID-19hitIndianstateswithregressionmodeling. IntJAcadMed. (2020)6:91–5.doi:10.4103/IJAM.IJAM_60_20

14.GovernmentofRajasthan. DepartmentofMedical,HealthandFamily Welfare. (2020).Availableonlineat:http://www.rajswasthya.nic.in/PDF/ COvid%20Facility%20Rajasthan.pdf(accessedJune23,2020).

15.BhandariS,SharmaR,SinghShaktawatA,BanerjeeS,PatelB,TakA, etal.COVID-19relatedmortalityprofileatatertiarycarecentre:a descriptivestudy. ScrMed.(2020)51:69–73.doi:10.5937/scriptamed5127126

16.KakkarS,BhandariS,ShaktawatA,SharmaR,DubeA,BanerjeeS,etal. Apreliminaryclinico-epidemiologicalportrayalofCOVID-19pandemicat apremiermedicalinstitutionofNorthIndia. AnnThoracicMed. (2020) 15:146.doi:10.4103/atm.ATM_182_20

17.NicolaM,O’NeillN,SohrabiC,KhanM,AghaM,AghaR.Evidencebased managementguidelinefortheCOVID-19pandemic-Reviewarticle. IntJ Surg. (2020)77:206–16.doi:10.1016/j.ijsu.2020.04.001

18.GuX,LiX,AnX,YangS,WuS,YangX,etal.Elevatedserumaspartate aminotransferaselevelidentifiespatientswithcoronavirusdisease2019and predictsthelengthofhospitalstay. JClinLabAnal. (2020)34:e23391. doi:10.1002/jcla.23391

19.BhandariS,ShaktawatAS,TakA,PatelB,ShuklaJ,SinghalS,etal.Logistic regressionanalysistopredictmortalityriskinCOVID-19patientsfrom routinehematologicparameters. IbnosinaJMedBiomedSci. (2020)12:123–9. doi:10.4103/ijmbs.ijmbs_58_20

20.MoriconiD,MasiS,RebelosE,VirdisA,MancaML,DeMarcoS,etal. ObesityprolongsthehospitalstayinpatientsaffectedbyCOVID-19,and mayimpactonSARS-COV-2shedding. ObesityResClinPract. (2020)14:205–9.doi:10.1016/j.orcp.2020.05.009

21.HongY,WuX,QuJ,GaoY,ChenH,ZhangZ.Clinicalcharacteristics ofCoronavirusDisease2019anddevelopmentofapredictionmodel forprolongedhospitallengthofstay. AnnalTransMed. (2020) 8:443.doi:10.21037/atm.2020.03.147

22.ChenS,ZhangZ,YangJ,WangJ,ZhaiX,BärnighausenT,etal. Fangcangshelterhospitals:anovelconceptforrespondingtopublichealth emergencies. Lancet. (2020)395:1305–14.doi:10.1016/S0140-6736(20)3 0744-3

23.HeymannDL,ShindoN.COVID-19:whatisnextforpublic health? Lancet. (2020)395:542–5.doi:10.1016/S0140-6736(20)3 0374-3

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Bhandari,Tak,Singhal,Shukla,Shaktawat,Gupta,Patel,Kakkar, Dube,Dia,DiaandWehner.Thisisanopen-accessarticledistributedunderthe termsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distribution orreproductioninotherforumsispermitted,providedtheoriginalauthor(s)and thecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournal iscited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

published:11December2020 doi:10.3389/fpsyg.2020.590271

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: XueLei, EastChinaUniversityofScience andTechnology,China MichalBeno, InstituteofTechnologyandBusiness, Czechia

*Correspondence: FrancoiseContreras francoise.contreras@urosario.edu.co

Specialtysection: Thisarticlewassubmittedto OrganizationalPsychology, asectionofthejournal FrontiersinPsychology

Received: 31July2020

Accepted: 17November2020 Published: 11December2020

Citation: ContrerasF,BaykalEandAbidG (2020)E-LeadershipandTeleworking inTimesofCOVID-19andBeyond: WhatWeKnowandWhereDoWe Go.Front.Psychol.11:590271. doi:10.3389/fpsyg.2020.590271

E-LeadershipandTeleworkingin TimesofCOVID-19andBeyond: WhatWeKnowandWhereDoWeGo

FrancoiseContreras1* ,ElifBaykal2 andGhulamAbid3

1 SchoolofManagementandBusiness,UniversidaddelRosario,Bogotá,Colombia, 2 SchoolofBusinessandManagement Sciences,IstanbulMedipolUniversity,Istanbul,Turkey, 3 DepartmentofBusinessStudies,KinnairdCollegeforWomen, Lahore,Pakistan

Suddenly,COVID-19haschangedtheworldandthewaypeoplework.Companies hadtoacceleratesomethingtheyknewwasimminentinthefuture,butnotimmediate andextremelyhumongous.Thissituationposesahugechallengeforcompaniesto surviveandthriveinthiscomplexbusinessenvironmentandforemployees,whomust adapttothisnewwayofworking.Aneffectivee-leadership,whichpromotescompanies’ adaptability,isneeded.Thisstudyinvestigatestheexistingknowledgeonteleworking ande-leadership;andanalyzesthesupposedchallenges.Theliteraturereviewshows thatcompanieswitheffectivee-leadershipcanviewteleworkingasanopportunity.It isadvantageousfornotonlycompanies’productivitybutalsotheenvironmentand peoplewhoworkremotely.However,atraditionalornoleadershipcanresultinsome risks.Thrivinginremoteworkenvironmentsimpliesthatmanagersmustadjustthe companies’structure,makingthemlesshierarchical,anddevelopingnewabilitiesto establishastrongandtrustworthyrelationshipwiththeiremployeestomaintaintheir competitiveness,whileretainingagenuineconcernfortheiremployees’well-being. Similarly,successfule-leadershipmustbeabletoconsolidateandleadeffectivevirtual teamstoaccomplishorganizationalgoals.Thisstudycontributestotheliteratureand leadersduringthepandemic.

Keywords:e-leadership,teleworking,COVID-19,virtualteams,remoteworkenvironments

INTRODUCTION

Inthepastfewmonths,teleworkorworkingfromhomehasexperiencedrapidgrowthowingtothe pandemic,leadingtosignificantchangesinworkmethods. Itreferstoaflexibleworkingmethod thatisnotlimitedbytime,location,typeofcommunicationtechnology,andtheuseofinformation. Thesuccessfulimplementationofthisrequirestechnology,social,andorganizationalsupport specificallyintheformofe-leadershippracticeswheretheemergenceofdigitaltechnologyand Internetserviceshasfacilitatedtheprogressofteleworking.Thecurrentpandemic(COVID-19) hasgeneratedamassiveandsuddenchangeinhowcompaniesoperate.Aftertheoutbreakof

COVID-19,socialdistancing,whichmeansadeliberate physicalspacebetweenindividuals,hasbeenadoptedasa soundpreventionmethod(PrinandBartels,2020)andthus necessitatedremoteworking.Inthiscontext,informationand communicationtechnologies(ICTs)allowemployeestowork anytimeandalmosteverywhere(MüllerandNiessen,2019). Moreover,teleworkingwasimminent,butthepandemichas madeitacompulsion.Itisspeculatedthatthisnewglobalwork normwouldcontinueevenafterthepandemicisovercome.This changehasdeeplyimpactednotonlyhoworganizationsoperate butalsotherelationshipbetweenemployeesandemployers. Thus,inthisnewworkenvironmentwithpossiblerisks(see Bouzirietal.,2020; Lambertetal.,2020),opportunities,and flexibleworkarrangements,leadershippracticescannotbe thesame.Leadershippracticesmustadapttonewremote orvirtualconditionsforeffectiveleadershipandsustainable performance.Thisiswhy Bennis(2009) onhisfamousbook “onbecomingaleader”arguedthatleadersarenotbornthey aremade.Leadersshouldtransformthemselvestoachieve organizationalgoalsbyengagingteleworkerswhoenjoyafruitful virtualworkenvironmentandallowthemtothriveintheir work.Undoubtedly,leadershipinthisnewlaborrealitywill bedecisivefororganizationstosurviveandgrow.Asnature hasdemonstratedandthiscanbeappliedtocompanies,if companiesdonotrespondtocrisesandadapttothenew conditions,theyarelikelytodisappear.Basedonaliterature review(from2000to2020),thisstudyinvestigatestheexisting knowledgeaboutteleworkingande-leadershipandpre-and post-COVID-19risksandopportunitiesfororganizations. BetweenMarchandJuly2020,wecarriedoutthisliterature review,lookingforscientificpublicationsonteleworkand e-Leadershipinacademicjournals-databases(WebofSciences, PsychINFO,SCOPUS,SciELO).Theliteraturesearchwascarried outusingthefollowingkeywordsandcombinationsbetween them:Telework,e-leadership,telecommutingande-leadership, virtualenvironments,virtualwork,virtualteams,teleworkand COVID-19.Non-recentarticleswereexcludedunlesstheywere quiterelevant.Thebodyoftheretrievedliteraturewasreviewed andorganizedforpresentationinthisdocument.Frommore thanonehundredarticles,weidentifiedandsynthesizedthe findingsandcontributionsofabout80academicpublications, specificallypeer-reviewedarticles.

Thepresentstudyrevolvesaroundunderstandingthe associationbetweenteleworking,leadershipande-leadershipthat representstheemergenceofleadershipinthee-environment contextwheretheworkismediatedbyinformationtechnologies, highcomplexityandachangingworkingenvironmentthat makesimperativeforleaderstochangetheirpractices,attitude, andbehaviorforlongtermorganizationalsustainability.In ordertobettercomprehendtheabovephenomena,thisstudy isstructuredasfollows.Insection“Teleworkingandthe EmergenceofCOVID-19,”wediscusstheopportunitiesand riskswithteleworkingwiththeemergenceofCOVID-19.Section “Management,LeadershipandTeleworkEnvironments”deals withunderstandingthemanagementandleadershipinthe environmentofteleworking.Insection“E-leadershipandits Conceptualization,”wediscussthephenomenonofe-leadership

anditsconceptualization.Insection“E-leadership,Teleworking andVirtualTeams,”theassociationamonge-leadership, teleworkingandvirtualteamsisanalyzed.Finally,insection “ConclusionandPropositionsforFurtherStudies,”weputforth somepropositionsforfurtherstudies.

TELEWORKINGANDTHEEMERGENCE OFCOVID-19

Inthepastdecades,companieshaveevolvedaccordingtonew conditionsoftheworkenvironment,suchasglobalization, fiercecompetition,newdemographicstructures,andincreasing developmentofICTs(Wojcaketal.,2016).Thetransitionfrom theindustrialeratoadigitalizedbusinessenvironmentled toashiftfromamechanisticperspectivetoamoreorganic perspective,whereorganizationsembraceflexiblestructures (PulleyandSessa,2001).After2000s,workhasbeenincreasingly detachedfromon-site(FelsteadandHenseke,2017)tofacilitate theworkforceandtoprovidebetterservicestothecustomers. Therefore,teleworkingwassteadilygrowinggloballyinseveral sectors.Amongthesesectors,serviceindustryencompassesthe highestoverallpercentageofworkforcewhoworkremotely (17%),followedbyhealthcareindustry(12%),financesand insuranceindustry(10%),manufacturingsector(8.5%),and educationindustry(7.5%)(Heetal.,2020).Teleworkingisalways debatedbecauseoftheblurringboundariesregardingnon-work andwork,personal,andsocialeffectsofnotbeingphysically presentatajob,andtherisksandbenefitsofflexibleworking hours.Undertraditionalconditions(e.g.,beforeCOVID-19), teleworkingwasneededtemporarily(Allenetal.,2015).However, inthiscurrentpandemicsituation,mostoftheemployeesaround theworldarefulltimeawayfromtheofficeandworkingfrom home.Thus,thispandemichassuddenlychangedhowpeople workanditisnotyetveryclearhowlongwehavetocontinue workingfromhomeindifferentcountries.

TheWorldHealthOrganization(WHO)officiallyannounced theoutbreakofcoronavirusdiseaseonMarch11,2020,as apandemicandsuggestedpreventivemeasurestocontain itsspread.Teleworkwasanimportantmeasuresuggestedby WorldHealthOrganization(2020) andsuccessfullyimplemented byorganizationsandgovernmentsaroundtheworld.Thus, sinceMarch2020,morethan3.5billionindividualshavebeen confinedtotheirhomes,whichmeantthatseveralmillionswere teleworking(Bouzirietal.,2020).Thisteleworkingmaylead tosocialorprofessionalisolation,whichisreferredtoasthe missingoftheeverydaysocialaspectofworkbecauseemployees arephysicallyawayfromotherworkmates,henceleadingto notbeingactivelyparticipatingininformationsharingandcolearning.Thisfeelingofprofessionalisolationadverselyaffects jobperformance(Goldenetal.,2008)becauseemployeesdo nothavetheirsupervisorandcolleagues’supportinproblem solvingastheywouldiftheywerephysicallypresentatwork.In thiscontext,theroleofe-leadershipliesinfacilitatingthework conditionsandkeepingemployeesmotivatedtowardachieving thedesiredgoals.Thissituationcallsforadifferenttypeof leadership,knownase-leadership,whichentailsthedevelopment

ofdistinctabilitiestoimproveorganizationalfunctioningin virtualandremoteworkenvironments(Romanetal.,2019).

BeforetheCOVID-19,teleworkingwassteadilygrowing globallyacrossmanysectors.Thepandemicacceleratedthis processandnowcompaniesmustoperatewithemployeeshaving toworkinplacesdifferentfromthetraditionalworkplace throughteleworking.Infact,teleworkingwaspopulareven beforethepandemic(Heetal.,2020)andtheinfrastructurefor teleworkingalreadyexisted.Hence,theadoptionofthisworking stylehasbeenrelativelyeasyforseveralcompanies(Bélandetal., 2020). TietzeandMusson(2005) assertedthatthefutureofwork willbe“flexible,mobile,temporaryandmediatedbytechnology” (p.1331),thatis,byteleworking.Telework,telecommuting,or workingremotelyisawide-rangingconceptthatcoversanypaid workperformedfromadistanceinanyplacedifferentfrom thephysicalpresenceintheorganizationwhereemployeesmeet organizationalobjectivesthroughICTs,sometimesmanaging theirowntimeunderlessdirectsupervision(Wojcaketal.,2016). Theseemployeesusuallyworkremotelywithautonomyforat leastafewdaysoftheirlabortime(Nayanietal.,2018).However, Bentley(2014) highlightedtheimportanceofdelimitingthe notionofteleworktoavoidconfusionwithemployeeswhowork forcompaniesfromoutside,suchasthosewhoworkincall centersorasfreelanceemployees.

OpportunitiesofTeleworking

Teleworkinghassomepotentialadvantages.Empiricalstudies havefoundfavorableoutcomesofteleworkingsuchasjob performance,jobsatisfaction,lesserwork-familyimbalance, reducedratesofstress,andlesserturnoverintentions(Kossek etal.,2006; FonnerandRoloff,2010; CoenenandKok, 2014; Vegaetal.,2015).Likewise, Othmanetal.(2009) demonstratedthepositiveeffectofteleworkingonemployees’ work-lifebalance.Additionally, AzarbouyehandNaini(2014) statedthatteleworkingiseffectiveinenhancingthequality oflife,whereas, Kazekami(2020) foundthatteleworking improvesemployees’happinessandworksatisfaction.However, thebenefitsareevidentwheretheemployeesfindmanagerial, peer,andtechnologicalsupport.Thissupporthelpsreduceany potentialnegativeimpactsarisingfromsocialisolation,mitigate thework-familyconflict,andreducethestress(Bentley,2014).

Teleworkingcanalsoinfluenceonthereputationand corporateimagebecausegreencompaniesareconcernedabout theenvironment.Currently,heavytrafficandaircontamination aresomeofthemostrelevantglobalissues(Giovanis,2018). Teleworkingisaviableshortandlong-termsolutiontoimprove thequalityofairmainlyinurbanareaswhileimprovingthe qualityoflife(Giovanis,2018).Consequently,theworldwill witnesslesscontaminationbecauseemployeesdonothaveto usedailytransport,thussavingtimeandmoney.Interestingly, theterm“telecommuting”wasusedforthefirsttimeinthe 1970storelievetrafficandreducepollutionthroughflexible andbetterwork-lifebalance(Nilles,1998).Anotheradvantage ofahighlycomplexworkenvironmentisthatcompanieshave accesstospecializedexpertise,regardlessoftheteammembers’ location,whichallowscompaniestofindmorecreativesolutions tothiscomplexglobalworkenvironment(Malhotraetal.,2007).

Similarly,digitalization,newcommunicationtools,andmore availabilityandspeedofinformationincreasetheefficiency andprocessofstandardization(Cortellazzoetal.,2019).For employees,teleworkingoffersmoreflexibilitytodealwithfamily mattersbecausetheycanworkanywhereandanytime,thus improvingthefamilyatmosphere(FedakovaandIštoˇnová,2017), andtheautonomytomanagetimeallowsthemtoharmonize theirpersonalandworkduties(Wojcaketal.,2016).Hence, itincreasesjobopportunitiesforwomenandemployeeswith disability(Morgan,2004).

Furthermore,workautonomythroughfreechoicetodirectly influenceone’sworkingtime,place,andmethodsisassociated withhigherproductivity(Pavlova,2019).Moreover,intheir meta-analysisof46studies GajendranandHarrison(2007) showedthattelecommutinglowersturnoverintentionsand stress.Theabsenceofanimmediatesupervisorandalessformal workingatmospherereducestheworkstressforemployees. Moreover,teleworkinghelpsemployeescreatetheirownrhythm ofworkandpreventsdistractionsfromotheremployees (Kłopotek,2017).Additionally,itdecreasestheindividual andorganizationalburdensofabsenteeismbecauseitallows employeestofulfilltheirworkobligationsevenintimeswhen thereistroublereachingtheoffice,allowingemployeesto fulfilltheirduties(Nakrošieneetal.,2019).Indeed,these advantagescontributetogreaterorganizationalcommitment,job satisfaction,andwell-being.

RisksofTeleworking

Somerisksposedbyteleworkingmustbeconsidered,namely, socialisolationfromworkteams(Pyoria,2011).Socialisolation leadstoemployeesbeingdisconnectedfromtheworking environmentleadingtolowerperformanceandgradual demotivation(Wojcaketal.,2016; FedakovaandIštoˇnová, 2017).Long-termisolationhasadverseeffectsonemployees’ performanceandincreasesturnoverintention,family-workand work-familyconflict(Goldenetal.,2008).Inwork-to-family conflictindividualsarehinderedtomeetroledemandsin theirprivatelifebecauseofworkdemandswhileinthefamilyto-workconflict,theycanbehinderedtomeettheirprivate rolesbecauseofhomedemands.Theirstudyalsoempirically revealedthatvolition,perceivedworkpressureandperceived homepressureareallrelevantforunderstandingemployees’ work-to-homeconflictratherthanhome-to-workconflictand work-homepracticestobebeneficialemployeesshouldnotfeel pressuretoeitheruseornotuseofferedpractices(Delanoeije andVerbruggen,2019).Furthermore,as CooperandKurland (2002) indicateteleworkingreducesthelearningbenefitsthat peopleenjoywhenworkinginthesameworkplace.Moreover, teleworkingrequiresgreaterorganizationalskills(Kłopotek, 2017);itissuitableforonlyself-organizedpeoplewhoare successfulintimeallocation.Ontheonehand,teleworkingcan leadtoanxietyamongemployeesaboutthepossibleshrinking ofcareerprospectsowingtoreducedvisibility(Maruyamaand Tietze,2012),andunfortunatelytheadvantagesofteleworking comeatthecostofintensifiedwork.Therefore,acommonlycited concernofmanagersregardingteleworkingisthepossibilityof decreasedjobperformance.Inotherwords,thelackoftrustin

employees’abilityandwillingnesstoperformatthesamelevel comparedwithwhattheycouldattainiftheyweretoworkwith theirmanagerinthesameplace(Kaplanetal.,2018).Digital environmentshavesomecommonproblems,suchasemail/data overload,employees’alienation,weaksocialrelationships,poor accountabilityinteams,lowtrust,insufficienttechnological skills,andaninabilitytoinfluencechangebasedoncommitment (VanWartetal.,2019).

Finally,teleworkraiseethicalconcernsfore-leaders,suchas exploitationofemployeeswithworkandinformationoverload thatoverlapwithdomesticandworksettings,resultinginan intrusionintoemployees’personallife(Cortellazzoetal.,2019; Gálvezetal.,2020).Althoughteleworkinggivesindividuals greaterautonomyintermsoftimeandspace,thesimultaneous useofdifferentnormativecontrolmechanismsundertheguise ofautonomyleadstoworkintensificationandextraburden toemployees.Thisobscurecontrolmechanismresultsin greaterself-regulationandpromotesgreaterworkeffortsfrom employees(BathiniandKandathil,2019).Moreover,individuals whoaregratefulfortheflexibilityprovidedbyteleworking makegreatereffortandachievehigherperformance,endingup withahighersacrificethanwithtraditionalworkingmethods (Putnametal.,2014). Table1 showsthemainreportedfindings ofopportunitiesandrisksofteleworking.

MANAGEMENT,LEADERSHIPAND TELEWORKENVIRONMENTS

Leadershiphasseveraldefinitions;however,generallyleadership canbedefinedasaninfluenceprocesstoachieveorganizational goals.Inthetraditionalworkenvironment,thisinfluence isexertedbynotonlyformalleadersbutalsoemployees withoutformalauthority(informalleadership).Inteleworking, theinfluenceofformalleadersismoreobvious.Theymust influencetobuildeffectiveandfunctionalvirtualteamsto reachorganizationalgoals.Beforeanalyzingtheconceptof leadershipinvirtualenvironments,thisstudymakesthe followingpropositionssupportedintheliteratureonleadership: (1)thereisnoleaderwithoutfollowers;(2)onecanbeconsidered aleaderonlywhenpeoplerecognizehimorherassuch;(3) leadershipcanbeconsideredaninteractiveprocessofsocial influenceanditisbasedonrelationships;and(4)asaresult ofeffectiveleadership,employeesmaketheirbesteffortto accomplishorganizationalgoals.Hence,inadditiontotheformal authority,leadersmustdeveloptheabilitytoinfluenceothers togetworkdone.

Beyondthepolemicandtheunfinisheddebateaboutwhether leadershipandmanagementshouldbeconceivedasthesame construct(Mintzberg,2009)ordistinct(Kotterman,2006),in teleworkingtherolebetweenoneandtheotherappearsmore distinctthanintraditionalworkplaces.Teleworkingbringsmore challengesforleadersthanmanagers.Inotherwords,teleworking ismorefeasibleandevenimprovestheefficiencyofthetraditional roleofmanagement(i.e.,planning,budgeting,controland establishingadministrativeprocedures)thanexertingeffective leadership(i.e.,influenceotherstoachieveorganizationalgoals)

throughelectronicdevices.Accordingto Nayanietal.(2018), bothleadershipandmanagementareequallyimportantin teleworking.However,adaptingtraditionalleadershippractices toatechnologicallymediatedenvironmentismorecomplicated (PulleyandSessa,2001).Adistributedworkforcemustbeledby adoptingnewandmorecomplexmethodsincommunication, performancemanagement,training,andrelationshipbuilding (Flood,2019).

Fromthemanagementperspective,teleworkingcanbe favoredbyflatterandmoredecentralizedstructures(Cortellazzo etal.,2019).Theincreaseinconnectivitywithinthecompanies inadditiontoinformationavailabilitycontributestodiminishing hierarchiesandorganizationalboundaries,leadingtocompanies workingbyprojectsmorethantraditionalactivitiesandthus, employeesparticipateinthecreationofvalueforthecompanies (Cortellazzoetal.,2019).Owingtoinformationavailability, thepowerofthecompanytendstobemoredistributedand lesscentralized,involvingemployeesinthedecision-making process.Thisparticipativedecision-makinghelpsleadersanalyze andprioritizerelevantinformationfromthelargeamount ofavailabledata,respondfasterandmoreinnovativelyfor betterdecisionmaking(Cortellazzoetal.,2019). Darics(2020) highlightedthatinaremoteworkenvironment,management andleadershipfunctionsarecombinedandmanagersmust manageperformanceandimplementsolutionswhenneeded andcreateandmaintainateamidentitybyestablishingand sharingavision,corporatevalues,andorganizationalgoals intoatrustingworkingenvironment.Moreover,inteleworking, consideringareductioninthesocialandinterpersonaldistance, leadersshouldbemoredemocraticwithaccesstoinformation andwillingtokeepanopencommunication(Montgomery etal.,2016).Inthiscontext,theadaptivestructurationtheory (DeSanctisandPoole,1994)suggeststhatmanyorganizational phenomenaincludingorganizationalleadershiptransformwhen interactingwithAdvancedInformationTechnologies(AITs). Fromthisapproach,AITsmediateleadershipinfluenceandcreate anintegratedmechanismofleadershipandmanagement.In fact,fromamanagementperspective,AITscanhavevarious purposes,includingsharinginformation,planning,record keeping,ordataanalysis.Fromaleadershipperspective,effective leadersate-leadershippositionsaresuccessfulwhentheycan usevariousAITstoachievegreaterperformance,enhance employees’jobsatisfactionwhilereducingtheratesofturnover (Montgomeryetal.,2016).

E-LEADERSHIPANDITS

CONCEPTUALIZATION

Electronicore-leadershipisnotjustanextensionoftraditional leadershipbutalsoimpliesacrucialchangeinhowleadersand followersrelatetoeachotherwithintheorganizationsandwith stakeholders(AvolioandKahai,2003),makingitimperative forleaderstochangetheirpractices(Malhotraetal.,2007). Kahaietal.(2013) assertedthatscholarsshouldgobeyond traditionalleadershiptheoriestoexplaintheroleofleadersand leadershipinremoteworkenvironments.E-leadershipimplies

TABLE1| Opportunitiesandrisksofteleworking.

OpportunitiesSourceRisksSources

Offersjobopportunitiesforpeoplewith disabilitiesandforwomenincreasesjob opportunitiesforwomenandemployees withdisability.

Globalworkforceavailable,accesstoa specializedknowledgeregardlessof geographiclocation.

Greatercompetitivenesstosuccessfully insertinglobalworkenvironments.

Lowerstress,lesserturnoverintentions, lesserwork-familyimbalanceandjob satisfaction.

Autonomyandflexibilityatworkallow harmonizingthepersonalandworkmatters favoringtheworkers’well-being.

Informationavailabilityincreasesjob performance.

Contributetothesolutionofglobal problemssuchaspollutionandairquality, whileinfluencingthefirms’reputation.

Theteammembers’heterogeneity promotescreativityandinnovationthrough acombinationofvariousperspectivesto achieveanobjective.

Decreasesabsenteeismduetoemployees donothavetofacedifficultiestoreachthe workplace.

Opportunitytointeractandestablish effectivevirtualteams,increasingtheir creativecapacity.

Workautonomyandlessdistraction potentiallyallowhigherproductivity.

Source:Authorsownelaboration.

Morgan,2004

Reductionofthelearningbenefitsthat isavailablewhenpeopleareworkingin thesameworkplace.

CooperandKurland,2002

Malhotraetal.,2007

Avolioetal.,2014; Narayananetal., 2017

Kosseketal.,2006; Gajendranand Harrison,2007; FonnerandRoloff, 2010; CoenenandKok,2014; Vega etal.,2015

FedakovaandIštonová,2017

Schwarzmülleretal.,2018

Giovanis,2018

GuptaandPathak,2018

Socialandprofessionalisolation.

Employeesconcernsduetothe reductionofcareerprospectsbyfeeling lessvisible.

Becausetheflexibility,highlymotivated employeescanworkmorehoursthan intraditionalworkenvironment, resultinginexhaustion.

Physicaldistanceandculturaldiversity threatentrustbuilding,commitment andcohesionamongtheteam members.

Lowerjobperformanceand demotivation.

Work-homeconflicts.

Workandinformationoverloadthat overlapwithdomesticandwork settings.

CooperandKurland,2002; Goldenetal.,2008; Pyoria, 2011; Bentley,2014

MaruyamaandTietze,2012

Putnametal.,2014

HochandKozlowski,2014

Goldenetal.,2008; Wojcak etal.,2016; Fedakovaand Išto ˇ nová,2017

Goldenetal.,2008; Bentley, 2014; Delanoeijeand Verbruggen,2019

Cortellazzoetal.,2019; Gálvez etal.,2020

Nakrošieneetal.,2019

Malhotraetal.,2007; Schwarzmüller etal.,2018; Cortellazzoetal.,2019

Kłopotek,2017; Pavlova,2019

thedevelopmentofdistinctabilitiestoimproveorganizational functioninginvirtualworkenvironments(Romanetal.,2019). Fore-leaders,theknownsocialskills,suchasthecharacteristics ofeffectiveface-to-facecommunicationmaynotbeenoughto leadinvirtualenvironments,wherethesecharacteristicsmust becomplementedwiththeskillstomanagevariousvirtual communicationsplatforms.However, Liuetal.(2020) asserted thatmanypropositionsusedingenericleadershiptheoriescan beappliedtoe-leadership.Thispremiseshouldbetestedto buildagenuinetheoryofe-leadership. DulebohnandHoch (2017) highlightedtheneedfordevelopinganewtheoryand conductingempiricalresearchtohelporganizationsindesigning, structuring,andmanagingvirtualteams.

Cortellazzoetal.(2019) statethatthereisnosharedapproach tostudyandtheorizeaboutthisphenomenon.However,because e-leadershipisamultidimensionalphenomenon,itshould bestudiedfromdifferentdisciplines,avoidingfragmented knowledge,andfromdifferentlevelsofanalysis:macro(eleadershipandorganization)andmicro(e-leader’sskillsand leadingvirtualteams).Thus,asassertedby Liuetal.(2020),

e-leadershipisanimportanttrendnotonlyfortherapidprogress intechnologyanditsapplicationduringthepandemicbutalso presentsachallengeforcompaniestoadoptthetechnology, thatis,tobenefitfromitsadvantages.Theseauthorsstated thatifthisprocessisnotwelladdressedbyleadersandused onlytoimposemandates,e-leadershipcouldincreasealienation andchaos.Uptonow,hybridteleworking(workfromhome fewdaysaweek)appearstoprovidethebestbalancebetween remoteworkflexibilityandbenefitsofworkingfacetoface withmanagementandcoworkers.However,moreevidenceis needed(Bentley,2014).Supportingthisview,astudyconducted inAustraliaonteleworking,productivityresultsshowedthat employeespreferredamaximumof1–3daysawayfromtheoffice asthemostfeasibleteleworkarrangement(Bosuaetal.,2017).

Someyearsago,e-leadershipwasdescribedasanineludible challengeforcompanies(EsguerraandContreras,2016).The “quietrevolution,”asnamedby AvolioandKahai(2003), occurredtocompaniesmuchearlier.Beingpreparedforvirtual workenvironmentswasaprioritytorespondtoaglobalized worldimmersedinthedigitalera.Nowduringthepandemic

andonward,itiscrucialforbusinesssurvival.Thus,e-leadership willbearelevantchallengethatcompaniesmustfaceforsuccess andsustainability.E-leadershipisanirreversibletrendthat isheretostay.

Leadershipasafieldofstudyhaslargelyfocusedon organizationswhereemployeesareworkingonsite.Studies onleadershipandteleworkersarescarce. Avolioetal.(2014) statedthatthestudyofe-leadershipisintheearlystageof development. VanWartetal.(2019) assertedthatthestudyon howthecurrentdigitalrevolutionischangingtherelationship betweenleadersandfollowershasbeenmodest.Interestingly, though,from2001todate,thereare102publishedarticles relatedtoe-leadershipintheWebofScienceCoreCollection. Ofthese,only32papersincludedtheterme-leadership intheirtitle.Intheirseminalwork, Avolioetal.(2000) definede-leadership“asasocialinfluenceprocessmediated byAITtoproduceachangeinattitudes,feelings,thinking, behavior,and/orperformancewithindividuals,groups,and/or organizations”(p.617).Similarly, Al-jedaibi(2001) explained e-leadershipasthekindofleadershipinthee-environment contextwhereworkismediatedbyinformationtechnologies, especiallytheInternet.However,theleaderisnotnecessarily a“techguru.”Heorsheonlyshouldknowhowtobenefit fromhightechnologyandleadefficientlythroughtechnology. Gurr(2004) alsofocusedone-leadershipandclaimedthat technology-mediatedenvironmentsrequireuniqueleaderswho aregoodatcopingwithcomplexity.Theyshouldestablish asuitablesocialclimatewithsustainedcommunicationand candemonstrateexemplaryinterpersonalskillsthroughrelated technology.Recently, Cortellazzoetal.(2019) statedthatinspite oftheadvances,thereisnowell-establishedandconsensual definitionofe-leadership.

Cowan(2014) proposedthateffectivee-leadershipshould becharacterizedbybuildingtrustwitheachmemberof theteamandestablishingavirtual“presence”preventing distancefrombecomingabarrier.Similarly,e-leadersshould addresstheteams’social-emotionalneedsandtheirmembers andpromotehealthyteamsthroughinteractions.E-leaders shoulddevelopeffectivecommunicationskills,thatis,selecta suitablecommunicationtool,providerelevantandcontextual communicationconsideringpossibleculturaldifferences, providepositivefeedbacktotheteams,andrecognizetheir performance. Nayanietal.(2018) assertedthatbesideshigh levelsofinstrumentalsupportandcompetentcommunication, leadersshouldpromotetrustusingmotivationallanguage. Morerecently, Romanetal.(2019) assertedthateffective e-leadersshouldcommunicateclearly,promoteadequatesocial interactions,knowhowtousethetechnologicalmedia,beable tobuildresponsibleteams,inspirechange,anddeveloptrust virtually. VanWartetal.(2019) definede-leadershipas“...the effectiveuseandblendingelectronicandtraditionalmethods ofcommunication.ItimpliesanawarenessofcurrentICTs, selectiveadoptionofnewICTsforoneselfandtheorganization, andtechnicalcompetenceinusingthoseICTsselected.”(p.83). Accordingtotheauthors,effectivee-leadershipisnotonly useofICTsbutalsoimpliesthatwhenthismediaoffersthe bestadvantages,selectthemostappropriateone,basedonthe

needs,usingface-to-facecommunicationchannelswheremore appropriate,integratingdistanceandnon-distancemethods, accordingtothepurposes.

VanWartetal.(2019) conceptualizede-leadershipas theeffectiveuseandblendingofelectronicandtraditional methodsofcommunicationandproposedthedefinitionof e-leadershipthroughthefollowingcompetenciesthatshouldbe empiricallytested:(1)Communicationskills(communication clarity,avoidanceofmiscommunication,managementof communicationflow),(2)Socialskills(leaders’support), (3)Teambuildingskills(encompassingteammotivation, teamaccountability,andteammemberrecognition),(4) Changemanagementskill(coveringchangetechniques),(5) Technologicalskills(correctuseofrelevantICTs,blending traditionalandvirtualmethods,technologicalknowledge, andtechnologicalsecurity)and(6)Trustworthiness(senseof trust,honesty,consistency,follow-through,fairness,integrity, work-lifebalance,andsupportofdiversity).

Invirtualorremoteworkenvironments,leadersshould demonstrateamoreinclusiveleadershipstyle(Schwarzmüller etal.,2018).Fore-leaders,thesocialskills,suchasthe characteristicsofeffectiveface-to-facecommunication,maynot sufficetoleadinvirtualenvironments(Romanetal.,2019). Cortellazzoetal.(2019) highlightedthate-leadersshoulddevelop acommunicationwhereemployeesfeelfreetopresenttheirideas, allowingthemtoparticipateinthedecision-makingprocess andencourageautonomy,collaboration,andresponsibility,and promotingapositiveorganizationalenvironmentwiththeir leadership.Inthisnewworkenvironment,informationismore visibleandeasiertoshare,allowingemployeestobemore independentintheirwork.Thus,companiesnotonlybenefit fromemployees’goodperformancebutreducetheneedto supervisethem(Schwarzmülleretal.,2018).

Inthisregard, Romanetal.(2019) definede-communication astheabilitytocommunicateproperlythroughICTs,avoiding errorsorexcessesthataffectgoodperformance.Thisability ismarkedbytheuseofanappropriatetone,providingclear messagestoemployeesthroughtherightcommunicationmedia. Theseauthorsalsosuggestedthatthisprocessinvolvestechnical issues,suchasselectingthebestmethodtocommunicate consideringtherichnessofthetool,thereceiver’spreferences, anddecideupontheuseofsynchronousorasynchronous methods.Withregardtotheuseofsynchronousorasynchronous methods,bothtemporaryformsofcommunicationoffer advantages.Forexample,asynchronouscommunicationallows acontinuousflowofinformation(GuptaandPathak,2018). Additionally, Cortellazzoetal.(2019) highlightedtheimportance ofmaintainingclearnormsofcommunication,havingregular interactionwiththeteams,providingpositivefeedback,avoiding ambiguousmessages,andconductinggoodsupervisionofeach member’scontribution.Incontrast,deficientcommunication fromleadersmayleadtounknownsituations,leavingemployees withafeelingofhelplessness(Wojcaketal.,2016).The e-socialenvironmentisthesecondimportantpropertyof e-leadership(Romanetal.,2019),thatis,creatingapositive workatmospherewithasenseofconnectednesswiththegroup toincreasecommunicationandcollaborationthroughdigital

communicationmethods.Throughe-socialcharacteristicsof e-leadership,isolationamongteammemberscanbesuccessfully prevented(WaltherandBazarova,2008).Furthermore,the e-changepropertyreferstothee-leaders’capabilityofmaking noteworthychangesrequiredforadaptationofAITs.Whilethe e-teampropertyofe-leadershipisaboutaleader’scapabilities increatingaccountable,satisfied,andefficientteamsinvirtual businessenvironments,e-technologicalskillsarealsoimportant e-leadershipproperties.Itisthecompetencyofane-leaderto beawareofnoveltechnologies,beingabletokeepupwith relevanttechnologicaldevelopments,andembracinghigh-level cybersecurity(Romanetal.,2019).

Finally,anotherimportantcharacteristicofe-leadershipisthe capacitytoinnovate.E-leadersshouldbeabletoidentifythe needforchangeandpromoteinnovationintheirorganizations andteams(Schwarzmülleretal.,2018).However,e-leadersmust becarefulthatthesecontinuouschangesdonotdisruptthe company’sfocusanditsmission.Therefore,theseleadersshould beflexible,innovative,haveclarityabouttheorganization’sgoals (Cortellazzoetal.,2019). Table2 presentsthemainissuesrelated toe-leadership.

E-LEADERSHIP,TELEWORKINGAND VIRTUALTEAMS

Asmentionedbefore,teleworkingisanewformofwork organizationthatgainedgroundinmostorganizationsaround theworldduetothepandemic,increasingdistanceinthe interpersonalrelationsintheworkenvironment.Thiswayof workingoffershugeopportunitiestocompanies,butahuge challengetoleaderswhohavetoleadanenvironmentof boundarylessworkthroughtechnology.Thischallengeimplies thatbothleadersandfollowersdeveloptechnicalcompetencies tofacilitatethemonitoring,coordination,andalignment ofworkthroughnoveltechnology-supportedstructures,in ordertodiminishbarriers(AlfehaidandMohamed,2019). Forthispurpose,e-leadershavetobecompetentwiththe latestICTs(Groysberg,2014)E-leadersnotonlyhavethe responsibilitytoadoptinternet-basedcomputertechnologiesin theirorganizationsbutalsohavetocreateawarenessregarding thesetechnologiestomaketeleworkingpossibleandconvenient (VanWartetal.,2019).

TABLE2| Mainissuesaboute-leadership.

Mainissues

E-leadershipisnotanextensionoftraditionalleadership(AvolioandKahai,2003). Itisaprioritytobuildandshareagenuinetheoryofe-leadership(Dulebohnand Hoch,2017).

Thereisnowell-establishedandconsensualdefinitionofe-leadership(Cortellazzo etal.,2019).

E-leadershiphastobestudiedfromdifferentdisciplines(Cortellazzoetal.,2019). Studiesone-Leadershiparestillscarce,theknowledgeofthistopicisinanearly stageofdevelopment(Avolioetal.,2014; VanWartetal.,2019).

Somecharacteristicsofgenericleadershiptheoriescouldbeappliedto e-leadership(Liuetal.,2020).

Totakeadvantageofthepossibilitiesthatteleworking offers,companiescannotbeledinthesamewayashas beendonetraditionally. DeVriesetal.(2019) indicatesthat hierarchicalformsofleadershiparelesssuitableinvirtual workenvironments.Traditionalleadershipissupportedinsocial influencemechanisms.However,invirtualenvironmentsthis influenceismediatedbycomputertechnologiesproducing changesinbehaviors,emotions,thoughts,andperformance ofworkers(VanWartetal.,2019).Inremoteworksettings, e-leaderscannotbeorientedtoorganizefragmentedtasks;they havetobeclosetotheiremployeesreducingthenegative impactthatproducesthephysicalandpsychologicaldistances (Stokolsetal.,2009).Similarly, Macieletal.(2017) statedthat effectivee-leadershipencouragestheperformanceinteleworking byminimizingthedistancebetweentheorganizationandits employeesandbringstheorganizationanditscustomerscloser withthehelpofhightechnology.Toreachthat,e-leaders havetodeveloptrustintheirrelationships,allowinggreater exchangeofideas;theyencourageinformationflow,andgenerate creativesolutions(Avolioetal.,2014).Likewise,findingsof Pantelietal.(2019) showedthate-leadersboostemployees’work engagementthrougheffectiveuseofresourcesandtheirattitude ofdevelopment,support,andnourishment.Theseproperties arehelpfulincontextscharacterizedbygreatergeographic distance,diversity,someambiguity,andunfamiliaritywith remoteworking.Moreover,throughthedelegationandthe effectiveprovisionoffeedback,e-leadersdevelopandsupport theirspatiallydispersedandsometimes,sociallydistanced employees.As Kahaietal.(2013) suggeste-leaderswiththeir behaviorscanrelievethepotentialproblemsofteleworking suchasthegreaterphysicalandsocialdistancethatmakes socialinteractionsdifficult.Eventhoughintherelatedliterature mostoftheresearchersarefocusedontheimportanceof e-leaderstoprovideemotionalandtechnologicalsupporttotheir employees(FriedmanandWestring,2015; Bentleyetal.,2016), somenoteworthystudiesarefocusedontheneedtoprovide ergonomicssupporttotheemployee’shomeofficewhich,inturn, hasbeenrelatedtotalentretentionofteleworkers(Eversoleetal., 2012; Allenetal.,2015).

Virtualteamisanattendantconceptofe-leadership (DasGupta,2011).Animportantchallengefore-leadersisto buildeffective,autonomous,interdependent(Cortellazzoetal., 2019),andcommittedvirtualteams(Politis,2014)forwhichtrust iscrucial.Virtualteamsincludememberswhoaregeographically dispersedbutworkingtogetherinaninterdependenttask throughelectronicmeanswithlowface-to-faceinteraction (Malhotraetal.,2007).Diversevirtualteamshavethechallenge ofcoordinatingtasksacrossdifferentlocations,timezones,and cultures(Siebdratetal.,2014).Infact,managingadistributed workforcecreatesheightenedleadershipchallenges(Hoegland Muethel,2016).Theinclusionofdigitalmediainthecompanies, affectstheirdesignofworkandthewayemployeesworktogether ineffectivevirtualteams(Schwarzmülleretal.,2018).Because ofthepandemic,e-leadershipisrequiredmorethanface-tofaceleadership.However,inthefuture,virtualteamswould persistduetotheopportunitiestheyoffer.Regardlessofthe leadershipstyle,similartoinperson,leadersofvirtualteams

shouldarticulateandcommunicatethevisionwithpassion, shapingaculturebasedonorganizationalvalues;however,the methodisstillunclear.Evenindevelopedcountries,thereis alackofknowledgeofe-leadershipskillsneededtoaddress successfulvirtualteamsincomplexworkprocesses(Liuetal., 2020).Thus,howe-leaderscanbuildeffectivevirtualteamsisa relevantchallengetotheleadershipfield.

Leadingvirtualteamseffectivelyofferenormouscompetitive advantagesforthecompanies.Thepossibilityofbuildingeffective teamsconsistingofpeoplewithdifferentexperiences,from diverseculturesandknowledgeofdifferentfields,regardless ofthetimeanddistance,isenormous. Nayanietal.(2018) explainedthatalthoughdistributedworkersarediverse,they sharecommonworkcharacteristicsoftemporospatialdistance fromcoworkers,managers,andleaders.Avirtualenvironment providesopportunitiestointeractandestablishconnectionswith peoplearoundtheworld(Cortellazzoetal.,2019). Malhotra etal.(2007) claimedthatthispossibilityallowsthinking globallyandactinglocally,showingthecreativecapacityof suchavirtualteam.However,becausethenationalculture impactsleadership(DorfmanandHouse,2004),thegeographical dispersionandculturaldiversitybetweenteammemberscan beabarriertobuildingtrustwithintheteams(Guptaand Pathak,2018).Indeed,thephysicaldistanceandcultural diversitythreatentrustbuildingamongtheteammembers, affectingtheircommitmentandcohesion(HochandKozlowski, 2014).Inthisregard,e-leadersshoulddevelopintercultural competencestocommunicateadequatelywithteammembers andbuildtrustthroughinterrelationship.Avirtualteamleader shoulddevelopcross-culturalskillstounderstanddifferent cultures,theirsimilarities,anddifferences(Schwarzmülleretal., 2018).Nevertheless,thereisaneedforfurtherresearchon theimpactofcultureone-leadership(Cowan,2014).Under effectivee-leadership,suchdiversityintheteamsincreasesthe members’innovativebehaviorandwillinfluencethecompanies’ innovation.Inthisregard,morethantraditionalleaders, e-leadersshouldleaddiversityiftheymustleveragetheadvantage offeredbyvirtualteams.Inthisregard, GuptaandPathak (2018) assertedthatteammembers’heterogeneitypromotes creativityandinnovationthroughacombinationofvarious perspectivestoachieveanobjective.Anotherimportantchallenge fore-leadersistorecruit,retain,reward,andmotivateglobally talentedemployeestomaintaintheircompetitiveadvantagein theglobalizedworld(Avolioetal.,2014).

Similartotraditionalteams,leadingavirtualteamrequires leadershipandmanagementskills.As Nayanietal.(2018) asserted,organizationsshouldensureoccupationalsafetyand healthofteleworkersthroughappropriatemanagement(i.e., systems,procedures,andpractices)andeffectiveleadership practices.However,thereisapaucityofresearchinthisfieldand itsresultsarefragmented.Leadingvirtualteamshasanadditional challengebecauseleadersshouldensurethateachteammember iscommittedtotheprojectandgivesthebestaccordingtohis orherexpertise(Malhotraetal.,2007).Recently, Schwarzmüller etal.(2018) highlightedthate-leadersshoulddeveloptoleranceto theambiguityandbecreativeinestablishingtheorganizational structuresandprocessesthatassurethatallmembersofvirtual

teamsareworkingforthesharedobjective.Supportingthisview, Darics(2020) claimedthate-leadershavetwoimportantroles: (1)managingperformanceandimplementingnovelsolutionsto work-relatedproblems,and(2)creatingandmaintaininggroup identitybyestablishingasharedmission,vision,values,andgoals. Thus, Malhotraetal.(2007) proposedsixleadershippractices tohavesuccessfulvirtualteams:(1)establishandmaintainthe thrustthroughtechnology;(2)appreciateandunderstandthe diversity;(3)managethework-lifecyclewellthroughmeetings; (4)monitorprogressofteamwork;(5)enhancethevisibilityof theteammembers(withinandoutsideoftheteam),and(6)allow individualmemberstoavailofthebenefitsfromtheteamwork.

JonesandO’shea(2004) statedthatthehierarchicalleadership approachesine-teamshavelimitationsintermsofproviding flexibilitytogroupmembersduringtheprocessofcollaboration. Invirtualenvironments,e-leadersshoulddistributethe leadershipwellwithintheteams.Thisallowsteamstoshapetheir ownleadershipstyleandpromotethecollectivedevelopment ofleadership(GuptaandPathak,2018).However,sharing leadershipdoesnotexcludetheformalleaderfigurebutassumes thatanymembercanleadtheteam,followup,andmakethebest decisionfortheteam(Cortellazzoetal.,2019).Throughshared leadership,notjusttheteamleaderbutalsoteammemberstake responsibilityandassumeauthoritytoconsiderboththeirown spheresofworkandtheentireproject(HoeglandMuethel, 2016).Sharedleadershippromotesteammembers’identification withinthegroupandinitiatesactionflowsforgoalachievement. However,forsharedleadership,theleadershouldrealizeand appreciatemembers’potentialandwillingnesstoassumethe responsibilityofafewleadershipduties(HoeglandMuethel, 2016).Finally,communicationinvirtualteamsismorecomplex thanintraditionalteamsthatuseface-to-facecommunication. Inmostvirtualteams,e-leadersshouldcommunicateand workasynchronouslythroughAITs.Hence,timeandspace separationinvirtualteamscreateimportantchallengesfor leadersbydemandingextraleadershipcompetenciesin ensuringandpromotingorganizationalmanagement(Fan etal.,2014).Giventhatthecoordinationofvirtualteamsfor taskaccomplishment,responsibility,andknowledgesharing isdonethroughtelecommunicationtechnologies,sometimes theremaybedistortionininformationinterpretationleadingto misunderstandingsandemployeedemotivation.Thus,e-leaders shouldbehighlycompetentintheirverbalcommunicationsto motivatetheiremployees(Fanetal.,2014).Virtualteamleaders shouldavoidemployees’feelingofisolationandpromoteteam cohesion.Thisimpliesadequateestablishmentofnormsof collaboration,knowledgesharing,recognition,andrewarding theteamsandtheirmembers(Malhotraetal.,2007)tobe “present”sociallyandemotionally(Cowan,2014).

CONCLUSIONANDPROPOSITIONSFOR FURTHERSTUDIES

Thepandemichasincreasedtheneedtoaugmentourknowledge onhowtoleadeffectivelyandbuildhighlyfunctionalvirtual teams.Despitebeingrecognizedmuchearlier,thereislimited

knowledgeone-leadershipandnotheoryspecifictosuch leadership.Itisunclearwhetherthecurrentknowledgeon leadershipcanbeappliedtoe-leadership.Similarly,resultsfrom variousstudiesontheeffectivenessofe-leadershipanditseffects onemployeeshavebeeninconclusive.Thereissomeconsensus thatleadersshouldconsidergivingtheopportunitytosome employeestoteleworkwhenthejoborthetaskcanbedoneout oftheworkplaceandtoavailofthebenefitsofthismodeofwork. Thus,asaresultofappliedresearch,itisimperativetocreate profilesofeligibilitytotelework.Inotherwords,peoplewho canleveragetheadvantageofworkingremotelymustestablish differentlevelsofattendancebasedontheworkortask(e.g.,once aweek,somedaysaweek,orfull-time).

Therevisedliteraturehighlightedtheimportanceofachieving abetterunderstandingoftheeffectsofteleworkingonemployees’ well-beingandorganizationalperformance.Currently,duetothe pandemic,thereisahugeglobalinterestinstudyingthistopic fromtheperspectiveofbothpractitionersandresearchers.Itis neededtoconductstudiesthatrigorouslyexaminedteleworking ande-leadershipandthereasonsforsuccessandevenforthe failurestolearnmoreabouthowtomanagethisnewway towork.However,thereisapaucityofknowledgeonthe outcomesofsuchamethodofwork,anditsresultshavebeen inconclusive.Forexample, Narayananetal.(2017) mentioned thatcompaniessuchasHewlett-Packard,Yahoo,andBestBuy reducedthehoursofteleworkingandaskedworkerstoreturnto thetraditionalworkplace.Casestudiesareneededtounderstand thesefailedexperiences.

Finally,oneofthemainweaknessesinthestudiesof teleworkingande-leadershipistheirmethodology,smallsamples arenotrepresentative,androbusttheoreticalfoundationsare scarce.Itisimportanttoimprovemethodologicalrigorfor acquiringreliableandvaliddata.Morethandescriptiveor correlationalstudiesarenecessary.Moreexperimentalandquasiexperimentalstudiesareneededaswellasmorelongitudinal studiesandmixedmethodsforbettercomprehension ofthephenomena.

Duetotheavailabilityofaglobalworkforce,itisimportant toconductcross-culturalstudiesandanalyzetheroleof e-leadershipandculturaldifferences.As Narayananetal.(2017) suggested,researchshouldbeconductedonpsychologyand sociologyandtopicssuchassocialisolation,group,andteam behaviorandmanagementpracticesinteleworking.Howto promotetrustthroughorganizationalcultureandleadership shouldbeexamined.Attheindividuallevel,researchon psychologyshouldbeconductedtounderstandthepersonality, qualities,skills,andcognitiveneedsofthoseemployeeswho

REFERENCES

Alfehaid,L.,andMohamed,E.E.(2019).Understandingtheinfluence ofE-leadershiponVirtualTeamPerformanceEmpiricalStudy. Int.J.Bus.Appl.Soc.Sci. 5,21–36.doi:10.33642/ijbass.v5n 10p3

Al-jedaibi,H.K.(2001). Determininghowinformationtechnologyischangingthe roleofleadershipinvirtualorganization.Wisconsin:TheGraduateCollege UniversityOfWisconsin-Stout.

aremoresuitabletoworkremotelyandconductfinancial researchforthecost-benefitanalysisofteleworking. Liuetal. (2020) and Cortellazzoetal.(2019) suggestedthatatheory ofe-leadership,sharingapproaches,andtheorizingaboutthis phenomenonisneeded.Finally,basedon Nayanietal.(2018), theteleworkers’healthisanotherpromisinglineofresearchthat shouldbedevelopedthroughrobustconceptualframeworksand rigorousmethods.

Insum,fromthetheoreticalperspective,furtherstudies shouldhelptobuildatheoryofe-leadershipthatiscommon forallresearchersinthistopic.Inthisway,findingsaround theworldcanbecontrasted,whichwillcontributetobuildinga solidbodyofknowledgeofhowtoleadinvirtualenvironments. Thesestudieswillhelpalsoe-leaderstodeveloptheirintercultural competenciestoleadinglobalenvironments.Likewise,the methodologyofempiricalstudiesshouldbestrengthenedto conductresearchincontrolledsettings(researchinalaboratory) makingrelevantcontributionsthatexplainhowtosuccessfully leadinvirtualenvironments.Infact,thebodyofknowledge thatwillcontinuetobebuiltinthenextyearswillallowto identifyandtestthecompetenciesthatneedtobedeveloped bye-leadersinordertobeeffectiveasleadersandefficientas managersinthisnewwayofwork,whichapparentlywillbe kepttovaryingdegreesoncethepandemicisovercome.Asa resultofthesestudies,leaderscanbetrainedandhumanresource managerscanbeguidedinordertoincreaseorganizational performancewhileimprovingtheemployees’well-beingina healthyworkenvironment.

AUTHORCONTRIBUTIONS

FCwasengagedintheinvestigation,literaturesearchand selection,writingoriginaldraft,preparation,andfinishingthe lastversion.EBwasinvolvedininvestigation,literaturesearch andselection,contributiontotheoriginaldraft,andcontribution tothelastversion.GAwasengagedininvestigation,literature searchandselection,contributiontotheoriginaldraft,and contributiontothelastversion.Allauthorscontributedtothe articleandapprovedthesubmittedversion.

ACKNOWLEDGMENTS

Theauthorsaregratefulforfinancialassistancefor proofreadingserviceprovidedbytheUniversidaddelRosario, Bogotá,Colombia.

Allen,T.D.,Golden,T.D.,andShockley,K.M.(2015).Howeffectiveis telecommuting?Assessingthestatusofourscientificfindings. Psychol.Sci. PublicInterest 16,40–68.doi:10.1177/1529100615593273

Avolio,B.J.,andKahai,S.S.(2003).Addingthe"E"toE-Leadership:Howitmay impactyourleadership. Organiz.Dynamics 31,325–338.doi:10.1016/S00902616(02)00133-X

Avolio,B.J.,Kahai,S.,andDodge,G.E.(2000).E-leadership:Implicationsfor theory,research,andpractice. Leaders.Quart. 11,615–668.doi:10.1016/S10489843(00)00062-X

Avolio,B.J.,Sosik,J.J.,Kahai,S.S.,andBaker,B.(2014).E-leadership:Reexaminingtransformationsinleadershipsourceandtransmission. Leaders. Quart. 25,105–131.doi:10.1016/j.leaqua.2013.11.003

Azarbouyeh,A.,andNaini,S.(2014).Astudyontheeffectofteleworkingonquality ofworklife. Manage.Sci.Lett. 4,1063–1068.doi:10.5267/j.msl.2014.5.027

Bathini,D.R.,andKandathil,G.M.(2019).Anorchestratednegotiatedexchange: Tradinghome-basedteleworkforintensifiedwork. J.Bus.Ethics 154,411–423. doi:10.1007/s10551-017-3449-y

Béland,L.P.,Brodeur,A.,andWright,T.(2020).“Theshort-termeconomic consequencesofCovid-19:exposuretodisease,remoteworkandgovernment response,”in IZAInstituteoflaboreconomicsDiscussionPapers,No.13159, (Bonn:IZAInstituteoflaboreconomics).

Bennis,W.G.(2009). Onbecomingaleader.NewYork:BasicBooks.

Bentley,T.(2014).Howcanorganisationsrealizethepositivebenefitsof’anywhere working’? Hum.Resour.Magaz. 2014,8–11.

Bentley,T.,Teo,S.,McLeod,L.,Tan,F.,Bosua,R.,andGloet,M.(2016). Theroleoforganizationalsupportinteleworkerwellbeing:asocio-technical systemsapproach. Appl.Ergonom. 52,207–215.doi:10.1016/j.apergo.2015. 07.019

Bosua,R.,Kurnia,S.,Gloet,M.,andMoza,A.(2017).“TeleworkImpacton ProductivityandWell-Being,”in SocialInclusionandUsabilityofICT-Enabled Services,edsJ.Choudrie,S.Kurnia,andP.Tsatsou(NewYork:Routledge),201. doi:10.4324/9781315677316

Bouziri,H.,Smith,D.R.,Descatha,A.,Dab,W.,andJean,K.(2020).Working fromhomeinthetimeofCovid-19:howtobestpreserveoccupational health? Occupat.Environ.Med. 77,509–510.doi:10.1136/oemed-2020-10 6599

Coenen,M.,andKok,R.(2014).Workplaceflexibilityandnewproduct developmentperformance:theroleofteleworkandflexibleworkschedules. Eur.Manage.J. 32,564–576.doi:10.1016/j.emj.2013.12.003

Cooper,C.D.,andKurland,N.B.(2002).Telecommuting,professionalisolation, andemployeedevelopmentinpublicandprivateorganizations. J.Organiz. Behav. 23,511–532.doi:10.1002/job.145

Cortellazzo,L.,Bruni,E.,andZampieri,R.(2019).Theroleofleadershipina digitalizedworld:areview. Front.Psychol. 10:1938.doi:10.3389/fpsyg.2019. 01938

Cowan,L.D.(2014).E-Leadership:Leadinginavirtualenvironment-guiding principlefornurseleaders. Nurs.Econom. 32,312–322.

Darics,E.(2020).E-leadershipor“HowtobebossinInstantMessaging?”.The roleofnonverbalcommunication. Int.J.Bus.Commun. 57,3–29.doi:10.1177/ 2329488416685068

DasGupta,P.(2011).Literaturereview:e-Leadership. Emerg.Leaders.Journeys 4, 1–36.doi:10.1109/tmag.2013.2278570

DeVries,H.,Tummers,L.,andBekkers,V.(2019).Thebenefitsofteleworkingin thepublicsector:realityorrhetoric? Rev.PublicPerson.Administr. 39,570–593. doi:10.1177/0734371X18760124

Delanoeije,J.,andVerbruggen,M.(2019).TheUseofWork-HomePracticesand Work-HomeConflict:ExaminingtheRoleofVolitionandPerceivedPressure inaMulti-MethodStudy. Front.Psychol. 10:2362.doi:10.3389/fpsyg.2019. 02362

DeSanctis,G.,andPoole,M.(1994).Capturingthecomplexityinadvanced technologyuse:AdaptiveStructurationTheory. Organiz.Sci. 5,121–147.doi: 10.1287/orsc.5.2.121

Dorfman,P.,andHouse,R.(2004).“Culturalinfluencesonorganizational leadership,”in Culturalleadershipandorganizations:Theglobestudyof62 societies,edsR.House,P.Hanges,M.Javidan,P.Dorfman,andV.Gupta (ThousandOaks,CA:Sage),51–73.

Dulebohn,J.H.,andHoch,J.E.(2017).Virtualteamsinorganizations. Hum. Resour.Manage.Rev. 27,569–574.doi:10.1016/j.hrmr.2016.12.004

Esguerra,G.A.,andContreras,F.(2016).Liderazgoelectrónico,unretoineludible paralasorganizacionesdehoy. EstudiosGerenciales 32,262–268.doi:10.1016/ j.estger.2016.08.003

Eversole,B.A.,Venneberg,D.L.,andCrowder,C.L.(2012).Creatingaflexible organizationalculturetoattractandretaintalentedworkersacrossgenerations. Adv.Dev.Hum.Resour. 14,607–625.doi:10.1177/1523422312455612

Fan,K.T.,Chen,Y.H.,Wang,C.W.,andChen,M.(2014).E-leadership effectivenessinvirtualteams:Motivatinglanguageperspective. Indust.Manage. DataSyst. 114,421–437.doi:10.1108/IMDS-07-2013-0294

Fedakova,D.,andIštoˇnová,L.(2017).SlovakIT-employeesandnewways ofworking:impactonwork-familybordersandwork-familybalance. CeskoslovenskaPsychol. 61,68–83.

Felstead,A.,andHenseke,G.(2017).Assessingthegrowthofremoteworkingand itsconsequencesforeffort,well-beingandwork lifebalance. N.Technol.Work Employ. 32,195–212.doi:10.1111/ntwe.12097

Flood,F.(2019).“Leadershipintheremote,freelance,andvirtualworkforceera,” in GlobalEncyclopediaofPublicAdministration,PublicPolicy,andGovernance, ed.A.Farazmand(LakeFrederick,VA:Springer),1–5.doi:10.1007/978-3-31931816-5_3825-1

Fonner,K.L.,andRoloff,M.E.(2010).Whyteleworkersaremoresatisfiedwith theirjobsthanareoffice-basedworkers:Whenlesscontactisbeneficial. J.Appl. Commun.Res. 38,336–361.doi:10.1080/00909882.2010.513998

Friedman,S.D.,andWestring,A.(2015).Empoweringindividualstointegrate workandlife:insightsformanagementdevelopment. J.Manage.Dev. 34, 299–315.doi:10.1108/JMD-11-2012-0144

Gajendran,R.S.,andHarrison,D.A.(2007).Thegood,thebad,andtheunknown abouttelecommuting:meta-analysisofpsychologicalmediatorsandindividual consequences. J.Appl.Psychol. 92:1524.doi:10.1037/0021-9010.92.6.1524

Gálvez,A.,Tirado,F.,andAlcaraz,J.M.(2020).“Oh!Teleworking!”.Regimesof engagementandthelivedexperienceoffemaleSpanishteleworkers. Bus.Ethics AEur.Rev. 29,180–192.doi:10.1111/beer.12240

Giovanis,E.(2018).Therelationshipbetweenteleworking,trafficandairpollution. Atmospher.Poll.Res. 9,1–14.doi:10.1016/j.apr.2017.06.004

Golden,T.D.,Veiga,J.F.,andDino,R.N.(2008).Theimpactofprofessional isolationonteleworkerjobperformanceandturnoverintentions:Doestime spentteleworking,interactingface-to-face,orhavingaccesstocommunicationenhancingtechnologymatter? J.Appl.Psychol. 93:1412.doi:10.1037/a0012722

Groysberg,B.(2014). ThesevenskillsyouneedtothriveintheC-suite Massachusetts:HarvardBusinessReview.

Gupta,S.,andPathak,G.S.(2018).Virtualteamexperiencesinanemerging economy:aqualitativestudy. J.Organiz.ChangeManage. 31,778–794.doi: 10.1108/JOCM-04-2017-0108

Gurr,D.(2004).ICT,LeadershipinEducationandE leadership. Discour.Stud. Cult.Polit.Educ. 25,113–124.doi:10.1080/0159630042000178518

He,S.,Lai,D.,Mott,S.,Little,A.,Grock,A.,Haas,M.R.,etal.(2020).Remote e-workanddistancelearningforacademicmedicine:bestpracticesand opportunitiesforthefuture. J.Grad.Med.Educ. 12,256–263.doi:10.4300/ JGME-D-20-00242.1

Hoch,J.E.,andKozlowski,S.W.(2014).Leadingvirtualteams:Hierarchical leadership,structuralsupports,andsharedteamleadership. J.Appl.Psychol. 99, 390–403.doi:10.1037/a0030264

Hoegl,M.,andMuethel,M.(2016).Enablingsharedleadershipinvirtualproject teams:Apractitioners’guide. Proj.Manage.J. 47,7–12.doi:10.1002/pmj.21564

Jones,N.,andO’shea,J.(2004).Challenginghierarchies:Theimpactofe-learning. HigherEduc. 48,379–395.doi:10.1023/b:high.0000035560.32573.d0

Kahai,S.S.,Sosik,J.J.,andAvolio,B.J.(2013).“Effectsoftransformational leadershipandmediaoncollaborationandperformanceinvirtualteams,” in LeadershipinVirtualGroups:LookingBackandChartingPathsForward. SymposiumConductedattheMeetingsoftheAcademyofManagement,edsN.S. HillandN.M.Lorinkova(Orlando,FL:AcademyofManagement).

Kaplan,S.,Engelsted,L.,Lei,X.,andLockwood,K.(2018).Unpackaging managermistrustinallowingtelework:comparingandintegratingtheoretical perspectives. J.Bus.Psychol. 33,365–382.doi:10.1007/s10869-017-9498-5

Kazekami,S.(2020).Mechanismstoimprovelaborproductivitybyperforming telework. TelecommunPolicy 44:101868.doi:10.1016/j.telpol.2019.101868

Kłopotek,M.(2017).Theadvantagesanddisadvantagesofremoteworkingfrom theperspectiveofyoungemployees. Organiz.Manage. 4,39–49.doi:10.29119/ 1899-6116.2017.40.3

Kossek,E.E.,Lautsch,B.A.,andEaton,S.C.(2006).Telecommuting,control,and boundarymanagement:Correlatesofpolicyuseandpractice,jobcontrol,and work-familyeffectiveness. J.Vocat.Behav. 68,347–367.doi:10.1016/j.jvb.2005. 07.002

Kotterman,J.(2006).Leadershipversusmanagement:What’sthedifference? J.Qual.Particip. 29,13–17.

Lambert,A.,Cayouette-Remblière,J.,Guéraut,É,LeRoux,G.,Bonvalet,C.,Girard, V.,etal.(2020).HowtheCOVID-19epidemicchangedworkingconditionsin France. Popul.Societ. 579,1–4.

Liu,C.,VanWart,M.,Kim,S.,Wang,X.,McCarthy,A.,andReady,D.(2020).The effectsofnationalculturesontwotechnologicallyadvancedcountries:Thecase ofe leadershipinSouthKoreaandtheUnitedStates. Aus.J.PublicAdminist. 79,298–329.doi:10.1111/1467-8500.12433

Maciel,A.G.,Carraro,N.C.,deSousa,M.A.B.,andSanches,A.C.(2017).An alisedoteletrabalhonoBrasil. Rev.GestaþoEmpresarial 1,20–33.

Malhotra,A.,Majchrzak,A.,andRosen,B.(2007).Leadingvirtualteams. Acad. Manage.Perspect. 21,60–70.doi:10.5465/amp.2007.24286164

Maruyama,T.,andTietze,S.(2012).Fromanxietytoassurance:Concerns andoutcomesoftelework. Person.Rev. 41,450–469.doi:10.1108/ 00483481211229375

Mintzberg,H.(2009). Thebestleadershipisgoodmanagement.BloombergBusiness week:OnlineMagazine.AvailableOnlineat:https://www.bloomberg.com/ news/articles/2009-08-06/the-best-leadership-is-good-management(accessed August06,2009)

Montgomery,V.A.,Roman,A.,andPierce,S.(2016).Theriseandeffectofvirtual modalitiesandfunctionsonorganizationalleadership:Tracingconceptual boundariesalongthee-managementande-leadershipcontinuum. Transyl.Rev. Administ.Sci. 12,102–122.

Morgan,R.E.(2004).Teleworking:Anassessmentofthebenefitsandchallenges. Eur.Bus.Rev. 16,344–357.doi:10.1108/09555340410699613

Müller,T.,andNiessen,C.(2019).Self leadershipinthecontextofpart time teleworking. J.Organiz.Behav. 40,883–898.doi:10.1002/job.2371

Nakrošiene,A.,Buˇciuniene,I.,andGoštautaite,B.(2019).Workingfromhome: Characteristicsandoutcomesoftelework. Int.J.Manpower. 40,87–101.doi: 10.1108/IJM-07-2017-0172

Narayanan,L.,Menon,S.,Plaisent,M.,andBernard,P.(2017).Telecommuting: Theworkanywhere,anyplace,anytimeorganizationinthe21stcentury. J.Market.Manage. 8,47–54.

Nayani,R.J.,Nielsen,K.,Daniels,K.,Donaldson-Feilder,E.J.,andLewis,R.C. (2018).Outofsightandoutofmind?Aliteraturereviewofoccupationalsafety andhealthleadershipandmanagementofdistributedworkers. WorkStress 32, 124–146.doi:10.1080/02678373.2017.1390797

Nilles,J.M.(1998). MakingTelecommutingHappen:Aguidefortelemanagersand telecommuters.NewYork:VanNostrandReinhold.

Othman,N.,Yusef,S.A.M.,andOsman,W.R.S.(2009).Aconflictbetween professionalvs.domesticlife?UnderstandingtheuseofICTinteleworkingfor balanceinworkandfamilyunits. Comp.Infor.Sci. 2,3–15.

Panteli,N.,Yalabik,Z.Y.,andRapti,A.(2019).Fosteringworkengagement ingeographically-dispersedandasynchronousvirtualteams. Infor.Technol. People. 32,2–17.doi:10.1108/ITP-04-2017-0133

Pavlova,O.(2019).Theimpactofflexibleworkingarrangementsoncompetitive advantagesoforganization. VilniusUniv.OpenSer. 2019,55–61.doi:10.15388/ OpenSeries.2019.18404

Politis,J.(2014).“Theeffectofe-leadershiponorganisationaltrustand commitmentofvirtualteams,”in EuropeanConferenceonManagement, LeadershipandGovernance,(Reading:AcademicConferencesInternational Limited),254.

Prin,M.,andBartels,K.(2020).Socialdistancing:Implicationsfortheoperating roominthefaceofCOVID-19. Can.J.Anaesthes. 67,789–797.doi:10.1007/ s12630-020-01651-2

Pulley,M.L.,andSessa,V.I.(2001).E leadership:tacklingcomplexchallenges. Indust.Commer.Training 33,225–229.doi:10.1108/00197850110405379

Putnam,L.L.,Myers,K.K.,andGailliard,B.M.(2014).Examiningthetensionsin workplaceflexibilityandexploringoptionsfornewdirections. Hum.Relat. 67, 413–440.doi:10.1177/0018726713495704

Pyoria,P.(2011).Managingtelework:risk,fearsandrules. Manage.Res.Rev. 34, 386–399.doi:10.1108/01409171111117843

Roman,A.V.,VanWart,M.,Wang,X.,Liu,C.,Kim,S.,andMcCarthy,A.(2019). Defininge leadershipascompetenceinICT mediatedcommunications:An exploratoryassessment. PublicAdminist.Rev. 79,853–866.doi:10.1111/puar. 12980

Schwarzmüller,T.,Brosi,P.,Duman,D.,andWelpe,I.M.(2018).Howdoes thedigitaltransformationaffectorganizations?Keythemesofchangeinwork designandleadership. Manage.Revue 29,114–138.doi:10.5771/0935-99152018-2-114

Siebdrat,F.,Hoegl,M.,andErnst,H.(2014).Subjectivedistanceandteam collaborationindistributedteams. J.Prod.Innov.Manage. 31,765–779.doi: 10.1111/jpim.12122

Stokols,D.,Mishra,S.,Gould-Runnerstrom,M.,andHipp,J.(2009).Psychologyin anageofecologicalcrisis:Frompersonalangsttocollectiveaction. Am.Psychol. 64,181–193.doi:10.1037/a0014717

Tietze,S.,andMusson,G.(2005).Recastingthehome-workrelationship:A caseofmutualadjustment? Organiz.Stud. 26,1331–1352.doi:10.1177/ 0170840605054619

VanWart,M.,Roman,A.,Wang,X.,andLiu,C.(2019).Operationalizingthe definitionofe-leadership:identifyingtheelementsofe-leadership. Int.Rev. Administ.Sci. 85,80–97.doi:10.1177/0020852316681446

Vega,R.P.,Anderson,A.J.,andKaplan,S.A.(2015).Awithin-personexamination oftheeffectsoftelework. J.Bus.Psychol. 30,313–323.doi:10.1007/s10869-0149359-4

Walther,J.B.,andBazarova,N.N.(2008).Validationandapplicationof electronicpropinquitytheorytocomputer-mediatedcommunicationin groups. Commun.Res. 35,622–645.doi:10.1177/0093650208321783

Wojcak,E.,Bajzikova,L.,Sajgalikova,H.,andPolakova,M.(2016).Howtoachieve sustainableefficiencywithteleworkers:Leadershipmodelintelework. Proc.Soc. Behav.Sci. 229,33–41.doi:10.1016/j.sbspro.2016.07.111

WorldHealthOrganization(WHO)(2020). Gettingyourworkplacereadyfor COVID-19:HowCOVID-19spreads.Geneva:WorldHealthOrganization. Availableonlineat:https://apps.who.int/iris/handle/10665/331584(accessed March19,2020).

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Contreras,BaykalandAbid.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.No use,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

published:16December2020 doi:10.3389/fpubh.2020.607832

Editedby: MagdalenaKlimczuk-Kochanska, UniversityofWarsaw,Poland

Reviewedby: MarianellaHerrera-Cuenca, CentralUniversityof Venezuela,Venezuela AntonellaPoce, RomaTreUniversity,Italy

*Correspondence: AdrianaPoppe apoppe1@smail.uni-koeln.de

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 18September2020 Accepted: 10November2020 Published: 16December2020

Citation: PoppeA(2020)Impactofthe HealthcareSystem,MacroIndicator, GeneralMandatoryQuarantine,and MaskObligationonCOVID-19Cases andDeathinSixLatinAmerican Countries:AnInterruptedTimeSeries Study.Front.PublicHealth8:607832. doi:10.3389/fpubh.2020.607832

ImpactoftheHealthcareSystem,

MacroIndicator,GeneralMandatory Quarantine,andMaskObligationon COVID-19CasesandDeathinSix LatinAmericanCountries:An InterruptedTimeSeriesStudy

AdrianaPoppe*

FacultyofManagement,EconomicsandSocialScience,UniversityofCologne,Cologne,Germany

Background: Differentcopingstrategieshavebeenimplementedbyvarious governmentsworldwidetoaddresstheemerginghealthcrisisofCOVID-19.Whilemost developedcountriescountonsupportinghealthcareandsocialsystems,developing countriesfaceadditionalchallengesduetolowmacroindicators.Theimplementation ofmeasurementssuchasquarantineareshowntobesuccessfultoflattenthecurveof infectionanddeath.Inthiscontext,itisimportanttotestwhetherthosemeasurements haveanimpactonthedistributionofcasesofCOVID-19indevelopingcountriesthat faceadditionalchallengessuchaslackofsocialsecurityduetoinformalemployment. AcountrycomparisonforColombia,CostaRica,Peru,Ecuador,Mexico,andChilehas thereforebeenconducted.

Method: Thehealthcaresystemsandmacroindicatoraswellasthedistributionofdeath duetoCOVID-19perthousandinhabitantsarecompareddescriptively.UsingMultiple InterruptedTimeSeriesAnalysiswithsyntheticcontrolunitstheimpactoftheGeneral MandatoryQuarantineinColombia,Peru,andEcuadoraswellastheimpactofMask ObligationinpublicinColombiaandChilehavebeentested.

Results: Noclearimpactofthepovertyheadcountratioatthenationalpovertyline andurbanpopulationonthepercentageofdeathwithintheconfirmedcaseshasbeen found.Theout-of-pockedspendingwithinhealthexpenditureasabarrierinaccessto healthcarecanbeconsideredasadeterminantofdeathwithintheconfirmedcases ofCOVID-19.Theimplementationofageneralmandatoryquarantinedidnotshowa curve-flatteningeffectinEcuadorandPerubutdidsoinColombia.Theimplementationof Maskobligationinpublicspacedshowedpositiveimpactonthedistributionofconfirmed caseinbothcountriestested.

Conclusion: Theimplementationofageneralmandatoryquarantinedoesnot guaranteethecurve-flatteningeffect.Variousmacroindicatorsshouldthereforealways beconsideredwhileanalyzingtheeffectofpolicies.

Keywords:COVID-19,LatinAmerica,copingstrategies,macroindicators,ITSA = interruptedtime-seriesanalysis, countrycomparison,mandatoryquarantine,maskobligation

INTRODUCTION

Anewcoronavirus(SARS-COV-2/COVID-19)emergedon December12,2019inWuhan,China(1).Inthefollowing months,thediseasespreadaroundtheworld.TheWorldHealth Organization(WHO)declaredthecoronavirusoutbreakaGlobal PublicHealthEmergencyonJanuary20,2020.OnMarch11, theWHOdeterminedthatCOVID-19canbecharacterizedas apandemic(2).Duetothehighnumberofcasesandtherapid spread,healthcaresystemsarefacingthemostseriousglobal pandemiccrisisinacentury[(3),p.1].

Thelackofknowledge aboutremediesandvaccinationsare aproblemstrainingthestabilityofhealthcaresystems(4, 5). Theneedtoimplementpolicies toreducetheincidenceof infectionisindangerofoverloadinghospitalcapacitiesand healthcaresystems.ThehealthcaresystemsinLatinAmerican Countries(LAC)havebeenshapedbythehistoryoftheworst incomeinequalitiesworldwide[(6),p.1230].Universalaccess tohealthcare isincludedasabasicrightintheconstitution ofeachcountry(7, 8).However,theavailabilityandtheaccess tohealthcare,evenincountrieswithuniversalcoverage,are unequal[(3),p.3].Accordingly,nearly30%ofthepeoplein thelowestincomequintileforgocarebecauseaffordabilityin OECDcountries(3).WiththeincreasingspreadofSARS-COV2viruses,thedemands ontheseunevenlydistributedhealthcare systemsaregrowing.Thecriticaltaskofhealthcaresystemsisto protectthehealthofallcitizen,especiallyintimesofpandemics suchasCOVID-19[(8),p.9].

Manyhealthcare systemsinLACarecharacterizedby fragmentationbecauseprovidingacleartypologyforhealth coverageisadifficultendeavor[(9),p.15].Insomecountries, suchasMexico, coexistingmodelsandoverlappingcoverage makesitdifficulttodefinethepercentageofpopulationwith healthcarecoverage(7, 10, 11).Inthismode,beingaffiliatedor contributingtoahealth systemdoesnotnecessarilyguarantee effectiveaccessorthequalityofservicesreceived[(10),p.38]. Thegenerallyweakandfragmentedhealthsystemsareevenmore strainedbytheCOVID-19pandemic,astheyhavealreadybeen hitbyZikaandChikungunyaoutbreaks[(10, 12),p.38].A syndemic1 ofmeasles,dengue,andCOVID-19,amongothers, makesitallthemoreimportantforcountriesintheregionto keepCOVID-19caseslow(12).Forexample,inEcuador,82.57% oftheconfirmedCOVID-19casesand84%ofdenguecasesare presentinthecoastandthecityofGuayaquil(13).Effortsto stopthespreadof theviruscouldbeunderminedbygapsin accesstohealthservicesandthequalityreceived[(10),p.38]. Thelackinthe availabilityofintensivecareunitsandspecific diagnostictestshasbeenaconcernregardingtheupcoming healthcrisis(12).Abaselinescenarioduringtheoutbreakofan healthcarecrisis isimbalancebetweensupplyanddemandfor medicalresources,whichmaygrowrapidlyinmanycountries [(14),p.1].TofacethedemandsurgefromCOVID-19,health workforces,such asdoctorsandnurses,arekeyindicatorsofa timelyandeffectiveresponse[(8),p.10].Thenumberofbedsto copewiththeincreasingdemandforhospitalserviceduetothe

1Interlinkedhealth problems.

TABLE1| IndicatoroftheHealthcareSystems(latestyearavailable).

Hospital beds × 1,000 inhabitants

Doctors × 1,000 inhabitants

Nurses × 1,000 inhabitants

Out-of-pocket (OOP)shareof healthspending (%)

Chile 2.1 2.5 2.7 34

Colombia1.7 2.2 1.3 16 Costa Rica 1.1 3.1 3.4 22

Ecuador1.5 2.0 2.5 39 Mexico 1.4 2.4 3.9 41

Peru 1.6 1.3 2.4 28 OECD(8).

spreadofthevirus isindicativeofhowpreparedthehealthcare systemsare(8).

Withtheaimto measurethegeneralaccesstohealthcare,Outof-Pocket(OOP)2 maybeconsidered,asithighlightsbarriersto access.Onaverage,34%ofthetotalhealthspendinginLACare OOP[(8),p.9].OntheOECDaverage,theOOPexpendituresare above21%(8).ItcanbesaidthatahigherlevelofOOPspending indicatesweakerhealthcareSystemsintheLACwithlowerlevels ofhealthservicecoverageandanoverallworsebaselinescenario toconfronthealthcrisis(8).Thebasiccharacteristicsofthe healthcaresystems aredisplayedin Table1

Thespreadofthevirus,andwiththis,thelikelihoodofthe healthcaresystemtocollapse,isinfluencedbyvariousmacro indicators.Firstly,higherpopulationdensitymayincreasethe chancesofhumaninteraction[(15),p.117].Duetohigher populationdensity,thehumaninteractionsmayincrease,which favorsthespreadofviruses(15).Inthepast,ithasbeenshown thatdenselypopulatedurbanareashavebeenmorelikelyto beaffectedbyepidemicsofrespiratorydiseases,suchasin theinfluenzapandemicof1918–1919(16).Secondly,ageand underlyinghealthconditionshavebeenshowntobeindicators determiningthelikelihoodofinfection,criticalconditions,and consequentlypassingawayduetotheinfection(17).Dowdetal. (18)showedahigherfatalityamongcountrieswithahighershare ofoldercitizencomparedtoyounger societies.Thelikelihood ofenteringacriticalconditionthusincreaseswithage,which leadstoahigherdemandforhospitalcareunitswithinthe healthcaresystem.Itcanthusbyhypothesizedthatthehospitals arefacingahigherdemandwithanincreaseintheshareofolder populations,whichcanincreasethelikelihoodforacollapseof thehealthcaresystem.

InLAC,ahighdegreeofinformalityandinequalitymakethe situationpotentiallymorecatastrophiccomparedtootherparts intheworld[(8),p.11].Alackofsocialprotectionlikelyresults intheneedtocontinue toworktomakealiving,whichlimits thecapabilitytofollowsocialdistancingmeasures(8).Moreover, thepossibilityofworkingfrom home,overcrowdedconditions, andlackofaccesstowaterandsanitationrestrictsthecapability 2Directpayments madebyindividuals.

TABLE2| Marcoindicator(latestdateavailable).

GDPpercapita in$(2018)a Population density(2018)b

Povertyheadcountrationat nationalpovertylines(%)c Populationaged 65+ (%)d Urban population(%)e Sanitation (%)d Accesstodrinking water(%)d

Chile 14,670 25.189 8.6(2017) 11.530 84.8%100 100

Colombia 6,180 44.749 27.0(2018) 8.478 80.4% 90 97

Costa Rica 11,520 97.913 21.0(2019) 9.550 80% 98 100

Ecuador 6,110 68.789 25.0(2019) 7.157 63% 88 94

Mexico 9,180 64.915 41.9(2018) 7.224 83.9% 91 99

Peru 6,470 24.992 20.5(2018) 8.088 79.1% 74 91

a Worldbank(21).

b Worldbank(22).

c Worldbank(23).

d OECD (8).

e Worldometer.info(24).

ofindividualstocopewith healthemergenciessuchasCOVID19[(4, 19, 20),p.5].Supportingtheinequalitiesbasedonthe accesstocleanwater,Brojas(20)foundahigherprobability ofhavingapositive COVID-19testresultforpeoplelivingin poorneighborhoods,inneighborhoodswherelargenumbers ofpeopleresidetogetherwithinthesamehousehold,andin neighborhoodswithalargeblackorimmigrantpopulation,like inNewYork[TheUnitedStates(U.S.)].Basedonthis,the macroindicatorsofthecountriesunderstudyaredisplayed in Table2

Inordertonarrowthegapbetweenmedicalneedandavailable supplyoftreatments,publichealthmeasuresknowntoreduce viralspread,suchassocialdistancingandhandhygiene,may beimplemented[(14, 25),p.3].Duringtheimplementationof measuresagainstthespreadofthevirus,policymakersmust drawonknowledgefrompreviouspandemicsandepidemics. Ausefulreferenceintheevaluationofpossiblepoliciesaiming toflatterthecurveofSARS-COV-2isSARS-COV(SARS) (25).Tocontrolperson-to-persontransmission,measuressuch asisolation,quarantine,socialdistancing,andcommunity containmentwereimplementedinthemainaffectedcountries ofChina,Taiwan,HongKong,Singapore,andCanadain ordertolowerthetransmissionofthevirus(25).Patients suspectedofhaving SARSwereisolatedineithertheirhomes, ahospital,oringovernment-designatedplaces(e.g.,hotels) untilSARScouldberuledout(25).Individualinteractions werereduced,responsibilityto self-identifythediseaseand socialdistancewereencouraged,andcancellationofpublic gatheringsandimplementationofcommunityquarantinewere introduced(25).

Researchershavealreadyconductedstudiestestingthe efficiencyofvariousmeasuresagainstthespreadofCOVID19.Figueiredoetal.(26)haveshownthatthesocialdistancing measuresintwo Chinesprovinceswereeffectiveinreducing incidencesandmortalityratesofCOVID-19(26).Ithasbeen shownthatthe effectivenessoflockdownpoliciesdeclineswith GDPpercapita,populationdensityandsurfaceareaandit increaseswithhealthexpenditureandproportionofphysicians inpopulation(15).

MostoftheLatin AmericanCountries(LAC)rememberedthe lessonslearnedduringSARS-COVandtheinfluenzapandemic of2009(12).However,thestrategiesaimingtolowerthe infectedanddeath byCOVID-19vary.ArangeofnonpharmaceuticalInterventions(NPI)havebeenimplemented, includingclosureofschools,mandatoryhealthcarecoverage, mandatoryquarantine,andaimingtoincreasinglyreducethe populationcontactratesandslowthetransmissionofthevirus. ThepresentstudyfocusesonsixLatinAmericancountries, Chile,Colombia,CostaRica,Ecuador,Peru,andMexico.The selectionofthecountrieswasmadebasedontheavailability ofdataonhealthsystemsinthecaseofColombia,Chile, andMexicoasOECDcountries.Inaddition,COVID-19 infectionanddeathrateshavebeenconsideredtoallowthe formationofsyntheticcohorts.Furthermore,thecountrieswere selectedaccordingtotheimplementedpolicies,sothatcountries withdifferentcopingstrategiesareincluded. Table3 shows themainpoliciesaimingtoreducethespreadofthevirus implementedthecountriesunderstudy.Allcountriesincluded inthestudyhadimplementedatleastsixpoliciesbyMay 17(27).

Theaimofthisstudy istoanalyzewhetherandtowhat extenttheimplementationofageneralmandatoryquarantine andmaskobligationinpublicspacesaffectthedistributionof COVID-19cases.Inaddition,theimpactofresourcesinthe healthcaresystemsandseveralmacroindicatorsofthedeath duetoCOVID-19willbedescribed.Forthispurpose,adata setwasassembledfromvariousdatasources.Theindividual sourcesareOurWorldinDatabasedontheEuropeanCenterfor DiseasePreventionandControl,thewebsitesofthegovernments ofthecountriesincluded,theWorldBank,WorldOMeter,and OECD.Bynow,variousstudieshavebeenconductedtotestthe effectofimplementedpoliciesonthecurveofcasesanddeath duetoCOVID-19.However,mostareconductedforindustrial countriessuchasU.S.A.,ChinaorSpain(20, 26, 28).Thisstudy thereforeaimstoclosetheresearchgapbyconductingacountry comparisonoftheinfluenceofmacroindicatorsinsixdifferent LACinordertoprovidedeeperknowledgeaboutthespread ofCOVID-19.

TABLE3| Numberofactions(regardinghealth)implementedbythecountries(stateofMay17th).

ChileColombiaCostaRicaEcuadorMexicoPeru

Healthemergency 1 3 2 1 1 1

Mandatorycoverage 0 1 1 1 0 0

Mandatoryquarantinefor foreigntravelers,confirmedorsuspectedcases1 1 1 1 0 1 Mandatorygeneralquarantine 0 5 0 3 1a 1

Typeofpolicyontesting(universal,reducedtocertaingroups,etc.) 2 1 3 1 1 3

Freetestcoverageexpansions 1 2 2 1 1 0 Hospitals 3 2 6 0 1 0

Facemasksinpublictransport/closedpublicspaces 1 1 0 0 0 0 Other 0 1 3 2 1 0

Total 9 17 18 10 6 6

CEPALandUnitedNations(27). a Notmandatoryyet.

DATAANDMETHODS

DataandVariables

Thedatafortheanalyseswereobtainedfromvarioussources. Forthisreason,thedataoriginisdescribedtogetherwiththe descriptionofthevariablessothatitispossibletodetermine whichdatasourceisrelevantforeachvariable.

DataofconfirmedCOVID-19casepermillioninhabitants andthefatalitypermillioninhabitantswereobtainedbyOur WorldinData(29).Theplatformcollectsdatapublishedbythe EuropeanCenterforDiseasePreventionandControl(ECDC) andmakesitavailableforfree(29).

Forthepurposeofmeasuringtheeffectoftheimplemented policies,thelastdateofobservationissetonMay24,asthiswas thebeginningoftherelaxingoftherestrictions.Datastarting February29untilMay24areincludedinthedataset.However, thestartingpointforeachcountryissettothefirstconfirmed caseanduntil77daysafterforeachcountry.SinceSARS-CoV2hasanaverageincubationperiodof5.1days,with97.5%of casesprogressingtoCOVID-19ataround11.5days,itisassumed thatthecasesdiagnosedinthefirstdaysaftertheimplemented policieswereinfectedbeforetheimplementation(26, 30).For thisreason,adelayed effectoftheimplementedpoliciesmust beassumed.

Missingvaluesinthedataofconfirmedcasesanddeathof COVID-19werefoundinthefollowingcasesanddates:Costa RicaonMarch8andEcuadoronMarch7andMarch8.Inthe caseofbothcases,themissingvalueswerefoundinthefirstweek aftertheconfirmationofthefirstCOVID-19valueinthecountry. Sincethenumberofreportednewcaseshasbeenbelow5inboth casesbeforeanddirectlyaftertheevent,ithasbeenassumedthat nonewcaseswerereportedonthemissingdates.Themissing dateswerethereforeimportedwiththevalue0fornewcases anddeath.

Dataoftheimplementedpoliciesaretakenfromthewebsites ofthegovernmentsofthecountriesstudied(31 35).Withthe aimtopreventerrors inthedatacollectionprocess,thecollected dataisdoublecheckedwithOECDsreport“COVID-19in LatinAmericaandtheCaribbean:Anoverviewofgovernment responsestothecrisis”(2020).Theimplementedpoliciesare

codedaccordingtothedateofimplementationafterthefirst confirmedcaseasdummyvariables(0/1).

Themacroindicatorsinthestudyarecollectedfromthe “WorldBankWorldDevelopmentIndicators,”“WorldOMeter,” and“OECD”(see Table1)(23, 24).Allplatformsmakemacro indicatorsfromdifferentcountriesavailableforusefreeofcharge.

Methods

InterruptedTimeSeriesAnalysis

AllanalyseswillbedoneusingSTATA15.1andMicrosoftExcel 365.Theanalysesareorganizedasfollows.First,descriptive analysisoftheimpactofmacroindicatoronthedistribution ofcasesanddeathisprovided.Second,anInterruptedTime SeriesAnalysis(ITSA)isconductedtoexaminewhetherthe implementationofacertainpolicyhastakenadecreasingeffect onthedistributionofthecasespermillioninhabitants.

ITSAisaquasi-experimentaldesignwithwhichlongitudinal effectofinterventionscanbemodeledthoughregressions.Itis runbytheSTATAcommand itsa (36).Duetothedatastructure, statisticalanalysisusedfor ITSAmustaccountforautocorrelated data[(36)f].Inordertodoso,anOrdinaryLeastSquares(OLS) regressionmodeldesignedforautocorrelationusingNeweyWestestimatorsisemployed,whichcontrolsforautocorrelation andheteroscedasticityintheerrorterms[(37),p.639].

Inordertospecifythelagsoftheserialcorrelationinthedata, theSTATAcommand actest isused(38).ItperformsaCumbyHuizingageneraltestfor autocorrelationintimeseriesdatawith thenullhypothesisthatserialcorrelationexistsinthetimeseries, butitdiesoutataknownfinitelag(q > 0)(38).Thelagin whichtheseries correlationdiesoutwillbeincludedintothe ITSAmodelinordertocontrolforit.

Inthisstudy,theoutcomevariableinbothcasesarethe confirmedcasespermillioninhabitants.Thetimeelapsedsince thestartofthestudyismeasuredindays.TheITSAassumesthe followingform(36, 39):

Yt indicatestheoutcomevariablemeasuredateachtimepoint t. β0 representsthestartinglevel(intercept)oftheoutcome

TABLE4| Percentageofdeathwithinthe confirmedcasesandmacroindicators.

ChileColombiaCostaRicaEcuadorMexicoPeru

%ofdeathwithintheconfirmedcases

1.00 3.60 1.10 14.50 10.50 2.90

Povertyheadcountrationatnational povertylines(%) 8.6 27.0 21.0 25.0 41.9 20.5 UrbanPopulation(%) 84.8 80.4 80 63 83.9 79.1

TABLE5| Percentageofdeathwithinthe confirmedcasesandhealthcaresystems.

ChileColombiaCostaRicaEcuadorMexicoPeru

%ofdeathwithintheconfirmedcases

1.00 3.60 1.10 14.50 10.50 2.90

Resources(per1,000 inhabitants) 2 2 3 2 3 2

Hospitalbeds(per1,000inhabitants) 2.1 1.7 1.1 1.5 1.4 1.6 Doctors(per1,000inhabitants) 2.5 2.2 3.1 2 2.4 1.3 Nurses(per1,000inhabitants) 2.7 1.3 3.4 1.5 3.9 2.4

Out-of-pocket(OOP)shareofhealthspending(%) 34 16 22 39 41 28

TABLE6| ResultssingleITSA–GeneralMandatory Quarantine. Colombia Ecuador Peru

Implementationof + 14daysImplementationof) + 14daysImplementationof + 14days theIntervention delay theIntervention delay theIntervention delay (Model1a) (Model1b) (Model2a) (Model2b) (Model3a) (Model3b)

β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error

Pre-interventionintercept 0.942**0.345 0.942**0.3500.201***0.0220.201***0.022 0.139**0.045 0.139**0.046 Pre-interventionslope0.271***0.0420.271***0.0420.096***0.0040.096***0.0040.160***0.0110.160***0.011 Immediatelypost(dayof implementation) 48.488*22.630.7630.677 374.069**149.866 13.942***3.556 681.412*307.459 0.4320.236

Differencebetweenpre-and post-Interventionslopes (dayofimplementation)

Immediatelypost(14days delay)

Differencebetweenpre-and post-Interventionslopes(14 daysdelay)

5.244***0.7541.548***0.09634.131***3.5787.245***0.48545.727***8.2311.323***0.034

36.92518.838 233.389**3.062 588.751*225.507

5.106**0.796 34.720***3.062 59.412***7.368

Significancelevels: *p < 0.05, **p < 0.01, ***p < 0.001.

variable. β1 istheprior interventiontrend, β2 representsthe immediatelyoccurringchangeintheleveloftheoutcome variableaftertheintroductionoftheintervention, β3 isthe treatmenteffectovertime,whichisthedifferencebetweenpreinterventionandpost-interventionslopsoftheoutcome,and ǫt representstherandomerrorterm.Duetotheincubationtimeof COVID-19,theanalysiswillfocuson β3 ratherthan β2.AsinglegroupITSAisdesignedwithoutacomparablecontrolgroup; itratherprojectsthepre-interventiontrendintothetreatment period,whichservesasthecounterfactual[(36),p.482].

Consideringthemultiple-groupITSA, themainassumption testedisthattheexogenouspolicyshiftaffectsallthegroups [(36),p.484].Thechangeintheoutcomevariableistherefore presumedtobethe sameforboththecontrolandthetreatment group(36).Theregressionequationisexpandedbyfour

additionalterms(β4 to β7)[(36),p.483].Adummyvariable todenotethecohort assignment(treatmentorcontrol)Z isintroduced.

Inthecaseofthemultiple-groupITSA β0 to β3 represent thevaluesofthecontrolgroupand β4 to β7 representthe valuesofthetreatmentgroup.Goingintodetail, β4 represents thedifferencesbetweentreatmentsandcontrolspriortothe interventionintheinterceptoftheoutcomevariable. β5 representsthepriorinterventiondifferenceintheslopeofthe outcomevariable. β6 representsthedifferencebetweentreatment andcontrolimmediatelyfollowingtheintroductionofthe

TABLE7| ResultsmultipleITSA–GeneralMandatoryQuarantine.

Colombia Ecuador Peru

Implementationof + 14daysImplementationof + 14daysImplementationof + 14days theInterventiondelaytheInterventiondelaytheInterventiondelay (Model4a)(Mode4b)(Model5a)(Model5b)(Model6A)(Model6b)

β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error

Pre-interventionintercept 0.7970.420 0.7970.426 0.034**0.012 0.034**0.112 0.0990.053 0.0990.054 Pre-interventionslope 0.257***0.0520.258***0.0520.128***0.0020.128***0.0020.146***0.1290.146***0.013

Interceptdifferencesbetween treatmentandcontrol pre-Intervention

Slopedifferencesbetween treatmentandcontrol pre-Intervention

0.1450.596 0.1450.6040.236***0.0270.236***0.027 0.0400.077 0.0400.078

0.0140.0730.0140.074 0.032***0.005 0.032***0.0050.0150.0190.0150.019

Immediatelypost(dayof implementation) 92.2180.073 0.2780.836 51.409*24.367 0.5230.294 314.366*139.847 6.348*2.524

Differencebetweenpre-and post-Interventionslopes(dayof implementation)—controlgroup

Differencebetweenpre-and post-Interventionintercept(day ofimplementation)—treatment group

Differencebetweenpre-and post-InterventionSlope(dayof implementation)—treatment group

8.698***1.5162.152***0.1523.995***0.7300.732***0.04324.640***4.4533.614***2.524

43.72949.1601.0411.100 322.660*151.718 13.419**4.010 367.046332.9085.916*2.540*

3.454*1.705 0.604**0.19930.136***3.6866.513***0.54721.087*9.375 2.292***0.381

Immediatelypost(dayof implementation)14days 77.039*38.157 44.668*20.798 232.530125.683

Differencebetweenpre-and post-Interventionslopes(dayof implementation)—controlgroup 14days

Differencebetweenpre-and post-Interventionintercept(day ofimplementation)—treatment group14days

Differencebetweenpre-and post-InterventionSlope(dayof implementation)—treatment group14days

Significancelevels: *p < 0.05, **p < 0.01, ***p < 0.001.

9.288***1.652 4.4970.767 27.608***5.066

40.11442.843 188.721100.574 326.221263.356

4.181*1.856 30.223***3.296 31.804**9.145

interventionand β7 representsthe differencebetweentreatment andcontrolintheslopeafterinitiationoftheintervention comparingwithpre-intervention.

SyntheticControlUnit

Asyntheticcontrolunitisacomparisonunitasalinear combinationoftheuntreatedunitswithcoefficientsthatsum toone[(40),p.7]inordertotestagainstthecounterfactual. Itisestimatedbya weightedaverageoftheuntreatedunits thatcloselymatchthetreatedunitoverthepre-treatment period[(41),p.843].Theestimationisdoneusingthe STATApackagesynth(40 42).Inordertotestwhether thesyntheticcohortservesasavalidcounterfactual,some

outcomesinthepre-treatmentperiodareexcludedfromthe listofpredictorstocheckwhetherthesyntheticcontrol matcheswellwiththetreatedunitintheseperiods[(41, 43), p.838].

RESULTS

Thedatasetincludestheconfirmedcasesanddeaths inChilefromMarch4toMay22,inColombiafrom March7toMay22,CostaRicafromMarch7toMay 22,inEcuadorfromMarch1toMay19,Mexicofrom February29toMay15,andPerufromMarch7to May22.

TABLE8| ResultssingleITSA–MaskObligation.

Chile Colombia

Implementationof + 14days Implementationof + 14days theIntervention delay theIntervention delay (Model7a) (Model7b) (Model8a) (Model8b)

β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error

Pre-interventionintercept 90.088*37.745 90.088*38.272 4.024*1.706 4.024*1.730 Pre-interventionslope 10.113***1.61910.113***1.6410.720***0.1250.720***0.127 Immediatelypost(dayofimplementation) 186.244**111.46097.284*39.287 35.11618.9915.702**1.952

Differencebetweenpre-and post-Interventionslopes(dayof implementation)

48.785***7.83713.840***1.7705.758***0.8042.479***0.137

Immediatelypost(14daysdelay) 114.530*52.841 36.609*13.975 Differencebetweenpre-and post-Interventionslopes(14daysdelay) 63.210***5.239 5.228***0.727

Significancelevels: *p < 0.05, **p < 0.01, ***p < 0.001.

TABLE9| ResultsmultipleITSA–Mask Obligation.

Chile Colombia

Implementationof + 14days Implementationof + 14days theIntervention delay theIntervention delay (Model9a) (Model9b)theIntervention(Model10a)(Model10b) β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error β Coefficient Std. error

Pre-interventionintercept 69.97037.753 69.97038.280 3.716*1.603 3.716*1.626 Pre-interventionslope 6.703**1.9096.703**1.9360.705***0.115 0.705***0.115

Interceptdifferencesbetweentreatmentand controlpre-Intervention 20.11855.024 20.11855.794 0.3092.367 0.3092.401

Slopedifferencesbetweentreatmentand controlpre-Intervention 3.4102.5383.4102.5740.0150.168 0.0150.171

Immediatelypost(dayofimplementation) 93.22674.074135.830**47.152 263.564*109.830 11.163*5.613

Differencebetweenpre-andpost-Intervention slopes(dayofimplementation)—controlgroup 79.538***5.94847.556***4.59234.784***3.936 11.342***0.927

Differencebetweenpre-andpost-Intervention intercept(dayofimplementation)—treatment group

Differencebetweenpre-andpost-Intervention Slope(dayofimplementation)—treatment group

93.018136.201 38.54662.604228.449*111.521 16.864**5.980

30.753**9.876 33.717***4.965 29.026***4.022 8.863***0.937

Immediatelypost(dayofimplementation)14 days 42.72528.994 144.841*55.686

Differencebetweenpre-andpost-Intervention slopes(dayofimplementation)—controlgroup 14days

Differencebetweenpre-andpost-Intervention intercept(dayofimplementation)—treatment group14days

Differencebetweenpre-andpost-Intervention Slope(dayofimplementation)—treatment group14days

Significancelevels: *p < 0.05, **p < 0.01, ***p < 0.001.

48.168***5.057 33.826***3.295

157.254*66.735 108.23357.528

15.0457.829 28.598***3.374

MacroIndicatorandHealthcareSystem

Theanalysesofthe impactofthehealthcaresystemsandmacro indicatoronthedistributionofdeathandcasesisbasedonthe descriptivestatistics.Thedependentvariableistheprovenance ofdeathsasaproportionofthenumberofconfirmedcasesper millioninhabitantsperday.ThevaluesshowthatinEcuador 14.50%oftheconfirmedcasesdiedonday77.InMexico10.50% died,inColombia3.60%,inPeru2.90%,inCostaRica1.10%,and inChile1%.

Firstly,itisassumedthatahigherpovertyheadcountratioat nationalpovertylinesandalowerpercentageofthepopulation livinginurbanareasleadstoanincreaseinthepercentageof deathwithintheconfirmedCOVID-19cases.

Table4 indicatesthatMexicohasthehighestpoverty headcountratioatthenationallevel(41.9%)andthesecond highestpercentageofdeathwithintheconfirmedcases(10.5%). Chileshowsthelowestpovertyheadcountratiointermsofthe nationalpovertylines(8.6%)andthelowestpercentageofdeath withintheconfirmedcases(1%).Thesefindingsareinlinewith theassumptionthatahigherpovertyheadcountratioatnational levelleadstoahigherpercentageofdeathwithintheconfirmed cases.However,Ecuadordisplaysalowerpovertyratio(25%)

comparedtoColombia(27%)butahigherpercentageofdeath withintheconfirmedcases(14.5%Ecuador;3.5%Colombia).

Regardingtheinfluenceofthepercentageofthepopulation livinginurbanareas,thelowestamountisshownbyEcuador (63%)andthehighestamountisshownbyChile(84.8%). Inaddition,Ecuadorshowsthehighestpercentageofdeath withintheconfirmedcases(14.5%),andChileshowsthelowest percentageofdeathwithintheconfirmedcases(1%).The findingsrevealnocleartrendforthepovertyheadcountratioat thenationalpovertylinesnorforthepercentageoftheobservable urbanpopulation.

Nowweturntotheassumptionthathigherresourcesinthe healthcaresystemofacountryleadtoalowerpercentageof deathwithintheclosedcases.Thereportedresourcesinthe followingarealwaystobeinterpretedasresourcesper1,000 inhabitants.Theresultsin Table5 indicatenovisibledirection oftheinfluenceoftheresourcesinthehealthcaresystemson thepercentageofdeathwithintheconfirmedcasesregardingthe resourcesintotal(summedup).However,notrendwithinthe distributionoftheresourcesisvisibleinthesensethatnoneofthe countrieshavereportedalow/highnumberofbeds,doctors,and nurses.Chile,asthecountrywiththelowestpercentageofdeath

FIGURE1| ResultsofITSAgeneralmandatory quarantine-Colombia.

withintheconfirmedcases,hasthehighestamountofhospital beds(2.1)andahighnumberofdoctors(2.5).However,Costa Rica,asthecountrywiththesecondlowestpercentageofdeath, hasthelowestnumberofhospitalbeds(1.1)andthehighest numberofdoctors(3.1).ThenumberofdoctorsinMexico(2.4) isnearlyashighasinChile(2.5),butthepercentageofdeath withintheconfirmedcasesisthesecondhighest(10.5%).A possibleexplanationcouldbeanunevendistributionofhospital bedswithincountries.Itisconceivablethatthecasesclustered occurincertainregionsthatmaynothaveenoughbedsavailable. Itisthereforenotthetotalnumberofbedsinthecountrythatis relevantbutthenumberofbedsintheregionsconcerned.

Theresultsin Table5 indicatethatthecountrieswiththe highestshareofOOPspendinginthehealthspendingshowthe highestpercentageofdeathwithintheconfirmedcases(Ecuador 14.5%;Mexico10.5%).However,theshareofOOPspendingis higherinMexicocomparedtoEcuador,andthepercentageof deathislower.TheshareofOOPspendingofPeruandChileare highercomparedtoColombiaeventhoughtheyreportalower percentageofdeath.ThesameistrueforCostaRica.Thecountry withthelowestshareofOOPspendingdoesnotreportthelowest percentageofdeathamongthecases.

ImplementedPolicies

Toinvestigatewhethertheimplementedpolicieshavean influenceonthedistributionoftheconfirmedcasesanddeath duetoCOVID-19,ITSAwasemployed.Thefirstmodelincludes theimplementationofthepolicyatthetimeofentryintoforce. Inthesecondmodel,adelayof14daysisincludedassecond interruptiontimepointinordertocontrolfortheexpectedtime lackduetotheincubationtime.Duetotheexpectedtimedelay betweenimplementationandchangeinconfirmedcases,the interceptwillnotbediscussedintheanalysis.Finally,multiple ITSAundertheuseofthesyntheticcontrolunit,followingthe samemethodasthesingleITSA,areconducted.

Toestimatetheeffectoftheimplementationofthegeneral mandatoryquarantineinColombia,PeruandEcuadordirectly aftertheimplementationand14dayslatervariousITSAmodels havebeenestimated. Table6 presentstheparameterestimates. Thisanalysisexaminesthehypothesisthattheimplementation ofageneralmandatoryquarantinehasadecreasingeffectonthe distributionofconfirmedcases.

Focusingontheslope,ITSAidentifiedsignificant interruptionsinbothtimepointsforColombia(Model1B).The startinglevelofcasespermillioninhabitantsis 0.942(p ≤ 0.00)

FIGURE2| ResultsofITSAgeneralmandatory quarantine-Peru.

withanincreasingslopeincomparisonwiththepre-intervention periodof1.548(p ≤ 0.00)at thefirstinterruptionpoint.The secondinterruptionpointhasshownincomparisonwiththe pre-interventionperiodanincreasingslopeof5.106(p ≤ 0.01). Inotherwords,thedistributionincreasedafterbothinterruption timepointsincomparisonwiththepre-interventionperiod.

Theestimatesofthedifferencebetweenpre-interventionand post-interventionatbothtimepoints(theactualimplementation dayand14dayslater)showthatthedifferenceoftheslope isstatisticallysignificantforallthreecountries.However, theestimatedcoefficientsofColombia14daysafterthe implementation(ß = 5.106)aresmallercomparedtoEcuador(ß = 34.720)andPeru(ß = 59.412),whichindicatesalowerincrease inthedistribution.

Figure1 showsthedistributionoftheconfirmedcases permillioninhabitantsvs.thecounterfactualinColombia.It indicatesthattheimplementationofthegeneralmandatory quarantinedecreasedthenumberofcases. Figures2, 3 show ahigherdistributionofconfirmedcasesinPeruandEcuador comparedwiththecounterfactual.ThemultiplegroupITSAin Table7,Model4Bidentifiesasignificantpositivecoefficientof theslopedifferencebetweenpre-andpost-Interventionperiods forthetreatmentgroupatthefirstinterruptiontimepoint(ß

= 1.548)and14daysaftertheimplementationofthepolicyfor Colombia(ß = 5.106).Inotherwords,theanalysisidentifies asignificanteffectofthemandatorygeneralquarantinein Colombiaagainstthecounterfactual.

Forboth,Ecuador(Model5a/b)andPeru(Model6a/b),the estimatesindicatehighervaluesofconfirmedcasespermillion inhabitantsforthetreatmentgroupcomparedtothecontrol group.Theimplementationofthemandatorygeneralquarantine ishypothesizedtohaveareducingeffectonthenumberof infectedanddeath,therefore,theresultsofthemultipleITSAfor EcuadorandPeruwillnotbediscussedfurther.Thehypothesis cannotbeaccepted.

Toinvestigatewhethertheobligationtowearfacemasksin publictransportand/orclosedpublicspaceshasadecreasing effectonthedistributionoftheconfirmedcasespermillion inhabitantswhensingleandmultipleITSAforColombia andChilewereemployed.Thepolicywasimplementedby ChileandColombia43and28daysafterthefirstconfirmed case,respectively.

Table8 showstheresultsofthesingleITSA.Statistically significantdifferencesbetweenthepre-andpost-intervention periodscanbeidentifiedbytheanalysisforbothcountries. However,similartothepreviousmodelsin Table7,the

FIGURE3| ResultsofITSAgeneralmandatory quarantine-Ecuador.

FIGURE4| ResultsofITSAmaskobligation-Chile.

coefficientsindicateanincreaseintheconfirmedcasesper millioninhabitantsin thepost-interventionperiod,and, therefore,itisindicatedthattheimplementationdidnothavea decreasingeffectonthedistribution.

ThemultipleITSAusingsyntheticcontrolunitsaredisplayed in Table9.In Figures4, 5 theresultsarevisualized.The resultsofthemodel,includingthedelayof14daysafter theimplementation,identifyforbothcountriesasignificant decreasingeffectofthepolicyonthedistributionofconfirmed casespermillioninhabitants.TheInterceptofthetreatment groupinColombiaindicateshighervaluesforColombiain comparisontothesyntheticcontrolunitsatbothtimepoints (ß = 16.854;ß = 108.233)eventhoughtheonlythecoefficient oftheimmediatelypost-interventionisstatisticallysignificant. Theslopesbetweenthepre-andpost-Interventionperiodof thetreatmentgroupindicatesignificantlylessconfirmedcases comparedtothecontrolunit(ß =−8.863;ß =−28.598).In thecaseofChile,onlythecoefficientofthedifferencebetween thepre-andpost-Interventionperiodintheperiodimmediately aftertheimplementationisstatisticallysignificantandnegative (ß =−33.717).Thecoefficientofthe14-daydelayindicatesa highernumberofconfirmedcasesintheslopebetweenpre-and post-interventionperiodforthetreatmentgroupcomparedto

thecontrolgroup,whichis,however,notstatisticallysignificant (ß = 15.045).Insummary,theresultsofthemultipleITSAfor ChileandColombiagenerallyindicatethattheintroductionof compulsorymaskshasreducedthespreadofthevirus.

DISCUSSION

Theobjectiveofthestudywastoshowwhethertheproportion ofdeathsamongCOVID-19casesandtheefficiencyofNPIs areinfluencedbymacroindicatorsofthecountriesunderstudy. Firstly,thisstudyshowsnoclearinfluenceofthemacroindicator povertyheadcountratioatnationalpovertylinesandurban populationonthepercentageofdeathwithintheconfirmed cases.Thesameistruefortheresourcesofthehealthcaresystem andtheaccesstothosemeasuredbyOOPspending.However, EcuadorandMexicoreportthehighestpercentageofdeath amongtheconfirmedcases,andtheyreportthehighestshare ofOOPspending.ThedataindicatesthathigherOOPspending takesanimpactonthepercentageofdeathamongtheconfirmed cases.AmongthecountrieswithalowershareofOOPspending, notrendisvisible.Furtherresearchshouldthereforeaddressthe questionwhetherOOPspendinghasanimpactonthepercentage ofdeathamong.

Secondly,themostimportantfindingofthisstudyconcerns theeffectoftheimplementedpoliciesonthedistributionof theconfirmedcases.Thefirstanalysisshowedapositiveimpact oftheimplementationofamandatorygeneralquarantineon thedistributionofconfirmedcasesforColombiabutnotfor EcuadorandPeru.PeruandEcuadorsharesimilarpatternsin theOOPshareofhealthspending,whichishighercompared toColombia.Thepercentageofpovertyheadcountratioand nationalpovertylinesishigherinColombiacomparedto EcuadorandPeru.Healthsystemresourcesaresimilarin allthreecountries.EventhoughthepovertyinColombiais higher,theaccesstodrinkingwaterandsanitationinColombia isbettercomparedtoPeruandEcuador(8).Theneedfor accesstosanitationanddrinkingwaterasbasichumanneeds determinethepossibilityofkeepingthequarantine,and,for thisreason,itisconclusivethattheinhabitantsofPeruand Ecuadorhadlessopportunitytocarryoutthequarantine comparedtoColombia.Inaddition,factorssuchasinformal employmentincreasingtheneedtoleavetohouseinorder toprovideforlivingcouldplayarole,whichcannotbe sufficientlyverifiedduetolackofdata[cf.(44)].Itmust beconsideredthatonly countriesthathaveimplementedthe

policyduringthetimeofobservationcanbeconsideredin thediscussion.

Finally,theanalyseshaveshownthattheintroductionofmask obligationinColombiaandChilehashadapositiveeffectonthe reductionofCOVID-19cases.Inthissense,theanalysesshow thattheeffectofobligationtowearamaskislessinfluencedby externalfactorssuchaspovertycomparedtogeneralquarantine. However,themaskobligationwasonlyimplementedbytwo outofsixcountriesunderobservation.Theresultthereforeonly accountsforChileandColombiabutnotfortheothercountries.

Theresultsindicatethattheeffectoftheimplementedpolicies dependsonvariousfactorsandtheimplementationofapolicy isnotaguaranteeofaflattenedcurve.Theseresultsgoinline withthoseofpreviousstudies,whichshowedthattheefficiency oflockdownmeasuresisinfluencedbyvariousmacroindicators suchaspopulationdensity(26).

Severallimitationsmustbe borneinmindwheninterpreting thefindingsofthisstudy.Firstly,itmustbeconsideredthatonly reportedandconfirmedcasescanbeincludedintheanalysis. ThispaperonlyreferstoreportedcasesofCOVID-19diseases publishedbytherespectivecountries.Inthissense,thenumber ofunreportedcases,whichisestimateddifferentlydependingon

FIGURE5| ResultsofITSAmaskobligation-Colombia.

thereproductivevalue,cannotbeincluded(45).Thepossibilityof abiasduetoahighnumberofunreportedcasesexists,depending onthetestingfrequencyofthecountries.Asdataontesting performedarenotsufficientlyavailableforthecountriestreated, itwasnotbepossibletocontrolforit[cf.(29)].Inaddition,only policiesfromthecountry levelweretreated.Countriesthathave mainlyimplementedpoliciesatthestatelevel,asitisthecase inMexico,weretreatedascountrieswithno/fewerimplemented policies.Thisapproachwaschosentomanagecomplexity,which alsoleadstoapossiblebias.Furthermore,notallcountries publishdataonhealthinsurancecoverage,whichiswhythe shareofOOPwaschosentoincludethehealthsystem[cf.(8)]. Moreover,additionalresourcesofthehealthcaresystemcould notbeincludedbecauseinthiscase,too,therewasnoconsistent transparentreportingbythecountriesatthetimeoftheresearch. Futurestudiesshouldthereforeinclude(asmuchaspossible) theadditionalresourcesandtestsdonebythestatesinorderto controlforthosebiases.

HealthcaresystemresourcesandOOPspendingcouldonlybe includedintheanalysistoacertainextent.Sincethefocuswason theimpactoftheintroductionofquarantineandtheintroduction oftheobligationtowearamask,onlythosecountriesthat haveintroduceditcouldbecompared.Countriesthatdidnot introducethemaskobligationweregenerallyneglectedinthe analysesandplayedanimportantroleintheformationofthe syntheticcontrolunit.Infuturestudies,however,allcountries shouldbeanalyzed,possiblyincludingmoremeasurementdates. TheModelFitmustalsobeconsidered.Theanalysesshowhigh

REFERENCES

1.ZhouF,YuT,DuR,FanG,LiuY,LiuZ,etal.Clinicalcourse andriskfactorsformortalityofadultinpatientswithCOVID-19in Wuhan,China:aretrospectivecohortstudy. Lancet.(2020)395:1054–62. doi:10.1016/S0140-6736(20)30566-3

2.WorldHealthOrganisation.Coronavirusdisease2019(COVID-19):Situation Report-51(2020).Availableonlineat:https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200311-sitrep-51-covid-19.pdf? sfvrsn=1ba62e57_10(accessedApril24,2020).

3.OECD. BeyondContainment:HealthSystemsResponsestoCOVID-19in theOECD.(2020).Availableonlineat:https://read.oecd-ilibrary.org/view/? ref=119_119689-ud5comtf84&title=Beyond_Containment:Health_systems_ responses_to_COVID-19_in_the_OECD(accessedMay03,2020).

4.HargreavesJ,DaveyC,AuerbachJ,BlanchardJ,BondV,BonellC,etal.Three lessonsfortheCOVID-19responsefrompandemicHIV. LancetHIV.(2020) 7:e309–11.doi:10.1016/S2352-3018(20)30110-7

5.vanBavelJJ,BaickerK,BoggioP,CapraroV,CichockaA,CrockettM,et al.UsingsocialandbehaviouralsciencetosupportCOVID-19pandemic response. NatHumBehav.(2020)4:460–71.doi:10.31234/osf.io/y38m9

6.AtunR,AndradeLO,deAlmeidaG,CotlearD,DmytraczenkoT, FrenzP,etal.Health-systemreformanduniversalhealthcoveragein LatinAmerica.Lancet.(2015)385:1230–47.doi:10.1016/S0140-6736(14) 61646-9

7.LorenzoniL,PintoD,GuanaisF,PlazaRenesesT,DanieF,AuraaenA.

HealthSystemsCharacteristics:ASurveyof21LatinAmericanandCaribbean Countries.OECDHealthWorkingPapers111.Paris:OECDPublishing (2019).

8.OECD. HealthataGlance:LatinAmericaandtheCaribbean2020 Paris:OECD(2020).doi:10.1787/6089164f-en

9.OECD. OECDHealthWorkingPapers.Paris:OECD(2019).

standarderrorsforsomecoefficients,whichindicateabadmodel fit.Nevertheless,thestandarderrorsofthecoefficientsrelevant fortheanalysisarenottoohigh.

Theworkprovidesaboveallanexplorativeoverview inafieldthatisnewandlargelyuntreated.Previous analyseshavemainlyreferredtoindustrializedcountriesbut nottodevelopingcountries.Futureresearchmusttherefore furtheraddresswhetherandhowpoliciesthathavebeen effectiveinindustrializedcountriescanmakeanimpactin developingcountrieswithdifferentdemographiccharacteristics andchallenges.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle,furtherinquiriescanbedirectedtothe correspondingauthor.

AUTHORCONTRIBUTIONS

APcontributedtothedesignandimplementationoftheresearch, totheanalysisoftheresultsandtothewritingofthemanuscript.

ACKNOWLEDGMENTS

APwouldliketothankPedroIvoBastosdeCastroandDr.Dina Maskileysonfortheiradviceandencouragement.

10.ECLAC. The2030AgendaforSustainableDevelopmentintheNewGlobaland RegionalContext:ScenariosandProjectionsintheCurrentCrisis.Santiago: ECLAC(2020).

11.OECD. OECDReviewsofPublicHealth.Chile:OECD(2019).

12.Rodriguez-MoralesAJ,GallegoV,Escalera-AntezanaJP,MéndezCA, ZambranoLI,Franco-ParedesC,etal.COVID-19inLatinAmerica:the implicationsofthefirstconfirmedcaseinBrazil. TravelMedInfectDis.(2020) 35:101613.doi:10.1016/j.tmaid.2020.101613

13.NavarroJC,Arrivillaga-HenríquezJ,Salazar-LoorJ,Rodriguez-Morales AJ.COVID-19anddengue,co-epidemicsinEcuadorandothercountries inLatinAmerica:Pushingstrainedhealthcaresystemsovertheedge. TravelMedInfectDis.(2020)37:101656.doi:10.1016/j.tmaid.2020. 101656

14.EmanuelEJ,PersadG,UpshurR,ThomeB,ParkerM,GlickmanA,etal.Fair allocationofscarcemedicalresourcesinthetimeofCovid-19. NEnglJMed (2020)382:2049–55.doi:10.1056/NEJMsb2005114

15.CastexG,DechterE,LorcaM. COVID-19:Cross-CountryHeterogeneity inEffectivenessofNon-PharmaceuticalInterventions.London:CEPRPress. (2020),175–199.

16.ChandraS,Kassens-NoorE,KuljaninG,VertalkaJ.Ageographicanalysis ofpopulationdensitythresholdsintheinfluenzapandemicof1918-19. IntJ HealthGeogr.(2013)12:9.doi:10.1186/1476-072X-12-9

17.WuZ,McGooganJM.Characteristicsofandimportantlessonsfrom thecoronavirusdisease2019(COVID-19)outbreakinChina:summary ofareportof72314casesfromtheChineseCenterforDisease ControlandPrevention. JAMA.(2020)323:1239–42.doi:10.1001/jama. 2020.2648

18.DowdJB,AndrianoL,BrazelDM,RotondiV,BlockP,DingX, etal.Demographicscienceaidsinunderstandingthespreadand fatalityratesofCOVID-19. ProcNatlAcadSciUSA.(2020)117:9696–8. doi:10.1073/pnas.2004911117

19.CEPAL. ElDesafíoSocialenTiemposdelCOVID-19.SantiagodeChile: CEPAL(2020).

20.BorjasG. DemographicDeterminantsofTestingIncidenceandCOVID-19 InfectionsinNewYorkCityNeighborhoods.Cambridge,MA:NationalBureau ofEconomicResearch.(2020).doi:10.3386/w26952

21.Worldbank.GDP(currentUS$)(2018).Availableonlineat:https://data. worldbank.org/indicator/NY.GDP.MKTP.CD?locations=CL(accessedMay 15,2020).

22.Worldbank. Population,Total-Chile.(2018).Availableonlineat:https://data. worldbank.org/indicator/SP.POP.TOTL?end=2018&locations=CL&start= 1960&view=chart(accessedMay15,2020).

23.Worldbank. PovertyHeadcountRatioatNationalPovertyLines(%of population).(2018).Availableonlineat:https://data.worldbank.org/indicator/ SI.POV.NAHC(accessedMay15,2020).

24.Worldometer.info. Worldometer DoverDelewareU.S.A.(2020).Available onlineat:www.worldometer.info(accessedJuly21,2020).

25.Wilder-SmithA,ChiewCJ,LeeVJ.CanwecontaintheCOVID-19outbreak withthesamemeasuresasforSARS? LancetInfectDis.(2020)20:e102–7. doi:10.1016/S1473-3099(20)30129-8

26.FigueiredoAM,deCodinaAD,FigueiredoD,SaezM,LeónAC. ImpactoflockdownonCOVID-19incidenceandmortalityinChina:an interruptedtimeseriesstudy. BullWorldHealthOrgan[Preprint].(2020). doi:10.2471/BLT.20.256701

27.CEPALandUnitedNations. COVID-19ObversatoryforLatinAmericaand theCaribbean:MeasuresbyCountry.(2020).Availableonlineat:https://drive. google.com/file/d/131KJ2OWrhyTr_oCodZowhAzz7-ZSjiq8/view(accessed May20,2020).

28.TobíasA.EvaluationofthelockdownsfortheSARS-CoV-2epidemicinItaly andSpainafteronemonthfollowup. SciTotalEnviron.(2020)725:138539. doi:10.1016/j.scitotenv.2020.138539

29.RoserM,RitchieH,Ortiz-OspinaE,HasellJ. CoronavirusPandemic(COVID19).(2020).Availableonlineat:https://ourworldindata.org/coronavirus (accessedJune05,2020).

30.LauerSA,GrantzKH,BiQ,JonesFK,ZhengQ,MeredithHR,etal.The incubationperiodofcoronavirusdisease2019(COVID-19)frompublicly reportedconfirmedcases:estimationandapplication. AnnInternMed.(2020) 172:577–82.doi:10.7326/M20-0504

31.MinisteriodelaSaludPúblicaEcuador. Noticias.(2020).Availableonline at:https://www.salud.gob.ec/category/comunicamos/noticias/noticiasdestacadas-noticias/(accessedMay19,2020).

32.GobiernodePerúNoticias(2020).Availableonlineat:https://www.gob.pe/ busquedas?contenido=noticias&institucion=minedu&reason=sheet&sheet= 1&term=covid-19(accessedMay19,2020).

33.PresidenciadelaRepúblicadeCostaRica.CostaRicacontrael#Covid19 [cited2020May19].Availablefrom:https://covid19.go.cr/

34.GobiernodeColombia. AccionestomadasporelGobierno.(2020). Availableonlineat:https://coronaviruscolombia.gov.co/Covid19/accionesdel-gobierno.html(accessedMay19,2020).

35.GobiernodeMéxico. Coronavirus.(2020).Availableonlineat:https:// coronavirus.gob.mx(accessedMay19,2020).

36.LindenA.Conductinginterruptedtime-seriesanalysisforsingleandmultiple-groupcomparisons. StataJ.(2015)15:480–500. doi:10.1177/1536867X1501500208

37.SmithJ,McAleerM.Newey–Westcovariancematrixestimatesfor modelswithgeneratedregressors. ApplEconomics.(1994)26:635–40. doi:10.1080/00036849400000034

38.BaumCF,SchafferME. Actest:StataModuletoPerformChumy-Huizinga GeneralTestforAutocorrelationinTimeSeries.(2015).Availableonline at:http://ideas.repec.org/c/boc/bocode/s457668.html(accessedJuly 03,2020).

39.BernalJL,CumminsS,GasparriniA.Interruptedtimeseriesregressionfor theevaluationofpublichealthinterventions:atutorial. IntJEpidemiol (2017)46:348–55.doi:10.1093/ije/dyw098

40.AbadieA,DiamondAJ,HainmuellerJ.Comparativepoliticsandthesynthetic controlmethod. SSRNJ.(2012)59:495–510.doi:10.2139/ssrn.1950298

41.GalianiS,QuistorffB.Thesynth_runnerpackage:utilitiestoautomate syntheticcontrolestimationusingsynth. StataJ.(2017)17:834–49. doi:10.1177/1536867X1701700404

42.AbadieA,DiamondA,HainmuellerJ.Syntheticcontrolmethodsfor comparativecasestudies:estimatingtheeffectofcalifornia’stobacco controlprogram. JAmStatisticalAssociation.(2010)105:493–505. doi:10.1198/jasa.2009.ap08746

43.CavalloE,GalianiS,NoyI,PantanoJ.Catastrophicnaturaldisasters andeconomicgrowth. RevEconomicsStatistics.(2013)95:1549–61. doi:10.1162/REST_a_00413

44.NU,CEPAL,OIT. EmploymentSituationinLatinAmericaandtheCaribbean. WorkinTimesofPandemic:TheChallengesoftheCoronavirusDisease (COVID-19).(2020).Availableonlineat:https://repositorio.cepal.org/ bitstream/handle/11362/45582/S2000306_en.pdf?sequence=4&isAllowed=y (accessedNovember07,2020).

45.ZhaoS,MusaSS,LinQ,RanJ,YangG,WangW,etal.Estimating theunreportednumberofnovelcoronavirus(2019-nCoV)casesin Chinainthefirsthalfofjanuary2020:adata-drivenmodellinganalysis oftheearlyoutbreak. JClinMed.(2020)9:388.doi:10.3390/jcm90 20388

ConflictofInterest: Theauthordeclaresthattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2020Poppe.Thisisanopen-accessarticledistributedundertheterms oftheCreativeCommonsAttributionLicense(CCBY).Theuse,distributionor reproductioninotherforumsispermitted,providedtheoriginalauthor(s)andthe copyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournal iscited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

published:08January2021 doi:10.3389/fpubh.2020.618642

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland

Reviewedby: JoséM.Marbán, UniversityofValladolid,Spain GuvencKockaya, ECONiXResearch,Analysisand ConsultancyPlc.,Turkey

*Correspondence: VasilikiVlacha vasovlaha@gmail.com

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 17October2020 Accepted: 24November2020 Published: 08January2021

Citation: VlachaVandFeketeaGM(2021) Return-to-SchoolEvaluationCriteria forChildrenWithSuspected CoronavirusDisease2019. Front.PublicHealth8:618642. doi:10.3389/fpubh.2020.618642

Return-to-SchoolEvaluationCriteria forChildrenWithSuspected CoronavirusDisease2019

VasilikiVlacha 1* andGavrielaMariaFeketea 2,3

1 DepartmentofEarlyYearsLearningandCare,UniversityofIoannina,Ioannina,Greece, 2 Ph.DSchool,“IuliuHatieganu” UniversityofMedicineandPharmacy,Cluj-Napoca,Romania, 3 PaediatricDepartment,KaramandanioChildren’sHospitalof Patras,Patras,Greece

Keywords:COVID19,schoolagechildren,return-to-school,SARS-CoV-2RT-PCR,criteria

Duringthecomingwinter,thespreadofCoronavirusdisease2019(COVID-19)willco-existwith othercommonviralinfections.EvenifmostofthechildrenwithCOVID-19areasymptomatic orhaveminimalsymptoms,theycanstillspreadthevirustovulnerableadults.Thecorrect clinicaldiagnosisofmildcasesofCOVID-19becomesoftenextremelydifficultsincethepresenting symptomscouldbesimilarwithothercommonviralillnesses.Furthermore,eachchildmayhave severalviralinfectionsduringthewinterandinconjunctionwithinsufficientsuppliesandthehigh costofSARS-CoV-2PCR-RTtestinseveralcountriesmakesthediagnosisofCOVID-19avery complicatedone.Weshouldalsoconsiderthewholecascadeofconsequencefromchildren’slack ofschoolattendancerangingfromfamily’sfinancialsecuritytosupportthechildren’seducational needsandtheemotionalwell-being.Theschoolabsencecouldcompromisetheabilityofparents togotoworkduetopossiblelackofchildcarewithmajoreconomiceffectssincein73%ofthe familieswithschoolagechildrenintheUnitedStates,bothparentsareemployed(1).Similarly, theparentalemploymentstatus inAustraliahasbeenreportedtobeabout69%(2),whilein Europethepercentageofbothparentshavingfulltimeemploymentreaches41%(3).Regarding alterationsineducation,COVID-19pandemic hasacatalyticimpactontheeducationalsystem thathadtoadoptnewlearningmodalitiesandmovetodistantlearning.However,31%ofschool agechildrenaroundtheglobedonothaveaccesstoremoteschooling(4).AmericanAcademyof Pediatricsstronglyadvocatestheinpersoneducationforthepresentschoolyearstressingthefacts thatstayingawayfromschoolforalongtimecanresultinsocialisolationandcomplicatesthe recognitionandmanagementoflearningdeficits(5).Evenifblendededucationalcurriculumshave beenimplementedbyseveralinstitutes(6),itseemsthatinpersonschoolinghasmajoradvantages especiallyforyoungchildren. Thegoalisthechildrentoattendschoolregularlyandtominimize asmuchaspossiblethedisruptivequarantineperiodwiththemajorconcernofthestudents’ protectionfromCOVID-19.

AsthefluseasonisapproachinginNorthernhemisphereandtheschoolsarereopened,the governmentofficialsaretakingactionsformanagingthechildhoodminorrespiratoryinfections inCOVID-19era.Severalpolicieshavebeenestablishedindifferentcountrieswiththegoalto minimizetheriskoftransmissionofSARS-CoV-2(7 9).Inaddition,clinicalalgorithmstreated childrensuspectedwithCOVID-19 havebeendesigned(10).However,thequestionremainsasto whenachildwith symptomsofaviralillnesscansafelyreturntoschoolreducingtheunnecessary homestay.Tryingtoanswerthatquestion,wedevelopareturn-to-schoolcriteriaforchildren withfeverand/orcoughcombiningseveralclinicalandepidemiologicalparametersandtakinginto considerationthelimitedsupplyandtheexpenseofSARS-CoV-2PCR-RTtest(Figure1).

FIGURE1| Return-to-schoolevaluationcriteriafor non-hospitalized childrenwithsuspectedCoronavirusDisease2019.

Thegoalofthisalgorithmisnotonlytomakeasafedecision toreturn-to-schoolbutalso toreducetheschoolabsenceas muchaspossible.Amongthemajorcriteriaaretheclose,recent contactwithapersonwithCOVID-19,avulnerablechildor afamilymemberandanewonsetofanosmiaand/orageusia, characteristicsymptomsforCOVID-19(11).Onemajorcriterion isenoughtoplace thechildinhighriskandtorequirea SARS-CoV-2RT-PCRtest.Thechildrencanreturntoschool ifthetestisnegative,theyareafebrilewithoutantipyretics, andtheothersymptomsareimprovedforatleast3days. ConsideringthepossibilityofaSARS-CoV-2RT-PCRfalse negativetestresult,a3-dayintervalwithsignificantimprovement ofthesymptomswithoutantipyreticswasadvisedpriorto returntoschool.Theminorcriteriaconsistofacombinationof clinicalandepidemiologicalfactors.Weselectthemostcommon epidemiologicalcircumstancesthatplacethechildinveryclose proximitywithotherclassmatesduringdifferentactivitiesat school,extracurriculum,sports,schooldinning,andschool transit.Thecommunityspreadofthediseaseandlivinginclose communityhavealsobeenconsidered.Alimitof15studentsin theclassroomwasselectedbasedontheexperienceatDenmark andNorway.TheyhaveshownnoincreaseintherateofCOVID19bydecreasingtheclasssizeto <15students(12).Another studycontactinginTokyo metropolitanarearevealedthatthe classreductionandthesocialdistancingofatleast1.5mreduces theschoolclosureduetoflupandemicby90%(13).Centers ofDiseaseControland Prevention(CDC)andWorldHealth Organizationhavepublishedrecommendationsforschools, schooldinning,schooltransit,andsports(7, 8).Thosearebased onmaintainingphysicaldistanceamongstudentsduringtheir activities.Severalofthoseguidelineshavebeenincorporatedinto ourproposedstratificationcriteria.Oneoftheminorcriteria istheuseofpublictransportationforschooltransit.Astudy intheZhejiangprovince,Chinahasbeenshownthatriding abusmakes42.2(95%CI,2.6–679.3)timesmorelikelyto developCOVID-19ifafellowpassengerispositivetoSARSCoV-2(14).Anadditionalcriterionweincludeinthepresent algorithmistheuse offacemasksintheclassroom.Many healthauthoritiesrecommendtheproperuseoffacemasksby studentsandteachers(5, 8).Eikenberryetal.haveevaluatedthe effectivenessofmaskwearinginthecommunitybydeveloping modelsimulations.Thoseresultsindicatethattheuseofeven moderately(50%)effectivemaskscouldprevent,ontherange of17–45%,theprojecteddeathsovera3monthperiodin NewYorkCity(15).Inaddition,anepidemiologicanalysishave

shownthatthe viraltransmissionfrompre-symptomaticpatients wassignificantlylowerinmask-wearingpersonscompareto unmaskedones(19.0%vs.8.1%, p < 0.001)(16).Afamily memberworkinginthepublic sectorhasbeenalsoaddedasa minorcriterionduetofacilitationofcommunitytransmission ofSARS-CoV-2inthatcase.Wehavealsoincludedthefamily withlowincomestatusasithasbeenshownthatthepeople livinginpoorerandmorediverseareashaveahighincidence ofCOVID-19(17).Thechildrenwiththreeormoreminor criteriaareconsideringashighriskandSARS-CoV-2PCR-RT testisrequired.Thecaseswithtwominorcriteriaareassigned tomediumriskandweproposetostayinhomeisolationfor 10days.SARS-CoV-2PCR-RTtestisadvisedifavailable.The childrenwithnoneoroneminorcriterionareappointedto verylowandlowriskandtheyreturntoschoolwhentheyare afebrilewithoutantipyreticsandthesymptomsareimprovedfor 24hand3days,respectively.Inthesettingofnofluvaccine, thechildshouldstayhomeforatleast5daystominimizethe riskofflutransmissionandtoavoidtheco-infectionbetween fluandCOVID-19(18, 19).Influenzaimmunizationisstrongly recommendedduringthepresentwinterbytheCDC(20).We wouldliketoemphasize thatthecaregiversshouldconsulttheir primarycarephysicianregularly,duringthehomeisolation periodpreferablyviatelemedicineandifthepatientdeteriorates theyshouldaskimmediatelymedicaladvice(10).

Thesestratificationcriteria,combining clinicaland epidemiologicalfactors,couldbeausefultoolfortheprimary carephysicianstoevaluateachildwithfeverand/orcough andmakeasafereturn-to-schooldecisionminimizingthe unnecessaryhomestay.Itisimportant,thisproposedalgorithm, toberevisedasnewdatabecomesavailable.

AUTHORCONTRIBUTIONS

VVandGFcontributedequallytothedesign,analysis,and writingofthemanuscript.

FUNDING

DuetotheexceptionalnatureoftheCOVID-19situation, FrontiersiswaivingallarticlepublishingchargesforCOVID19relatedresearchworks.Thismanuscriptissubmitted toresearchtopic:CoronavirusDisease(COVID-19):SocioEconomicSystemsinthePost-PandemicWorld:Design Thinking,StrategicPlanning,Management,andPublicPolicy.

REFERENCES

1.EmploymentCharacteristicsofFamiliesNewsRelease.Availableonlineat: https://www.bls.gov/news.release/famee.htm(accessedOctober17,2020).

2.LabourForceStatusofFamilies,June2020|AustralianBureauofStatistics (2020).Availableonlineat:https://www.abs.gov.au/statistics/labour/ employment-and-unemployment/labour-force-status-families/latestrelease(accessedNovember14,2020).

3.EuropeanCommission. Eurostat.ReconciliationBetweenWork,Privateand FamilyLifeintheEuropeanUnion.LU:PublicationsOffice(2009).Available

onlineat:https://data.europa.eu/doi/10.2785/30167(accessedNovember15, 2020).

4.COVID-19andschoolclosures:arechildrenabletocontinuelearning. UNICEFDATA(2020).Availableonlineat:https://data.unicef.org/ resources/remote-learning-reachability-factsheet/(accessedNovember 15,2020).

5.COVID-19PlanningConsiderations:GuidanceforSchoolRe-entry.Available onlineat:http://services.aap.org/en/pages/2019-novel-coronavirus-covid19-infections/clinical-guidance/covid-19-planning-considerations-returnto-in-person-education-in-schools/(accessedNovember15,2020).

6.Coronavirus:blendedlearningguidance[Internet].NEU.Availableonlineat: https://neu.org.uk/advice/coronavirus-blended-learning-guidance(accessed November15,2020).

7.Q&A:SchoolsandCOVID-19.Availableonlineat:https://www.who.int/ news-room/q-a-detail/q-a-schools-and-covid-19(accessedSeptember24, 2020).

8.CDC.Communities,Schools,Workplaces,&Events[Internet].Centersfor DiseaseControlandPrevention(2020).Availableonlineat:https://www. cdc.gov/coronavirus/2019-ncov/community/schools-childcare/studentbecomes-sick-diagnosis-flowchart.html(accessedSeptember7,2020).

9.Panovska-GriffithsJ,KerrCC,StuartRM,MistryD,KleinDJ,VinerRM,et al.Determiningtheoptimalstrategyforreopeningschools,theimpactoftest andtraceinterventions,andtheriskofoccurrenceofasecondCOVID-19 epidemicwaveintheUK:amodellingstudy. LancetChildAdolescHealth (2020)4:817–27.doi:10.1016/S2352-4642(20)30250-9

10.FeketeaGM,VlachaV.ADecision-makingalgorithmforchildrenwith suspectedcoronavirusdisease2019. JAMAPediatr.(2020)174:1220–2.doi:10.1001/jamapediatrics.2020.2999

11.VairaLA,SalzanoG,DeianaG,DeRiuG.Anosmiaandageusia: commonfindingsinCOVID-19patients. Laryngoscope.(2020) 130:1787.doi:10.1002/lary.28692

12.WashingtonStateDepartmentofHealth. SummaryofSchoolRe-Opening ModelsandImplementationApproachesDuringtheCOVID19Pandemic (2020).Availableonlineat:https://www.doh.wa.gov/Portals/1/Documents/ 1600/coronavirus/20200706-SchoolsSummary.pdf(accessedOctober17, 2020).

13.DoClassSizeReductionsProtectStudentsfromInfectiousDisease?Lessons forCOVID-19PolicyfromFluEpidemicinTokyoMetropolitanArea. Availableonlineat:https://www.iza.org/publications/dp/13432/do-classsize-reductions-protect-students-from-infectious-disease-lessons-forcovid-19-policy-from-flu-epidemic-in-tokyo-metropolitan-area(accessed November15,2020).

14.ShenY,LiC,DongH,WangZ,MartinezL,SunZ,etal. CommunityoutbreakinvestigationofSARS-CoV-2transmission amongbusridersinEasternChina. JAMAInternMed.(2020) 180:1665–71.doi:10.1001/jamainternmed.2020.5225

15.EikenberrySE,MancusoM,IboiE,PhanT,EikenberryK,Kuang Y,etal.Tomaskornottomask:modelingthepotentialfor facemaskusebythegeneralpublictocurtailtheCOVID-19 pandemic. InfectDisModel.(2020)5:293–308.doi:10.1016/j.idm.2020. 04.001

16.HongL-X,LinA,HeZ-B,ZhaoH-H,ZhangJ-G,Zhang C,etal.Maskwearinginpre-symptomaticpatientsprevents SARS-CoV-2transmission:anepidemiologicalanalysis. Travel MedInfectDis.(2020)36:101803.doi:10.1016/j.tmaid.2020.10 1803

17.AdhikariS,PantaleoNP,FeldmanJM,OgedegbeO,ThorpeL,Troxel AB.AssessmentofCommunity-LevelDisparitiesinCoronavirusDisease 2019(COVID-19)infectionsanddeathsinlargeUSmetropolitanareas. JAMANetwOpen.(2020)3:e2016938.doi:10.1001/jamanetworkopen.2020. 16938

18.WormserGP.COVID-19versusseasonalinfluenza2019-2020:USA. WienKlinWochenschr.(2020)132:387–9.doi:10.1007/s00508-020-01 685-y

19.MaS,LaiX,ChenZ,TuS,QinK.Clinicalcharacteristicsofcritically illpatientsco-infectedwithSARS-CoV-2andtheinfluenzavirusin Wuhan,China. IntJInfectDis.(2020)96:683–7.doi:10.1016/j.ijid.2020.0 5.068

20.SeasonalFluShot|CDC.(2020).Availableonlineat:https://www.cdc.gov/flu/ prevent/flushot.htm(accessedNovember15,2020).

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021VlachaandFeketea.Thisisanopen-accessarticledistributed underthetermsoftheCreativeCommonsAttributionLicense(CCBY).The use,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

published:13January2021 doi:10.3389/fams.2020.620064

Editedby: MagdalenaKlimczuk-Kocha´nska, UniversityofWarsaw,Poland

Reviewedby: DavidAlfredoMedinaOrtiz, UniversityofChile,Chile Cheng-FangYen, KaohsiungMedicalUniversity,Taiwan ChaoshengZhang, NationalUniversityofIrelandGalway, Ireland MariemeNgom, ArgonneNationalLaboratory(DOE), UnitedStates

*Correspondence: OmarElDeeb omar.deeb@liu.edu.lb

Specialtysection: Thisarticlewassubmittedto DynamicalSystems, asectionofthejournal

FrontiersinAppliedMathematicsand Statistics

Received: 21October2020 Accepted: 23November2020 Published: 13January2021

Citation: ElDeebO(2021)Spatial AutocorrelationandtheDynamicsof theMeanCenterofCOVID-19 InfectionsinLebanon. Front.Appl.Math.Stat.6:620064. doi:10.3389/fams.2020.620064

SpatialAutocorrelationandthe DynamicsoftheMeanCenterof COVID-19InfectionsinLebanon

OmarElDeeb 1,2*

1FacultyofTechnology,LebaneseUniversity,Aabey,Lebanon, 2DepartmentofMathematicsandPhysics,LebaneseInternational University,Beirut,Lebanon

InthispaperwestudythespatialspreadoftheCOVID-19infectioninLebanon.Weinspect thespreadingofthedailynewinfectionsacrossthe26administrativedistrictsofthe country,andimplementtheunivariateMoran’s I statisticsinordertoanalyzethetempospatialclusteringoftheinfectioninrelationtovariousvariablesparameterizedby adjacency,proximity,population,populationdensity,povertyrateandpovertydensity. We findoutthatexceptforthepovertyrate,thespreadoftheinfectionisclusteredand associatedtothoseparameterswithvaryingmagnitudeforthetimespanbetweenJuly (geographicadjacencyandproximity)orAugust(population,populationdensityand povertydensity)throughOctober.Wealsodeterminethetemporaldynamicsof geographiclocationofthemeancenterofnewandcumulativeinfectionssincelate March.Theunderstandingofthespatial,demographicandgeographicaspectsofthe diseasespreadovertimeallowsforregionallyandlocallyadjustedhealthpoliciesand measuresthatwouldprovidehigherlevelsofsocialandhealthsafetyinthe fightagainstthe pandemicinLebanon.

Keywords:COVID-19,spatialautocorrelation,meancenterofinfection,Lebanon,mathematicalmodelling

1INTRODUCTION

ThespreadofCOVID-19pandemichaspracticallyaffectedtheentireplanet,andcreatedenormous challengesoneveryaspectofhumanlifeandorganization,startingwiththehealthsectorandwithfar reachingconsequencesontheeconomy,education,sports,transportationandpolitics.Sincethe first caseswereregisteredinWuhan,ChinainDecember2019[1],theglobalspatialdynamicsofthe infectionhavebeenchangingasthediseaseswiftlymovedtowardtheWest[2]intoEuropetheninto theUnitedStates,SouthAmerica,andeventuallytothewholeworld,withnearly38.1millioncases and1.1milliondeathsregistereduntilOctober12,2020[3].

Giventheglobalgeographicspreadofthevirusandthelocalwidespreadinmanycountries,and thenatureofthetransmissionofthevirus,itisimportanttounderstandthespatialmechanismsof thisspreadanditsdependenceonproximity,demographicsandsocialcharacteristicsofinfected areas.Spatialanalysisprovidesabetterunderstandingoftheroutesoftransmissionofinfections[4], consequently,itallowsthedecision-makerstodraftandimplementeffectivehealthandmitigation measurestoreducerisksassociatedwiththepandemic.

InLebanon,the firstcasewasregisteredonFebruary21,2020[5]andbyOctober12,54,624cases and466deathswereregistered[6].The firstfewweekswitnessedarelativelyrapidincreasebutit sharplydeclinedasaresultofthestrongmitigationmeasuresenforcedbythebeginningofMarch. Theliftoftheinternationaltravelbanandthepartialeasingofmeasuresledtotherevivalofhigher

FrontiersinAppliedMathematicsandStatistics|www.frontiersin.org

FIGURE1| AmonthlymapoftheregionalcumulativenumberofinfectionsinLebanesedistrictsbetweenAprilandOctober2020.The figureshowsatimeseriesof theinfectionspread,usingalogarithmicscaletoaccountfortherapidincreaseinthenumberofinfections.ThecentralneighboringdistrictsofBeirutandMountLebanon arethemostinfectedthroughoutthetimespanstudied.

spreadratessinceJuly.Only1,788caseswereregisteredbyJuly1, 2020beforeasharprisefromJulythroughOctober.Thecases weremainlyconcentratedinBeirut,itssuburbsandits neighboringareasinMountLebanon.OnAugust4,ahuge explosionrattledtheportofBeirutanddestroyedthousands ofhousesandbuildingsinthesurroundingareas.Peoplewere rushedintohospitals,withthousandsofinjuriesrecordedonthat day[7].Onsuchahorribleincident,hundredsofvolunteersand civildefenseteamswereinvolvedinrescueworkforseveraldays. Thesocialdistancingmeasureswerelargelyneglectedinsuchan emergencysituation.Thespreadacceleratedintheupcoming weeks,withsharpriseinBeirutanditssurroundingsandwitha nationalwidespreadreachingallregionsandmajortownsand cities[8].

RelatedLiterature:Spatialautocorrelationisthestatistical analysisofdatastudiedinspaceorinspace-timeaimingforthe identi ficationandestimationofspatialprocesses[ 9, 10].Ithas beenimplementedtostudyandanalyzethespreadofvarious diseasesandinfectionsincludingcancer,diabetes,SARS, in fluenzavirus,COVID-19,etc.[11 14 ].Theconceptof geographicalspatialautocorrelationhasbeenexpandedinto thestudyofclusteringofinfections,includingthatofthe Coronavirus,amongregionssharingsimilar(neighboring) demographicorsocialfeatures[4 , 15, 16].Recentstudiesalso inspectedtheeffectofcitysize,population,transportation systemsanddemographicsonthediseasespreadandits mortalityrate[ 17 21].Theunderstandingofspatialspread dynamicsisessentialfordraftingandimplementing

preventivemeasuresinthe fi ghtagainstinfectiousdiseases includingthemostrecentspreadofCOVID-19[ 22, 23].Thedeterminationofthemeancenterofapopulation (centroid)wasdiscussedinRefs.[ 24 26 ]andextendingthe concepttothedeterminationofthemeancenterofwealthand infectionsallowedforaspatialanalysisofthetemporal dynamicsofwealthdistribution,economicgrowthand infectiousdiseases[27 ].Thedynamicsoftheoutbreakof COVID-19inLebanonanditsreproductionnumber dynamicswerestudiedinRefs.[ 28 31].Recentpublications exploredotheraspectsofthespreadinLebanononthe preventivelevel[ 32 ]aswellasonthelevelofpsychological, pharmaceuticalandmentalneedsandresponsestofacethe consequencesoftheinfection[ 33 35].

DespitetheacceleratingspreadinLebanon(see Figure1), therearenorelevantstudiesanalyzingthespatialdynamicsof theCoronavirusinfectionsinthecountry.Inthispaper,we studytheclusteringandspatialprogressionofnewinfectionsin Lebanonbyapplyingthemethodsofspatialautocorrelation withdifferentmodelparameterizationsofgeographic, demographicandsocialvariablesincludingadjacency, proximity,population,populationdensity,povertyrateand povertydensity.Locatingthemeancenteroftheepidemic spreadasafunctionoftimeisusedtoanalyzethetemporal geographicdevelopmentofthespread.Themethodsusedare general,butourcurrentworkisfocusedonspatialdynamics onlyinLebanon.Thepaperhasmanynovelaspectsasit addressesandstudiesthespatialspreadofCOVID-19in

TABLE1| Thetableshowsthedistributionofthecumulativenumberofcasesamongthe26LebanesedistrictsonOctober12,2020,withtheirrespectivepopulations, populationdensities,povertyratesandpovertydensities.

RegionnameNumberofcases (Cumulative)

Population × 100

Populationdenisty (Resident/km2) Poverty Rate(%) Povertydensity (Resident/km2)

Akkar1,1713,20441838.438 Minieh-Denniyeh7231,40838948.6189 Tripoli4,1982,4389,03031.72,862 Zgharta85487739925100 Koura55684648914.370

Bcharre11522114013.419 Batroun3415892125.512 Jbeil9541,29530112.738

Kesrwan19782,60576218.5141

Meten6,1395,110192820.4393 Beirut6,4433,41717,25825.54,401

Baabda7,2775,5382,85526.8765

Aley3,0473,0081,14429.4336 Chouf19652,77056024.2135 Jezzine12532113321.929

Saida2,4722,9661,07919.1206 Nabatieh683180259328.2167

Sour1,0232,55793330.3283 BentJbeil33196236422.983 Marjeyoun21474027924.268 Hasbaya7628710823.926 Rachaya79338621610 WestBeqaa47486418425.547 Zahleh2,367177442437.3158 Baalback8772,1469440.638 Hermel863054247.120

Lebanoncoveringtheexistinggapincurrentliterature.Italso introducestheanalysisofspreadinrelationtosocial characteristicsofinfectedregionsbyanalyzingtheeffectsof povertyrateandpovertydensity,andappliestheconceptofthe meancenterofinfectiononthespreadoftheCoronavirus.The obtainedresultsprovideasolidbasisfortheconcernedpolicy makerstodrawwell-groundedandscientificallybasedlocaland regionalmeasuresthatwouldcontributetocontrollingthe infectionspreadinthecountry.

Thepaperisorganizedasfollows:in section2 weintroduce theimplementedanalyticmathematicalandstatisticalmethods andtools.Resultsarepresentedanddiscussedin section3,and section4 concludesthepaper.

2ANALYTICMETHODSANDTOOLS

2.1Moran’sIIndex

Moran’ s I indexisaunivariateinferentialstatisticusedto measurethespatialautocorrelationbasedbothonlocations andfeaturevaluessimultaneously.ItisdefinedasRef.[9]:

(1)

where Wij representsdifferenttypesofadjacencybetweenregion i andregion j,correspondingtodifferentmodelsofinfectious spread. N isthenumberofregionsunderconsiderationand Xi

representsthenumberofnewdailyinfectionsindistrict i X isthe averagenumberofnewdailyinfectionsperregion,anditisgiven by X Σi Xi N .Thenumericaloutcomeof I fallsbetween 1and1 anditindicateswhetheradistributionisdispersed,randomor clustered.Avalueof I closeto0indicatesarandomdistribution, whilepositivevaluesindicateclusteredspatialdistributionand negativevaluesindicatedispersion.Largervaluesof |I | nearerto1 meanstrongerclustering(positive I)orstrongerdispersion (negative I).

The zI -scoreassociatedtothisstatisticisdefinedby: zI I E [I ] V [I ] (2)

wheretheexpectedvalue E[I]andthevariance V[I]aredefinedin theAppendix.The z-scoreorthecorresponding p-valueofthe statisticareusedtorejectthenullhypothesis,eliminatethe possibilityofarandompatternleadingtotheobtainedvalue oftheMoran I statisticandensuringthenormalityofthe distributionunderconsideration.

2.1.1Methodology

Inthispaper,wetakeaconfidencelevelcorrespondingto |zI | > 1.96orequivalentlyto p < 0.05inordertoconfirmtheoutcomeof clusteringordispersionofourspatialdataindicatedby I.Inthis casewesaythatthe p-valueisstatisticallysignificantandthe distributionisnormal,andbasedonthevalueof I wecan determinethepatternofthedistribution.

Lebanesedistricts.SinceJuly,thereisastrongclusteringofdailyinfectionsinregionssharingcommonbordersandamongnearerregions.

Weconsideramodelwithsixdifferentcasesof parameterizationoftheadjacencymatrix Wij correspondingto geographicadjacency(caseI),proximity(caseII),population (caseIII),populationdensity(caseIV),povertyrate(caseV)and povertydensity(caseVI).The firstfourcasesfollowanalogous parameterizationstothoseimplementedinRefs.[4, 16],while casesVandVIintroduceanewparameterizationinorderto inspectpossibleeffectsofpovertyrateandpovertydensityonthe viralspread. Table1 summarizesrelevantdatafromtheLebanese districts.

IncaseI,wetake W ij 1fordistrictssharingcommon borders,andcontributingtospatialspread,and W ij 0 otherwiseassumingthatthespreaddoesnotoccurdirectly betweennon-neighboringdistricts.IncaseIIwedetermine Wij 1 dij where d ij isthedrivingdistancebetweenthe administrativecentersofregions i and j ,thusassumesthat thegeographicspatialspreadisinverselyproportionalto distancebetweendistricts.Thosetwocasesstudytheeffect ofadministrativeadjacencyandthedistanceproximityof differentdistrictsonthegeographicclusteringofnew infectionsinLebanon.

IncaseIIIandcaseIV,weanalyzetheeffectsofpopulationand populationdensityonthespreadofthediseasesincethevirusis carriedbypeopleanditsspreadissupposedtoberelatedtotheir interaction.Wesortthedistrictsbythenumberoftheirresidents

(obtainedfromRef.[36])andthenbythedensityoftheir residentsrelativetotheirareas,inspectingspreadbetween districtsaccordingtosimilaritiesintheirinhabitants’ number anddensityrespectively.Usingthesortedorderofresidents anddensities,districtsofconsecutivenumberofresidentsand populationdensitiesareassignedafactorof Wij 1,and Wij 0 otherwise.Thisprovidesastatisticabouttheclusteringof infectionsaccordingtopopulationandpopulationdensity respectively.

Lastly,incasesVandVI,weintroducenewparameters, namelythepovertyrateandthepovertydensityindifferent districtsandweanalyzetheireffectoninfectionclustering.We sortthedistrictsbytheirpovertyratesandpovertydensity[ 36 ] andassign W ij 1forregionsofconsecutiveorderofpoverty rateorpovertydensity,and W ij 0otherwise,inasimilar methodologytocasesIIIandIVinordertoinfertheeffectof similaritiesinpovertyrateanddensityonpatternsofinfection spread.

2.2MeanCenterofInfection

Themeancenterofinfection(henceforthMCI)isageographic locationthatrepresentstheweightedmeanofthepositionsof infectedindividualsonthesurfaceofEarth,assumedtobe spherical.AssigningthevalueofEarth ’ sradiustounity, thetwosphericalcoordinatesthatdeterminetheunique

FIGURE2| The figureshowsMoran’s I indexanditscorresponding p-valueforcasesIandIIaccountingforadjacencyandproximityofnewinfectionsregisteredin

FIGURE3| Moran’sIindexanditscorresponding p-valueforcasesIIIandIVaccountingforpopulationandpopulationdensityofdifferentdistricts.Thedailyspread wasnotclusteredwithrespecttodistrictpopulationanddensityuntillateAugust2020,whereitstartedachievingstrongspatialclusteringbetweendistrictsofadjacent populationranks.

positionofapointareitslatitude λi andlongitude ϕi .The latitudeisameasurementoflocationnorthorsouthof theequatorwhilethelongitudeisameasurementof locationeastorwestoftheprimemeridianatGreenwich, UnitedKingdom.

TheCartesianpositionvector ri → (xi , yi , zi ) isrelatedto sphericalcoordinateswithunitradiusbytherelationsRef.[37]:

AssuggestedbyRef.[24],theprecisepositiononthesurfaceofa spherecanbedeterminedfromthenormalizedpositionvector definedby ri → (x , y , z ) ri → ri → ,leadingto

x x 2 √ + y 2 + z 2 y y x 2 √ + y 2 + z 2 z z x 2 √ + y 2 + z 2 (5)

Consequently,wecanrecoverthesphericalpositionofthemean centerofinfectionsbycalculatingthemeanlatitudeand longitudeas:

Wedenotethedistrictnumberofinfections(neworcumulative) by Xi asdefinedabove,andtheCartesianpositionsofthe administrativecentersby(xi,yi,,zi).Then,theCartesian positionoftheweightedmeanofinfections ri → isgivenby:

(4)

Thelatitudeandthelongitudecanbelocatedandplottedonmaps andgeographicinformationsystems.Weemploythespherical coordinatesofgeographiclocationsofthecapitalsofthe26 administrativedistrictsinLebanonandthenumberofdaily andcumulativeinfectionsineachregioninordertodetermine thedailyMCIaccordingly.Thisprovidesatooltoanalyzethe temporaldynamicsofthemeangeographicspreadofthedisease.

ThedeterminationoftheMoran’ s I indexanditscorresponding p-valuefortheeffectofadjacencyandproximityofcasesIandII ontheclusteringofdailynewinfectionsofCOVID-19in Lebanonshownin Figure2,leadstotheconclusionthatsince July2020,thereisstrongclusteringofinfectionsinregions sharingcommonbordersandamongnearerregions.There wereonlyfewdayswhennewinfectionswerenotclusteredin adjacentregions,andonlyonedaywheredistancewasnotshown tobeadetrimentaleffectinthespatialspreadofnewcases.The maximumvalueofMoran’ s I reached0.660forcaseIand0.380 forcaseIIindicatingahighlevelofgeographicclusteringofthe diseasespreadsinceJuly.TheinfectionsbeforeJulyhadahigh p-value,indicatingahighprobabilityforrandomgeographic spread.

Theresultsofthespatialspreaddynamicsinrelationto populationandpopulationdensityadjacencyasshownin Moran’ s I and p-valueofcasesIIIandIVdepictedin Figure3 revealthatthespreadwasnotclusteredwithrespect totheregionalpopulationuntillateAugust2020,whereitstarted achievingapositivevalueof I with p < 0.05indicatingspatial clusteringbetweenregionsofadjacentpopulationrank,with severaldaysshowingaprobabilityofrandomspread.The maximumattained I was0.666.However,thestatisticsfor

districtswithadjacentrankofpopulationdensityshowvery strongspatialclusteringsincethemiddleofAugustwith I attainingamaximumvalueof0.832,whichisthehighest amongallsixstudiedcases.

TheresultsofcaseV(Figure4)showthatthespatialspread cannotbeattributedtoadjacentrankingofpovertyratesamong thedistrictssincethe p-valuesremainabovethe5%levelof confidenceupuntilOctober2020,hencenospatialclustering occurs.ButwhenweconsiderthepovertydensityincaseVI,we obtainpositivevaluesforMoran’ s I sincetheendofAugust,with p < 0.05exceptfor fivedays.Hence,spatialclusteringamong regionswithadjacentrankingofpovertydensityoccurs.The maximumattained I inthiscaseis0.666.

Incomparison,we findoutthatclusteringofnewinfections occursstartingondifferentdatesbetweenJulyandAugustforall consideredcasesexceptforcaseVcorrespondingtodistrict populations.Thestrongestlevelofspatialclustering(highest I) occursformodelIVofpopulationdensityaftermid-August, whileclusteringassociatedtogeographicadjacencyand proximity(casesIandII)hasthelongesttimespan(since earlyJuly)andthehighestlevelsofconfidence.

Byconstruction,spatialautocorrelationanditscorresponding Moran’ s I indexaredefinedintermsofunivariatedata observations[10, 38, 39].Multivariatespatialanalysisimplies acompromisebetweenmultivariateanalysis(relationsamong

FIGURE4| Moran’sIindexanditscorresponding p-valueforcasesVandVIaccountingforregionalpovertyrateandpovertydensity.Thepovertyrateisnota decisivefactorforspatialspreadbutwhenweconsiderthepovertydensity,weobtainspatialclusteringstartingontheendofAugust.

FIGURE5| This figureisaplotofthelatitudeandlongitudeoftheweightedgeographiccenterofCOVID-19infectionsinLebanon.Theuppergraphsrepresentthe temporalprogressionofthecumulativenumberofinfectionswhilethelowergraphsrepresentthatofthenewdailycases.

variables)andautocorrelation(spatialstructure)[40, 41],andit wasnotemployedinthecontextofthiswork,whichwasbasedon Moran’sunivariatestatistics.

ThelocationoftheMCIwasdeterminedasafunctionoftimeas shownin Figure5.Themeanlatitudeandlongitudeoftheinfection weredeterminedaccordingtothemethodsdescribedin Equation6 ThelocationofthecumulativeMCIisplottedonthegeographicmap ofLebanonduringthesameperiodin Figure6,togetherwiththe meancenterofpopulationofthecountry.Itstartednearthecityof Jounieh,north-westofthemeancenterofpopulation,butithas movedsouthwardsinceMaythroughAugust,whereitstartedmoving northwardagain.ThelocationoftheMCIofnewinfectionswasquite geographicallydistributedbeforeJulyasthelowerplotof Figure5 shows,beforebecomingmorehomogenousafterward.

Thereproductionnumber R (whichhasmaintainedarelatively highrateinLebanonsinceJune[28, 29])andtherateoftheinfection spreadcorrelatewithpeople’smobility[42].Geographicclustering occursbecausepeople’smotionandlocaltravelishigherintheir closeneighborhoods,especiallyinacountrylikeLebanonwhere withtheabsenceofnationalpublictransportationthroughoutthe country[43]diminishesnationwidemobility.Higherlevelsofsocial interactionamongpeopleindenseregionsalsocontributetothe spreadofthedisease,andthishasshownthestrongestclustering effect.

Inthisstudy,weemployedMoran’sIstatisticswithvarious parameterizations,inadditiontothemeancenterofinfectionwhich

isameasureofthecentralityoftheinfections,withitsdynamic temporalchanges.Thetwoapproachesarecomplementary,and allowustovisualizethedynamicsofspread,withitstemporal geographicalclusteringcharacteristics.Inaddition,spatial autocorrelationprovidesuniqueinformationaboutdemographic andsocialcharacterizationofthespread.

Ourstatisticaltestsandresultscorrespondtothenumberof registeredcases,whichmightdifferfromtheactualinfectionsin caseofunder-reporting,under-testingorincaseofasymptomatic infections.

4CONCLUSION

InthispaperweintroducedtheMoran’ s I indexwithitsassociated z-scoreand p-valuetostudythespatialautocorrelationofregistered newinfectionsofCOVID-19inLebanon.Weintroducedsix differentcasesofparameterizationofthespreadrelatedto adjacency,proximity,population,populationdensity,povertyrate andpovertydensity.Wediscoveredthatpovertyrateisnot statisticallyrelevanttothespatialspreadofthediseasewhile geographicbordering,distancebetweendistrictcenters,number anddensityofresidentsandpovertydensityleadtoclusteringof thedisease,withvaryingstrengthsandlevelofconfidencesinceJuly andAugustthroughOctober.Wealsointroducedmethodsto determinethegeographiccoordinatesofthemeancenterofthe

FIGURE6| The figureshowsthevariationofthegeographiclocationoftheMCIonamonthlybasisbetweenApril1andOctober1,2020,togetherwiththemean centerofthepopulation.TheMCIstartednearthecityofJounieh,north-westofthemeancenterofpopulation,butithasmovedsouthwardsinceMayuntilAugust,when itstartedmovingnorthwardagain.

infection,anddeterminedthiscentersinceApril2020,andplottedits variationsovertimeupuntilOctober.

Oneofthemajorlimitationsthatprohibitamoredetailed analysisisthepublicunavailabilityofdataonthemunicipalor sub-districtlevelthatwouldallowamoredetailedspatialanalysis, andconsequentlymorelocally-specificpoliciesandmeasuresto slowdownitsspread.

Thestudyofthespreadoftheinfectionallowsrelevant authoritiestodrawappropriatecountry-specificandregional measurestocurbthespread.Theunderstandingofthespatial, demographicandgeographicaspectsofthediseasespreadover timeprovidesanessentialbasisfortotakemoreefficient decisionsoflocalandinterandintra-regionalmeasures,thus

REFERENCES

1.WorldHealthOrganization Archived:WHOtimeline-COVID-19,World HealthOrganization(2020).Availablefrom:https://www.who.int/newsroom/detail/27-04-2020-who-timeline covid-19(AccessedOctober10,2020).

2.MathysN,GretherJ AplaguerushingtotheWest:theCoronaviruscenterof gravity.CCG(2020).

3.Worldometer COVID-19coronaviruspandemic2020.Worldometer(2020). Availablefrom:worldometers.info/coronavirus(AccessedOctober11,2020).

4.MengB,WangJ,LiuJ,WuJ,ZhongE.Understandingthespatialdiffusion processofsevereacuterespiratorysyndromeinBeijing. PublHealth (2005).119: 1080 87.doi:10.1016/j.puhe.2005.02.003

5.MinistryofPublicHealth COVID-19Coronavirusdisease2019.Republicof Lebanon:MinistryofPublicHealth(2020).Availablefrom:https://www.moph. gov.lb/ar/DynamicPages/index/2.

6.LebaneseGovernment Disasterriskmanagementunit (2020).Availablefrom: http://drm.pcm.gov.lb(AccessedOctober12,2020).

contributingtoincreasedsocialandhealthsafetyandsecurityin the fightagainstthepandemic.

DATAAVAILABILITYSTATEMENT

Therawdatasupportingtheconclusionsofthisarticlewillbe madeavailablebytheauthor,withoutunduereservation.

AUTHORCONTRIBUTIONS

Theauthorconfirmsbeingthesolecontributorofthisworkand hasapproveditforpublication.

7.BBCNews Beirutexplosion:whatweknowsofar.BBCNews(2020).Availablefrom: https://www.bbc.com/news/world-middle-east-53668493(AccessedSeptember25, 2020).

8.AridiR.Absolutelyhorrendous.” ScientistsdiscussBeirut’sblastandhowthey arecopingwithitsaftermath. Science (2020).[Epubaheadofprint].doi:10. 1126/science.abe6531

9.CliffA,OrdJ. Spatialautocorrelation.London:Pion(1973).

10.CliffA,OrdJ. Spatialprocesses:modelsandapplications.London:Pion(1981).

11.GlickB.Thespatialautocorrelationofcancermortality. SocSciMedMed Geogr (1979).13:123 30.doi:10.1016/0160-8002(79)90058-3

12.HippJA,ChaliseN.Spatialanalysisandcorrelatesofcounty-leveldiabetes prevalence,2009 2010. PrevChronicDis (2015).12:140404.doi:10.5888/ pcd12.140404

13.LaiP,WongC,HedleyA,LoSV,LeungPY,KongJ,etal.Understandingthe spatialclusteringofsevereacuterespiratorysyndrome(SARS)inHongKong. EnvironHealthPerspect (2004).112:1550 6.doi:10.1289/ehp.7117

14.StarkJ,SharmaR,OstroffS,CummingsDA,ErmentroutB,StebbinsS,etal. LocalspatialandtemporalprocessesofinfluenzainPennsylvania,

UnitedStates:2003 2009. PloSOne (2012).7:e34245.doi:10.1371/journal. pone.0034245

15.AlkhamisM,AlYouhaS,KhajahM,BenHaiderN,AlhardanS,NabeelA,etal. SpatiotemporaldynamicsoftheCOVID-19pandemicintheStateofKuwait. IntJInfectDis (2020).98:153 60.doi:10.1016/j.ijid.2020.06.078

16.KangD,ChoiH,KimJ-H,ChoiJ.SpatialepidemicdynamicsoftheCOVID-19 outbreakinChina. IntJInfectDis (2020).94:96 102.doi:10.1016/j.ijid.2020.03.076

17.RibeiroH,SunaharaA,SuttonJ,PercM,HanleyQS.Citysizeandthe spreadingofCOVID-19inBrazil. PloSOne (2020).15(9):e0239699.doi:10. 1371/journal.pone.0239699

18.LiX,ZhouL,JiaT,PengR,FuX,ZouY,etal.AssociatingCOVID-19severity withurbanfactors:acasestudyofWuhan. IntJEnvironResPublHealth (2020).17(18):6712.doi:10.3390/ijerph17186712

19.XieZ,QinY,LiY,ShenW,ZhengZ,LiuS,etal.Spatialandtemporal differentiationofCOVID-19epidemicspreadinmainlandChinaandits influencingfactors. SciTotalEnviron (2020).744:140929.doi:10.1016/j. scitotenv.2020.140929

20.CarteniA,DiFrancescoL,MartinoM.Theroleoftransportaccessibility withinthespreadoftheCoronaviruspandemicinItaly. SafSci (2021).133: 104999.doi:10.1016/j.ssci.2020.104999

21.SangiorgioV,ParisiF.AmulticriteriaapproachforriskassessmentofCovid19inurbandistrictlockdown. SafSci (2020).130:104862.doi:10.1016/j.ssci. 2020.104862

22.ZhouC,SuF,PeiT,ZhangA,DuY,LuoB,etal.COVID-19:challengestoGISwith bigdata, GeogrSustainability (2020).1(1):77 87.doi:10.1016/j.geosus.2020.03.005

23.LiH,LiH,DingZ,HuZ,ChenF,WangK,etal.Spatialstatisticalanalysisof coronavirusdisease2019(Covid-19)inChina. GeospatHealth (2020).15(1): 867.doi:10.4081/gh.2020.867

24.AboufadelE,AustinD.Anewmethodforcomputingthemeancenterof populationoftheUnitedStates. ProfGeogr (2006).58:65 9.doi:10.1111/j. 1467-9272.2006.00512.x

25.BachiR. Newmethodsofgeostatisticalanalysisandgraphicalpresentation .New York:Kluwer(1999).

26.BarmoreFE.Wherearewe?Commentsontheconceptof “Centerof Population” WisconsinGeogr (1991).7:40 50.

27.GretherJM,MathysN.Istheworld’seconomiccentreofgravityalreadyin Asia?. Area (2010).42(1):47 50.doi:10.1111/j.1475-4762.2009.00895.x

28.ElDeebO,JalloulM.ThedynamicsofCOVID-19spread:evidencefrom Lebanon. MathBiosciEng (2020).17(5):5618 32.doi:10.3934/mbe.2020302

29.ElDeebO,JalloulM.ForecastingtheoutbreakofCOVID-19inLebanon (2020).medRxiv.doi:10.1101/2020.09.03.20187880

30.MouradA,MroueF.Modelingandsimulationofthespreadofcoronavirus disease(COVID-19)inLebanon(2020).arXiv.2008.03264.

31.KharroubiS.ModelingthespreadofCOVID-19inLebanon:abayesian perspective. Front.Appl.Math.Stat (2020).6:40.doi:10.3389/fams.2020.00040

32.Kabakian-KhasholianT,MakhoulJ,BardusM.Towearornottowearamaskinthe COVID-19era?Thebrokenbridgebetweenrecommendationsandimplementation inLebanon. J.Glob.Health (2020).10(2):020311.doi:10.7189/jogh.10.020311

33.KhouryB,KhouryJ,AmmarJ.Psychologicalneedsandresponseduringthe COVID-19pandemicinLebanon. PsycholTrauma (2020). 12(5):497 8. doi:10.1037/tra0000757

34.ChammayR,RobertsB.UsingCOVID-19responsestohelpstrengthenthe mentalhealthsysteminLebanon. PsycholTrauma (2020).12(Suppl.1): S281 3.doi:10.1037/tra0000732

35.ZeennyR,RamiaE,AkikiY,HallitS,SalamehP.Assessingknowledge, attitude,practice,andpreparednessofhospitalpharmacistsinLebanon towardsCOVID-19pandemic:across-sectionalstudy. JPharmPolicyPract (2020).13:54.doi:10.1186/s40545-020-00266-8

36.LabourForceandHouseholdLivingConditionsSurvey2018-2019Lebanon: AllPublications,CentralAdministrationofStatistics(2020).Availablefrom: http://www.cas.gov.lb/index.php/all-publications-en(AccessedOctober2, 2020).

37.MalingD. Coordinatesystemsandmapprojections.Oxford:Elsevier(2013).

38.MoranP.Theinterpretationofstatisticalmaps. JRoyStatSocB (1948).10: 243 51.10.1111/j.2517-6161.1948.tb00012.x

39.MoranP.Notesoncontinuousstochasticphenomena. Biometrika (1950).37: 17 23.doi:10.1093/biomet/37.1-2.17

40.WartenbergD.Multivariatespatialcorrelation:amethodforexploratory geographicalanalysis. GeogrAnal (1985).17(4):263 83.doi:10.1111/j.15384632.1985.tb00849.x

41.DrayS,SaidS,DebiasF.Spatialordinationofvegetationdatausinga generalizationofWartenberg’smultivariatespatialcorrelation. JVegSci (2008).19(1):45 56.doi:10.3170/2007-8-18312

42.SantamariaC,SermiF,SpyratosS,IacusSM,AnnunziatoA,etal.Measuring theimpactofCOVID-19confinementmeasuresonhumanmobilityusing mobilepositioningdata.AEuropeanregionalanalysis. SafSci (2020).132: 104925.doi:10.1016/j.ssci.2020.104925

43.HadiBaajM.ThepubliclandtransportsectorinLebanon. JPublicTrans (2000).3(3):87 108.doi:10.5038/2375-0901.3.3.5

ConflictofInterest: Theauthordeclaresthattheresearchwasconductedinthe absenceofanycommercialor financialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021ElDeeb.Thisisanopen-accessarticledistributedundertheterms oftheCreativeCommonsAttributionLicense(CCBY).Theuse,distributionor reproductioninotherforumsispermitted,providedtheoriginalauthor(s)andthe copyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournalis cited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

APPENDIX

TheexpectedvalueofMoran’ s I statisticisgivenby: E [I ] 1 N 1

E I 2 A B (N 1)(N 2)(N 3) Σij Wij 2 and A and B aregivenby: A N 2 N 2 3N + 3 Σij W 2 ij 2N Σi Σj Wij 2 + 3 Σij Wij 2 B 2Σi Xi X 4 Σi Xi X 2 2 N 2 N Σij W 2 ij 2N Σi Σj Wij 2 + 3 Σij Wij 2 consequently,the zI -scoreisgivenby zI I E [I ] V [I ] √ ElDeeb SpatialAutocorrelationofCOVID-19inLebanon 173

published:01February2021 doi:10.3389/fpubh.2021.628073

Editedby: MagdalenaKlimczuk-Kochanska, UniversityofWarsaw,Poland

Reviewedby: VladimirHlasny, UnitedNationsEconomicandSocial CommissionforWesternAsia (UN-ESCWA),Lebanon JanKorbel, MedicalUniversityofVienna,Austria

*Correspondence: SoraLee sora.lee@anu.edu

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 11November2020 Accepted: 07January2021 Published: 01February2021

Citation: LeeSandKangW(2021)Precision RegulationApproach:ACOVID-19 TriggeredRegulatoryDriveinSouth Korea.Front.PublicHealth9:628073. doi:10.3389/fpubh.2021.628073

PrecisionRegulationApproach:A COVID-19TriggeredRegulatoryDrive inSouthKorea

SoraLee 1* andWoojinKang 2

1 MenziesCentreforHealthGovernance,SchoolofRegulationandGlobalGovernance(RegulatoryNetwork),ANUCollegeof Asia&thePacific,TheAustralianNationalUniversity,Canberra,ACT,Australia, 2 DepartmentofEconomics,Collegeof EconomicsandBusinessAdministration,HanbatNationalUniversity,Daejeon,SouthKorea

COVID-19hastriggeredvariouschangesinoureverydaylivesandhowweconceptualize thefunctionsofgovernments.Someareasrequirestricterformsofregulationwhile otherscallforderegulation.Thechallengefortheregulatoryauthoritiesistomanage thesepotentiallyconflictingdemandsinregulationanddefinecoherentlytheiroverall regulatoryrationale.Theprecisionregulationapproachcanbeahelpfulapproach.Itis definedhereasastreamlinedapproachtoregulationtodelivertherightmethodsof regulationfortherightgroupofpeopleattherighttime.Thisproblem-solvinginnovation inregulationtriggeredbytherecentepidemiologiccrisisinSouthKoreademonstrates theemergenceoftheprecisionregulationapproach.SouthKoreahasimplemented streamlinedfast-trackservicesforthebiotechnologyindustrytoproducetestkitsswiftly. ThisarticleexpandsthedefinitionofprecisionregulationfromAIregulationliterature,and positionsthetermasanewregulatoryrationale,notasaregulatorytool,usingthecase studyfromSouthKorea.

Keywords:COVID-19,precisionregulation,deregulation,biotechindustry,SouthKorea

INTRODUCTION

Crisesdrivevariouschangesinourlives.COVID-19isaglobalpandemicwith48.5millioncases, and1,231,017deathconfirmedworldwideasofNovember6th,2020(1).Theconfiningresponsesof COVID-19,suchaslockdowns, quarantine,andself-isolation,havesignificantlydisruptedhowwe live,work,study,andtravelandchallengethenormsofwhatconstitutesnormality(2).Beyondthe everydayroutine,the pandemichasbroadlyimpactedlegislativereformsandderegulationagendas worldwide;thenationsstrivedtoadapttotheneedsofgovernment,industry,andcivilsociety undertheCOVID-19.Regulatoryamendementsareoccurringbeyondthemedicalsystemtocope withCOVID-19andthepost-COVID-19era.

Thelevelofregulationslidesonabinaryscaleoftheregulatoryflexibility.Theextremities ofthebinarydistinctioninregulation,however,maycausepublicservicestobecontrolledin marketsor,conversely,movetowardapaternalistic“bigbrotherstate”(3).Furthermore,postpandemictransformationsarestillunfolding fastandremainuncertain(4).Thebinaryconception ofregulationdoesnot leavemuchroomforregulatorstoadjustafterthenumberofcases dropped.ThisarticlehighlightsanexamplesetbySouthKoreanbiotechnologyindustryregulation toillustrateaprecisionregulationapproach,anemergeantregulatoryapproachtobreakthebinary distinctionbycombiningthederegulationwithcarefulscrutiny.Thisarticleaimstoexpandthe conceptofprecisionregulation,whichisonlyappliedintechnologyregulationsatpresent.There

maybebenefitsforthetermtobepositionedasanewregulatory rationalebeyondaregulatorytool.

THE PRECISIONREGULATIONAPPROACH

Theprecisionregulationapproachcanthusbedefinedhereas aproblem-solvingapproachtoregulationtodelivertheright methodsofregulationfortherightgroupofpeopleatthe righttime.Ithasoriginatedfromtheterm“precisionmedicine,” whichisamodelthatproposesthecustomizationofhealthcare, withmedicaldecisions,treatments,practices,orproductsbeing tailoredtoasubgroupofpatients,insteadofanone-drug-fitsallmodel(5).Inmedicine,precisionmedicineisdefinedas ahealthcarethatisfinelytunedtoeachindividual.Properly implemented,ithasthepotentialtoshiftthefocusofthehealth systemfromthetreatmentofillnesstotheprotectionofhealth (6).Thescholarsintheareaofprecisionmedicineregulation explicitlyclaimthat“thesectorneedstoremainadaptive,flexible, andresponsive”[(7),p.299].Thus,Nicoleetal.(7)further suggestthat theregulationofsuchmedicalmodelshouldbebased onappropriateconsiderationofsafety,efficacy,costeffectiveness, consistencyacrossgeographical,technologicalandinstitutional borders,culturalrespect,andinclusiveness.

Theterm“precisionregulation”hastakenoffthefieldof medicinetobeappliedtootherrealmsofregulation.IBM PolicyLabalsomentionstheprecisionregulationapproach fortechnologyinJanuary2020tosuggestanalternative frameworktoregulatecompaniesincreating,distributing,or commercializingAIsystems(8).Theframeworkdetailsfivesteps tohavetrustworthy AI:nurturinganAIethicsspecialist;applying anindividualizedapproachtorisks,promotetransparency amongstakeholders;contextualizeAIandcommunicatewith regulators;andtestforfairnessandbias.Whiletheabove regulatoryrulesmaybespecifictoregulatingtheAItechnology, thisproblem-solvingregulatoryapproachresonateswithsectors andgovernmentsbeyondtheAI.Suchanapplicationofprecision regulationinAIsuggestthatperhapsthetermcanbepotentially usefulforregulatorswhostruggletofindtherightbalanceof regulationspost-COVID-19.

BINARYSCALEOFREGULATION:FROM STRICTERREGULATIONTO DEREGULATION

Thecurrentconceptualizationofregulationrestsmainlyon binaryperception.FacingthedirectrisksofCOVID-19,strict spatialconfinementswereaprominentfeatureoftheearlier phaseofthepandemic.Asaresponsetothisglobaldiseasethreat, strictmovementrestrictionsandthetravelbanwereplaced inandoutofWuhanonJanuary23rd,2020(9).Neighboring countries,HongKong,Singapore,andSouthKorea,quickly followedtheresponse,suppressingthediseasesuccessfully comparedtoothercountries(10).Despitethedelay,European countriescameon board,duringMarch2020,inplacingspatial restrictionstopreventfurtherspreadofthedisease(9).

Strictspatialregulationhasbeenreinforcedbytechnological advancementinepidemiologicaltracingusingmobileapps.They trackinteractionsbetweenthosediagnosedwithcoronavirusand thepeopletheyhavecomeintocontactwith.Thepurposeofthe appsistoeffectivelyidentifythosewhomayhavecontractedthe virusthattheymaynotbeaware(11).Manycountriesworldwide, includingSingapore,China, SouthKorea,Germany,Finland,and Australia,havesincedevelopedtheirtracingappordevice.When concernsaboutpersonalprivacyandstatesurveillancesurface, thegovernmentstendtofocusmoreontechnologicalissuesand “brushingthemasideasunwarrantedorparanoia”(3).

Ontheotherhand,therearedemandsforderegulationthat governseconomicaspectsoflives.Deregulationisintendedto increaseeconomicefficiency,raiseproductivity,and,ultimately, supportjobsandwages.Asthebelowaccountsillustrate, governmentsworldwidehaveidentifiedthatderegulationis essentialforthepandemicandthepost-COVID-19recovery.For example,regulatoryagenciesworldwidehaveissuedexpedited processesorstreamlinedregulationsfortheindustrytoset upmeetingswiththeagencyduringthedevelopmentprocess forpandemic-relatedproducts.IntheUS,thetransportation departmenthasallowedtruckdriverstorenewtheirlicenses withoutfollowingstandardproceduresiftheyaredirectly engagedwithemergencyreliefsupplies.Thegovernmentwill introduceaslewoftaxincentivestospurcorporateinvestment andreshoring,evenallowingbigcompaniestorunventure capitalbusinessbyeasingthecapitalinvestmentrestrictionsfor non-financialentities.AccordingtothepolicytrackerbytheIMF (12),thebanksworldwideareprovidinganextensionofloans withoutadditionalprovisioningordowngradesforborrower’s creditstatusordeferloaninstallmentswithoutpenaltiesto ensurethecashliquidityofbusinesses.Thevariousgovernments guaranteenewbankloansforbusinessestocoveroperating costsduringthepandemic(12).Repaymentreliefsonmortgages andpersonalloanstofinance housingwereannounced worldwide.Somecountrieswaivecreditcardfeesandinterests, suspendloaninterestspayment,andextendtenuresoftrade instruments(12).

However,asthepandemicbecomessaneverydayreality, regulatoryagenciesneedtoreviewthesepotentiallyconflicting demandsinregulationtocoherentlydefinetheiroverall regulatoryrationale.Whilethechangesduringthepandemic maybetemporary,policymakerswillhavetodecidewhether tokeepthesechangesaltogether,orreturntopre-COVID-19, orselectsomeofthechanges.Thechoicescomewithtradeoffsofvalues.Forinstance,streamliningmedicalproduct regulationtopromotetheiraccesscanbebeneficialinterms ofefficiency,affordability,improvedhealthoutcomes,and decreasedcoststothehealthcaresystemoverall.However, relaxedprivacyordatarequirements,lessfrequentinspections, andlessscrutinizedsafetyprotocolsmayriskotherpublic values.Howdowebalanceregulationsonthebinary scalewhenthecontradictionsandcomplicationsoccur inmultipledimensions?Thegovernanceofaggregating andshapingtheregulatorychangescanbeadifficulttask underabinaryscale.Thenextsectiondescribesaregulatory exampleofSouthKoreathatdescribesaprecisionregulation

approachasanalternativewaytocomplementthecurrent binaryapproach.

SOUTHKOREANAPPROACH IN REGULATIONDURINGAND POST-COVID-19

SouthKoreawasoneofthemostseverelyhitnationsinthe earlydaysoftheCOVID-19outbreak.FollowingtheCOVID19outbreak,companiesinthebio-technologyindustrywere givenalltheinformationandsupportinopencompetitionunder emergencyfast-trackedapprovalprocesses(13).Simultaneous massivepublictestingsreinforcedthetechnologiesofbiotech companiestoattainreliabledata,andtoimprovetheir inventions.COVID-19exportsoftestingkitsandpersonal protectionsuitsincreasedsharply,upliftingtheentireindustry anddevelopingtreatments,vaccines,andotherrelatedareas.The problem-solvingnatureofregulatoryresponsesbiotechnology industryinSouthKoreaaddressedtheregulatoryrisksintimely fashiontohaverapidCOVID-19testkitdevelopment.

TheKoreanCenterforDiseaseControl(KCDC)used emergencyfast-trackprocedurestopromoteCOVID-19testkits (13).Infectiousdiseaseexpertsinthepublicandprivatesectors werecalledintofrequentand urgenttaskforcemeetingstodevise protocolstoengageindustrypartnersindevelopingthetestkits. Appropriateincentiveswereprovidedandfulltransparencyof thepubliclyhelddataandtestmethodsonthedisease.The KCDCconsideredthefactthatinitialtestkitsmightnotbe ofhighquality,giventhelimitedtimefordevelopment.The KoreanSocietyforLaboratoryMedicine(KSLM)wasthekey actorinenablinglaboratorypreparednessandresponsivenessfor thequalityandrobustnesstestingofthetestkits.TheKSLM alsocontributedinmaintainingdiagnostictestingqualityfor prototypetestkitsbyprovidingunbiasedvalidationsitesand procedures(14).Morethan2,723,960peoplehadbeentestedby November10th(15). Thisinturn,allowedthebiotechindustry tosharelarge samplestoimproveonthetestkitaccuracy.Korea conductsupto15,000–20,000testsaday,withtheremainder exportedtoothercountries.

Hence,theprecisionregulationapproachinthiscase studyhastwocriticalcharacteristics:(i)embracingtheurgency oftheprobleminregulationsand(ii)involvingpluralactors toeffectivelyresolvetheproblem.However,addressing theregulatoryproblempromptlywhileupholdingquality standardsisnotaneasytaskandcanbeverycostly.Indeed, theprerequisitesfortheprecisionregulationarelikelyto bereasonablywell-establishedpublichealthinfrastructure, highlevelofinter-agencytrust,andefficientintersectoral communicationskillsamongthepolicyactors.Those characteristicshelpedtoacceleratethediscussionsandenable feedbackmechanismstoexpeditethepoliticalprocessinthe SouthKoreancase.

Nonetheless,creatingopportunitiesfordiscussionand negotiatingwaysforwardhasnotbeenthetraditionaltaskfor policydesigners(16).Thenotionof“polycentricgovernance” (17),capturesanincreasinglycomplexanddiversifiedpolitical

landscapein whichmanyactorsdrawonvariousformsof materialandsymbolicpowertoinfluencedecision-making processesandoutcomes.Theunderstandingofpolycentricityof theprecisionregulationapproachsituatesitselfinthestreamof regulationliterature1 emergedtofocusoninnovativeapproach toachievecompliance,including“responsiveregulation” (18),“nodalgovernance”(19),“steering-at-a-distance”(20), “smartregulation”(21), and“meta-regulation”(22)andMetagovernance(10).The strengthoftheseapproachesisthatthey recognizethatthecapacitytodeliveronregulatoryobjectiveslies primarilywiththoseregulated,ratherthanthosewhoregulate. Theconceptshighlightthepolycentricityoftheregulatedactors, contributingtobreakingthebinaryconceptionoftheregulation.

Thebinaryapproachtoregulationlooksattheregulation functioninglikeaflipswitchthatturnseitheronoroff(23). Thisapproachmayhavelimitedinsightsintothebehaviorof theindustryactorstothepoliciesandregulations.Suppose,for instance;adichotomousderegulationapproachwastakenfor thebio-technologyindustry.Inthatcase,thefutureregulator hastofacetheimpactsofthechangedbehavior,practices, andoutcomesoftheindustryactors,whichmaybelowqualityproducts,moralhazard,andpublicdependencyofthe privatesector.IntheSouthKoreancase,inordertoprevent potentialpitfalls,precisioninregulationswasemphasized.The regulatorystepswerescrutinizedtoensurethatthederegulation doesnotsufferfromthefuturecostsfortheregulatorand theindustry.Thatisthewaythegovernmentneededto includeavarietyofactorsintheregulatoryprocess.Therapid feedbackmechanismsenabledpolycentricgovernancethrough theregulatoryprecisionapproach.

Basedonthecasestudy,theprecisionregulationforthe pandemiccanbeusedtoreinforcemeta-governancewiththe explicitgoalofpublicvaluedelivery.Forthecaseofderegulation, effectiveregulationshouldaimtosatisfypoliticalexpectations andoperationalfeasibility(24).Preciseandtargetedderegulation inthebio-technology industryandeffectivecommunication inpublic-privateregulatorypartnershipshavebeenSouth Korea’scriticalenablersofCOVID-19testkitdevelopment(13). Furthermore,theindustry expertsandprivatesectormedical practitionersplayedcrucialpartsintestingandvalidatingtest kitsinthestreamlinedprocesses.Thesenseofurgencytoachieve suchchallenginggoalsfurthernecessitatedtheinvolvementof widespectrumofactorstojointhediscussion.

CONCLUSION

Thisarticleidentifiestheprecisionregulationapproach,usingthe casestudyofbiotechnologyindustryregulationinSouthKorea. Theregulatoryapproachworldwideisprimarilydividedbetween flexiblearrangementsandderegulation,dependingonthesectors andtheurgencycreatedbythedisease.Thearticlepointsout thatsuchbinaryunderstandingofregulationmayfallshortof

1Theliterature’s primaryfocusisonregulationinpursuitofpublicregulatory goals,whichwilloftenimplyregulationbypublicregulatorybodies,whichmayof courseinvolvethemobilizationofprivateactors,civilsociety,andpublic-private partnerships.

adequatelyaddressingthewidespectrumandtheinterconnected aftermathofthe pandemic.ItmaybetoosoontodeclareSouth Korea’sregulatoryapproachasprecisionregulationbecausethe regulatoryresponsescontinuetoevolveasthebattleagainst COVID-19continues.Nonetheless,theSouthKoreanCOVID19regulatoryresponseonthebiotechnologyindustrycanguide othernationsstrugglingtobalancethebinaryscaleofregulatory flexibilities.TheessenceoftheSouthKoreancaseisthefocused attentiononthespecificproblem,strivingtoincorporatemultiple aspectsoftheproblem,andanactiveengagementbetween privateandpublicsectors,whichcanbeintuitivelyappliedto variouscountries.Furthermore,futurestudiesmayfindmore examplesoftheprecisionregulatoryapproachincountries withrelativelyhigherqualityofpublichealthinfrastructure andhighinter-agencytrust.Itmaybetimelyforscholars worldwidetodiscussthenewrationaleforregulationin post-COVID-19governance.

DATAAVAILABILITYSTATEMENT

Thedatasetspresentedinthisstudycanbefoundinonline repositories.Thenamesoftherepository/repositories

REFERENCES

1.WorldHealthOrganization. Coronavirusdisease2019(COVID-19)situation report–November6th2020.WHO(2020).Availableonlineat:https:// www.who.int/docs/default-source/coronaviruse/situation-reports/20200514covid-19-sitrep-115.pdf?sfvrsn=3fce8d3c_6(accessedNovember10,2020).

2.GoodeJ,StroupD,GaufmanE. EverydayNationalisminUnsettledTimes:In SearchofNormalityDuringPandemic.NationalitiesPapers(2020).p.1–25. doi:10.1017/nps.2020.40

3.LeeT,LeeH.Tracingsurveillanceandauto-regulationinSingapore: ‘smart’responsestoCOVID-19. MediaIntAustr. (2020).177:47–60. doi:10.1177/1329878X20949545

4.LeachM,MacGregorH,ScoonesI,WilkinsonA.Postpandemictransformations:howandwhyCOVID-19requires ustorethinkdevelopment. WorldDev. (2020)138:105233. doi:10.1016/j.worlddev.2020.105233

5.NationalResearchCouncil(US)CommitteeonAFrameworkforDeveloping aNewTaxonomyofDisease. TowardPrecisionMedicine:Buildinga KnowledgeNetworkforBiomedicalResearchandaNewTaxonomyofDisease. Washington,DC:NationalAcademiesPress(2011).

6.KnoppersBM.Precisionmedicine:amatterofregulationorcollaboration? J LawBiosci. (2016)3:687–90.doi:10.1093/jlb/lsw049

7.NicoleD,BubelaT,ChalmersD,CharbonneauJ,CritchleyC,DickinsonJ,et al.Precisionmedicine:drowninginaregulatorysoup? JLawBiosci. (2016) 3:281–303.doi:10.1093/jlb/lsw018t

8.HagemannandLeclerc. PrecisionRegulationforArtificialIntelligence (2020).Availableonlineat:https://www.ibm.com/blogs/policy/ai-precisionregulation/(accessedNovember6,2020).

9.OksanenA,KaakinenM,LatikkaR,SavolainenI,SavelaN,KoivulaA. RegulationandTrust:ASocialSciencePerspectiveonCOVID-19Mortality (2020).doi:10.2139/ssrn.3569845.Availableonlineat:https://ssrn.com/ abstract=3569845

10.BraithwaiteJ.(2020).Meta-governanceofpathdependencies: regulation,welfare,andmarkets. AnnAmAcadPoliSocSci. 691:30–49.doi:10.1177/0002716220949193

11.ChoH,IppolitoD,YuYW.ContacttracingmobileappsforCOVID19:privacyconsiderationsandrelatedtrade-offs. arXiv[preprint]. (2020) arXiv:2003.11511.

12.InternationalMonetaryFund. PolicyResponsestoCOVID-19. IMF(2020). Availableonlineat:https://www.imf.org/en/Topics/imf-and-covid19/PolicyResponses-to-COVID-19(accessedNovember1,2020).

andaccessionnumber(s)canbefoundinthe article/supplementarymaterial.

AUTHORCONTRIBUTIONS

SLandWKhavecontributedequallytotheconceptualizationof thearticle.SLhasdraftedthearticle.WKaddedhisinsights.SL andWKrevisedthearticletogether.Bothauthorscontributedto thearticleandapprovedthesubmittedversion.

FUNDING

SLwassupportedbytheAustralianPostgraduateAward(APA) forhercurrentdoctoralstudiesatANU.

ACKNOWLEDGMENTS

Theauthoracknowledgestheworkofthefieldpractitionersand healthofficialsworldwidewhoarecommittedtocaringforthe healthandwell-beingoftheircitizens,aswellasallthoseworking toshareknowledgeinthispandemicera.Theauthorisalso gratefulforthetworeviewersfortheirconstructivefeedback.

13.LeeS.SteeringtheprivatesectorinCOVID-19diagnostictest kitdevelopmentinSouthKorea. FrontPublicHealth. (2020) 8:563525.doi:10.3389/fpubh.2020.563525

14.SungH,YooC-K,HanM-G,LeeS-W,LeeH,ChunS,etal.Preparednessand rapidimplementationofexternalqualityassessmenthelpedquicklyincrease COVID-19testingcapacityintheRepublicofKorea. ClinChem.(2020) 66:979–81.doi:10.1093/clinchem/hvaa097

15.KCDC. DailybriefingofcasesinKorea.KCDC(2020).Availableonlineat: http://ncov.mohw.go.kr/en/(accessedNovember10,2020).

16.MintromM.Policyentrepreneursandcontroversialscience:governing humanembryonicstemcellresearch. JEuroPublicPolicy.(2013)20:442–57.doi:10.1080/13501763.2012.761514

17.McGinnisMD. PolycentricityandLocalPublicEconomies:ReadingsFromthe WorkshopinPoliticalTheoryandPolicyAnalysis.Oxford,MI:Universityof MichiganPress(1999).

18.AyresI,BraithwaiteJ. ResponsiveRegulation:TranscendingtheDeregulation Debate.Oxford:OxfordUniversityPress(1992).

19.BurrisS,DrahosP,ShearingC.Nodalgovernance. AustlJLegPhil.(2005)30.

20.KickertW.Steeringatadistance:anewparadigmofpublicgovernancein Dutchhighereducation. Governance.(1995)8:135–57.

21.GunninghamN,GraboskyP,SinclairD.Smartregulation. RegTheor. (1998)133:133–148.doi:10.22459/RT.02.2017.08

22.ParkerC,BraithwaiteJ,CaneP,TushnetM. TheOxfordHandbookofLegal Studies.Oxford:OxfordUniversityPress(2003).

23.MolkP,RowellA.Reregulationandtheregulatorytimeline(March16,2016). IowaLRev.(2016)101.doi:10.2139/ssrn.2420289

24.MooreM,KhagramS. OnCreatingPublicValue:WhatBusinessMight LearnFromGovernmentAboutStrategicManagement. CorporateSocial ResponsibilityInitiativeWorkingPaper3.Cambridge,MA:JFKennedy SchoolofGovernment,HarvardUniversity.

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021LeeandKang.Thisisanopen-accessarticledistributedunderthe termsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distribution orreproductioninotherforumsispermitted,providedtheoriginalauthor(s)and thecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournal iscited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

published:18February2021 doi:10.3389/fpubh.2021.647955

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland Reviewedby: JuditSándor, CentralEuropeanUniversity,Hungary MohammadBellalHossain, UniversityofDhaka,Bangladesh MohammadMainulIslam, UniversityofDhaka,Bangladesh

*Correspondence: SalvatoreSciacchitano salvatore.sciacchitano@uniroma1.it

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 30December2020

Accepted: 25January2021 Published: 18February2021

Citation: SciacchitanoSandBartolazziA (2021)TransparencyinNegotiationof EuropeanUnionWithBigPharmaon COVID-19Vaccines. Front.PublicHealth9:647955. doi:10.3389/fpubh.2021.647955

TransparencyinNegotiationof EuropeanUnionWithBigPharmaon COVID-19Vaccines

SalvatoreSciacchitano 1,2* andArmandoBartolazzi 3,4

1 DepartmentofClinicalandMolecularMedicine,SapienzaUniversity,Rome,Italy, 2 LaboratoryofBiomedicalResearch, NiccolòCusanoUniversityFoundation,Rome,Italy, 3 LaboratoryofSurgicalandExperimentalPathology,StAndrea UniversityHospital,Rome,Italy, 4 DepartmentofOncology-Pathology,CancerCenterKarolinskaUniversitetssjukhusetSolna, Stockholm,Sweden

Keywords:COVID-19,vaccines,transparencyinnegotiation,bigpharmaceuticalcompanies,advancepurchase agreements

INTRODUCTION

Immunizationthroughvaccinationrepresentsoneofthemostcost-effectivepublichealth interventionsandthemaintoolforprimarypreventionofcommunicablediseases.Vaccination programsandvaccineprices,however,varyconsiderablyamongandwithincountriesinthe EuropeanUnion(EU),becauseofthedifferencesinthewayhealthcaresystemsareorganized atthenationalorregionallevels.Thesedifferencesmayleadtoanewthreatrepresentedbythe so-called“vaccinenationalism”thatkeepnegotiationswiththepharmaceuticalindustrybehind thecloseddoorsofeachsinglenation,thusunderminingglobaleffortstoensurefairaccessto vaccinesforeveryone(1).TheseverityoftherecentCOVID-19pandemicisurgingamajor changeinourcapabilitiestorespondinthemostappropriateandcoordinatedmannertothe emergencysituation.Transparencyaboutthedifferentrolesofallstakeholders,eitherpublicor private,ofvaccinemanufacturers,andofhealthauthoritiesand,mostimportantly,transparency innegotiationsregardingvaccineprice,couldhelpavoidmisconceptions,thusstrengtheningthe collaborationrequiredtoprotectagainstthepandemic.

VACCINEPRICE

Newvaccinepricingisacomplicatedprocess,includingtargetpopulationanalysis,mapping ofpotentialcompetitors,quantificationoftheincrementalvalue,determinationofthevaccine positioninginthemarketplace,assessmentofthevaccineprice-demandcurve,calculationof thecostsofmanufacturing,distribution,researchanddevelopment,andinclusionofthevarious legalandregulatoryexpenses(2).Theeffectivefinalpriceofthenewvaccinemay,eventually,be differentfordifferentpurchasersbecauseofvariousdiscounts,promotions,andincentivesthatthe manufacturersmayapplyconsideringgeographicandeconomicalsituations,aswellasdifferent timesoftheyear,especiallyforfluvaccines(3).Transparencyinthenegotiationforvaccineprices hasbeenamatterof debateformanyyears.In2014,WHOlaunchedthevaccineproduct,price, andprocurementinitiative,namedMarketInformationforAccesstovaccines(MI4A),aimedto improvevaccinepricetransparency(4).ThankstothedatabasecreatedbytheMI4Aandimproved pricetransparency,manylow-ormiddle-income countriesincreasedtheirpossibilitytoaccess information,theircapacitytonegotiateaffordablepricesandstrengthentheiraccesstoaffordable vaccines(5).However,theissueisstillfarfrombeingresolved.

THELESSON(UNLEARNED)FROMFLU VACCINE

Theemergenceandsubsequentglobalspreadofthe2009 A(H1N1)influenza,alsoknownasswineflu,withnearly2,000 deathsintheEU,promptedhealthauthoritiesaroundtheworld toreviewtheirresponseandtoimprovethereactiontothe pandemic.Duringthe2009pandemic,vaccinemanufacturers greatlyincreasedinfluenzavaccineproductioncapacityand adopteda“tiered-pricing”strategy,wherethepriceofavaccine wasmainlybasedonthelevelofincomeofthecountry(6). AtthattimeEU memberstatesstruggledtoobtainsufficient quantitiesofvaccinesasquicklyasneededandhadtoaccept unfavorablecontractualterms(7).Themostdevelopedcountries placedlargeadvanceordersforthe2009-H1N1vaccineand boughtvirtuallyallofwhatthevaccinecompaniescould manufacture.Nationalinterestsclearlyprevailedoverglobal solidarity.Wealthiergovernmentsthathadprovisionalcontracts withvaccinemakersmonopolizedtheglobalvaccinesupply.By meansofsuchcontractualobligations,manufacturerscommitted alltheircapacitytoproduceanddelivervaccinestothose whocouldpaythemost(8).Asaresult,the2009-H1N1 vaccineproductionaffectedtheamountandtimingofvaccines availablefordevelopingcountries.EventhoughWHOentered talkswithmanufacturersanddeveloped-countrygovernmentsto securesomevaccinesfordevelopingcountriesthroughmonetary donationsbothfrommanufacturersanddevelopedcountries, suchdonationsstillleftthedevelopingworldwithlimited suppliesorthevaccinesarrivedtoolatetobeofmuchbenefit. However,theimpactoftheH1N1viruswaslessseverethan anticipated,andhealthauthoritiesofmanycountrieshadto facetheproblemofstockpilesofunnecessaryswinefluvaccines. Theyhadtonegotiatewithmanufacturersoverthesuspension ofdeliveryforsurplusvaccines,andtheytriedtosellordonate atleastpartofthem.Theexperiencewithpreviouspandemic flupromptedthemanufacturersandthehealthauthoritiesto worktogethertoenhanceglobalaccess,andtostrengthenfuture preparedness.In2018,amultidisciplinaryexpertpanelwas invitedbytheEUtoidentifymeasuresandactionstoimprove vaccinationcoverageandtoencourageclosecooperationand betterintegrationofpublichealthandprimarycareservices amongmemberstatesintheEU1.Amongthechangesproposed, thereweresomecrucialscientificandtechnicalimprovementsto rapidlyselectoptimalvaccineviruses,actionstospeedupvaccine production,andinstrumentstoimplementvaccinesupplyby meansoftheestablishmentofappropriateagreementspriorto apandemic.

However,wasthatexperienceusefulinimprovingourability tocombattheactualCOVID-19pandemic?Arewefacinga replayofthepastH1N1influenzapandemicof2009,withwealthy countrieshoardingthevaccines?Aconcernwasraisedregarding transparencyofthedifferentrolesofallstakeholdersandabout price,liability,andavailabilityofvaccines.Fulltransparencyof thevaccines’contracts,aswellasthepublicationofclinicaltrials databeforemarketingauthorizationsaregranted,isrequested

1http://ec.europa.eu/health/expert_panel/index_en.htm

andthisrepresentsthekeytowidespreaduseofpotentially life-savingvaccines.

THECOVID-19PANDEMIC

TheglobalCOVID-19pandemichasstrickentheEUwithalmost 17millionpeopleinfectedandmorethan400,000deathsas ofdataobtainedonweek1of2021bytheEuropeanCenter forDiseasePreventionandControl.Thereisaglobalrequest forasafeandeffectivevaccineagainstCOVID-19(9).The urgencytomanufacture andtomakeaccessibletoeveryonea successfulCOVID-19vaccinepromptedtheEUtopromotea commonstrategy(EUCom.n.2020/245).Inthisregard,the COVID-19pandemicisacceleratingtheinterdependenceofall EUeconomiesandsocietiestoformacloselyintegratedsingle market,asindicatedbythe8thPresidentoftheEUcommission, JacquesDelors,wholaunchedthisprogramin1985,allowing ajointactionatEUlevelonhealthpolicies,includingthe marketfordrugsandvaccines.Thisrepresentsanexcellent opportunitytobeonestepclosertowardtheunificationofthe differentnationalhealthpolicies,thuseliminatingunjustifiable functionalduplicationsbetweentheEuropeanMedicinesAgency (EMA)andeverysinglenationaldrugagency,atleastregarding negotiationprocedures.

THEEUSTRATEGYFORCOVID-19 VACCINES

Accordingtotheprogramfortheyears2014–2020,theEU’s actioninthefieldofhealthwastocomplementandsupport nationalhealthpolicies,encouragecooperation,andpromote coordinationbetweentheirprograms,infullrespectofthe responsibilitiesofeachsinglememberstateforthedefinitionof theirhealthpoliciesandtheorganizationanddeliveryofhealth servicesandmedicalcare(EUReg.n.2014/282).Following theunprecedentedpublichealthemergencycreatedbyCOVID19,theEUhasmodifiedthepreviouschoiceofnotdefining anyspecifichealthpolicies,andarangeofmeasureshavebeen takenbytheEMAandbyanetworkofnationalcompetent authoritiestofacilitate,support,andspeedupthedevelopment andmarketingauthorizationoftreatmentsandvaccines(EU Reg.n.2020/1043).Anewprogram,namedtheEU4Health program,hasbeenapprovedfortheyears2020–2021,withthe aimofstrengtheningtheEU’sroleonhealth,anditscapacity toreact,manage,andcoordinateitspowersbymeansofa “EuropeanUnionofHealth”(EUCom.n.2020/405).Thenew EUstrategyforCOVID-19vaccineswaspresentedinJune2020 (EUCom.n.2020/245).Itconsistedofthreeobjectives:(i) ensuringthequality,safety,andefficacyofvaccines;(ii)securing timelyaccesstovaccinesformemberstatesandtheirpopulation, whileleadingaglobalsolidarityeffort;andiii)ensuringequitable accessforalltoanaffordablevaccineasearlyaspossible.Such astrategyfocusedontheproductionandontheprocurement ofsufficientdosesofvaccinesforeachmemberstate,through AdvancePurchaseAgreements(APAs)negotiatedwithvaccine producers.Legalinstrumentstosupportsuchemergencyaction

wereestablishedin2016(EUReg.n.2016/369)andamended in2020(EUReg.n. 2020/521).Basedontheconsiderablelegal andpracticaldifficultiesinpurchasingsuppliesorservicesin emergencysituationsbythecontractingauthoritiesfromeach memberstates,theEUcommissionextendeditspossibilitiesto purchasesuppliesorservicesonbehalfofthemandadvocatedthe authoritytodirectlynegotiateforthepurchaseofhealthsupplies and,particularly,ofCOVID-19vaccines,togetmaximumbenefit intermsofeconomiesofscaleandrisk–benefitsharing.

THEEUPOSITIONONTRANSPARENCY WHENNEGOTIATINGADVANCE PURCHASEAGREEMENTS

Accordingtotheseemergencyregulations,anumberof derogationsfrompreviousarticleshavebeensetoutandapplied foralimitedperiodoftime,fromFebruary1,2020until January31,2022.Innodocument,however,wasaderogation fromthetransparencyonnegotiationsofAPAsforCOVID19vaccinesreported.Inastatementtotheplenaryofthe EUParliamentontransparencyofpurchaseaswellasaccess toCOVID-19vaccinations,releasedbyMrs.StellaKyriakides, commissioneronhealthandfoodsafety,itwasreportedthat “vaccinations,oncewehaveavaccinewhichisprovensafeand effective,willplayacrucialrole:insavinglives,incontaining thepandemic,inprotectinghealthcaresystems,inhelpingto restoreoureconomy”(statementbyKyriakides,12.11.2020).The EUcommissionhasworkedintensivelytohaveacommonEU portfolioofdifferentvaccinesagainstCOVID-19asdiverseas possible.ManyAPAshavealreadybeensignedwith Johnson& Johnson,AstraZeneca,Sanofi-GSK,JanssenPharmaceuticaNV, BioNtech/Pfizer,CureVac,andModerna.Todate,thecommission hassecuredatleast1.2billiondosesandhasfulfilledits commitmentofensuringequitableaccessto“safe,effective, andaffordablevaccines.”Itappearsclearthatsuchahuge numberofdoseswillrepresentarelevantcostfortheEUhealth system,andnegotiationsforthepriceofeachsinglevaccineis asignificantmatterofdebate.FollowingtheEUcommission negotiations,theItalianministryofhealthhaslaunchedits vaccinestrategyplanaimedtoensure202.5milliondosesfor allItalianpeople(strategicplanforvaccineanti-SARS-CoV2/COVID-19,updatedon15.12.2020).Centralizednegotiation procedureshaveobviousadvantages;however,theydemand transparency,especiallywhentheyinvolvehugepublicfinancial resources.ItisthereforeexpectedthattheEUcommission maintainsahighlevelofaccountabilityandtransparency, anditisreasonabletoaskwhatprocurementrulesarebeing followedandhowtheprofessionalsinvolvedwererecruited.In herstatementMrs.StellaKyriakidesrecognizestheimportance oftransparency.However,sheadmitsthat“duetothehighly competitivenatureofthisglobalmarket,thecommissionislegally notabletodisclosetheinformationcontainedinthecontracts.”It isaspecialrequestbythecompanies,infact,that“suchsensitive businessinformationremainsconfidentialbetweenthesignatories ofthecontract.” Thecommission,therefore,cannotdecideto

unilaterallydisclosethetermsofnegotiationwithouttheconsent ofallinvolvedparties.

THEPOSITIONOFTHE PHARMACEUTICALCOMPANIES

Therearemanyrequests,comingfromseveraldifferentsources, directedtothepharmaceuticalcorporationstoopentheirbooks toshowtheeconomicaspectsofthecontract,thecostsofvaccine production,andhowmuchthecountriesagreedtopayforeach vaccinetype.Themajorconcernisthatwealthycountriescould buyuphugeamountsofvaccinestocks,leavingpoorercountries facinghugedifficultiestoaffordwhattheyneed.Themajor pharmaceuticalcompanies,representedbytheInternational FederationofPharmaceuticalManufacturersandAssociations (IFPMA)andbytheEuropeanFederationofPharmaceutical IndustriesandAssociations(EFPIA),respondthattheyare committedtoworkingwithgovernments,partners,andpayers toensurethatvaccineswillbeavailableandaffordableforpeople atafairandreasonableprice.Inaddition,followingtheEMA initiative,theyissuedajointpledgepromisingtoimplement extraordinarytransparencymeasuresinthecontextofCOVID19(10).Suchmeasuresincludespeedingupthepublicationofkey documents,acceleratingthe announcementsofdrugsincludedin thecompassionateuseprograms,implementingearlierdeadlines forpublishingpublicevaluationreports,publishingthecomplete versionofthemanagementplanaswellastheclinicaltrialdata, whilealsoprotectingprivacyrights.Althoughsuchaninitiative willundoubtfullyhaveadvantagesintransparencyforhealthcare professionals,researchers,media,policymakers,andthegeneral public,theyarefocusedonregulatoryprocessesandprocedures forpatients,andcontainnomentionconcerningtransparency inthenegotiationprocedures.Accordingtothepharmaceutical companies,non-disclosureclausesareastandardfeaturein APAs.Theyarenecessarytoprotectsensitivenegotiationsand business-relatedinformation,includingfinancialinformation, development,andproductionplans.Thetwopharmaceutical companies Moderna and Pfizer donothidethattheywouldbe makingaprofitontheirvaccines. Pfizer CEOAlbertBourla saidtoBarron’smagazineinJuly2020thatsincetheprivate sectorfoundthesolutionfordiagnosticsand,again,sincethe privatesectorfoundthesolutionfortherapiesandvaccines,it iswrongtothinkthattheprivatesectorshouldnotbemakinga profitonthedrugsandvaccinestheyintroducetofightCOVID19(11).Thisisfrustratingwhenweconsiderthatthereisa hugeamountofpublicinvestment behindthecontractsfor COVID-19vaccines.Thismayrepresentahugeprivatization ofpublicmoney.Ontheotherside, Johnson&Johnson and AstraZeneca indicatedthattheywouldsellvaccinesattheircost throughthepandemic.Recently, Johnson&Johnson announced anagreementinprinciplewiththeGlobalAllianceforVaccines andImmunization(GAVIAlliance)tosupply Janssen’sCOVID19vaccinetolower-incomecountriesin2021(12). Glaxo and Sanofi alsodeclaredthattheydonotexpecttoprofitduringthe pandemicphase(13).

TRANSPARENCYINTHENEGOTIATIONS FORCOVID-19VACCINES

Byadvocatingtheauthoritytodirectlynegotiateforthepurchase ofhealthsuppliesand,particularly,ofCOVID-19vaccines,the EUderogatedfromthispreviouscommitmenttorespectthe responsibilitiesofeachsinglememberstateforthedefinitionof theirhealthpolicies.Thisisjustifiedbytheemergencycreated bytheCOVID-19pandemic.However,shouldtransparencyon negotiationsforCOVID-19vaccinesbederogatedaswell?Why hasthecommissionacceptedtobelegallyboundtosecrecyand decidedtoforgoitsdutiesinaccountabilityandtransparencyto thepeopleitissupposedtoserve?HaveallthepotentiallongtermconsequencesofthissecrecyontheEUpharmaceutical marketbeenconsidered,andonwhatbasiswasitdecidedto acceptthissecrecyusingpublicfundswithoutseekingpublic consent?Vaccinepricingdifferswidelyamongcountries,anda globalapproachhasbeenadvocatedtoguaranteethatallsubjects canbevaccinated,especiallythoseoflow-incomecountries(14). ManyrelevantconcernshavebeenraisedaboutthenewCOVID19vaccines(15).Webelieveitisrelevanttoansweranother keyquestion:Istransparencyin thenegotiationsofhealth productsstillapriorityissue?Itcertainlywasin1988,whenthe EUcouncilmandatedaspecificdirectiveonthistopic(L40/8, 89/105/EEC).In2018,WHOpublisheditsdraftroadmapfor accesstomedicines,vaccines,andotherhealthproducts2019–2023,encouragingexchangesofinformationandknowledge amongdifferentcountriesandsupportingaglobalandregional collaborationtoincreasepricetransparencyforquality-assured healthproducts(WHO,144thsession,Provisionalagendaitem 5.7,EB144/17).TransparencyinthenegotiationsonCOVID19vaccineshasbeenadvocatedbymany(16, 17).Oneofthe mostactivemedicalhumanitarianorganizations,MédecinsSans Frontières,requestedbothtransparencyonhowpublicmoney ishandedovertopharmacorporations(18)andrecommended accessibilitywith equityforeveryonewhoneedsCOVID19vaccines.Theinternationalnon-governmentalorganization HumanRightsWatchfocusedattentionon“opaque”vaccine dealsthatcouldunderminetheglobalrecoveryfromthe pandemicandclaimingthat“healthnotwealth”should determineaccesstoaCOVID-19vaccine.Thetransparencyissue wasraisedagainin2019,atthe72ndWorldHealthAssembly, inGenevabyformerrepresentativesoftheItalianMinistry ofHealthandtheformerdirectorgeneralofAIFA,Dr.Luca LiBassi,inaresolutionfortransparencywhennegotiating drugprices(WHADoc.72.8/2019).Theaimwastopromote reformsinnational,European,andglobalframeworkstomake qualitymedicines,vaccines,diagnostictests,andnewmedical technologiesandtherapiesavailableandaffordable.Forhiswork, LiBassiwasawardedthe2019“InternationalTransparency inMedicinesPoliciesAwards”bytheFrenchCivilSociety watchdoggroupl’ObservatoireMédicamentsTransparences(the ObservatoryforTransparencyinMedicines).Anotherstepahead towardtransparencyonnegotiationforCOVID-19vaccines wasrecentlymadebytheBrazilianpublicresearchinstitution, FundaçãoOswaldoCruz(Fiocruz),whodisclosedtheterms

ofitsagreementwith AstraZeneca fortheproductionofa potentialfutureCOVID-19vaccine2.Despitealltheseinitiatives, transparencyintheEUnegotiationoftheCOVID-19vaccines isstilllacking.Recently,evenmembersoftheEUparliament (MEPs)calledformoreclarityandtransparencyonCOVID19vaccinecontractsandaskedtograntaccesstoalltheAPAs forCOVID-19vaccines.Therefore,evenMEPsdonothave accesstothemostbasicinformation,suchas:howmuchwill theproductionofthesevaccinescost?andwhatwillbethe liabilityofthecompaniesforanydamagecausedbyavaccine? ApartialpositiveresponsewasgivenbyMrsSandraGallina, theEU’sleadnegotiatoronCOVID-19vaccinecontracts.She openedadedicated“readingroom,”thatcurrentlyonlycontains thecontractwith CureVac,toallowaselectfewMEPstoreview theredactedversionsofthecontract,signedwithcompanies. Webelievethatthisisnotenough,andpersistenceofsecrecy inlegalagreementsbytheEUandvaccinemanufacturers representsabarriertoglobalequitableCOVID-19vaccine accessanddistribution(19).We,therefore,supporttherequest, recentlypostedby39civil societyorganizations,including theEuropeanPublicHealthAlliance,anddirectedtotheEU commissionandtotheEUnationalgovernmentstoensure amaximumdegreeoftransparencyintheEU’sexchanges, negotiations,anddealswithpharmaceuticalcompaniesover COVID-19vaccines3

COVID-19VACCINEPRICELEAKS

InDecember2020,documentsrelatingtoCOVID-19vaccines and,inparticular,toonefrom Pfizer/BioNTech werestolen fromtheEMAagency,which,afterBrexit,islocatedinthe Netherlands.EMAconfirmedthecyber-attack,andcriminal investigationsareongoingtoclarifywhetherthestolendata areupforsaleoriftheyhavebeenpublishedforanyone toaccess.

However,thisisnotonlyacaseofleakinginformation regardingCOVID-19vaccines.TheCOVID-19vaccine pricesthattheEUcommissionkeptsecretandcoveredby “confidentiality”werereleasedviaTwitter,seeminglyina blunder,byBelgium’sbudgetstatesecretary,EvaDeBleeker. ShetweetedthepriceofalltheCOVID-19vaccinesthatthe EUhadnegotiatedwithpharmaceuticalcompaniesonbehalf ofits27memberstates,withthelistofthecountry’snumber ofvaccinesandthepricetheywerepayingpereachdose.The tweetwasquicklyremoved,butthelisthadalreadybeenmade public,anditwasreportedbytheNewYorkTimes(20).The pricingdatacontained inthelistwerenotconfirmedbytheEU spokesman,whodeclaredthatthesecrecyaboutthepricespaid bytheEUislegitimateandispartofthenegotiationforthe vaccine.ItislikelythatsuchinformationonCOVID-19vaccines priceswillinfluencefuturenegotiationswithmanufacturers. Accordingtosuchleakedinformation,theUnitedStates,who

2https://agencia.fiocruz.br/sites/agencia.fiocruz.br/files/u34/contrato_etec.pdf

3https://epha.org/wp-content/uploads/2020/12/jointtransparency-statementfinal.pdf

AdvancePurchaseAgreements(APAs)onCOVID-19vaccines.TheEUiscoordinatingajointefforttosecurethe acquisitionofasufficientquantityofCOVID-19vaccinesintheEUthroughAdvancePurchaseAgreements(APAs)withvaccineproducers,buttransparencyin negotiationsislacking,andsensitivebusinessinformationremainsconfidentialbetweenthesignatoriesofthecontract.

negotiatedpricesandarrangedtobuydosesforeveryAmerican directly,ispayingmorethanEurope.Inanycase,itisrelevant tomentionthatduringthesedays,allthehospitalsthatoperate intheUnitedStateshavebeenrequiredtocomplywiththe centersformedicareandmedicaidservices’pricetransparency requirementsdetail,so-called“theRule.”Theyarerequired tomakepublicalistoftheirstandardchargesfortheservices theyprovide4.AccordingtoCOVID-19vaccinepoliciesand guidance,“theRule”alsoincludesthepriceofCOVID-19 vaccines,notonlyformedicarebutalsoformedicaidservicesas wellasforprivateinsurance.

CONSEQUENCESOFTHEABSENCEOF

TRANSPARENCYONCOVID-19VACCINE

NEGOTIATIONS

TheabsenceoftransparencyonthenegotiationforCOVID19vaccinesfrustratesattemptstounifyallEUmemberstates intoasinglemarketandleavesmanycountriescompeting againstoneanotherforabetteroffer,fortheoverallnumber

4https://www.federalregister.gov/documents/2019/11/27/2019-24931/medicareand-medicaid-programs-cy-2020-hospital-outpatient-pps-policy-changes-andpaymentrates-and

ofvaccinedosesdistributedorfortherightoffirstchoice. Maintainingahighleveloftransparencyiscrucialtoreinforce trustintheoverallhandlingofthepandemicbytheEU andbyeverynationalgovernment,toensureconfidencein vaccinesandtominimizeskepticism,doubts,andsuspicion. Inaddition,alackoftransparencymayincreasetheriskof corruption.Inthisregard,AntónioGuterres,thesecretarygeneraloftheUnitedNations,reportedinastatement thattheCOVID-19pandemiciscreatingnewopportunities forcorruption,andinadequatetransparencymayfurther increasesucharisk(21).Transparencyinnegotiationsas wellasequityin globalhealthissuesshouldreturnto representpriorityissuesforboththeEUandWHO,toavoid deplorableasymmetriesinaccesstoinformation,proliferation ofbilateralAPAs,entrenchingnationalism,anddirectingfuture vaccinedistribution,especiallyduringthenegotiationsfor themostprofitablebusinessever:theoneofCOVID-19 vaccines(Figure1).Fulltransparencyinnegotiationswiththe pharmaceuticalcompanieswillcontributetoguaranteethe successoftheEU’smassCOVID-19vaccinationcampaign.

AUTHORCONTRIBUTIONS

SSwrotethearticleandABrevisedthetext.Allauthors contributedtothearticleandapprovedthesubmittedversion.

FIGURE1| Transparencyinthenegotiationsfor

REFERENCES

1.FidlerDP.Vaccinenationalism’spolitics. Science. (2020) 369:749.doi:10.1126/science.abe2275

2.LeeBY,McGloneSM.Pricingofnewvaccines. Hum.Vaccines. (2010)6:619–26.doi:10.4161/hv.6.8.11563

3.BartonJH.Financingofvaccines. Lancet. (2000)355:1269–70.doi:10.1016/S0140-6736(00)02100-0

4.WorldHealthOrganization. MI4A:MarketInformationforAccessto Vaccines.(2018).Availableonlineat:https://www.who.int/immunization/ programmes_systems/procurement/~v3p/platform/en/(accessedJanuary 20,2021).

5.CernuschiT.Pricetransparencyisasteptowardssustainableaccessinmiddle incomecountries. BMJ. (2020)368:l5375.doi:10.1136/bmj.l5375

6.AbelinA,ColegateT,GardnerS,HehmeN,PalacheA.Lessonsfrompandemic influenzaA(H1N1):theresearch-basedvaccineindustry’sperspective. Vaccine.(2011)29:1135–8.doi:10.1016/j.vaccine.2010.11.042

7.FidlerDP.Negotiatingequitableaccesstoinfluenzavaccines: globalhealthdiplomacyandthecontroversiessurroundingavian influenzaH5N1andpandemicinfluenzaH1N1. PLoSMed. (2010) 7:e1000247.doi:10.1371/journal.pmed.1000247

8.YamadaT.Poverty,wealth,andaccesstopandemicinfluenzavaccines. N. Engl.J.Med. (2009)361:1129–31.doi:10.1056/NEJMp0906972

9.BloomBR,NowakGJ,OrensteinW.“Whenwillwehaveavaccine?”understandingquestionsandanswersaboutcovid-19vaccination. N.Engl.J. Med. (2020)383:23.doi:10.1056/NEJMp2025331

10.InnovativebiopharmaceuticalindustrycommentonCOVID-19vaccines dosingstrategiesandrecommendfollowingthescience(2021).Available onlineat:https://www.ifpma.org/wp-content/uploads/2021/01/StatementIFPMA_PhRMA_EFPIA_VE_BIO_ICBA.pdf

11.Nathan-KazisJ. PfizerCEOSaysCompaniesShouldMakeProfitOnCovid-19 Vaccines.Burron’sMagazineJuly28,2020.(2020).Availableonlineat:https:// www.barrons.com/articles/pfizer-ceo-says-companies-should-make-profiton-covid-19-vaccines-51595968611(accessedJanuary20,2021).

12.Johnson&JohnsonAnnouncesAgreementinPrinciplewithGavitoSupply Janssen’sCOVID-19VaccineCandidatetoLower-IncomeCountriesin2021 (2020).Availableonlineat:https://www.jnj.com/our-company/johnsonjohnson-announces-agreement-in-principle-with-gavi-to-supply-janssenscovid-19-vaccine-candidate-to-lower-income-countries-in-2021

13.Nathan-KazisJ. GlaxoandsanofitoProvideCovid-19VaccinetotheU.K. ‘WeDon’tExpecttoProfit.’Burron’sMagazineJuly29,2020.(2020).Available onlineat:https://www.barrons.com/articles/glaxo-sanofi-covid-19-vaccineuk-profit-earnings-51596028535(accessedJanuary20,2021).

14.Globalharmonisationinvaccineprice. LancetInfect.Dis. (2015) 15:249.doi:10.1016/S1473-3099(15)70067-8

15.GoodmanJL,GrabensteinJD,BraunMM.Answeringkeyquestionsabout covid-19vaccines. JAMA.(2020)324:2027–8.doi:10.1001/jama.2020.20590

16.SchwartzJL.Evaluatinganddeployingcovid-19vaccines-theimportance oftransparency,scientificintegrity,andpublictrust. N.Engl.J.Med. (2020) 383:18.doi:10.1056/NEJMp2026393

17.Transparencyduringglobalhealthemergencies. LancetDigit.Health. (2020) 2:e441.doi:10.1016/S2589-7500(20)30198-9

18.GriffinS.Covid-19:governmentsshoulddemandtransparencyonvaccine deals,saysMSF. BMJ. (2020)371:m4430.doi:10.1136/bmj.m4430

19.PhelanAL,Eccleston-TurnerM,RourkeM,MalecheA,WangC. Legalagreements:barriersandenablerstoglobalequitableCOVID-19 vaccineaccess. Lancet. (2020)396:800–2.doi:10.1016/S0140-6736(20)3 1873-0

20.Stevis-GridneffM,Sanger-KatzM,WeilandN. AEuropeanOfficialReveals aSecret:TheU.S.IsPayingMoreforCoronavirusVaccines.TheNew YorkTimes.(2020).Availableonlineat:https://www.nytimes.com/2020/12/ 18/upshot/coronavirus-vaccines-prices-europe-united-states.html(accessed January20,2021).

21.UnitedNationsSecretary-General. StatementonCorruptionintheContextof COVID-19.(2020).Availableonlineat:www.un.org/en/coronavirus/statemen t-corruption-context-covid-19(accessedJanuary20,2021).

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021SciacchitanoandBartolazzi.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

published:24February2021 doi:10.3389/fsoc.2021.629693

Socio-EconomicImplications ofCOVID-19PandemicinSouth Asia:EmergingRisksandGrowing Challenges

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: GodfreyTawodzera, UniversityofNamibia,Namibia SubhasKhajanchi, PresidencyUniversity,India

*Correspondence: GolamRasul golam.rasul@icimod.org golam.grasul@gmail.com

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 15November2020

Accepted: 15January2021 Published: 24February2021

Citation: RasulG,NepalAK,HussainA, MaharjanA,JoshiS,LamaA, GurungP,AhmadF,MishraAand SharmaE(2021)Socio-Economic

ImplicationsofCOVID-19Pandemicin SouthAsia:EmergingRisksand GrowingChallenges. Front.Sociol.6:629693. doi:10.3389/fsoc.2021.629693

ThedramaticspreadofCOVID-19hasthreatenedhumanlives,disruptedlivelihoods,and affectedtrade,economyandbusinessesacrosstheglobe.Theglobaleconomyhasbegun toshowmajordisruptionsandisheadingtowardasevererecessionwithan unprecedentedeconomiccrisis.Astheglobaleconomyishighlyintegratedand interdependentthroughtheglobalsupplychains,ithasbeenprofoundlyaffectedby theCOVID-19pandemic.AlthoughallcountrieshavefaceddifficultiesduetoCovid-19, SouthAsiancountriesinparticularhavehadtodealwithamorechallengingsituationdue totheirlargepopulation,weakhealthfacilities,highpovertyrates,lowsocio-economic conditions,poorsocialprotectionsystems,limitedaccesstowaterandsanitation,and inadequatelivingspace,necessarytomaintainphysicaldistancingandtakeotherrequired measurestocontainthispandemic.Tocontainthespreadofthevirus,SouthAsian countrieshaveimposedstringentlockdowns,whichhaveconsequentlyaffectedthelives andlivelihoodsofmillionsofpeopleintheregion,whereathirdofworld’spoorlive.Against thisbackdrop,thispaperexaminestheexistingandprospectiveimpacts,risksand challengesofCovid-19onkeysocialandeconomicsectorsincludingmigration, tourism,informalsector,agricultureandrurallivelihoods.Theanalysisrevealedthat COVID-19islikelytoaffecteconomicgrowth,increase fiscaldeficitandmonetary burden,increasetherisksofmacroeconomicinstability,decreasemigrationand remittance,reduceincomefromtravelandtourism,andresultindwindlingmicro-small andmediumindustriesandinformalbusinesses.Thisislikelytodeepenpovertyand increaseunemploymentandtherisksofhungerandfoodinsecurity.Ifnotaddressed properly,thismayreinforceexistinginequalities,breaksocialharmony,andincrease tensionandturbulence.TheeconomicandsocialcostsoftheCOVID-19outbreakare thereforelikelytobesignificantandlong-lastinginSouthAsia.

Keywords:COVID-19,socio-economicimpact,publichealth,Povertyandinequality,SouthAsia

INTRODUCTION

TheescalatingspreadofCOVID-19hasposedthegravestthreat notonlytotheworldeconomybutalsotolivesandlivelihoods. Whatstartedasahealthshockhasnowbeentransformedintoa globaleconomiccrisis.Inaheavilyglobalizedandinterconnected world,thishastranslatedintoastateofunparalleledeconomic recession(OziliandArun2020).COVID-19hasbecomeaglobal systemiceconomicriskasithasaffectedalmostalltheeconomies oftheworld,nomatterhowsmallorlargetheyare.Becauseof highglobalization,economicintegrationandinterconnectedness amongthedifferentsectorsofeconomy,achangeinanypartof theeconomyoranycountrynowaffectsothersectorsofthe economyinotherpartsoftheworldaswell.Likeclimatechange, pandemicsarenowglobalrisksasitcanspreadaroundtheworld quickly,regardlessofwhereitoriginates(AcharyaandPorwal, 2020; Ibn-Mohammedetal.,2020).

COVID-19hasposeduniquechallengestotheSouthAsian economiesduetotheregion’slargepopulationandhighratesof poverty,deplorablehealthinfrastructures,poorsocio-economic conditions,inadequatesocialprotectionsystems,limitedaccess towaterandsanitationfacilitiesandinadequatelivingspace arrangements(Rasul,2020; Hossain,etal.,2020).SouthAsiais oneofthepoorestregionsintheworld:aboutone-thirdofthe world’spoorliveinthisregionwithabout70percentlivingin ruralareasandprimarilydependentonagriculture.Beforethe COVID-19pandemic,649millionpeopleinSouthAsiawere moderatelyorseverelyfoodinsecureand271millionwere severelyfoodinsecure.Similarly,36percentofthechildren werestuntedand16percentwereacutelymalnourished.The situationislikelytoworsenfurtherduetotheeffectofCOVID-19 (Rasul,2020).

Theworld’smanymegacitiessuchasDelhi,Mumbai,Karachi andDhakaareinthisregionandtheirpopulationdensityis extremelyhigh.Inmanycountries,peoplelackaccesstobasic servicessuchascleanwater,sanitationandhygienefacilities.For example,closeto42%ofhouseholdsinAfghanistanare compelledtouseunsafedrinkingwaterandmorethan50% donothaveaccesstowaterandsoaptowashhands(ICIMOD, 2020).Furthermore,highpopulationdensity,poorworking conditionsandinadequatelivingspacemakesocialdistancing verydifficult.Theworld’slargestslumsareinSouthAsiaand manyofthesearehometohugenumbersofpeople,forexample theOrangiareainKarachi,Pakistan(2.5million),Dharaviin Mumbai,India(1million),andtheRohingyacampsinCox’ s Bazaar,Bangladesh(aboutonemillion)(Rasul,2020).These overcrowdedlivingspacesandlimited,andoftenshared,water andsanitationfacilitieshavemadephysicaldistancingandselfisolationdifficult,consequentlyincreasingtherisksofexposure andvulnerabilities(Hossain,etal.,2020).Becauseofthealready strainedeconomicconditions,themajorityofthepeopleinthis regionhavefewresourcesandweakcapacitytocopewiththe exposuresofapandemicshock.Thechallengesarereinforcedby thefactthatalargeshareofpopulationmaketheirlivingthrough informalsectorsorself-employment,withoutanyhealthorsocial protection(ICIMOD,2020).

BeingconcernedwiththefastspreadofCOVID-19,afew scholars,particularlyinIndia,havemadeeffortstounderstand thenaturedynamicsoftheCOVID-19pandemictomodeland forecastthepaceoftransmissionandratesofmortality (KhajanchiandSarkar,2020; Samuietal.,2020; Khajanchi etal.,2020).Similarly, AcharyaandPorwal(2020) havealso assessedwhetherthepopulation’svulnerabilityofbeinginfected andtheratesofmortalityduetotheinfectiondependonthe demographiccompositionofthepopulationinthedifferentstates ofIndia.Allthesestudiesemphasizedtheneedformaintaining physicaldistanceandcontracttracingtocontrolthespreadofthe coronavirus.Realizingtheimportanceofmaintainingphysical distance,thegovernmentsofthisregionhaveimposedstrong lockdownstosavepeople’slives.

AlthoughSouthAsiancountrieshavebeenrelatively successfulincontainingthespreadofthevirusandsaving people’slivesintheearlymonthsofthepandemic(both infectionandlossoflivesarerelativelylowinSouthAsia comparedtomanydevelopedeconomies),thesuccesshas comeatahigheconomiccostduetoextendedlockdowns whichdirectlyimpactedeconomicactivities.Simulationresults suggestthatlockdownofanyeconomyforamonthmightresult inanannualGDPlossof1.5% 2.0%.Itisestimatedthatthe IndianeconomyincursalossofUS$4.64billionforlockingdown theeconomyforasingleday(AcuitéRatings,2020).

SouthAsiancountrieshavepoorhealthcaresystems. Afghanistanhasonly2.8physiciansper10,000people,Bhutan 3.8,Bangladesh5.3,andNepal6.5,a10thofthenumberinmore advancedcountries.EvenIndia,whichhasoneofthestrongest healthsystemsintheregion,hasonly7.8physiciansper10,000 people(Rasul,2020).TheSouthAsiancountries,duetoweak healthfacilitiesandresources,havetakenverystringentpolicy measurestocontainthespreadofthecoronavirusandsave people’slives.Exceptafewessentialservices,theeconomic activitieshaveshutdown,travelsarebanned,movementof goodsandservicesarerestrictedandcross-bordermovements areclosed.Labor,themainfactorofproduction,hasbeen quarantined,bordershavebeenclosedandnational,regional andglobalsupplychainshavebeendisruptedmostlyintheSouth Asianregion.

Whilethecurrentpolicymeasuresofphysicaldistancingand lockdownarecriticalforsavingpeople’slivesandincombatting thespreadofthecorona virus, thesemeasureshaveaffectedthe livesandlivelihoodsofmillionsofpeopleintheSouthAsian region,whichishometoonethirdofworld’spoorestpopulation (ESCAP,2020).Thestrongerthelockdown,thegreaterthe economicimpactsare.Inthisbackdrop,thispaperbriefly examinesthefollowingquestions:Whataretheexistingand prospectiveeconomicimpactsofCOVID-19pandemicinSouth Asia,whatarethechallengesandissuesfacedbythepoor vulnerablepopulation,andwhatarethelikelyimpactsinthe nearfuture short,mediumandlong-term?Howtheeconomic sectorslike,migration,tourism,theinformalsector,and agricultureandrurallivelihoodswillbeaffectedbythis pandemic?Whatarethekeymeasuresandactionstakenby SouthAsiancountriestoaddressthesechallenges?Whatpolicy

TABLE1| MeasurestakenbytheGovernmentsinSouthAsiatocontainspreadofCOVID-19inearlystageofinfection.

CountryLockdownmeasures (duration)

International borders/travel restrictions

AfghanistanCompletelockdownfrom22Marchtill24MayClosed,openonly forimmigrants

BangladeshStartedfrom26Marchto16Mayandextended furthertoMay30.Hotspotlockdownsimposed

BhutanRestrictiononentryoftouristsfrom6March;23 March internationalborderssealedlockdown fromApril1to21

AirtravelLandtransportMaritime transport

Passiverestrictionenforcedby neighborcountriesatborder

ClosedDomestic flightsopenedfrom1st June.International flightsclosedtill 15thJune.Cargo flightsonly

Passiverestriction enforcedbyneighbor countriesatborder

Not applicable

FreighttrainsEssential goodonly

ClosedNotallowedEssentialgoodsonlyNot applicable

India25Marchto31Maylockdownextendedtill30th Juneincontainmentzones.Manyactivitieswere allowedafterJune8,2020

ClosedDomestic flightsresumedbut passiverestrictionsforinternational flight

Passiverestriction enforcedbyneighbor countriesatborder

ClosedPermissionrequiredNotapplicableAllowed

Nodata MaldivesPublichealthemergencywasdeclaredon19 March.Lockdownfrom1Aprilto12thJunein greaterMalé

Nepal23Marchto2June.Furtherextendedto14JuneClosedPermissionrequiredCon flictinginformationNot applicable Pakistan1Aprilto9May.lockdownliftedClosedInternational flightsallowedcargo flightsonly

ProhibitedAllowed SriLankaPublicholidaydeclaredfrom15Marchlockdown from20Marchto11May ClosedCargo flightsProhibitedNodata

Sources;Adaptedfrom UNESCAP,2020

responsesareneededbynational,regionalandglobal communitiestoaddressthesechallenges?

Thepaperisorganizedasfollows.Afterthisintroduction, EconomicImpactsofCOVIDinSouthAsia assessesthemacroeconomicimpactsofCOVIDinSouthAsia,particularlyon vulnerableeconomicsectors. EmergingSocialRisksand Vulnerabilities,examinesthecascadingeffectsandemerging socialrisksandvulnerabilities. EmergingOpportunities discussesemergingopportunitytousethedisruptiveforcesof theCOVID-19pandemicandtheassociatedpoliciesforrecovery. GovernmentandCivilSocietyResponses,discussesgovernment responsesandthe finalsectionofthepaperdrawsaconclusion andsuggestpolicymeasuresthatarerequiredtoaddressthese challenges.

ECONOMICIMPACTSOFCOVID-19

PANDEMICINSOUTHASIA

SouthAsiancountriestookvariousstringentmeasurestocontain thespreadofCOVID-19. Keymeasuresundertakenbydifferent countriesincludedclosureofoffices,restaurants,hotels,schools, collegesandeducationinstitutions,internationalborders, suspensionofvisas,impositionofcompleteinternationaland domestictravelbans,andbanonpublicgatherings(Table1). Whilethesemeasuressignificantlyhelpedcontrolthe coronavirusspreadinSouthAsia,theyalsoimposedhuge economicandsocialcostatthesociety.Tourism,exportsand remittances,whichareimportantsourcesofforeignexchange earingforSouthAsiancountries,havealsobeenaffected significantly.SouthAsianeconomiesarelikelytoshrinkfor the firsttimein4decades(IMF,2020).Thissection

summarizeskeysocio-economicimpactsthatSouthAsian countriesfacesduetotheCovid-19pandemic.

IncreasingRisksofMacroeconomic Instability

DecliningGDPgrowth: Whilethepandemicisstilldeveloping andtheactualeconomicimpacthasyettobefullyknown, differentforecastssuggestthattheSouthAsiancountrieswill experiencetheworsteconomicperformanceinthelast40years duetoCOVID-19.Themagnitudeoftheeconomicimpactwill dependuponthedurationandseverityofthehealthcrisis,the durationofthelockdown,andthemannerinwhichthesituation unfoldsoncethelockdownislifted.AspertheInternational MonetaryFund’sforecast,theoverallGDPgrowthrateforthe SouthAsiancountriesisexpectedtobeintherangeof-18% (Maldives)to3.8%(Bangladesh)in2020,where fivecountriesare expectedtohavenegativegrowthtrajectory(Table2).Asharpfall ofGDPornegativegrowthofGDPmeansthatasignificantpart ofthepopulationwouldloseincomeduring2020.While populationisgrowingandinflationisraising(Table1),the reductioninGDPmeansthatthepercapitaincomewill declinefurther,whichwillaffectthelivelihoodsofthegeneral public.Iftheglobaleconomyrecoversrapidly,theSouthAsian regionisalsoexpectedtohavebettergrowthprospectin2021, whereMaldivesisexpectedtoleadtheregionwith12.7%growth followedbyIndia(8%).

Decliningtradevolume: COVID-19hasseverelydisrupted internationalandregionaltradeandsupplychains(Baldwinand Tomiura,2020).Manycountrieshavetemporarilyclosedtheir borders,reducedorhaltednon-essentialimports,andcanceled importordersfromothercountries.SouthAsiancountries’

TABLE2| Macro-economicindicatorsofSouthAsia-RealGDPGrowth,Inflation,andCurrentAccountBalance.

RealGDPgrowth(annual%change)Inflation(%changeinconsumer prices)

Currentaccountbalance(%ofGDP)

ActualProjectionsActualProjectionsActualProjections

Country201920202021201920202021201920202021

Afghanistan3.9 5.04.02.35.44.811.79.57.8

Bangladesh8.23.84.45.55.65.9 1.7 1.52.8 Bhutan3.80.6 0.52.63.64.6 22.5 21.4 13.5

India4.2 10.38.84.84.93.7 0.9 0.3 0.9

Maldives5.7 18.612.71.30.42.7 26.0 31.8 17.0

Nepal7.102.54.66.46 7.7 2.5 7.0

Pakistan1.9 0.41.06.710.78.8 4.9 1.1 2.5

SriLanka2.3 4.65.34.34.74.6 -2.2 3.6 3.2

Sources: InternalMonetaryFund,2020

growthinthelastfewdecadeswerefueledbytheirexportgrowth. TheUSA,EuropeandChinaarethemaintradingpartnersofthe SouthAsiancountries,andhavethemselvesbeenaffectedbadly bythepandemicwiththeireconomiesslowingdown.Becauseof thesharpdropinexternaldemand,tradeandexportscontracted sharplyaswell.COVID-19hasthusheavilyimpactedboththe exportandimportofSouthAsiancountries.Whileexportshave beengrowingsteadilyinrecentdecades,thisyearitisexpectedto belessthanthatof2019inalloftheSouthAsiancountries. OverallinSouthAsia,exportgrowthwillbefrom 6.8to 3.9% andimportgrowthfrom 7.3to 6.2%duetoreducedexternal demand,whichwillbelowevenbeyondthelockdownperiodin 2021(WorldBank,2020a).Thereducedexportearningislikely tocompoundtheeconomiccrisisinothersectors,like employmentandhouseholdincome.Forinstance,thetextile andgarmentssector,whichemploysmillionsofpeopleand contributesalion’sshareoftheexportearning,isheavily dependentonexternalmarketsandwillsufferheavily.

Inflation: TheSouthAsiancountriesareexpectedto experienceaslightlyhigherinflationin2020owingtothe impactofCOVID-19.ExceptPakistan(10.7%),allotherSouth Asiancountriesareexpectedtohavealowlevelofinflation (0.40%inMaldivesto6.4%inNepal)in2020,whichis comparableto2019inflationrates(Table1).Thecurrent accountbalance(%ofGDP)isexpectedtobenegativeforall SouthAsiancountriesin2020,exceptAfghanistan.Thedeficit howeverisexpectedtobeslightlylowerthan2019becauseofthe sharpfallinoilpriceaswellasduetothedisruptioninglobal supplychain,whereimportsareexpectedtobereducedmore thanthereductioninexportsformostofthecountries.South Asiaregionisanetoilimporterandoiloccupiesthelion’sshareof theimportbill.

Macroeconomicconsequences.Lowerrevenuecollectionand higherrecurrentspendingarelikelytoincreasethe fiscaldeficitto 7.7percentoftheGDPin2020(WorldBank,2020a).Thehigh fiscaldeficitsintheregionareaddingtopublicdebt,affecting fiscalsustainability.LowornegativeGDPgrowth,declining exportearningsandincreased fiscaldeficithaveserious implicationtohouseholdincomeandpoverty.Overtime,the macroeconomiccrisiswilltranslatetobroadermacroeconomic

challengesthatwillleadtofallingdemandandmobility disruptions.Theexistingmacroeconomiccrisismaycascadeto differenteconomicsectorsandcompoundtheimpactsatlocal economyandunfoldmanyeconomiccrizesthroughboth forwardandbackwardlinkagesandimpactbothsupply (national,regionalandglobalsupplychains)anddemand (consumption,savingandinvestment)aswellaschange prices.Ifthecrisisprolongs,manySMEsmaynotsurviveand migrantworkerswillnotbeabletoreturntotheiroriginaljobs; therecoverycouldtakeevenlongerandtheseeconomiesmay enterintotheworsteconomicrecession.Thegovernmentsofthe SouthAsiancountries,therefore,facehugechallengesin managingthisunprecedentedsituation,whichhasmajor implicationforthepoorandmarginalizedcommunities.With temporarysealingoftheborderandrestrictionofthemovements, informalcross-bordertradeisheavilyaffected,notonlyputtinga numberofinformalenterprisesinvolvedinthesupplychainof thosegoodsatahigherrisk,butalsoleadingtoshortageof groceries,particularlyforlandlockedcountrieslikeBhutanand Nepalthatareheavilydependentonimportofbasicgoodsfrom India.

ImpactonMigrationandRemittances

Duetorestrictionsintravel,mobilityandgatherings,themost affectedsectorsaretourism,sports,entertainment(cinema), education,transport,manufacturing,migrationand remittances.SouthAsiancountriesrelyonforeignremittances asoneofthemainsourcesofforeignexchangeearningsand householdincome.Withclosureoftheremittancetransfer businesses,lossofemploymentabroad,andabsenceoftravel backhome,remittanceinflowinSouthAsiaisexpectedtodecline significantly.

Migrationandtheresultingremittanceisoneoftheimportant sourcesoflivelihoodsformillionsofpoorhouseholdsinthe region(KNOMAD,2020; WorldBank,2020c).Theinward remittancefrommigrantworkersservesasalifelinefortheir familiesandasanimportantsourceofforeigncurrency,which contributessignificantlytothenationaleconomy.Forinstance,in Nepal,remittancecontributesabout27%ofthenationalGDP (2019).Indiaisthelargestreceiverofinternationalremittance,

notonlyintheregionbutglobally,withUS$83billionin2019. Remittanceisalsoanimportantsourceofhouseholdincomein otherSouthAsiancountrieswheretheremittance-GDPratiowas 8.2%inSriLanka,7.9%inPakistan,5.8%inBangladeshand4.6% inAfghanistanin2019(WorldBankandKONOMAD,2020). Likeexternalmigration,internalmigrationalsocontributes significantlytosupportfamiliesandensurefoodandnutrition securityforthepoorersectionsintheruralareas.Theruralpoor migratetourbancentersandsupporttheirfamiliesresidingin ruralareas.Indiahasover100millioninternalmigrants,whoare alsoinhugenumbersinothercountries.TheCOVID-19 outbreakhasplacedmanyinternalmigrantworkersindire conditions,withmanylosingtheir(mostlyinformal)jobsand unabletoreturnhomeduetodisruptionsinpublictransport servicesandmovementrestrictions.Thisistherealityformost migrantworkers,especiallythoseworkingintheinformalsector andlivinginovercrowdedslums.Lockdowns,travelbans,and socialdistancingmeasuresinresponsetotheCOVID-19crisis havedisproportionatelyaffectedpoorandvulnerableinternal migrantworkers,whohavefoundthemselvesstranded,unableto returneithertotheirplacesofworkortheircommunitiesof origin.Anumberofnewspaperarticlesrevealthatthousandsof workersmarchedtotheirvillagesfromcities,despitemovement restrictionsandlockdowns.Withoutadequateaccesstohousing, basicwaterandsanitation,healthfacilities,orsocialsafetynetsto helpthemsurviveinsuchrestrictions,thesemigrantworkers havebecomeevenmorevulnerabletocontagionrisks.Arecent surveyinBiharandUPinIndiareportedthat73%ofthe respondentmigranthouseholdshavelosttheirjobsormain incomesource(PopulationCouncil,India,2020).

Themigrationandremittancesectorshavebeenaffected heavilybytheCOVID-19pandemic.Theinitialestimates suggestthatremittanceswillfallsharplyinallofSouthAsian countriesin2020.Theremittance flowwilldropabout23%in comparisonto2019inIndia,Pakistan,andBangladesh.InNepal isexpectedtofallby14%.Intotal,in SouthAsia,remittance flow islikelytodeclinefromUS$140billionin2019toUS$135billion in2020andprojectedtodeclinetoUS$120billionin2021 (WorldBankandKNOMAD,2020).Thecoronavirusrelated globaleconomicslowdown,fallingoilpricesandtravel

restrictionsmayalsoaffectthedemandformigrantlaborand migratorymovements,andthisislikelytokeepremittances subduedevenin2021.Theseforecastsweredoneintheinitial phaseofthelockdown,butrecentdatasuggestthattheremittance inflowmaynotbeaffectedasmuchwhencomparedto2019. However,manymigrantworkersfromtheregionareinfected withthevirusintheirworkdestinationswithsomecausalitiesand withmillionsstrandedinneedofrepatriation,whichposeshuge challengesandrisks.

LosingJobsinInformalSectorandMSMEs

InSouthAsia,amajorityofthepopulationiseitherself-employed orengagedinagriculturalandrelatedactivities.Serviceand industrysectorsareothermajoremployersintheregion, whilemicro,smallandmediumenterprises(MSMEs)andthe informalsectorservicesengagethelargestworkforce.(Figure1).

Forinstance,inIndia36millionMSMEsemployed60million peopleandcontributedsignificantlyinnationaleconomy(Dev andSengupta,2020).InNepal,MSMEsgeneratesovertwo millionjobsandcontributes22%ofthecountry’sGDP (Shrestha,2020).InotherSouthAsiancountries,MSMEsalso playaveryimportantroleinprovidingemploymentandincome, contributingtoexportsandearningforeigncurrency.

TheinformalsectoringeneralandMSMEsinparticularhave beenhithardbyCOVID-19acrosstheSouthAsia.Theinformal enterprisesandwagelabourersfacedauntingchallenges.Many MSMEsarenowclosedastheycouldnotsustainthemselves throughthelockdown,leavingmanyinformalsectorworkers unemployed;economiclossesaccumulatedduetoreduced demand,restrictionofmovement,lackofaccesstomarkets, andthelossofmobilityofpeopleandgoodshaveallaffected workers(ILO,2020a).COVID-19restrictionshavebrought majoreconomicactivitiestoastandstillandhaveclosedthe operationofalmostallMSMEsexceptafewhealthrelated enterprises.Forexample,inNepal,morethanamillion informalsectorworkershavelosttheirjobstemporarilyor permanentlyandareinneedofreliefmaterialsfromthestate (Awasthi,2020).Sincehotelsandrestaurantshavebeenclosedfor months,demandforfoodandrelatedmaterialshavealsodeclined sharply.

FIGURE1| InformalemploymentinSouthAsiainagriculture,industryandservicesectors.Source: ILO,2018

TABLE3| BasicfacilitiesinhealthsectorandSocialSecurityCoverageinSouthAsiancountries.

CountriesPublichealth exp(%GDP)

Basicsanitation services Employmentwith socialsecurity

Employmentwithout socialsecurity Potentialjob losses(millions)

Afghanistan0.4938.753.796.312.37

Bangladesh0.4743.782.597.5

Bhutan2.4965.6714.0086.00 India0.9150.4810.389.7112.8

Maldives5.2196.2

Nepal1.0051.283.496.62.27 Pakistan0.7254.453.996.111.71

SriLanka1.6293.4124.175.90.92 World5.869.9441.358.7

Sources: ESCAP,2020

TABLE4| HealthsecurityrankingandscoreofSouthAsiancountries.

CountriesGlobalhealthsecurityrankand score* RankScore India5746.5 Bhutan8540.3 Pakistan10535.5 Nepal11135.1 Bangladesh11335.0 SriLanka12033.9 Maldives12133.8 Afghanistan13032.3

Sourceandnotes:Higherthescorebetter(lower)therank.Scoreis0 100.100isthebest healthsecuritycondition.Therankandscoresarebasedonthefollowingcriteria: A) Preventionoftheemergenceofreleaseofpathogens; B) Earlydetectionandreportingfor epidemicofpotentialinternationalconcern; C) Rapidresponsetoandmitigationofthe spreadofanepidemic; D) Sufficientandrobusthealthsystemtotreatthesickandprotect healthworkers; E) Commitmenttoimprovingnationalcapacity, financingandadherenceto norms,and F) Overallriskenvironmentandcountryvulnerabilitytobiologicalthreats. source: Babuetal(2020)

InPakistan,about12millionworkerswerelikelytofacelayoffs duetolockdownandthecountry’ssluggisheconomicrecovery (PIDE,2020).ItisalsoanticipatedthatifCOVID-19induced situationrestrictstheGDPgrowthratebetween0and1.5%,itis likelytoincreasethepercentageofpoorpopulation(ofincome poverty)from25%toaround55%(PIDE,2020).

Thehighrateoflayoffsandclosureofaconsiderableportion ofbusinesswillhavemultipliereffectsonemployment,household income,foodandnutritionsecurityandlivelihoodsecurity.As mostoftheworkersintheinformalsectorarepoorandthe majorityofthemarewomen,ithassignificantimplicationsto poverty,genderandfoodandnutritionparticularlyforthe marginalizedcommunitieswhoengageheavilyonthesector forcashincomeandlivelihood.Foodinsecurityisanother majorchallengecausedbythedisruptionofagricultural production,foodsupplychains,andlossofincomeacross differentcountriesduetothepandemic.Atthesametimedue tothelowsupplyofagriculturalproduction,foodpriceshave beenincreasedleadingtosevereimpactsonhouseholdfood security.ThemostvulnerablepopulationinSouthAsiaare thoseexposedtoweatherrelateddisasters(flood,droughts),

conflictorarelivinginextremepovertyincountrieswith weaksocialprotectionprograms.Thestrainonincomes resultingfromthedeclineineconomicactivitywilldevastate workersclosetoorbelowthepovertylineandwillbring additionalpeopleunderpoverty.

InadequateSocialSecurityCoverage

AllSouthAsiancountrieshavelowerthanworldaveragepublic healthexpenditure(Table3).Aspercentofthegrossdomestic product(GDP),theMaldiveshasthehighershareofpublichealth expenditure(5.2%)whileBangladeshhasthelowestshare(0.47% ofGDP).ArecentstudyshowsthatthesomeofthecitiesinSouth Asia(KarachiinPakistanandDelhiinIndia)severelylack intensivecarebeds,healthcareworkersand financialresources tomeetthegrowingdemandforhealthcareservicesduetothe coronavirustransmission(Daviesetal.,2020).OtherthanSri Lanka(24%),Bhutan(14%)andIndia(10%),socialsecurity coverageoftheworkersisquitelowwherelessthan4%ofthe workershavesomekindofsocialsecurity.Around140million workersareexpectedtolosetheirjobsintheregion(ILO,2020b; UNESCAP,2020).

Thefollowingtable(Table4)showstheaveragescoreof GlobalHealthSecurity(GHS)indexforSouthAsiancountries. TheglobalaverageoftheGHSscoreis40.2.AmongtheSouth Asiancountries,IndiaandBhutanareabovetheglobalaverage whiletheremainingcountries(Pakistan,Nepal,Bangladesh, MaldivesandAfghanistan)arebelowtheglobalaveragescore.

EffectonTravelandTourism

SomeofthemostaffectedsectorsinSouthAsiaduetoCOVID-19 aretourism,hotelandrestaurant,manufacturing,construction andrealstate,agriculture,transport,tradeandsoforth(ESCAP, 2020).Intheregion,travelandtourismsectorcreatedaround50 millionjobsin2018(Table3),contributingsignificantlytothe nationalGDPs.ForinstanceinIndia,tourismandtravelservices employabout43millionpeoplecontributingover9%oftheGDP; inPakistan,itcontributesover7%oftheGDP;andinNepal,it employsoveronemillionpeoplecontributingabout8%ofthe GDP(Table5).

TheCOVID-19mitigationmeasuresincludingsocial distancingandtravelrestrictionshaveaffectedthetraveland tourismsectorthemost.Demandsinthetourism,travel,hotel

TABLE5| EmploymentandeconomiccontributionoftourismandtravelindustryinSouthAsia.

CountryShareofGDP(%)Numberofjobs inT&T (inThousand)

Shareintotal employment,mostrecent year(%)

Growth (2018orlatest year)

Bangladesh4.42,4143.911.6 India9.242,6738.16.7

Maldives66.46932.47.9 Nepal7.91,0516.73.6

Pakistan7.13,8506.37.4

SirLanka12.51,00012.112.4

Source: WorldBank(2020a)

andrestaurantsectorscollapsedimmediatelyafterthespreadof thecoronavirus,whichconsequentlyaffectedthetraveland tourismindustryseverely.Forinstance,onMarch12,the NepalgovernmentcanceledallEverestexpeditionsslatedfor 2020springseason.Inthepreviousyears,theDepartmentof TourismusedtocollectapproximatelyUS$4millionannuallyin royaltiesfromEverestclimbingpermits.Inadditiontopermits, eachclimbingteamusedtospendUS$40,000 90,000forother expenses(ICIMOD,2020).Thetourismsector,whichgenerates hugerevenueandprovideemploymenttoaconsiderableportion ofpeople,hasthereforebeenextremelyaffected(ICIMOD,2020).

Itisestimatedthatinthetrekkingsectoralone,thousandsof peoplewillbeseverelyaffectedwhileapproximately20,000tour guideswilllosetheirjobs(DeSilva,2020).Thehospitalitysector, whichemploysupto60,000workersinKathmandu,Pokharaand Chitwan,hasalreadybeenseverelyimpactedbythedropin tourism(Shrestha,2020).SimilarlyinIndia,40 50millionjob cutsareimminentfrombighotels,travelagenciesandtour operators(DevandSengupta,2020).Bhutanincurredalossof US$4.4millionandBangladeshlostUS$470millionfromboth domesticandinternationaltourism(UNWTO,2020).Becauseof thetravelban,theairlinesindustryisthehardesthitandunlikely torecoversoon.

TheCOVID-19pandemicisexpectedtoaffectthetourism demandandsupplyinSouthAsiadifferentially.Atthedemand side,internationalinboundtouristsareexpectedtobereduced, whileregionalanddomestictouriststobeincreased.Fromthe supplyperspective,lossofjobsandclosureofbusinessesrunby MSMEsintheshortterm,areexpectedtorecoverandrevivefrom themediumtermonwardsduetoagrowthinregionaland domestictourismintheregion.

ImpactonAgricultureandRuralLivelihoods

DuetotheCOVID-19pandemic,agriculturalvaluechainsand livelihoodsoftheagriculturedependentpopulationhasbeen suffering(Morton2020; SulserandDunston,2020).InSouth Asia,majorityoftheruralpopulationdependonagricultureand agri-relatedactivities.Agricultureinthisregionislaborintensive andemploysover50%oftherespectivecountries’ laborforce. Becauseofitshighlaborintensity,agriculturebasedrural economyandlivelihoodsaredisruptedbyCOVID-19and resultantquarantine,restrictionsonmovementofgoodsand servicesandclosureofcross-bordertrade(SulserandDunston, 2020; Rasul,2021).TheCOVID-19induceddisruptionaffectsthe

agricultureandtheentirefoodsystem theproduction, transportation,marketing,distributionandconsumption.Out ofpanic,evenafewgrainexportingcountriesintheearlymonths ofcovid-19restrictionshaverestrictedtheirexports,which disruptedtheinternationaltrade,erodedconfidenceonthe globalfoodmarketandcultivatedinsecurity(IFPRI,2020).

COVID-19hasdisruptedagriculturaloperationintheSouth Asianregionbecauseofshortagesoflaborandinputs,asshutdownsextendedtoruralareas,villageroads,transportationand marketingofgoods,alltocontrolthemovementofpeoplein ordertoeffectivelycurbthespreadofthepandemic.Theoutbreak wasinitiallyexperiencedduringtheplantingandharvesting seasonofmanycrops,includingwheatandpaddy,thetwo majorstaplefoodsintheregion(Rasul,2020).

Mostaffectedsub-sectorsarefruits,vegetables,poultryand dairy.Forexample,thepoultrysectorinNepalhasbeenlosingRs 220millionperdayinrecentmonths(Shrestha,2020).Fruitsare themajorcashcropsintheregion,andthesectorwasaffected badlyduetotransportationbanandlackofstorageand processingfacilities.Similarly,dairyfarmerscouldnotsell milk;beekeeperscouldnotmigratetheirbeesforspring bloomsorgetbucketsforcollection/storageofharvested honeyandperformhoneybeecolonymultiplicationwork/ queenrearing,andpeoplecouldnotcollect/harvestnontimberforestproducts(NTFPs)either.

ShocksinAgricultureandFoodSecurity duetotheCOVID-19

AlthoughindevelopedcountriestheimpactofCOVID-19on agricultureisrelativelyless,inSouthAsiatheimpactis substantialbecauseoflessmechanizationandhighlabor intensityinagriculture.AcrossSouthAsia,ruralpopulations dependonagricultureandagriculture-relatedactivitiesfortheir livelihoods;about50%oftheworkersareengagedinagriculture (Rasul,2020 ; Rasul,2021).Whilethecurrentpolicymeasuresof socialdistancingandlockdownarecriticaltosavepeople’slives andforcombatingthespreadofthecoronavirus,thesemeasures haveaffectedtheagriculturaloperationswithmanymigrant workersunabletoparticipateinagriculturalactivities.The disruptionsarisingfromCOVID-19responseshaveimpacted agriculturalactivitiesanditssupplychain,includingthe marketing,transportation,distributionandconsumptionof agriculturalgoodsandinputsinSouthAsia(Rasul,2021).

TheintensityofCOVID-19shocksonagricultureintheSouth AsiancountriesishighbecausethetimingoftheCOVID-19 pandemicoutbreakcoincidedwiththeplantingandharvesting seasonofmanycropsincludingwheat,paddy,fruitsand vegetables.Forinstance,inBangladesh,farmerscouldnot deliverharvestedwatermelontomarketsduetotransportation bans(Dasetal.,2020; ICIMOD,2020; vanBodegom,and Koopmanschap,2020).AccordingtoFAO(2020),the pandemicrestrictionsinBangladeshseverelyhamperedthe country’sexportoftropicalfruits.Additionally,duetotravel restrictions,seasonallabourerscouldnotreachtheagricultural sitesfortheBororiceharvest,whichaccountsforoverhalfthe nation’sriceproduction.Marketingandsellingofpoultry,dairy andfruitshavealsobeenaffectedseverelyinmanySouthAsian countries,particularlythehillandmountainregions.Despite governmentmanyefforts,urbanpoorhouseholdsinBangladesh facedacutefoodinsecurityduringthelockdownperiod(Das etal.,2020).

COVID-19hasdisruptedfoodtransportationandsupply chainindifferentpartsofSouthAsia.Becauseoftransport restrictionandmarketdisruptions,pricesoffarmproducts havecollapsedandfarmershavehadtoselltheirharvested productsatverylowrates.Forinstance,farmpricesforwheat inIndiahavedeclinedsubstantiallyduetolackoffacilitiesto transporttheharvesttothemarkets(DevandSengupta,2020). Similarly,demandforpoultryhasalsoshrunkenconsiderably. Whilepricesoffarmproductshavedeclined,theconsumerprice ofmanyessentialfooditemsincreasedinalmostalltheSouth AsiancountriesduringtheinitialoutbreakoftheCOVID-19. Duringthelockdownsmostofthecountriesexperiencedhigher pricesoffooditemsandevenshortageoffood.Thesituationwas furtheraggravatedbytherestrictionofcross-bordermovementof goodsandtrade.Afewofthemajorgrain-exportingcountries alsorestrictedtheirexportsoutoffearofdomesticfood shortages,whichdisruptedinternationaltradeandregional foodmarkets,andcausedacutescarcityinimportdependent countries.Borderrestrictionsfurthermoreaffectedthe transportofagriculturalinputssuchaschemicalfertilizers, seeds,andfarmequipment.Adeclineinfoodandinputstrade affectedfoodavailabilityinremoteareasandmayhavecaused pricehikeinfoodimportingcountrieslikeAfghanistan, Bhutan,MaldivesandNepal( ICIMOD,2020 ).Forinstance, inAfghanistan,initiallyfoodpricesincreasedby30%inKabul whenitsborderwithPakistanclosed,withwheat fl ourprices increasingby80 100%inMarch( Rahim,2020 ).Meetingfood andnutritionalrequirementsinmanySouthAsianhouseholds hasbeenachallengeduetotheincreasingfoodpricesandloss ofjobsduringtheperiodofthelockdown.Manypoor householdshavebeenpushedtocuttheirexpenditureon fooditemswhichhascompromisedtheirnutrition.Several householdshaveevenbeenforcedtoborrowmoneyoruse theirsavingstobuyfood.AsestimatedbytheUnitedNations University,theCOVID-19pandemicwillpush16million peopleinSouthAsiaintoextremepoverty( Sumneretal., 2020 ;UNESCAP,2020).Moreover,aglobaleconomic slowdownishighlylikelytoforceinternationalmigrant workerstoreturntotheirhomecountries,thusdryingup

vitalforeignexchangeresourcesinmanySouthAsian countrieswhichwillconsequentlyaffecttheirfood purchasingpower.

Socio-CulturalImpacts

Physicalisolationcausedbythelockdownshasimpactedsocial relationships,socialinteractions,andshedlightondeep-rooted socialnormsandexclusionsallovertheworldincludingSouth Asia.Suddenlayoffsandlossofworkhaveledtodepression, alcoholism,substanceabuse,andinsomecasessuicides(Hossain etal.,2020).Althoughpooranddisadvantagedgroupssuffers more.Newspaperreportsandvideoscirculatingonsocialmedia recordthousandsofmigrantworkersstuckatnationaland internationalborders,unabletoreturntotheirownhomes expressingasenseofabandonment,unfairtreatment,and rage.Thenegativepsychologicalimpactsofthepandemicand measurestocontainitareraisingconcernsaboutmental wellbeing,especiallythatofseniorcitizens,frontlinehealthcare providers,andindividualswithexistinghealthproblems.The restrictedmobilitycausedbylockdownshasbeenespecially challengingforchronicpatientsandthedifferentlyabledwho requireregularmedicalcare,butinmanycases,havebeenunable toaccessit.Thereisverylittlepublicinformationavailable regardingtheconditionsofthoselivinginstate institutions prisons,mentalhealthinstitutions,shelterhomes, andorphanages(ICIMOD,2020).Manystudentswhose campusesareclosed findthemselvesstranded,oftenveryfar fromtheirhomesandmanyexpressasenseofhopelessness. Suddenlayoffsandlossofworkhaveledtodepression, alcoholism,substanceabuse,andinsomecases,suicides. Closureofschoolshasalsodeniedtochildrenofpoorer households,accesstomid-daymealswhichcouldhaveadverse effectsonnutrition,resultinginincreasedratesofstunting (UNESCAP,2020).Itisalsoreporteddomesticabuseof womenhassharplyincreasedduringthelockdownperiodin manypartsofSouthAsia(ICIMOD,2020).Thecovid-19 pandemichasintensifiedtheexistinginequalitiesandfurther creatingnewformsofexclusion.

EMERGINGSOCIALRISKSAND VULNERABILITIES

SocialprotectionsystemisverylimitedacrosstheSouthAsian countries,wherevulnerablepopulationisexpectedtoface unprecedentedchallengeduetotheCOVID-19pandemicat theirownexpense.Ahugeshareofpopulationsintheregion isinvolvedininformalworkwithdailywagelabor.TheCOVID19pandemicislikelytobringadditionalrisksandchallengesfor SouthAsia,impactingcommunitiesandhouseholdsthrough multiplechannels.Thepoorestofthepoorhouseholdsand communitieshavealreadybeenimpactedthroughthe collapse/reductionoftourism,sharpfallinmigrationand remittances(bothexternalandinternal),andlossofjobsin theurbanareas.Informaljobsinthecitiesandurbanareas haveevidentlyshrunk.Largenumbersofinternalmigrant workershavereturnedbackhomeandmanyinternational

TABLE6| Emergingsocialrisksandchallengesandpossiblesocio-economicimplications.

Drivers/triggersEmergingrisksand challengesforsouth Asiancountries

•Coronavirushitsinwavesandthereishugeuncertainty aboutthefutureofthespreadofthecoronavirus

•Coronaviruscontinuestospreadandtheeconomic slowdowncontinues

•Extendedlockdown

•Shrinkingglobaldemand,reducedexports,increased spendingonCOVID-19riskmanagementandsocial protection

•Declininginformalemploymentwhenfactories, constructionsites,hospitality/servicesectorandother informalbusinessesareclosedinthecities

•SlowrevivalofMSMEs

•SomeSMEsdonotsurvivethecrisis

•Reversemigrationtakesplaceinmountainareas

•Increaseduncertaintyaboutfutureofthespreadof thecoronavirus

•Highriskof fiscaldeficitandmacroeconomic instability

•Devastatingeconomicimpactsespeciallyfor mountaineconomies

•Increasedlockdownanddevastatingimpactson theregionaleconomy

•Increasedrisksonmacroeconomicstabilityand investmentforeconomicrecovery

•Increased fiscalde ficitandmonetaryburdendueto decliningrevenuesandincreasedpublic expenditure

•Increasedunemploymentandunderemployment

•DwindlingMSMEsandinformalbusinesses

•Declininghouseholdincome

•Increasedeconomicvulnerability

•Losingdevelopmentgainandincreasingpoverty

Socio-economicimplications

•Higherrisksandvulnerabilitiesinmountainareas

•Increasedhealthrisksandinaccessibilitytohealth services

•Overburdenedhealthsystems

•Prolongedeconomicrecoveryandhigheconomicand socialcosts

•Compoundedeconomicchallenges

•Sloweconomicrecovery

•Increasedpressureonalreadyfragilelivelihoods

•Doubleburdenformountaineconomiesandincreased economicvulnerability

•Losingjobsandincome

•Deterioratedmountaineconomiesandlivelihoods

•Increasedneedforimprovinglocaleconomic opportunitiestoengagethereturneemigrantsin productiveactivities

•Increasedchallengeforcreatingjobsinmountainareas includinginpublicworks

•Migrantworkerscannotreturntotheiroriginaljobsinthe country

•Increasedreturnofmigrantworkersfromabroaddueto limitedjobopportunitiesindestinationcountries

•Slowrevivaloftourismduetohighavoidanceandrisk behavior

•Extendedlengthofavoidancebehavior

•Decreaseddomesticandinternationalmigration andremittance

•Increasedvulnerabilitiesofmigranthouseholds

•Increasedriskonfoodinsecurity

•Reducedincomefromtravelandtourism

•Affectedjobsandlivelihoods

•Protractedchallengeofrepatriationofreturneemigrants andengagingtheminproductiveeconomicactivities

•Increasedneedforensuringcross-bordermigrationin theregion

•Undermineseconomicstabilityandaffectslivelihoods

•Fallingintopovertytrap

•Increasedchallengeofrevivingtourismsector

•Bhutan,Nepalandothermountainareasmayface protractedchallengesduetohighdependenceon internationaltourists

•Increasedrisksandvulnerabilitiesonmountain livelihoods

•Lossoflivelihoods,indebtedness,lossofproductive assets

•Increasedriskofslippingintopoverty

•

•

•Increasedindebtedness,lossofproductiveassets

•

•

•

•

•

•

•

•Adverseimpactonfoodproductionandsupply chainandonfoodprices

•

•

•

•Highvulnerabilitiesandfoodinsecurity

•Heightenedneedformaintainingbufferfoodstocks

•Increasedneedforregionalcooperationtosmooth movementoffood

•

•Long-termadverseimpactonfuturegeneration

•

•

•

•

•

TABLE6|

•Soaringunemployment,lowincome,foodinsecurity andincreasinglevelofanxietyamongpeoplemay generatediscontentandfrustrationfuelingviolenceand conflict

•Increasedsocialtension,disturbancesandcrimes

•Increasedgenderandsocialcon flict

Socio-economicimplications

•Exacerbatedexistinginequalitiesandsocialtensionand con flicts

•Chronicpovertyslidingbackinthehillsandmountains

•Deeperpovertyandinequalitytraps

•Reinforcedinequality

•Increasedsocialtension,disturbancesandcrimes

migrantsarealsoreturningorwillhavetoreturntotheir respectivecountriesofnationalityintheshort-ormediumterm.TheseinitialimpactsofCOVID-19will,however, permeatetoothersectorsincludingagriculture.

Besidesthelossofincomefromjobandmigration,theSouth Asianpopulationwillsufferfromthedampeneddemandoftheir productsandservicesduetofallinaggregatedemandand avoidancebehavior(e.g.,tourism,travel,recreation)dueto ongoingrisksofcontractingthevirus.Moreover,thelossof incomeandfallinremittancesmayincreaseindebtednessand forcehouseholdstoselltheirproductiveassetsand/orseverely restricttheabilityofthepoorhouseholdstoinvestineducationof theirchildren,and/orcompromiseontheirnutrition,whichwill havelong-lastingeffects.Thismaydeepenpoverty,inequalitiesand vulnerabilitiesintheregion.Theeconomicandsocialcostsofthe COVID-19outbreakarelikelytobesignificantandlong-lasting.

Besidesfewonlineschooling,mostoftheschoolsareclosed andmillionsofchildrenareoutofschool.Itisexpectedthatmany children,especiallygirls,marginalizedcommunities,andthe disabledmaynotbebacktoschool,astheywillbeforcedto makeupfortheirhouseholdincomelosscausedbythepandemic. Table6 presentstheexistingdrivers,emergingrisksand challenges,andpotentialimplicationsforSouthAsia.

Itisevidentfrom Table4 thattheCovid-19pandemichasled tomultiplerisksandchallenges.Duetotherestrictionontravel, tourism,andgatheringofpeopletomaintainphysicaldistancing, thedemandforallkindsofgoodsandservicesaresuppresseddue toforwardandbackwardlinkages.Asaresult,tradevolumes (bothimportsandexports)havedeclinedconsiderably.However, thedomesticspendingonhealthsector,andsocialsecurityhas beenincreased,buttaxrevenuedeclinedwhichhave macroeconomicimplications.

AsalargeshareofeconomicactivitiesinSouthAsiaare informal,theclosureoffactoriesandrestaurants,andthedecline oftourismanddemandforgoodsandservices,hasshrunkthe region’slaborabsorptioncapacity.Asaresult,unemployment rateshavesoaredwhileincomeshavedeclined(CMIE,2020). Thishasmademillionsofhouseholdsvulnerabletopoverty.

Whenfactories,constructionsites,travelandtourismsectors closed,migrantworkersreturnedbacktotheirvillages.This return-migrationtrendisalsotakingplaceattheinternational level,wheremigrantworkersworkinginforeigncountrieshave losttheirjobsandarereturningbackhome.Returneemigrants needadditionalsupportfortheirsurvivalandintheabsenceof

suchsupportsystem,theirfamiliesaremorelikelytobe vulnerabletopovertysincehouseholdsnotonlyneedto supportadditionalmembersbuthavealsolostremittances. Covid-19islikelytodeepenpovertyandreinforceinequality, increasesocialtension,disturbancesandcrimesinSouthAsia.

EMERGINGOPPORTUNITIES

Thecurrentsituationprovidesauniqueopportunitytousethe disruptiveforcesoftheCOVID-19pandemicandtheassociated policiesforrecovery;toacceleratethetransitiontomore sustainableandresilientsocieties(Rasul,2020).Someofthe short-termmeasurestoaddressthechallengesofCOVID-19 canbelinkedtoeconomicgrowthbyinvestinginnatural capitaltoimprovethelong-termproductivityandresiliencein theregion.Thisrequiresstrategicthinkingandstrategiesforlongterminvestmenttoensurethatshort-termactionsresultinlongtermbenefits.Short-termsupportcanbelinkedtolong-term socio-economicgrowththroughappropriateplanningand strategizingwhichwillimprovethesocialandenvironmental conditionsforthesustainablerecoveryofthehealthand economicsectors(Rasul,2020).Forexample,foodforwork programscanbelinkedtoprogramsthatconstructormaintain localinfrastructuresuchasroads,irrigationcanals,managementof watershedthushelpingpoorhouseholdstocopewithvulnerability whilebuildingassetsthatareessentialforsociety.Similarly, requirementstoincludeenergyefficiencyinbuildingdesigns canbelinkedtosupportprovidedtobuildingconstruction companiestorestorejobs,thusprovidingjobrestorationinthe short-termandclimatebenefitsinthelong-term.

LeveragingCivilSocietyandPrivate Innovation

Thelockdownhasalsopromptedactorsinvolvedinsupplychains toadaptanumberofimportantprivatesectorinnovationstocope withthepandemicrestrictions(SulserandDunston,2020). E-commercehasbeengrowingsteadilyintherecentyearsin SouthAsiaduetoincreaseddigitalconnectednessandthe developmentofinformationandcommunicationstechnologies. Duringthisperiod,forinstance,consumer-ledgroupson Twitter,Facebook,andWhatsApphaveorganizedwithFarmer ProducerOrganizationsinseveralcountriesto findwaysofbringing

foodtomarkets(NarayananandSaha,2020).Manyfarmersbegan deliveringproducedirectlyusingWhatsApptosecureaggregated ordersinhousingcooperativesinnearbycities(Narayanan,2020). InIndia,Swiggy,afast-growingfooddeliveryappandlogistics company,deliversfor40,000restaurantpartners,helpingthemwith its “jumpstartpackage” torecoversales,whiletheSwiggyCapital AssistProgramhelpspayforhygieneanddistancingupgrades. Duringthefarmers’ marketsshutdown,somefarmerstraveledto citiestosetupshopatroadsidesmaintainingphysicaldistance.In India,FlipkartisgrowingfastduringtheCOVID-19crisisand developeda “hyperlocaldelivery”groceryservicelinkingSME supplierswithdomesticsupermarketchainslikeVishalMega Martwithitse-commerceoperations(TheEconomicTimes, 2020).Nepal’snascente-commercesectorhasalsogrowing steadilysincethelockdownstarted.

Globalenergydemandhasdeclinedsharplyduetothe mitigationmeasuresofCOVID-19andenergypriceisalso goingdownsharply.SincemostoftheSouthAsiancountries arenetenergyimporters,thefallingoilpricecouldbenefitthese countries.Thereducedoilpriceswillnotonlylowertheimport billbutalsohelpsaveforeignexchangeandwillhavepositive impactsonthecurrentaccountbalance.Forexample,Indiaisthe fourthlargestconsumerofoilintheglobalmarketandarough estimatesuggeststhat “aUS$10fallincrudecouldreducethe currentaccountdeficitbyapproximately0.5%ofGDPandthe fiscaldeficitbyaround0.1%ofGDP” (SandeepNayak,The EconomicTimes,January12,2015).Theloweroilpriceswill havepositiveimpactsonmanufacturing,costoffertilizer productionforagriculture,costsoftransportationandmany otherenergydependentsectors.ThePakistangovernmenthas alreadydeclaredareductioninoilpricesbyRs.20perliter (DAWN,2020).Thedecreaseinoilpriceswilldecrease productioncostandcanhavepositiveimpactsonmanaging inflationandlivingexpenses.

Anothersectorwithfuturegrowthpotentialishealthservices andmedicalgoodsandservices.BecauseofCOVID-19pandemic, peoplearenowmoreconsciousabouthealthandthe governmentsmaythusinvestmoreinstrengtheninghealth facilities.Thisislikelytoincreasethedemandforhealthand medicalproducts,includingfooditemswithhealthbenefits.This couldcreateanincreaseddemandforhealthandmedicinal products,includingthefoodswithnutritionalbenefits.The pandemicandresultantdisruptioninsupplychainhascreated aneedforproperdevelopmentoflocaleconomy,localfood system,andbothon-andoff-farmactivities.Otherimportant areasofemergingopportunitiescouldbethedevelopmentof internet-basedservicesectors.Thepandemichascreated additionaldemandforinternet-basedeconomicactivities,such asonlineshopping,distanceeducation,aswellasonlinemedical servicesandworkfromhome,whichmaychangethedemandfor officespaceandtravelneeds.Policiesthatreducejobmarket frictionsandfacilitatelaboradaptationtothesejobopportunities wouldbeneeded,oncethepandemiciscontrolledinworking towardaself-relianteconomyfortheregion.

TheCOVID19pandemicalsoprovidesanopportunityto buildresilienceinthemostvulnerableregionthroughtheuseof stimuluspackagestotacklethepovertyandotherissues.The

governmentmayplanstrategicallytopreventrisksandimprove resiliency,forinstancebypromotingsustainabledevelopmentto reducetheimpactofothershocks,suchasnaturaldisasters,inthe future.AsSouthAsiancountrieshavecommittedtomeetthe SDGsby2030,thegovernmentsshouldutilizetheirresourcesand investinassistingthepeopleaffectedbytheCOVID-19.

GOVERNMENTANDCIVILSOCIETY RESPONSES

ThegovernmentsofSouthAsiancountrieshaveresponded promptlyandadoptedseveralpolicymeasurestocontainthe spreadoftheCOVID-19,supportthepoorpeopletoensurefood, andprovidestimulustoeconomicsectors.Inthissection,we brieflypresenttheeconomicresponsemeasurestakenbySouth Asiancountries.

ResponsetoSupportVulnerablePeople

Themajorfocusofgovernmentresponseonpreparationsto containthespreadofthevirus,increaseresourcesforthehealthcaresystemincluding financialsupportformedicaltestingand treatmentofthedisease,aswellas fiscalsupportforemergency publicinterventionstoincreasehospitalcapacityandmedical supplies.Allthegovernmentshavestrengthenedtheirsocial protectionprogrammes(cashandassettransfer,including food)andprovidedresourcesforsupportingpoorand vulnerablegroups,andprovidedwagesupporttolow-wage workers.Forinstance,theGovernmentofAfghanistan allocatedUS$15milliontocontaincoronavirus;the GovernmentofBangladeshallocatedUS$29milliontofund theCOVID-19preparednessandresponse;theGovernmentof IndiaallocatedUS$22.6billiontoprovideessentialfooditems, healthfacilities,fuelanddirectcashtosupportthepoorpeople andseniorcitizens;andtheGovernmentofPakistanintroduceda reliefpackageworthUS$7billionfornextthreemonths.The governmentsofBhutan,andNepalalsoadopteddifferentsocial protectionmeasurestosupportpoorandvulnerablegroups.For example,Nepalgovernmenttookfullresponsibilityofbearingthe costoftestingandtreatmentsofpeoplewhohavebeeninfectedby thecoronavirus.Insomeofthesecountries,monetaryincentives andsupportwasalsoprovidedtoencouragepeopletocomply withthequarantineefforts.Besidesgovernmentsupport,NGOs, civilsocieties,privatesectorandreligiousorganizationsalso extendedtheirsupportinprovidingfoodandessentialitems tothepoor.InPakistan,governmenthasEhsaasprogramto strengthencoordinationwithNGOsandothercivilbodiesto targetthepoorpopulationfordeliveryofrationsmoreeffectively.

ResponsetoMinimizetheShort-Term EconomicPain

Besidessupportingvulnerablepeople,governmentsofSouth Asiancountrieshavealsoadoptedvarious fiscalandmonetary measurestominimizetheshort-termeconomicpainandtoinject liquidityintothe financialsystem.Thegovernmentshave adopteddifferentmeasuresincludingconcessionallendingto

prioritizedsectors,reducedrestrictionsonpaymentssuchas forbearanceoftaxes,rentandutilitypaymentsanddeadlines forloanpaymentstomakeliquidityavailableandtoprovide flexibilityfordebtors.Forinstance,theReserveBankofIndia rolledoutaplanof1.8%ofGDPtoincreaseliquidityinthe financialsectors.Inadditiontothecentralgovernmentefforts, someStatesinIndiaalsoadoptedstimulusmeasurestosustain economicactivitiesandsupportthepoor.ForinstanceKerala StatehasannouncedUS$2.6billionpackage(2.5%ofthestate GDP)foreconomicrecoveryandsomedirecttransferstopoor households(WorldBank,2020a).Similarly,Governmentof Pakistanintroducedahugestimuluspackageand financial supportincludingUS$600millionsupporttoSMEsandtax refundstotheexportindustry(WorldBank,2020a).Government ofBangladeshannouncedtheplanofUS$588millionsalary supporttogarmentandotherexportindustriestosupporttheir workers.GovernmentofNepalalsointroducedconcessional loansforSMEstopaytheirworkers.

ResponsetoReopenandRevitalize Economy

Differentcountriesadopteddifferentstrategiesforgradualopeningof theeconomiesandproviding financialsupporttoprioritysectorsto reviveeconomicactivities.GovernmentofIndiahasadopteda measureofzoningthecountrybasedontheprevalenceofthe coronaviruscasestorelaxthelockdownandgraduallyrestart economicactivitiesinareaswherethevirusisabsentorlowin number,yettakingstringentmeasuresinthehotspotareas.The stategovernmentofAssam,Indiahasconstitutedataskforcetodesign strategiestorevivethestate’seconomy.India’scentralbankhas introducedmeasurestoincrease liquiditytoincreaseaccessto creditforthepharmaceutical,constructionandtourismindustries. Bangladeshgovernmentisproviding50 70%subsidytofarmersfor buyingharvesterstoaddressthechallengesoflaborshortageinpaddy harvesting.ThegovernmentsofBhutan,MyanmarandNepalhave alsorolledoutdifferentmeasurestostimulateSMEs(WorldBank, 2020a).ItishearteningthatBenapole-Petrapolelandborderbetween BangladeshandIndiahasopenedrecentlyafterthreeweeksof lockdowntofacilitatemovementofpeopleonemergencyground (ICIMOD,2020).

CONCLUSIONANDPOLICY RECOMMENDATIONS

TheCOVID-19pandemichasposedahugeriskandseverely impactedthesocio-economicconditionandlivelihoodofpeoplein SouthAsia.Thecoronavirusisstillspreadinganditisdifficultto predictwhenitwillbecompletelycontained.Theunprecedented challengeposedbytheCOVID-19pandemiccallsforveryurgentand decisiveactionstoensurethatpeople’slivesaresaved,livelihoodsare protectedandtheeconomyrecovers.TheCovid-19outbreakhas causeddirecthighcostsonhumanhealthandeconomicactivities,and posesthemostadverseeffectsonlivelihoodsofthepoorandthemost vulnerablecommunities.Thisstudydiscussessomeofthecrucialkey pointsthatmayhelpassistvulnerablegroupofpeoplewhoare

sufferingfromthispandemic.Sincethecoverageofsocialsecurity systemisminimalorabsentaltogetherinmostoftheSouthAsian countries,thegovernmentshouldmanagetogivesomesortofsocial securityfacilitiestothepoorestpopulation,morespecificallywhen theylosetheirinformalemploymentopportunities.Improvingsaving habitsofthepoorandprovidingaccesstobankingserviceswould,for instance,providesafetynetsduringtimesofcrisis.

Ashealth,environmentandsocialissuesareinterconnected, concertedeffortsarerequiredtomitigateandrecoverfromthe damagesbroughtbytheCOVID-19onoursocietiesand economies.Governmentsneedtoprioritizetheiractivitiesfor short,medium,andlong-term.Regionalandglobalcooperation isalsonecessarytoaddresstherippleeffectsofCOVID-19on differentsocieties.ThecountriesofSouthAsiamustact collectivelytoaddresstheirchallengesandtocreatefavourable conditionsforeconomicrecovery.Importantly,innovative strategiesandapproachesareneededtoaddressthe coronaviruschallenges.ThegovernmentsoftheSouthAsian countriesmayconsiderthefollowingpolicymeasurestomitigate thenegativeimpactsofthepandemiconthepoorandmost vulnerablesectionsofthesocietyandtopromoteeconomic recovery.

• PlanforaneconomicrecoveryfromCOVID-19 todevelop astrategytoadaptquicklybasedonthesituation,avoiding blanketlockdownssothatareaswithlowintensityriskarenot affectedduetoclosureofthelocaleconomies,sinceblanket shutdownoftheeconomyhastakenadevastatingtollonthe economyandpeople’slivelihoods.TheIndianapproachof categorizationofthecountrybasedontheprevalenceofthe coronaviruscasesandopeningtheeconomicactivitiesin areaswherevirusisabsentorlow,andintroducingstringent measuresinhotspotareascouldbeagoodstartingpoint. Detailedguideline,however,isnecessarytooperationalize suchpolicies,suchasfollowingclearprotocoldeveloped basedonlocalconditionandevidenceaswellasclear strategiesforcontainingthevirusafteropening.Dueto thelackofsuchprotocols,theriskofresurgenceofthe COVID-19virusisquitehighinthesecountries,asitis hasevidentlybeenoccurringintheUnitedStatesand Europeancountries.Itisimportanttousethemedia intensivelytoraiseawarenessamongpublicand disseminatetargetedhealthcareeducationandselfprotectionaswellassupportingmentalhealth(Khajanchi etal.,2020).

• Developroadmapforachievingshort,medium,and long-termgoals torevitalizethenationalandsubnationaleconomybytakingintoaccountthespeci fi c conditionandneedsofthepoorandvulnerablegroups atsub-nationallevel.Intheshortterm,focusshouldbe onaddressingtheimmediatehealthcrisis,ensuringfood andnutritionalsecurity,sho rter-termjobcreationand transferringincomestotheneedypopulationtosurvive theeconomy.Mediumtermfocusshouldbeonboosting economicactivitiestorecovertheeconomyandin designingandimplementingthebestpossible stimulustoachieve fi nancialrecovery.Thelong-term

goalshouldbe t ransformingorbouncingtheeconomy forwardbypromotinglong-termsustainablegrowth andpovertyreduction.

• Orchestratethe fiscal,monetaryanddevelopment interventioninanintegratedandcoordinatedmannersso thatdifferentpolicymeasurescomplementeachotherand multiplytheireffectsineconomicrecovery.Whiletheshorttermfocuswillbeonaddressingtheimpactsofthepandemic andrestoringjobsandemployment,thelong-termfocuscould beonimprovinglong-termproductivityandresilienceby investinginabalancedportfolioofphysical,human,social andnaturalcapitals,whichwillbuildcapacitytodealwith futurechallengesandmitigatetheimpactoffuturepandemics andothersocio-economicshocks.Forexample,investmentin health,education,skillsdevelopment,innovation,technological upgrading,andgreeninfrastructureandnaturalcapitalwill increasetheproductivecapacityofthepopulationand providesustainablereturnsforfuturegenerations.

• Redoubletheeffortsofsocialprotection toprotectthepoor, vulnerablegroups,andmigrantworkersandcompensatethe lossofincomesothattheycanmaintainminimumstandardof livinganddonotslidebacktopoverty.Investmentinsocial protectionandjobcreationwillbeneededtoprotectthe vulnerableintheshortterm,butpolicyprioritiescould graduallyshifttoreducingtheenvironmentalrisksaffecting humanhealthandvulnerabilitytoclimatechange.Protecting andenhancingnaturalcapitalsuchasforests,soils,water resources,ecosystems,biodiversity,airquality,andclimate cansupporthumanhealthandproductivityandimprove long-termresilience.Forexample,investmentingreen infrastructuresuchasrenewableenergycansupplyclean energyandimproveairquality,whichleadstolong-term healthbenefitsandpositiveclimateoutcomes

• Boostingeconomic activityandinvestinginjobcreationinareas wherepoorandlowlyskilledworkerscanparticipateandget benefits.Instrivingforsustainability,policychoices,and investmentdecisionsshouldbearrangedstrategicallyinsuch awaythattheynotonlyaddress immediateproblemsbutalso buildlong-termresilience, strengthentheexistingpoverty alleviationprogram andtargetedpovertyreduction programsinassetbuildingandeconomicrecovery.

REFERENCES

Acharya,R.,andPorwal,A.(2020).Avulnerabilityindexforthemanagementof andresponsetotheCOVID-19epidemicinIndia:anecologicalstudy. Lancet 8,E1142 E1151.doi:10.1016/S2214-109X(20)30300-4

AcuitéRatings(2020).Covid-19lockdownestimatedtocostIndia$4.5billiona day:acuitéRatings. TheHINDUBusinessLine. April,2. Awasthi,G.,(2020).Gokarnarevivingtheworldaftercovid-19crisis. Kathamdu Post. April,24.

Babu,G.R.,Khetrapal,S.,John,D.A.,Deepa,R.,andNarayan,K.V.(2020). PandemicpreparednessandresponsetoCOVID-19inSouthAsianCountries. Int.J.Infect.Dis.,104,169 174.doi:10.1016/j.ijid.2020.12.048

Baldwin,R.,andTomiura,E.(2020).Thinkingaheadaboutthetradeimpactof COVID-19. EconomicsintheTimeofCOVID-19. A59,March,6. CMIE(CenterforMonitoringIndianEconomyPvt.Ltd)(2020).Unemployment rateshootsoutofrange.Availableat:https://www.cmie.com/kommon/bin/sr.

• Promoteregionalcooperation tofacilitateexpedientcrossbordermovementofessentialgoodsandservicesincluding medicines,medicalequipment,foods,andotheressential items.SouthAsiancountriesmustworktogethertoaddress thechallengeofpandemicandfastandsustainable economicrecovery.

• Reviewandrevisethepolicypriorities bywithdrawing subsidiesfromfossilfuelsandprovidingsubsidiesto greenrecovery,improvinghealthfacilities,boosting economicactivities,andfocusingonprogramsthat alleviatepovertyandvulnerabilities.Thedropinoil pricesoffersanopportunitytowithdrawtheexisting subsidiesonoilandotherfossilfuelsandinvestmore onrenewableenergysectorsthatsupportgreenjobs. Localfoodsystemshouldalsobestrengthenedat communitylevelstoimprovelocalfoodself-suf fi ciency andnutritionaloutcomes.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincludedin thearticle/SupplementaryMaterial,furtherinquiriescanbe directedtothecorrespondingauthor.

AUTHORCONTRIBUTIONS

GR,conceptualization,writingandrewriting;AN,AH,AM,SR, AL,PG,FA,AM,ESprovidedinputs.

ACKNOWLEDGMENT

ThisresearchwassupportedunderICIMOD’scorefund. ICIMODgratefullyacknowledgesthesupportofitscore donors:theGovernmentsofAfghanistan,Australia,Austria, Bangladesh,Bhutan,China,India,Myanmar,Nepal,Norway, Pakistan,Sweden,andSwitzerland.Theviewsandinterpretations inthispublicationarethoseoftheauthorsandarenotnecessarily attributabletoICIMODoritsmembercountries.

php?kall warticle&dt 2020-04-07%2008:26:04&msec 770(AccessedMay1, 2020).

Das,S.,Rasul,M.G.,Hossain,M.S.,Khan,A.R.,Alam,M.A.,Ahmed,T.,etal. (2020).Acutefoodinsecurityandshort-termcopingstrategiesofurbanand ruralhouseholdsofBangladeshduringthelockdownperiodofCOVID-19 pandemicof2020:reportofacross-sectionalsurvey. BMJOpen. 10,e043365. doi:10.1136/bmjopen-2020-043365

Davies,N.G.,Sweeney,S.,Torres-Rueda,S.,Bozzani,F.,Kitson,N.,Barasa,E.,etal. (2020).TheimpactofCoronavirusdisease2019(COVID-19)onhealthsystemsand householdresourcesinAfricaandSouthAsia. medRxiv Availableat:https://www. medrxiv.org/content/10.1101/2020.05.06.20092734v1.article-info(AccessedMay8, 2020).

DAWN(2020).MovetocutpetrolpricebyoverRs.20perlitre. DAWN. Available at:https://www.dawn.com/news/1553369(AccessedJanuary26,2021).

DeSilva,R.(2020).Nepal:massesconfrontenormoushardshipsfrom coronaviruspandemic. WorldSocialistWebsite. Availableat:https://www. wsws.org/en/articles/2020/04/04/nepa-a04.html(Accessed2020).

Dev,S.M.,andSengupta,R.(2020).Covid-19:impactontheIndianeconomy. IndiraGandhiInstituteofDevelopmentResearch. Availableat:http://www. igidr.ac.in/pdf/publication/WP-2020-013.pdf(Accessed2020).

ESCAP(2020).COVID-19andSouthAsia:nationalstrategiesandsubregional cooperationforacceleratinginclusive,sustainableandresilientrecovery. COVID19response.UnitedNations.EconomicandSocialCommissionfor AsiaandthePacific(ESCAP).

Hossain,M.S.,Ferdous,S.,andSiddiqee,M.(2020).MasspanicduringCOVID-19 outbreak AperspectivefromBangladeshasahigh-riskcountry. J.Biomed. Analyt. 3(2),1 3.

Ibn-Mohammed,T.,Mustapha,K.B.,Godsell,J.M.,Adamu,Z.,Babatunde,K.A., Akintade,D.D.,etal.(2020).AcriticalanalysisoftheimpactsofCOVID-19on theglobaleconomyandecosystemsandopportunitiesforcirculareconomy strategies. Resour.Conserv.Recycl. 105169.doi:10.1016/j.resconrec.2020. 105169

IMF(2020).Worldeconomicoutlook:alonganddifficultascent.Washington,DC: InternationalMonetaryFund.

ICIMOD(2020). COVID-19impactandpolicyresponsesintheHinduKush Himalaya. Lalitpur,Nepal:InternationalCentreforIntegratedMountain Development.

ILO(2018).Womenandmenintheinformaleconomy:Astatisticalpicture. Avialableat:https://www.ilo.org/global/publications/books/WCMS_626831/ lang en/index.htm(AccessedMarch1,2018).

ILO(2020a).ILOMonitor:COVID-19andtheworldofwork.Fifthedition Updatedestimatesandanalysis.Availableat:https://www.ilo.org/wcmsp5/ groups/public/@dgreports/@dcomm/documents/brie fingnote/wcms_749399. pdf(AccessedJune15,2020).

ILO(2020b).ILOMonitor:COVID-19andtheworldofwork.SecondeditionUpdated estimatesandanalysis.InternationalLabourOrganization.Availableat:https:// www.ilo.org/wcmsp5/g roups/public/@dgrepor ts/@dcomm/documents/ brie fi ngnote/wcms_740877.pdf(AccessedApril7,2020).

Khajanchi,S.,andSarkar,K.(2020).Forecastingthedailyandcumulativenumber ofcasesfortheCOVID-19pandemicinIndia. Chaos 30(7),071101.doi:10. 1063/5.0016240

Khajanchi,S.,Sarkar,K.,Mondal,J.,andPerc,M.(2020).DynamicsoftheCOVID19pandemicinIndia.[Preprint].doi:10.21203/rs.3.rs-27112/v1

KNOMAD(2020).Migrationanddevelopmentbrief33.Globalknowledge partnershiponmigrationanddevelopment(KNOMAD).Availableat:https:// www.knomad.org/sites/default/files/2020-11/Migration%20%26%20Development_ Brief%2033.pdf(Accessed2020).

Morton,J.(2020).Onthesusceptibilityandvulnerabilityofagriculturalvalue chainstoCOVID-19. WorldDev. 136,105132.doi:10.1016/j.worlddev.2020. 105132

Narayanan,S.(2020).HowIndia’sagrifoodsupplychainsfaredduringthe COVID-19lockdown,fromfarmtofork.IFPRIBlog.Availableat:https:// www.ifpri.org/blog/how-indias-agrifood-supply-chains-fared-during-covid19-lockdown-farm-fork(AccessedJuly20,2020).

Narayanan,S.,andSaha,S.(2020).Onestepbehind:thegovernmentofIndiaand agriculturalpolicyduringthecovid-19lockdown. Rev.AgrarianStudies. 10(1), 111 127.

Ozili,P.K.,andArun,T.(2020).SpilloverofCOVID-19:impactontheglobal economy.Availableat:https://papers.ssrn.com/sol3/papers.cfm?abstract_id 3562570 (AccessedMarch27,2020).

PIDE(PakistanInstituteofDevelopmentEconomics)(2020).PIDECovidBulletinNo. 4.SectoralanalysisofthevulnerablyemployedCOVID-19andthePakistan’slabour market.Islamabad:PakistanInstituteofDevelopmentEconomics.

PopulationCouncil,India(2020). Migrationandcovid-19:UttarPradeshand Bihar. India:PopulationCouncil.

Rahim,S.(2020).Covid-19hitsAfghaneconomy. TradeInsight. 16(1 2),16 19.

Rasul,G.(2020).Aframeworkforimprovingpolicyprioritiesinmanaging COVID-19 challengesindevelopingcountries Front. PublicHealth. 8, 589681.doi:10.3389/fpubh.2020.589681

Rasul,G.(2021).TwinchallengesofCOVID-19pandemicandclimatechangefor agricultureandfoodsecurityinSouthAsia. Environ.Challenges 2,100027. doi:10.1016/j.envc.2021.100027

Samui,P.,Mondal,J.,andKhajanchi,S.(2020).Amathematicalmodelfor COVID-19transmissiondynamicswithacasestudyofIndia. Chaos, SolitonsFractals. 140,110173.doi:10.1016/j.chaos.2020.110173

Shrestha,P.M.(2020).Withoutimmediatesupport,smallandmediumenterprises onvergeofcollapse. TheKathmanduPost. April,28.

Sulser,T.,andDunston,S.(2020).COVID-19-relatedtraderestrictionsonriceand wheatcoulddriveuppricesandincreasehunger.IFPRI,Blog.Availableat: https://www.ifpri.org/blog/covid-19-related-trade-restrictions-rice-and-wheatcould-drive-prices-and-increase-hunger(AccessedMay15,2020).

Sumner,A.,Hoy,C.,andOrtiz-Juarez,E.(2020).UNU40WIDER.Estimatesofthe impactofCOVID-19onglobalpoverty.800 809.Availableat:https:// reliefweb.int/report/world/estimates-impact-covid-19-global-poverty (AccessedApril8,2020).

TheEconomicTimes(2020).Flipkartpreparingtostarthyperlocaldeliveryservices. Availableat:https://retail.economictimes.indiatimes.com/news/e-commerce/e-tailing/ flipkart-preparing-to-start-hyperlocal-delivery-services-sources/76416609(Accessed June17,2020).

UNESCAP(2020).TheimpactofCOVID-19onSouthEastAsian.PolicyBrief. UnitedNationsEconomicandSocialCommissionforAsia.Availableat:https:// www.unescap.org/sites/default/d8files/2020-07/SG-Policy-brief-COVID-19-andSouth-East-Asia-30-July-2020.pdf

vanBodegom,A.,andKoopmanschap,E.(2020). TheCOVID-19pandemicand climatechangeadaptation,Wageningen,TheNetherlands:WageningenCentre forDevelopmentInnovation.

WorldBank(2020c).COVID-19crisisthroughamigrationlens,migrationand developmentbrief2020.Availableat:https://www.knomad.org/sites/default/ files/2020-06/R8_Migration&Remittances_brief32.pdf(AccessedApril2020). WorldBank;KNOMAD(2020).PhaseII:COVID-19crisisthroughamigration lens.Availableat:https://www.findevgateway.org/paper/2020/10/phase-iicovid-19-crisis-through-migration-lens(AccessedOctober2020). WorldBank(2020b). “EastAsiaandpacificinthetimeofCOVID-19” eastAsiaand pacificeconomicupdate(April).Washington,DC:WorldBank.Availableat:https:// openknowledge.worldbank.org/handle/10986/33477(AccessedMarch3,2020). WorldBank(2020a). “Publicbanks” SouthAsiaeconomicfocus(April), Washington,DC:WorldBank.

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialor financialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021Rasul,Nepal,Hussain,Maharjan,Joshi,Lama,Gurung,Ahmad, MishraandSharma.Thisisanopen-accessarticledistributedunderthetermsofthe CreativeCommonsAttributionLicense(CCBY).Theuse,distributionor reproductioninotherforumsispermitted,providedtheoriginalauthor(s)and thecopyrightowner(s)arecreditedandthattheoriginalpublicationinthisjournalis cited,inaccordancewithacceptedacademicpractice.Nouse,distributionor reproductionispermittedwhichdoesnotcomplywiththeseterms.

published:16March2021

doi: 10.3389/fcomm.2021.641199

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland Reviewedby: AngelBelzunegui-Eraso, UniversityofRoviraiVirgili,Spain PiiaTint, TallinnUniversityof Technology,Estonia

*Correspondence: MichalBeno beno@mail.vstecb.cz

Specialtysection: Thisarticlewassubmittedto OrganizationalPsychology, asectionofthejournal FrontiersinCommunication

Received: 13December2020

Accepted: 23February2021 Published: 16March2021

Citation: BenoMandHvoreckyJ(2021)Data onanAustrianCompany’s ProductivityinthePre-Covid-19Era, DuringtheLockdownandAfterIts Easing:ToWorkRemotelyorNot? Front.Commun.6:641199. doi:10.3389/fcomm.2021.641199

DataonanAustrianCompany’s ProductivityinthePre-Covid-19Era, DuringtheLockdownandAfterIts Easing:ToWorkRemotelyorNot?

MichalBeno* andJozefHvorecky

FacultyofBusinessStrategy,InstituteofTechnologyandBusinessinCeskeBudejovice,CeskeBudejovice,Czechia

TheCovid-19crisisacrosstheworldhasincreasedtheproportionofe-working.The transitionfromcubiclestothehomeofficeraisedmanyquestionsinconnectionwith companiesadoptingthenewworkingconditions.Ourpaperprovidesrecentevidence ontheextentofthismove,itsimpactonworkplaceevolution,productivityandthefuture prevalenceoftheface-to-displayworkplaceaftertheeasingofthelockdown.Ituses datafrom154serviceemployeesofanAustriansportsandleisureproductcompany obtainedusingonlinesurveysonemployees’opinionsone-working.Byacoincidence, weconductedthefirstofthemshortlypriortotheepidemic.Wedecidedtomodifyour plannedresearchgoalsanddecidedtostudytheiropinionsduringdifferentCovid-19 stages.Asaresult,ourfindingsdonotfollowalltheacademicstandards.First,they arealmostimpossibletoreplicateduetothespecificcoincidence.Then,theshiftinour aimsleadsustominorchangesinthecontentofthequestionnaire.Therearenotonly significantdifferencesintheproportionofworkersintheofficeandathomeduringthe differentperiodsofthelockdown.Afteritsend,therewasasignificantincreaseinthe numberofthosewhohadstartedworkingathome—morethanonehalf.Comparedto theperiodpriortothelockdown,theyhaveatolerantattitudetotheirworkfromhomeand believethattheirproductivitymightremainthesame.Formanyofthemthechangewas anunavoidableobligationsotheywouldprefertoreturntothetraditionalworkplace.The resultssuggestthatmorethanonefifthwanttocontinueworkingfromhomepermanently, aboutonethirdmorefrequentlythanbefore,morethanaquartersometimesandjust oneseventhnotatall.Westudiedtheissuesrelatedtotheirproductivityanditslimits duringallthreestages.Therearethreeimportantreasonsforthefallinproductivityrelated toe-working:(1)Providingchildcare/homeschooling,petsittingand/orcareforothers whileworking(>one-fourth);(2)Work-from-homeroutine(>one-fourth);and(3)Having lessworktodo(>one-fifth).

Keywords:face-to-displayworkplace,productivity,fallinproductivity,COVID-19,futureprevalance

INTRODUCTION

Covid-19hadspreadworldwide bythefirstweeksof2020 andwasdeclaredapandemicinMarch2020(WHO,2020). Reducingface-to-face contactsisanimportantactiontomitigate itsimpact(ILO,2020).Accordingto BaldwinandWeder diMauro(2020),the Covid-19economiccrisishasbeenan unprecedentedshockfortheEuropeaneconomyandsociety,and itrequiresswiftpolicyactionandacoordinatedfiscalresponse. Manygovernmentsenforcedregionallockdowns.TheAustrian governmentrespondedbyrequestingpeopletorefrainfrom leavingtheirhomesandbyencouraginge-workingwherever possible(OTS,2020).Companieswereforcedtoincreasetheir remotework.Witha figureof9.9%,Austriahadahighpercentage ofteleworkamongthecountriesoftheEuropeanUnionin 2019(Eurostat,2020a).Despitewidespreadpromotionbythe governmentandorganizationsin recentyears,theutilizationrate ofteleworkhasremainedstable(Eurostat,2020a).TheEuropean figuresareratherlow. Blinder (2009) estimatedtheupperlimit ofjobsinthe USthatcouldpotentiallybedoneoffshorein2004 atbetween22and29%.In2013,allmeasuresfoundthatroughly 25%ofUSjobscanbedoneoffshore(BlinderandKrueger,2009). Inarecentstudy,theauthors’classificationshowsthat37%ofUS jobscanplausiblybeperformedathome(DingelandNeiman, 2020).

Theepidemiclaunched ane-working experimentacrossthe world.Priortoit,thehomeofficewasonlyusedbyafew individualsorsmallgroupsin75%ofAustriancompanies. Thesituationhaschangedsuddenly.Atotalof90%ofthose surveyedstatedthatatleasthalfoftheworkforceworkedfrom homeduringthelockdown(Deloitte,2020).Innearly60%of companies,almostallemployees workedfromhome.Among thecompaniesthattookpartinthesurvey,96%usedhome officesintensivelyduringthelockdown(Deloitte,2020).Across theEuropeanUnion,overa third(33.7%)reportedworking exclusivelyfromhomeduringthepandemic(Eurofound,2020). Furthermore, Brynjolfssonet al.(2020) foundthatabouthalfof USemployeesarenowworkingfrom home,including35.2%who reportedtheywerepreviouslycommuting,butrecentlyswitched toworkingfromhome.Theirsurveyestimatesthattheshareof remoteworkersintheUShasquadrupledtonearly50%ofthe nation’sworkforce.Inthepast,e-workingwasaprivilegefor aselectfew.Inthiscrisis,however,ithasbecomeanecessity andanestablishedwayofworking.Thefactorsthatdriveeworkingarelongcommutingtimes,theriseofgig-economy employmentopportunities,work-life-balancedemandsandthe spreadofCovid-19.

Telecommuting,virtualoffice,andteleworkareafewof thetermsusedtodescribethesamephenomenon(Siha andMonroe,2006)with differentdimensions,e.g.,duration, schedule,location,task,synchrony,voluntariness,ICT,contract (Allenetal.,2015;Nicklinetal.,2016)andCovid-19.E-working isamethodofworking bymakinguseofinformationand communicationstechnology(ICT)inasituationinwhichthe workisnotboundtoanyparticularlocation.Traditionallythis hasbeenunderstoodasworkingawayfromtheoffice,usuallyat home,eitherfull-timeorforpartoftheworkingweek(WDC,

2017).Inourstudy,e-working (face-to-displayworkplace)is whereemployeesworkat home full-time/part-time,onahybrid basisoratadifferentplaceorvirtually.Inbriefe-workersare thoseworkerswho,inthetimeofCovid-19,areworkingoutside theorganization’spremisesusingmoderntechnology.

Disagreementovertheperformanceofremoteemployeeshas receivedwidespreadattentioninrecentyears.Somearguethat workingfromhomeallowsemployeestobemoreproductive duetofewerofficedistractions,whileothersdisagreedand maintainedthatthehomeisnotthebestenvironmentbecause itissubjecttohomedistractions(FonnerandRoloff,2010). Bloometal.(2015) foundthatcall-centerworkersatalarge Chinesetravelagency randomlyassignedtoworkfromhome 4daysaweekfor9monthsincreasedtheirperformanceby 13%comparedwiththosewhostayedintheoffice.Work-fromanywherearrangementscouldbeevenbetterforproductivity thanworkingfromhome,dependingonthetypeofwork (Choudhuryetal.,2019).However, Battistonetal.(2017) revealedinanaturalexperimentthatthephysicalproximityof workersinthesameofficeimprovesproductivitythroughbetter face-to-facecommunications. Dutcher(2012) found,onthebasis ofalaboratoryexperiment,thatatelecommutingenvironment mayhavepositiveeffectsonproductivityforcreativetasksbut negativeeffectsonproductivityfordulltasks.Generally,eworkingmakesemployeeshappy,andsatisfiedemployeesare usuallymoreproductive.

Thewidespreaddemandfore-working,thesignificantpolicy driversandtheincreaseofitsutilizationduringCovid-19have emphasizedtheneedforreal-lifeevidence.Ourresearchwas conductedbymeansofonlinesurveys.Itaddressedthefollowing researchquestions:

• RQ1:Isthereadifferenceofproportionbetweencubicle workersandtransitede-workers(i.e.,thosewhowerenot workingonlinepriortothepandemic)?

• RQ2:Whatimpacthase-workinghadontheproductivityof face-to-displayworkers?

• RQ3:Whatmaycausefallingproductivityathome?

• RQ4:Thepandemichasacceleratedtheimplementationof e-working—willitlast?

Itisimportanttosaytheythefourthquestionwasaddedduring theresearch.Ourinitialaimwastostudyjustthefirstthreeonly. Asthepandemiccriticallyaffectedallparticipantsandtheyhad tomovetotheirhomeoffices,wewereinterestedwhetherthis experiencewouldaffecttheirfutureandhow.

Thefollowingsectionprovidesanaccountoftheconcept ofworkplaceproductivity.Thethirdbrieflyoutlinesthe methodologyusedinthisresearch.Thefourthsectiongivesan overviewofourresults.Thenfollowsasectionpresentingour discussion,andthelastsectiongivestheconclusions.

THEORETICALBACKGROUND

Workplaceflexibility,thedigitisationofwork,theincreased blurringofboundariesbetweenworkandprivatelife,modern ICT,theglobaleconomyandtheCovid-19crisis,allthese

developmentswillcontinuetoaffecteverypartofoursocialand economiclife.Theinvestigationofthesefactorsstartedyears beforethepandemic.

Evansetal. (2004,p.2)defineflexibilityintheemployment relationshipas“cedingcontrol toworkersoverthecircumstances oftheirworkbyenablingthemtovarythosecircumstances toaddresspersonalandfamilyneedsanduncertainties.” Flexibilitygenerallycoverstemporalflexibility(flexitime,ninedayfortnights),spatialflexibility(howthephysicalworkspace isdesignedandused)andgeographicflexibility(wherethe workisdone).E-workingisoneofanumberofpossiblework practicesofthiskind.Currently,itisthemostpreferred,effective andcompleteamongthemasitincorporatesmanyelementsof temporal,spatialandgeographicflexibility.

Taylor(1911) arguedthatthebestwaytoboostproductivity wastoembracethreerules:breakcomplexjobsdowninto simpleones,measureeverythingthatworkersdoandlinkpay toperformance,givingbonusestohigh-achieversandsacking sluggards.DigitalTaylorismseemstobeamorepowerfultool thanitsanalogpredecessor(Schumpeter,2015)becauseevery moveofe-workerscan beeasilycontrolledbydedicatedsoftware. Withthedemandsonthemodernworkplacegenerallyrising, Moore(n.d.) highlights“businessesarefacedwithawealthof newexternalandinternaldriverstoforcemanagerstoprovide aworkplacethatsupportsbusinessobjectiveswhileproviding employeeswithanenvironmentwheretheywanttoworkand thatwillallowthemtobeattheirmostproductive.”Fromthis pointofview,e-workisalsoawayofdiminishingthestressthat isoftenprevalentintoday’sworkplace.Stressandexcessivelylong workinghourscontributetothedeathsof ∼2.8millionworkers everyyear(ILO,2019).Thisisalsoconfirmedbyastudyby Sayah andSüß(2013),which illustratesthatthework-lifeconflictof contractworkersissignificantlyinfluencedbyworkinghoursand income.Researchshowsthatchangesinworkingconditionscan provokeconflictbetweenworkandprivatelife(Byron,2005). Theextractiveapproach,whichtreatspeopleandplanetmerely asresourceswaitingtobeexploitedforprofit,doesnotrepresent thecurrentsituation.

Productivityiscommonlydefinedasaratiobetweenthe outputvolumeandthevolumeofinputs(OECD,2020).The productivityofworkerscouldthusbemeasuredasanoutput, e.g.,salesorunitsproduced,relativetoaninput,e.g.,the numberofhoursworkedorthecostoflabor.Traditionally, laborproductivityisderivedfromaggregatemeasuresatthefirm level,e.g.,valueaddedperworker(Sauermann,2016).Further, Pritchard (1992,p.455)definesproductivityasfollows:“...how wellasystemusesits resourcestoachieveitsgoals.”Withthis definition,productivityisacombinationofbothefficiencyand effectiveness.Productivityasatermiscloselyrelatedtoboth performanceandeffectiveness(JayamahaandMula,2011).While performanceandeffectivenessrelatetotheemployees’ability toperforminaccordancewithwhatisexpectedofthemand measurestheiroutputintermsofquality,productivitytakesthe costofachievingperformanceoreffectivenessintoaccount(Jex andBritt,2014).Whileproductivityincreaseisabenefitforthe individualemployee,because itimprovesefficiency(forexample, itremovesdistractionsandreducestimespentcommuting),it

hasalsoshownevidenceofincreasingtheproductivityofoutput, i.e.,performance,andthusgeneratingabeneficialproductivity increasefortheorganization;Nillesbelievesthatteleworkon averageincreasestheproductivityofemployeesby5–20%(Nilles, 1997).

Generally,productivitydependson severalfactorsthataffect theemployee’sproductivitylevels.Todays’e-workershaveawide rangeofchoicesonhow,whenandwheretheirworkwillbe done.Severalstudieshaveinvestigatedtheimpactofe-working onproductivity(Dutcher,2012;Laihonenetal.,2012;Bloom etal.,2015;Gambardella etal.,2015;Battistonetal.,2017; Beno,2018;IazzolinoandLaise,2018;Palvalin,2019).Generally, teamproductivityisdifferentfrom individualproductivity.Some studiesanalyzedtherelationshipbetweenworkingfromhome andemployees’productivity.Theresultsrevealedapositive effectonemployees’productivity(Bailyn,1988;Olson,1989; Dubrin,1991;Hilletal.,1998; Bélanger,1999).Furtherresearch investigatedtheinfluence ofworkingfromhomeonemployees’ productivity;datafromlaboratoryorfieldexperimentswere usedinordertoestimatethepositivecausaleffectofworking fromhomeonemployees’productivity(Dutcher,2012;Bloom etal.,2015). Peterset al.(2004) findthatorganizationsrank productivityandworkqualityproblemssecondamongthe drawbacksofworkingfromhome. Monteiroetal.(2019) suggest thatremoteworkhasasignificantnegativeeffectonlabor productivity,thoughtheproductivitylossisrelativelymodestin magnitude(around2.3%).

DATAANDMETHODOLOGY

DataCollection

Thecurrente-workingframeworkinourexaminedcompany(an Austriansportsandleisureproductcompany)wasimplemented 10yearsgowithitspoliciesandpractices,andthesettingup andmonitoringofresults.E-workingenabledtheorganizationto drivedowntheircostbaseandincreasetheengagementoftheir people.Tobeeligible,employeeshadtoputtheirrequestforeworkingtotheirmanager.Thenumberoftheseapprovalswas34 outoftotal250employees.

Thepreparationofourresearchstartedpriortotheepidemic. Asalargeproportionoftheworkershadhadsomeexperience ofhome-officeworking,ourinitialaim(RQ1)wastoinvestigate whethertherewasadifferenceofproportionbetweencubicle workersandtransitede-workers(i.e.,thosewhowereworked onlineoccasionally).Wewantedtolearnwhetherthereisany impactfrome-workingontheproductivity(RQ2)aswellaswhat maycausefallingproductivityathome(RQ3).

Thequestionnairewaspre-testedbyaselectedgroupof 12employees.

Afteritsrevision,ourfirstquestionnairewasemailedtoall employeesandcompletedby154(responserate61.6%).Togeta realisticpicture,wewantedtocoveratleast20%oftheircurrent workingweek.Forthatreason,all34employeeswhowerealready workingwereinvitedtoparticipate.

Emailnotificationsweresenttoallemployeesinorderto informthemofthequestionnaire,itspurpose,dates,etc.Atotal

of154employeesparticipatedinthesurvey(includingthe12pretesters).Forthe studyofwork/e-workproductivity,thefollowing criteriawereusedinourfinalselection:

• Allwereworkersintheservicesector;

• Allhadsomeexperiencewithe-working;

• Duetothepresumedlong-termstudy,allagreedtoparticipate inalltheroundsofthesurvey(thecurrentandnextones).

Thegroupconsistedof34e-workers(20maleand14female) and120cubicleworkers(68maleand52female).Thesample wasaheterogeneousgroupofprofessionalsworkinginseveral areas,includingcustomerservices,accounting,electronicdata processing,researchanddevelopment,marketingandlogistics.

Ourresearchwascarriedoutusingaquantitativeapproach. Thefirstsurveywasrunon28February2020—beforetheextent ofthepandemicwasrecognized.Responsestothequestionnaires wereanonymous.Thequestionsofthesurveycoveredanagreed setoftopics(suchasjobsatisfaction,technology,working patterns,etc.)anddemographicinformation.Characteristicsof thesurveyrespondents,suchasgender,age,maritalstatus, parity,andofficialhomeworkingstatuswereincludedunderthe presumptionoftheirrelevancetotheirpersonalpositiontoward e-working(see Table1).

Thegroupsaresimilarinallparametersexceptone—their age.Thedistributionindicatesahigherageamonge-workers thanamongcubicleworkers.Theagedifferenceispresumably causedbythenecessitytomentorlessexperiencedemployees; themoreexperiencedonesaregivenmorefreedom.This explanationfitswellwiththetraditionalviewofmanagement, andwithouroriginalaim,whichwasdesignedanddeveloped toprovideabetterunderstandingofworkplacechangesand employeeproductivityinon-lineandon-siteworkingconditions. Forthisreason,weoptedforcubicleworkersande-workers whohadsomeexperienceofe-workpriortoourresearch(see TABLE1| Socio-demographiccharacteristics. Cubicles E-working N % N % 12077.92%3422.08% Sex Male 6844.16%2012.99% Female 5233.76%149.09% Age 20–29 2516.23%31.95% 30–44 5837.66%127.79% 45–59 3724.03%1912.34% Maritalstatus Single(divorced,separated)6743.51%2214.29% Married/partnership 5334.41%127.79% Parity Childreninhousehold 9964.29%2616.88% Childless 2113.64%85.19%

Table2).Thereasonforthisrequirementwassothatrespondents werecapableofrespondingtoanddiscussingtheissuesofeworkproductivity.

Suddenly,thesituationchanged.Duetothepandemic,all participantshadtorespectrestrictions.Asaresult,additional questionsaddressingRQ4wereaddedtoreflectthespread ofCovid-19.Thisextendedversionwasthenrunduringthe lockdown(31March2020)andafteritwaseased(29May2020). Table2 showsasuddenjumpintheFebruaryandMarchfigures. Thesizeoftheincreasedemonstratestheeffectofthelockdown. ThedifferencebetweenFebruaryandMayismoreinteresting. Thenumberofe-workersmorethandoubled.Furtherresearch willhavetobedoneaftertheepidemicisoverinorderto determinethefutureimpactontheface-to-displayworkplacein thecompany.

Tables3, 4 relatetoproductivityanddealwithpossiblecases ofafallinproductivityamonge-workers.Thescaleofresponses comparingproductivityattheendofMarchandattheendof Maywereasfollows:Igetmuchmoredone,Igetalittlemore done,Igetthesamedone,Igetalittlelessdone,andIgetmuch lessdone.Inthefinalstageofthesurvey,respondentswerealso giventhechoiceofanumberofpossiblereasonsforthefall inproductivity.

IntheMaysurvey,weincludedanotherquestionaboutthe futureprevalenceoftheface-to-displayworkplaceaftertheeasing ofthelockdown(see Table5).Thelastaddedquestion(RQ4) was:Aftertheeasingofthelockdown,howoftenwouldyou liketoworkfromhome?Theresponsechoiceswere:never, sometimes,oftenandalways.

Thereisareliabilityriskwithe-mailquestionnairesbecause itismoredifficulttoguaranteeanonymity,andrespondentsmay haveconcernsthattheinformationtheyprovidemaybemisused. Toassurethemthatthiswouldnothappen,theauthorsofthe paperproceededinthefollowingmanner.First,theanonymityof theirresponseswasemphasizedinthequestionnaireinvitation. Therewasalsoadescriptionoftheprocedurethatwasthen followed.Weusedtrustedsoftwarethatdidnotallowlinking identifierswiththeirresponses.Theirpersonalinformationand responseswerestoredinseparatefiles.Andthentheauthors madecertainthatallIPaddresses,e-maildataandotherpersonal datawerenotarchived.

DataAnalysis

Inthefirststage,weusedcross-tabulationofdatatoexamine relationshipswithinthedata.Inthesecondstageofouranalysis,

TABLE3| E-workingproductivity.

Profilingmain placeofwork E-workers(34)%Transited e-workers(108) % duringlockdown

Igetmuchmore done 1441.18 11 10.19

Igeta littlemore done 1235.29 9 8.33 Igetthesame done 2 5.88 57 52.78

Igetalittleless done 3 8.82 19 17.59

Igetmuchless done 3 8.82 12 11.11

Profilingmain placeofwork E-workers(34)%Transited e-workers(54) % aftereasing lockdown

Igetmuchmore done 1441.18 20 37.04

Igeta littlemore done 1235.29 13 24.07

Igetthesame done 2 5.88 9 16.67 Igetalittleless done 3 8.82 8 14.81

Igetmuchless done 3 8.82 4 7.41

TABLE5| Workingathomepreferencesaftersocialdistancing. Workingathomepreferencesaftersocial distancing(%) N %

Never 23 14.94 Sometimes 43 27.92 Often 54 35.06 Always 34 22.08

FINDINGS

Thefollowingparagraphsprovide anoverviewofthefindings fromthequantitativecomponentoftheresearchstudy.Austria traditionallyhaslowlevelsofunemploymentandhighsocial standards.IncreasedICThasgivenrisetonewformsof employmentinAustriaandthroughoutEurope(Eu2018at, 2018).Accordingto Eurostatdata(Eurostat,2020b),the Netherlandstoppedthe listofEUmemberstatesforthe numberofpeopleworkingfromhome,closelyfollowedby Finland(13.3%),Luxembourg(11.0%),andAustria(10.0%).The lockdownrestrictionsimposedbytheAustriangovernmentled toarapidgrowthofe-working.

TABLE4| Mainreasongivenforfall inproductivity(N = 88).

Mainreasongivenforfallinproductivity N %

Providingchildcare/homeschooling,petsittingand/or careforotherswhileworking 2528.41 Work-from-homeroutine 2326.13 Havinglessworktodo 1921.59 Lackofmotivation/focus/concentration Limitedaccesstoworkplaceresourcesandinteraction withothers,andchangestoworkorganizationbecause ofCovid-19

Inourinvestigatedcompany,workcarriedoutincubicles (77.92%)exceededtheratefore-workers(22.08%)before thelockdown.Duringthelockdown,theproportionchanged dramaticallyinfavorofe-workers(cubicles 7.79%toeworkers 92.21%),andaftertheeasingofthelockdownthe proportionbecamemorebalanced(cubicles 42.86%toeworkers 57.14%).See Table3.Thiswaspossibleduetoexcellent technologicalconnectivity,whichaccordingto Messengerand Gschwind(2016) facilitatestheprocess,sinceitallowsworkto bedoneanywhereandatany time.Datacollectedbeforethe lockdownshowthate-workingwasmoreprevalentamongmale employees,whereasduringandafterthelockdownitbecamea necessityforeverybody.Thisconfirms Beno’s(2019) surveydata thatteleworkisamale-dominated workingmethod.Nearly4in 10peopleintheEUbeganworkingfromhomeasaresultofthe Covid-19pandemic(Eurofound,2020).

1213.64

Sharingspaceandequipment 66.82 Equipment,software,and/orinternetconnection 33.41

weusedtheMcNemartesttodeterminetheconsistencyin theresponsesacrosstwovariables.Wetestedtwoworkplace movestodeterminewhetherthereisasignificantdifference betweentheproportionofworkersworkingfromhomeand thoseworkingfromcubiclesinallthreeexaminedperiods.In thenextstep,weexaminedproductivity.WeusedPearson’s chi-squaretesttodeterminewhetherthereisadifference betweentheproductivityofe-workersduringandafter thelockdown.

Toanswerthefirst researchquestion(RQ1),weexaminedthe outcomedatastatisticallywiththeassistanceoftheMcNemar test.Inthisfirstquestion,weusedpre-,duringandpostlockdowndatatofindoutwhetheremployeesworkedathome ornot.All p-values(markedinyellow,see Tables6 8)ofthe McNemartestarebelowthesignificancelevelof0.05.According tothedata,therewereconsiderabledifferencesintheproportion ofworkersintheofficeandathomeduringallthreeperiods.Over thecourseofthesurveyedperiods,thee-workingproportion increasedonaverageby57.14%.Briefly,thissurgeine-working occurredduringthelockdown(92.21%).

Employersexpectedabout44%ofworkerstostartworking fromhomeduringthepandemic;78%ofbusinessleaders thinkhybridandhome-workingwillhaveanegativeimpact onproductivity(WEF,2020).InthemidstoftheCovid-19 crisis,e-workingbecame a lifesaverforallemployeeswhocould dothiskindofwork.Thenaquestionappeared:Wouldthe

TABLE6| Workplace*PeriodCross-tabulationandChiSquaretests.

Profilingmainplaceof workFebruary

Period Total

Profilingmainplaceof workduringlockdown

Workplace Determinedcubicle-workersNumber 120 12 132 %withinperiod 77.9% 7.8% 42.9% Determined e-workers Number 34 142 176 %withinperiod 22.1% 92.2% 57.1%

Total Number 154 154 308 %withinperiod 100.0% 100.0% 100.0%

Chi-SquareTests

Value Exactsig.(2-sided)

McNemartest 0.002a

N ofvalidcases308

a Binomialdistributionused.

TABLE7| Workplace*PeriodCross-tabulationandChiSquaretests.

Workplace*PeriodCross-tabulation

Profilingmainplaceof workFebruary

Workplace

Period Total

Profilingmainplaceofworkafter easinglockdown

Determinedcubicle-workersNumber 120 66 186 %withinperiod 77.9% 42.9% 60.4% Determined e-workers Number 34 88 122 %withinperiod 22.1% 57.1% 39.6%

Total Number 154 154 308 %withinperiod 100.0% 100.0% 100.0%

Chi-squaretests

McNemartest 0.002a

N ofvalidcases308

a Binomialdistributionused.

suddenanddramaticincreaseofe-workingmaketheworkers moreproductiveornot? Bloometal.(2015) foundthata company’sstaffbecamenotablymoreproductivebyworking fromhome4daysaweek.RecentresultsfromaCanadiansurvey suggestthatonethirdofrespondentssaidtheyfeelthattheir productivityhasincreasedsincetheystartedworkingremotely— thisdespitethefactthatmorethanhalftheparticipants inthestudyareworkingwithanotherpersonathome (Udemnouvelles,2020).

Ourevidence,usingPearson’schi-square,suggeststhatafter thelockdowntherewasasignificantincreaseinthenumber oftransitedhome-centeredworkers(thosewhohadjuststarted workingathome)whohaddonealittlemoreormuchmore thanduringthelockdown.Thebiggestdifferenceisforworkers withlongexperiencewhoclaimthattheirlaborproductivitydid notchangeinanyperiod.Duringthelockdownthisapplied tomorethanhalfoftheworkers,whereasafterthelockdown itwasonlyathirdoftheworkerswhocontinuedworkingat home(afterpreviouslyworkinginanoffice)asshownin Table9

Apparently,thosewhodonotfeelcomfortablewithe-worktend tobelessproductive.

The P-value(1.64396)islowerthanthechosenlevelof knowledge;werejectthenullhypothesisofindependence.The periodsbeforeandafterthelockdownshowasignificantimpact onlaborproductivity.Theseperiodsalsodiffermarkedlyinthree categories:Igetalittlemoredone,IgetmuchmoredoneandI getthesamedone.

Whatcausesproductivitytofallathome?Therearethree importantreasonsforthefallinproductivityrelatedtoeworking:(1)Providingchildcare/homeschooling,petsitting and/orcareforotherswhileworking(28.41%);(2)Absenceof work-from-homeroutine(26.13%);and(3)Havinglessworkto do(21.59%).Thereisnomagicformula.Whatemployeesshould dotomaintainagoodbalanceofproductivityandhappiness whileworkingfromhomedependsontheirownpersonalityand probablyontheirindividualtimemanagement.

Thelastresearchquestionrelatedtothefutureprevalenceof theface-to-displayworkplaceaftertheeasingofthelockdown.

TABLE8| Workplace*PeriodCross-tabulationandChiSquaretests.

Workplace*PeriodCross-tabulation

Period Total

Profilingmainplaceofworkafter easinglockdown Profilingmainplaceof workduringlockdown

WorkplaceDeterminedcubicle-workersNumber 66 12 78 %withinperiod 42.9% 7.8% 25.3% Determined e-workers Number 88 142 230 %withinperiod 57.1% 92.2% 74.7% Total Number 154 154 308 %withinperiod 100.0% 100.0% 100.0% Chi-squaretests Value Exactsig.(2-sided) McNemartest 0.000a N ofvalidcases308

a Binomialdistributionused.

TABLE9| Cross-tabulationfore-workersproductivity.

Productivity DuringlockdownAftereasingoflockdown AbsoluteRelativeAbsoluteRelative frequencyfrequencyfrequencyfrequency

Igetalittlelessdone1917.59%8 14.81% Igetalittlemore done98.33%1324.07%

Igetmuchlessdone1211.11%4 7.41% Igetmuchmoredone1110.19%2037.04% Igetthesamedone5752.78%9 16.67% Total 108100.00%54100.00%

TheMay2020surveyaskedrespondentshowoftenemployees wouldliketoworkfromhome aftertheendofsocialdistancing. Theresultssuggestthatmorethanonefifth(22.08%)want tocontinueworkingfromhomealways,morethanonethird (35.06%)often,morethanaquarter(27.92%)sometimesandjust overoneseventh(14.94%)notatall.

DISCUSSION

Thepandemichaschangedourworkingopportunitiesand habits.Itaffectsallfivegenerationsincludedintheproduction processes:traditionalists(bornpriorto1946),babyboomers (bornbetween1946and1964),GenX(bornbetween1965and 1976),Millennials,alsocalledGenY(bornbetween1977and 1997)andiGenerationbornafter1997.Theyallhavetofindtheir newworkplacesontheInternet.

ThisallowsustodefineWorkplace5.0asamultigenerational workplacecontinuityinmanagementandsupervisorypractice whichareimportantforsuccessinsupportingmultiple generations(YangandGuy,2006).Clearly,therewouldbe similaritiesaswell asdifferencesbetweenthem.Theterm“period

waroftalent”wascoinedin1997andreferstothechanging landscapeattheworkplacetoattractandretaintalent.Sincethen, thesituationisbecomingmorechallenging.Nowadays,itisvery hardtofixtheborderssinceitalsodependsonpersonalmindsets. Forthosewhocomethroughthecurrentcrisisreasonablywell, theeconomicaspectwillbethemostimportant.Morethanever, thereductionofcostswillbethemainfocusandwillplaya centralroleinthecontextofWorkplace5.0.Covid-19brought acompletelynew,previouslyunseenaspect:socialdistancing (includingthetighteningofhygienerestrictions).E-workingand thehomeofficearenotjustasolutiontoacrisis,theywillbe essentialcomponentsofthefuturestyleofwork.

Thisimpliesthatthefocusonthepost-Covid-19workplace willbedeterminedbythefollowingformula:

C × S × E = Workplace5.0

where:

Cstandsforcostreduction; Sstandsforthenecessitytomaintainasocialdistance;and Estandsfore-andhybridworking,i.e.,thepossibilitytowork regardlessone’slocation.

Atthesametime,therearenoadequatetoolstomeasure employeeproductivity,taskcompletionandtimeliness(Joice, 2000).That is whyourresearchhasconcentratedonthe employee’spersonalfeelingsabouthis/herproductivity.As aminimum,suchsubjectiveevaluationcanexpresstowhat degreetheperson’sproductivitydiffersfromits“standard.”Any deviationwillaffecttheproductivityofthecompanyasawhole.

However,ithasbeensaidthatmeasuringproductivityisnot asimportantasmeasuringthequalityofitsoutcome.Managers needtodevelopawaytomeasureboth(Joice,2000).Theability toevaluateanemployee’sproductivityisimportant,becauseit relatestothepossibilityofpromotion,compensationandmore (BaffourandBetsey,2000).Again,individualevaluationsdonot solvetheproblem,but canserveasabenchmarkfordecisions

whethertomakeatransfertohomeoffice,withwhomandto whatdegree.

Howdoemployersmeasuretheproductivityofe-workers andco-locatedworkersinane-economy?Thebasicformula forproductivity,namelyoutputdividedbyinput,measures production(output)overasetperiodoftime(input).Canwe implementasimilarformulafore-working?Whatisitthatis beingproducedine-working?Isinput(time)important?In unskilledwork,thetaskobviouslyis,butine-workingthisis rarelythecase.Wecannotremovethehumanaspectfromwork andproductivity.Asatisfiedemployeeproducesworkofhigh quality,andviceversa.Weareoftheopinionthatamixtureof quantitativeandqualitativemeasuresisneeded.Wastedwork timemustalsobetakenintoaccount,whichincludesabsenteeism andpresenteeism(beingatwork,butnotbeingproductive).Ina productiveorganization,everyonesharesthesameapproachto whatiscrucial,butnoturgent,vs.urgentbutnotcrucial.This appliesnotonlytotheemployee,theteamorthedivision,butto theorganizationasawhole.

Canemployersmeasuretheproductivityofe-workersand co-locatedworkersinane-economy?Accordingto Choudhury (2019),companiesthatlettheirworkersdecidewhereandwhen todotheirjobs—whetherinanothercityorinthemiddle ofthenight—seeincreasedemployeeproductivity,reduced turnoverandlowerorganizationalcosts.Auniversalmetric formeasuringthetrueproductivityofe-workershasnot beendevisedyet.Employershavefoundinnovativewaysto measureandimproveproductivity.Inouropinion,theeffective measuringandimprovingofproductivityinacompanydepends onthesector,butitskeycomponentsmustbeachievedoutputs andindividualsatisfaction(internalorexternal),i.e.,measuring objectivesinsteadofworkinghours.

E-workingiscurrentlytheonlysafeworkformintheface ofCovid-19.Willthise-workingexperimentleadtogreater expansionofthismodeofworkinginthefuture,orwillitremain aprivilegeforthefew,asitwasbeforeCovid-19?

CONCLUSION

Themainresearchquestionsinvestigatedinthispaperare:

• RQ1: Isthereadifferenceofproportionbetweencubicleworkers andtransitede-workers(i.e.,thosewhowerenotworkingonline priortothepandemic?)Thenumberofemployeesworking remotelyhasincreasedinallthreeperiods,accordingtoour results.Thee-workingproportionincreasedonaverageby 57.14%betweenFebruaryandMay,i.e.,betweentwoperiods whentheemployeeswerenotobligedtodoe-working.

• RQ2: Whatimpacthase-workinghadontheproductivityof face-to-displayworkers? Basedonourdata,productivityhas increasedonaverage.Ontheotherhand,thosewhodonot feelcomfortablewithe-work,tendtobelessproductive.

• RQ3: Whatmaycausefallingproductivityathome? (1) Providingchildcare/homeschooling,petsittingand/orcare forotherswhileworking(28.41%);(2)Absenceofworkfrom-homeroutine(26.13%);and(3)Havinglessworkto do(21.59%).

• RQ4: Thepandemichasacceleratedtheimplementationofeworking—willitlast? E-workingandthehomeofficearenot justasolutiontoacrisis,theywillbeessentialcomponentsof thefuturewayofworking.TheconceptofWorkplace5.0isthe keytothis.

BeforeCovid-19,Europeancountrieswerereluctantto implemente-working.Teleworkincreasedslowlyinthe10 yearsbeforetheoutbreakofCovid-19,mostlyasanoccasional workpattern(EC,2020).InthetwodecadesbeforeCovid-19, remoteworkincreasedsteadily,butcomprisedarelatively modestshareofthelaborforce(Ozimek,2020).Allinall,the post-Covidsurveyresultssuggestthatoverhalftheworkforce isnowremote(Brynjolfssonetal.,2020).Ourresultsshow e-workingincreasing,havingasignificanteffectonproductivity andundergoingincreasedimplementationinthefuture.Initially, weconcludethate-workingisheretostay.AccordingtoaBBC Survey,50ofthebiggestUKemployershavenoplansforall theirstafftoreturntotheofficefull-timeinthenearfuture. Furthermore,24firmsdidnothaveanyplansforworkersto returntotheoffice(Jack,2020).Wehavecometotheconclusion thattheshift toworkingfromhomeisandwillremainapossible waytoadapttotheCovid-19demandsontheworkplacefor thefuture.Datapresentedinourpapershowthegreatextentto whiche-workingwasadoptedduringtheperiodsinvestigated.

Accordingtoourdata,therearesignificantdifferencesinthe proportionofworkersintheofficeandathomeinallthree periods.Afterthelockdown,therewasamarkedincreasein thenumberofworkers(thatisthosewhostartedworkingat home)whowilldoasmallamountoragreatdealmorethan duringthelockdown.Thebiggestdifferencewasforworkerswho claimthattheirlaborproductivitywasthesameinbothperiods. Duringthelockdown,morethanhalfofthosewhopreviously workedinanofficeremainedathometowork,afterthelockdown onlyathirdofthemdid.Therearethreeimportantreasons forthefallinproductivityrelatedtoe-working:(1)Providing childcare/homeschooling,petsittingand/orcareforotherswhile working(28.41%);(2)Work-from-homeroutine(26.13%);and (3)Havinglessworktodo(21.59%).Theresultssuggestthat morethanonefifth(22.08%)wanttocontinueworkingfrom homealways,morethanonethird(35.06%)often,morethana quarter(27.92%)sometimesandjustoveroneseventh(14.94%) notatall.

Covid-19hascauseduncertaintyandsorrowacrossthe globe,butitalsolaunchedane-workingexperiment.The shifttoincreasedremoteworkcouldeliminatemanyofthe challengesbroughtaboutbytheconsequencesofCovid-19.But historyhasshownthatsociety,organizationsandmanagersneed toanticipateworkforceproblemsaspeoplereturntowork. Covid-19hasnotonlyeconomic,butalsopsychologicaland socialimplications.Althoughmanagersarekeyintherecovery process,theyarealsosubjecttohumanuncertainty.Information flow,scenarioplanningandriskimprovementareextremely importantduringuncertaintimes.Managersareinaunique positiontorecognizee-workingchallengesthatwillputthem inabetterpositionthaneverbeforetoprovidecalmleadership andhelpfulguidance.Herein,liestheproblemintheremote

vs.in-officedebate.Thequestionisnotwherewearemore productive,itisrather aboutwhichspace(office,homeorvirtual) providesmorefocus.Webelievethequestiontobeconsidered iswhatemployeesdesire,namelyhowtoprovideanengaging experiencewithoutsacrificingconcentrationandproductivity (whichimpliesthatDigitalTaylorismshouldbediminished asmuchaspossibleinordertomakehomeofficessafeand protectedplaces).

FURTHERRESEARCH

Furtherresearchshouldbecarriedoutwithdatafromthesecond seriesoflockdowns.Thisisneededinordertounderstand howadditionaldatacanthrowfurtherlightone-workingasa dominantmethodofworking.Theseinvestigationsareimportant duetotheprolongedisolationofemployeeswhichcanaffect theirsocialcomfortandresultinthemchangingtheirprevious attitude.Upcomingresearchshouldinvolveamorethorough investigationofhowtomeasuree-workers’productivity.Thiscan bedoneboththroughqualitativelyfocusingoncasestudiesand throughquantitativeeffectstudies.

STUDYLIMITATIONS

Thestudyinitspresentformatisaresultofcoincidence. Whenitstarted,noonecouldpredicttheappearanceofthe Covid-19pandemic.Duetoourquickreaction,wecouldcarry outtheresearchdescribedabove,butitcannotbereplicated inthisformat(unlessonehadacrystalball).Nevertheless,

REFERENCES

Allen,T.D.,Golden,T.D.,andShockley,M.K.(2015).Howeffectiveis telecommuting?Assessingthestatusofourscientificfindings. Psychol.Sci. PublicInterest 16,40–68.doi:10.1177/1529100615593273

Baffour,G.G.,andBetsey,C.L.(2000). HumanResourcesManagementand DevelopmentintheTeleworkEnvironment.Teleworkandthenewworkplace ofthe21stcentury,122-135.Washington:U.S.DepartmentofLabor.

Bailyn,L.(1988).Freeingworkfromtheconstraintsoflocationandtime. New TechnolWorkEmploy.3,143–152.doi:10.1111/j.1468-005X.1988.tb00097.x Baldwin,R.,andWederdiMauro,B.(2020). EconomicsInTheTimeOfCOVID-19 |VOX,CEPRPolicyPortal Voxeu.Org. Availableonlineat:https://voxeu.org/ content/economics-time-covid-19(accessedNovember25,2020)

Battiston,D.,iVidal,J.B.,andKirchmaier,T.(2017). IsDistanceDead?Faceto-FaceCommunicationandProductivityinTeams.CEPDiscussionPapers dp1473,CentreforEconomicPerformance,LSE.

Bélanger,F.(1999).Workers’propensitytotelecommute:anempiricalstudy. Inf. Manag.35,139–153.doi:10.1016/S0378-7206(98)00091-3

Beno,M.(2018).“ManagingTeleworkfromanAustrianManager’sPerspective,” in TrendsandAdvancesinInformationSystemsandTechnologies, WorldCISTS’18,AdvancesinIntelligentSystemsandComputing,edsÁ. Rocha,H.Adeli,L.P.Reis,andS.Costanzo(Cham:Springer),16–29. doi:10.1007/978-3-319-77703-0_2

Beno,M.(2019).“Home-basedTeleworkandtheRoleofGender-Resultsofa StudyinAustria,”in CONF-IRM2019Proceedings,12(Toronto,ON).

Blinder,A.S.(2009).HowmanyUSjobsmightbeoffshorable? WorldEconomics 10,41–78.

Blinder,A.S.,andKrueger,A.B.(2009).Alternativemeasuresofoffshorability:a surveyapproach. J.LaborEcon. 31,97–128.doi:10.1086/669061

someotherfactorsalsorestrictthefullgeneralizationofour outcomes.Firstly,datacollectiontookplacebymeansofemailquestionnairesbecauseofdistance,financialaspectsand Covid-19.Thereisnoguaranteethattheresearchersobtained allthepossibleinformationfromtheparticipantsthatcould beusedintheanalysisofthedataandresults.However,the qualityofthedatadependsuponthequalityofthequestions asked.Secondly,thesampledoesnotreflectthepopulation bysectoralstructure.Lastly,theresearchershavenowayof ascertainingwhethertherespondentsrepliedhonestlyornot.It shouldbestatedthattheresultsofthisstudydonotnecessarily reflecthowthewaythatworkersgettoworkwillevolveinthe post-pandemicperiod.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle/supplementarymaterial,furtherinquiriescanbe directedtothecorrespondingauthor/s.

AUTHORCONTRIBUTIONS

MBconceivedofthepresentedidea,wasengagedinthe investigation,literaturesearchandselection,verifiedthe analyticalmethods,writingoriginaldraft,preparation,and finishingthelastversion.JHwasinvolvedinproofreading, formingconclusions,andlimitationsaswellasincontribution tothelastversion.Bothauthorsdiscussedtheresultsand contributedtothefinalmanuscript.

Bloom,A.N.,Liang,J.,Roberts,J.,andYing,Z.J.(2015).Doesworkingfrom homework?EvidencefromaChineseExperiment. QJEcon.130,165–218. doi:10.1093/qje/qju032

Brynjolfsson,E.,Horton,J.J.,Ozimek,A.,Rock,D.,Sharma,G.,andTuYe,H.-Y. (2020).“Covid-19andremotework:anearlylookatUSdata,”in NBERWorking Papers27344,NationalBureauofEconomicResearch,Inc (Cambridge,MA).

Byron,K.(2005).Ameta-analyticreviewofwork-familyconflictandits antecedents. JVocationalBehav.67,169–198.doi:10.1016/j.jvb.2004.08.009

Choudhury,P.(2019).(Liveand)WorkfromAnywhere:GeographicFlexibilityand ProductivityEffectsattheUnitedStatesPatentOffice.Availableonlineat:https:// marriottschool.byu.edu/upload/event/event_755/_doc/Raj%20Choudhury %20WFA_Utah_submission.pdf(accessedNovember25,2020).

Choudhury,P.,Foroughi,C.,andLarson,B.(2019).Work-From-Anywhere:the productivityeffectsofgeographicflexibility. Strateg.Manag.J. 43,655–683. doi:10.1002/smj.3251

Deloitte(2020). WieCOVID-19dasArbeiteninÖsterreichverändert,Flexible WorkingStudie2020. Availableonlineat:https://www2.deloitte.com/content/ dam/Deloitte/at/Documents/presse/Deloitte-Flexible-Working-Studie-2020. pdf(accessedNovember25,2020).

Dingel,I.J.,andNeiman,B.(2020).Howmanyjobscanbedoneathome? J.Public Econ. 189:104235.doi:10.1016/j.jpubeco.2020.104235

Dubrin,A.J.(1991).Comparisonofthejobsatisfactionandproductivityof telecommutersversusin-houseemployees:aresearchnoteonworkinprogress. Psychol.Rep. 68,1223–1234.doi:10.2466/pr0.1991.68.3c.1223

Dutcher,E.G.(2012).Theeffectsoftelecommutingonproductivity:an experimentalexamination.TheRoleofDullandCreativeTasks.J.Econ.Behav. Organ. 84,355–363.doi:10.1016/j.jebo.2012.04.009

EC(2020). TeleworkintheEUBeforeandAftertheCOVID-19:WhereWe Were,WhereWeHeadTo. Availableonlineat:https://ec.europa.eu/jrc/sites/

jrcsh/files/jrc120945_policy_brief_-_covid_and_telework_final.pdf(accessed November25,2020).

Eu2018at(2018). DigitalisationofWorkConference.Availableonlineat:https:// www.eu2018.at/calendar-events/political-events/BMASGK-2018-09-19Conf-Digitalisation.html(accessedNovember25,2020).

Eurofound(2020). Living,WorkingandCOVID-19.Availableonlineat: https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ ef_document/ef20059en.pdf(accessedNovember25,2020).

Eurostat(2020a). EmployedPersonsWorkingfromHomeasaPercentage oftheTotalEmployment,bySex,AgeandProfessionalStatus(%). Availableonlineat:https://appsso.eurostat.ec.europa.eu/nui/show.do?dataset= lfsa_ehomp(accessedNovember25,2020).

Eurostat(2020b). HowUsualIsIttoWorkFromHome? Availableonlineat:https:// ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-202002061?fbclid=IwAR2S_ueYijAuH6Zau3pN5OOUnubQ7EDDnBgx5H8N_ bDIIeryp6Wpaj3N-jc(accessedNovember25,2020).

Evans,A.J.,Kunda,G.,andBarley,S.R.(2004).Beachtime,bridgetime,and billablehours:Thetemporalstructureoftechnicalcontracting. Admin.Sci.Q 49,1–38.doi:10.2307/4131454

Fonner,K.L.,andRoloff,M.E.(2010).Whyteleworkersaremoresatisfiedwith theirjobsthanareoffice-basedworkers:whenlesscontactisbeneficial. J.Appl. Commun.Res.38,336–361.doi:10.1080/00909882.2010.513998

Gambardella,A.,Panico,C.,andValentini,G.(2015).Strategicincentivesto humancapital. Strateg.Manag.36,37–52.doi:10.1002/smj.2200

Hill,E.J.,Miller,B.C.,Weiner,S.P.,andColihan,J.(1998).Influencesofthevirtual officeonaspectsofworkandwork/lifebalance. Pers.Psychol. 51,667–683. doi:10.1111/j.1744-6570.1998.tb00256.x

Iazzolino,G.,andLaise,D.(2018).Knowledgeworkerproductivity:isit reallyimpossibletomeasureit? Meas.BusinessExcell.22,346–361. doi:10.1108/MBE-06-2018-0035

ILO(2019). Stress,Overtime,Disease,Contributeto2.8MillionWorkers’Deaths PerYear,ReportsUNLabourAgency.Availableonlineat:https://news.un.org/ en/story/2019/04/1036851(accessedNovember25,2020).

ILO(2020). AnEmployer’sGuideonWorkingfromHomeinResponsetothe OutbreakofCOVID-19. Availableonlineat:https://www.ilo.org/wcmsp5/ groups/public/---ed_dialogue/---act_emp/documents/publication/wcms_ 745024.pdf(accessedNovember25,2020).

Jack,S.(2020). NoPlanforaReturntotheOfficeforMillionsofStaff.Available onlineat:https://www.bbc.com/news/business-53901310(accessedNovember 25,2020.).

Jayamaha,A.,andMula,J.M.(2011).Productivityandefficiencymeasurement techniques:identifyingtheefficacyoftechniquesforfinancialinstitutionsin developingcountries. J.Emerg.TrendsEcon.Manag.Sci.2,454–460. Jex,S.M.,andBritt,T.W.(2014). OrganizationalPsychology:AScientistPractitionerApproach.NewJersey:JohnWileyandSons.

Joice,W.(2000). TheEvolutionofTeleworkintheFederalGovernment. Available onlineat:https://rosap.ntl.bts.gov/view/dot/14140(accessedNovember25, 2020).

Laihonen,H.,Jääskeläinen,A.,Lönnqvist,A.,andRuostela,J.(2012).Measuring theproductivityimpactsofnewwaysofworking. J.Facil.Manag.10,102–113. doi:10.1108/14725961211218749

Messenger,J.C.,andGschwind,L.(2016).Threegenerationsoftelework:newICT andthe(R)Evolutionfromhomeofficetovirtualoffice. NewTechnolWork Employm.31,195–208.doi:10.1111/ntwe.12073

Monteiro,N.P.,Straume,O.R.,andValente,M.(2019). DoesRemoteWork ImproveorImpairFirmLabourProductivity?LongitudinalEvidencefrom Portugal.Availableonlineat:https://repositorium.sdum.uminho.pt/bitstream/ 1822/62137/1/NIPE_WP_14_2019.pdf(accessedNovember25,2020).

Moore,P.(n.d.). DemandsoftheModernWorkplace.Availableonline at:http://fmj.ifma.org/publication/?i=437957andarticle_id=2882452andview= articleBrowserandver=html5(accessedNovember25,2020).

Nicklin,M.J.,Cerasoli,P.,Ch.,andDydyn,K.L.(2016).“Telecommuting:What? Why?When?andHow?,”in TheImpactofICTatWork,edJ.Lee(Singapore: Springer),41–70.

Nilles,J.M.(1997). Telework:EnablingDistributedOrganizations Inf.Syst.Manag 14,7–14.doi:10.1080/10580539708907069

OECD(2020). Productivity.Availableonlineat:https://www.oecd-ilibrary.org/ economics/productivity/indicator-group/english_0bb009ec-en(accessed November25,2020.).

Olson,M.H.(1989).Workathomeforcomputerprofessionals:current attitudesandfutureprospects. ACMTrans.Inf.Syst.7,317–338. doi:10.1145/76158.76891

OTS(2020). Kogler:Home-OfficeundTelearbeitweiternotwendigzur EindämmungderCorona-Krise.Availableonlineat:https://www.ots.at/ presseaussendung/OTS_20200406_OTS0166/kogler-home-office-undtelearbeit-weiter-notwendig-zur-eindaemmung-der-corona-krise(accessed November25,2020).

Ozimek,A.(2020). Report:OverboardonOffshoreFears. Availableonlineat: https://www.upwork.com/press/releases/report-overboard-on-offshore-fears (accessedNovember25,2020).

Palvalin,M.(2019). KnowledgeWorkPerformanceMeasurementintheNewWays ofWorkingContext. PhDdiss.TampereUniversity.Availableonlineat:https:// core.ac.uk/download/pdf/250166693.pdf(accessedNovember25,2020).

Peters,P.,Tijdens,K.G.,andWetzels,C.(2004).Employees’opportunities, preferences,andpracticesintelecommutingadoption. Inf.Manag.41,469–482. doi:10.1016/S0378-7206(03)00085-5

Pritchard,R.D.(1992).“Organizationalproductivity,”in Handbookof Industrial/OrganizationalPsychology,2ndedn.,Vol.3,edsM.D.Dunnette, andL.M.Hough(PaloAlto,CA:ConsultingPsychologistsPress),443–471.

Sauermann,J.(2016).Performancemeasuresandworkerproductivity. IZAWorld Labor 2016,260.doi:10.15185/izawol.260

Sayah,S.,andSüß,S.(2013).Conflictbetweenworkandlife:thecaseofcontract workersintheGermanITandMediaSectors. Manag.Rev.24,222–244. doi:10.5771/0935-9915-2013-3-222

Schumpeter(2015). DigitalTaylorism.TheEconomist,3-5.Availableonlineat: https://www.economist.com/business/2015/09/10/digital-taylorism(accessed December10,2020).

Siha,M.S.,andMonroe,W.R.(2006).Telecommuting’spastandfuture:a literaturereviewandresearchagenda. BusinessProcessManag.J.12,455–482, doi:10.1108/14637150610678078

Taylor,F.W.(1911). ThePrinciplesofScientificManagement. NewYork,NY: HarperandBrothers.

Udemnouvelles(2020). WorkingfromHomeMakesUsMoreProductiveand Innovative,SaysSurvey. Availableonlineat:https://nouvelles.umontreal.ca/en/ article/2020/05/08/teleworking-should-we-keep-at-it/(accessedNovember 25,2020).

WDC(2017). E-workingintheWesternRegion.Availableonlineat:https:// www.wdc.ie/wp-content/uploads/WDC_Policy-Briefing-no-7.pdf(accessed November25,2020).

WEF(2020). TheFutureofJobsReport2020.Availableonlineat:http://www3. weforum.org/docs/WEF_Future_of_Jobs_2020.pdf(accessedNovember25, 2020).

WHO(2020). WHODirector-General’sOpeningRemarksattheMediaBriefing onCOVID-19-11March2020. Availableonlineat:https://www.who.int/ director-general/speeches/detail/who-director-general-s-opening-remarksat-the-media-briefing-on-covid-19---11-march-2020(accessedNovember 25,2020).

Yang,S.-B.,andGuy,M.E.(2006).GENXERSVERSUSBOOMERS: workmotivatorsandmanagementimplications. PublicPerform. Manag.Rev.29,267–284.doi:10.2753/PMR1530-95762 90302

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021BenoandHvorecky.Thisisanopen-accessarticledistributed underthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse, distributionorreproductioninotherforumsispermitted,providedtheoriginal author(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublication inthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

ORIGINALRESEARCH published:18March2021 doi:10.3389/fsoc.2021.629587

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: MuhammedElhadi, UniversityofTripoli,Libya ZeljkoStojanov, UniversityofNoviSad,Serbia RachelBonnette, UniversityatBuffalo,UnitedStates

*Correspondence: BarbaraKieslinger kieslinger@zsi.at

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 15November2020 Accepted: 08February2021 Published: 18March2021

Citation: KieslingerB,SchaeferT,FabianCM, BiasinE,BassiE,FreireRR,MowohN, ArifNandMelisP(2021)Covid-19

ResponseFromGlobalMakers:The CareablesCasesofGlobalDesignand LocalProduction. Front.Sociol.6:629587. doi:10.3389/fsoc.2021.629587

Makers:TheCareablesCasesof GlobalDesignandLocalProduction

BarbaraKieslinger 1*,TeresaSchaefer 1,ClaudiaMagdalenaFabian 1,ElisabettaBiasin 2 , EnricoBassi 3,RicardoRuizFreire 4,NadineMowoh 5,NawresArif 6 andPaulienMelis 7

1CentreforSocialInnovation,TechnologyandKnowledge,Vienna,Austria, 2KatholicUniversityLeuven,CentreforIT&IP Law imec,Leuven,Belgium, 3OpenDot,Milan,Italy, 4FacultyofAdministrationSciences,UniversityofPernambuco,Brazil, 5MboalabBiotech,Yaounde,Cameroon, 6ScienceCamp,Basrah,Iraq, 7WaagSociety,Amsterdam,Netherlands

Makerspaces informalsharedspacesthatofferaccesstotechnologies,resourcesanda communityofpeerlearnersformaking acrosstheglobeinitiatedarapidresponsetothe lackofmedicalhardwaresuppliesduringtheglobalpandemicoutbreakinearly2020 causedbytheCoronavirus(COVID-19).Asourhealthsystemsfacedunexperienced pressure,beingclosetocollapsinginsomecountries,andglobalsupplychainsfailingto reactimmediately,makersstartedtoprototype,locallyproduceandgloballysharedesigns ofOpenSourcehealthcareproducts,suchasfaceshieldsandothermedicalsupplies. Localcollaborationwithhospitalsandhealthcareprofessionalswereestablished.These bottom-upinitiativesfrommakernetworksacrosstheglobeareshowingushow responsibleinnovationishappeningoutsidetheconstraintsofprofit-drivenlarge industries.Inthisqualitativestudywepresent fivecasesfromaglobalnetworkof makersthatcontributedtotheproductionofpersonalprotectiveequipment(PPE)and healthcare-relatedproducts.Wedrawourcasesfromtheexperiencesmadein Careables, amixedcommunityofpeopleandorganizationscommittedtotheco-designandmaking ofopen,personalizedhealthcareforeveryone.Withthepresentedcaseswereflectonthe potentialimplicationsforpost-pandemiclocalproductionofhealthcareproductsand analyzethemfromasocialinnovationperspective.Theseglobalexperiencesarevaluable indicationsoftransformativeinnovationsthatcanreducedependenciesfrominternational supplychainsandmainstreammassproduction.

INTRODUCTION

“Makerspacesareinformalsharedspaceslocatedincommunal,educationalandincreasinglyalso commercialsettings,whichprovidetheirmemberswithaccesstotechnologies,resourcesandmost importantlyacommunityofpeerlearnersformaking” (Ahmadietal.,2019).

DuringtherapidspreadofthenovelCoronavirus(COVID-19)worldwide,whichputsourhealth systemsunderunexperiencedpressureandbringsthemclosetocollapsinginsomecountries,weare allwitnessestotheimportanceofthemakercommunityforarapidresponsetothelackofmedical hardwaresupplies(Ranneyetal.,2020).Acrosstheworldweseeinitiativespoppingupwhere makerspacesarecalledtousetheirdigitalfabricationtoolsto,e.g.,3Dprintvalvesforlife-saving Coronavirustreatmentsorfaceshieldstooffersomeprotectivegearfordoctors(DiezandBaeck,

2020).Butnotonlydoesthemakercommunitycontributetothe rapidproductionofneededpieces,italsoshowsitsresponsible innovationcapacitiesbyrapidlyprototyping,testing, documenting,andreproducingnewproductsthatareneeded intimesofthispandemic,suchashands-free3D-printeddoor openerstohelpagainstthespreadofCoronavirus.Medical Hackathonsareorganizedaroundtheglobetodesignand deployOpenSourceHardware(OSH)medicalproducts.

However,this firstaidresponseofthemakercommunitydoes notgowithoutfriction,especiallywhendealingwithcritical medicalequipmentthatneedstoadheretostrictquality controlandstandardsandrepresentsalargebusiness fieldfor companiesspecializedinthisarea.Oneofthe firstinstancesof suchaconflictappearingininternationalmediawasthecaseofa volunteermakerinItaly,whoproduced3D-printedvalvesfor life-savingCoronavirustreatments.Theoriginalmanufacturing companyrefusedtoreleasethedesign filesforthevalves,forcing thevolunteermakertoreverse-engineerthevalve(Peters,2020). Theethicalquestionthatremainstobeansweredinthiscaseis whethertheoriginalmanufacturerdidnotreleasetheoriginal filesduetoaconcernofqualityorduetoabusiness-driven motivation.Thegreatconcernforqualitystandardsisshared acrossthemakercommunityandtherapidlyestablishedworking groupsandtestingspaceswithdoctors.Makersareworkingwith medicalreviewteamstovalidatetheutilityandsafetyofnew solutionsquickly,beforeenteringthemintoOpenSource Hardwarecollaborationandhostingplatforms(Brown,2020).

Thebottom-upinitiativesfrommakernetworksacrossthe globearecurrentlyshowingushowresponsibleinnovationis happeningoutsidetheconstraintsofprofit-drivenlarge industries.Wearewitnessingcritical,sociallyresponsible makingthesedaysandaprofessionalizationofthemakerdrivenopenhardwaremovementthatiscomparabletoOpen SourceSoftwarewhichisrunningtheworldnowadays.Butisthe makercommunityputtingsocialinterestsbeforebusiness interests?WhateffectswilltheOpenSourcehardwaredesigns, thatarecurrentlybeingcreatedandshared,haveonthefutureof manufacturing?Willweseenewcollaborationsacrossestablished industriesandmakersemerging?Howwillthisaffectsocietyand especiallytheyoungergeneration?Thesearejustsomeofthe emergingquestionsthatscienceandtechnologystudiesinajoint effortofdifferentdisciplinesstillhavetoaddress.

Inthispaper,webuildontheexperiencesmadeduringthe COVID-19pandemicbyasmallnumberofgloballydistributed makerspacesandfablabs.Weaimtoproviderichdescriptionsof themakers’ COVID-19responseandreflectontheirpotential widersocietalimplicationsinthefuture.Themainobjectiveof thisstudyistocriticallyreflectfromwithinthemakercommunity onthecrisisresponseactionstaken,showingcurrentchallenges andlimitationsaswellasofferingastimulusforfurtheranalysis ofthetransformativecharacterofmakerspaces.Wehavechosena casestudyapproachasinqualitativeresearchthecomplexityof eachcaseprovidesuswithanimportantcontextfor understandingtheissuewearestudying(Flick,2017).

The fiveselectedcaseshavepreviouslybeenactiveinopen healthcarepracticesandhavebeenlooselyconnectedvia Careables,aprojectdedicatedtopersonalizedopenhealthcare

(www.careables.org).Whilethesemakercommunitiesallvaryin theirCOVID-19responseapproaches,whichwediscussin detailedcasedescription,afocusgroupdiscussionrevealeda seriesofcommonalitiesamongstmakerswhenitcomestoscaling theiractivities,whichwethenrelatedtothetheoriesofsocialand transformativeinnovationtheories.

DO-IT-YOURSELF(DIY)HEALTHCARE, MAKERSANDHEALTHANDCARE PRODUCTS Overview

Bottom-updigitalsocialinnovationsareontherise,includingin healthcare.Overrecentyearswehavewitnessedagrowing numberofgrassrootssolutionsindo-it-yourself(DIY) healthcare,includingthedevelopmentofOpenSource hardwareandDIYpracticeswhichmaycounteractcurrent healthcaresupplyshortages.ViaOpenSourceapproaches communitiescancollaborativelyimproveandco-producenew solutions,inconsultationwithpublichealthauthorities (Richterich,2020).Innovators,usersofhealthcareproducts, andcommunitiesinhealthcarearestartingtocollaborateby usingdigitaltechnologiestoco-createknowledgeandsolutions forawiderangeofneeds.ThesesolutionsrangefromOpen Sourcehandprosthetics,3Dprintedwritingtoolstosupportkids withphysicallimitations,toadd-onsforwheelchairs,and everythinginbetween.Ifwelookintothemedical field,we seesimilartendenciestowardsexperimentationandcreationof alternativesolutionsbeyondthestandardizedpractices,e.g.,in the fieldsofbiohacking,patientexperimentation,andOpen Sourcehardwareformedicaldevices.

Thesecommunity-ledorcivicinnovationsareresponsesto societalissuesthatcannotbemetbyourhealthcaresystemsnor byindustry. Criado,Rodriguez-GiraltandMencaroni(2016) evenpositionopendesignandparticipatoryprototyping strategiesinamorepoliticalcontextandstresstheactivist characterwhenappliedbytheindependentlivingmovement inSpain.Theyrelatetheexperiencesofopenprototypingwith andbydisabledpeopletothecriticalmakingnotiondefinedby Ratto(2011),whichstressedthelearningaspectsandthesocietal relevanceofDIYactivitiesinmakercommunities.

Closelyrelatedtothesecriticalmakingpropertiesis Careables, aninitiativethatisrootedinthecontextofpersonalizedopen healthcaredevelopment.Itisamixedcommunityofpeopleand organizationscommittedtotheco-designandmakingofopen, personalizedhealthcareforeveryonedrivenbyasetofunderlying principlesforresponsiblemaking.Itstarted2018asaEuropean fundedinnovationactionundertheHorizon2020programand hassincegrowntoaworldwidecommunity,mostlyviaaglobal networkofsocialandtechnologicalinnovatorscalledGlobal InnovationGathering(GIG).The Careables platform1 andits documentationrepositoryonWelder-app2 currentlyregisters

1https://www.careables.org/discover-careables/ 2https://www.welder.app/careables

over180opendesignsforopenhealthcaresolutions,nexttoother resources,suchaslegalandethicalguidelinesortraining resources. Careables encouragescarereceivers,healthcare professionals,andmakerstojoinforcesandtoco-create tailor-madesolutionsdesignedforsupportingandbetter suitingthecarereceivers’ needs.

Further,theglobalnetworkoffablabsrecentlylaunchedFab Careasaglobalinitiativetosupportfablabs,makerspacesand hackerspaceswhichareworkinginassistivetechnologies,in creatingpersonalizedsolutionsforpeoplewithphysical challengestoimprovetheirqualityoflife.

Beyondthecivic-innovationcharacter,wealsoseemoreand moreestablishedhealthcareinstitutions,suchashospitals, therapeuticandcarecenters,startingtoworkwithdigital fabricationtools.Insomehospitals,makerspacesarealready partoftheirinfrastructure(MarshallandMcGrew,2017). Whiletheseinitiativesarelessdrivenbyactivismorsocially driveninnovationneeds,theyequallyrecognizethevaluesoflocal on-demandproductionofsparepartsinhealthcareequipment, therapeuticdevices,creativity,andinnovativeprototyping.In thesehealthmakerspacesmedicalstaff findaccesstotools, materials,andtherequiredknowledgetotestnewideasand buildprototypes.Withtheexperiencesofthemomentary personalprotectiveequipment(PPE)andothermedicaldevice shortageduringtheCOVID-19crisisontheonehandanddigital fabricationtoolsandskillsontheriseontheother,wemay experienceagrowingpenetrationofademandforlocal productioninhealthcare.

Thesedevelopmentsobviouslybringlegalandethicalissuesto thetablesuchasdo-it-yourselfsolutionsthatmaynotalways complywithmedicalstandardsandregulations.Problemsmay range,forexample,fromintellectualpropertylaw(e.g.,seethe above-mentionedcaseofthe3-Dprintedvalve)tosafetyand specificlawsformedicaldevicesandPPE.Partoftheseproblems arises,asinmostcasesproductlawsareaimedatlarge organizationsratherthansmallentities.Makerspacesand thesenewformsofcollaborationblurtheclassichierarchical dichotomybetweenproducersandconsumers(Daly,2016; KamenjasevicandBiasin,2018)andresultingreaterproblems inensuringthelegalcomplianceoftheco-designedandcocreatedproducts.

Maker’sCOVID-19ResponseInitiatives

Inearly2020,whentheCOVID-19pandemichadcompletely turnedintothegloballydominatinghealthconcern,bringingthe healthsystemsinmanycountriestotheirabsolutelimits,the reactionofthemakermovementwasinstantaneous.Maker communitiesaroundtheglobehavebeenveryactiveduring the firstwaveoftheCOVID-19crisisbyrespondingtothe shortageofPPEandothermedicalandhealthcare-related products.Oneofthelargercivicresponsecommunitiesisthe OpenSourceMedicalSupplies(OSMS)3.InitiatedbyGui Cavalcanti,thefounderandCEOofaroboticscompany, OSMSlaunchedinMarch2020asaFacebookgroup,and

rapidlybroughttogetheraglobalnetworkofover70,000 makers,fabricators,communityorganizers,andmedical professionalsin55countriescollaboratingonthe unprecedentedmedicalsupplychallengescausedbythe COVID-19pandemic.Intheirglobalimpactdashboard,the networkcurrentlyindicatesthatover16Millionsupplieshave beendeliveredbytheglobalcommunity,withfaceshieldsbeing byfarthemostfrequentlyproduceddevice.

ThevarietyofPPEandmedicalsuppliesthathavebeen producedinthesecollectivenetworksaresaidtoinclude around50differentproducts,rangingfromdooropeners,and earsaverstointubationboxes.ThesePPEserveasameansto reducethespreadofthevirusfollowingtheavailableevidence thatthevirusistransmittedviaairdropletswheninclosecontact withinfectedpersonsandnotair-borne.Thereforebyproviding equipmentthatsupportsfrequentandeffectivehandwashingor actsasdisinfectants,helpspreventingcontactwithdropletsor helpsavoidingcontactwithcontaminatedsurfaceslikedoor handles,aneffectivepreventivemeasureisbeingtaken especiallyinhealthcareandcommunitysettings.The knowledgeandresearchdonebytheOSMSglobalnetwork havebeendocumentedandsharedincasestudies,community stories,aprojectlibrarythatgivesaccesstomanyopendesigns,a mapto findlocalresponsegroups,andtheOpenSourceMedical SupplyGuide(OpenSourceMedicalSupplies,2020).Also,the Careables communityshifteditsfocusofactivitiesfrom supportingDIYhealthcareforpeoplewithdisabilitiesto collecting,documentingandsharinginformationandOpen Sourcesolutionsto fightCOVID-19.The Careables COVID19collectioncurrentlyincludesaround50OpenSourcehardware projects,rangingfromdifferentversionsoffacemasksandshields tointubationboxesanddooropeners.Inaddition,background informationandlegalguidanceontheresponsibleproduction anduseofDIYproductsaresharedwiththemakercommunity worldwide.

AccordingtoasurveydonebytheFabfoundation (Fabfoundation,2020),whichwasansweredby42fablabs aroundtheworld,morethanhalfofthe43productsmadeby therespondingfablabsasareactiontotheCOVID-19crisiswere locallyapprovedormedicallyreviewedbyanagencyor organization.Theseincludehospitals(for22products), healthcareprofessionals(for15products)ornational(for6 products)andlocal(for2products)healthcareinstitutions. Thesamereportstressesthelocalcontextwheremostofthe workhappenedtoservesmalllocalorganizationsinneed.The authorsofthestudyconcludethat “Alocallysourced,globally distributedmanufacturingprocesscouldcontinueto fillan immenselyimportantroleinthemonths(andyears)tocome” (Fabfoundation,2020,p.13).

Notonlyhasthefailureofglobalmanufacturingsupplychains acceleratedthemakers’ response;anotherimportantfactor triggeringthecommunityactionhasbeenthe financially underservedandfragilehealthcaresystemsinmanycountries. IntheUnitedKingdomananalysisofthemakerresponseto COVID-19pandemicby Richterich(2020) clearlyestablishesa linkbetweenthenationalausteritypoliticsandthestrained healthcaresystem.Whenrelatingthemakers’ DIYproduction

ofhealthcareequipmenttothecriticalmakingtheoryof Ratto (2011) thereisalsoapoliticaldimensioncomingintoplay,as volunteersinmakerspacesreactedtoagovernmentalfailurein healthcaresupplies(Richterich,2020).

Overall,themakerCOVID-19responseinitiativesstrongly reliedonthesharingofopendesignsandaself-organized productionanddispatchmentoftheDIYequipment,via onlineandsocialmedia(Corsinietal.,2020; Zastrow,2020). Whenacertainmaterialwasnotlocallyavailablealternatives wereexplored,eitherbymodifyingthedesign,adaptingmaterial thatwasalreadyavailableorhackingdifferentpartsofthe productdesign(Fabfoundation,2020). Richterich(2020) stressesthissynergyofOpenSourceproductdesign,it’ sreuse,it’sadjustment,andit’slocalproductionasanopen hardwareproductasacorecharacteristicofthemaker communities’ COVID-19response.

SOCIALANDTRANSFORMATIVE INNOVATIONTHEORYANDSOCIETAL IMPLICATIONSOFDIYOPEN HEALTHCARE

Thevolunteer-driven,self-organizedactivitiesofthemaker communityhavesignificantlycontributedtotheresponse phaseoftheCOVID-19pandemicandalsodrewattentionto thelatentinnovationpotentialofthegeneralpublic(Corsinietal., 2020).Sincetherapidemergingoflocalmakerspaces, hackerspaces,fablabsandthecallingoutofaglobalmaker movement(Dougherty,2012)expertshaveassignedthisnew cultureoflocalmanufacturingcertainsocialtransformation power(Diez,2012; Smith,2017; Millardetal.,2018; Bosse etal.,2019; Unterfrauneretal.,2020).Thetechnological innovationsadvancingthemanufacturingcapacitiesofdigital fabricationtoolshaveofferedawiderangeofpossibilitiesfor socialandcommunityaction.As RuizFreireetal.(2019) exemplifywiththethree-dimensionaladditiveprinters,that arenowadaysaccessibleonthehomemarket,technological innovationscanleadtostrongsocial,environmental, economic,andpoliticalimplications.Basedonabibliographic analysisofinnovationprocesses,theauthorsarguetoregard socialandtechnologicalinnovationsnotasseparatephenomena, butrathertoconsiderinnovationsintheirsocial,technical, economic,educational,andpoliticalrealm(RuizFreireetal., 2019).TheexamplesofDIYopenhealthcareproductionthatwe havediscussedaboveneedtobeanalyzedinamultilayered perspectiveaswell.

Smith(2017),whostudiesmakerspacesassitesfor democratizinginnovationactivity,assignsthemsocial innovationpotential.Hedescribesthemas socially transformative,educationallyusefulandentrepreneurially promising. Theyoffercapabilitiesforparticipation,deliberation andcommunitydevelopment,whichconstitutetheir transformationalanddemocraticpotential.Atthesametime makerspacesalsoreproducedominantvaluesofsocietyandthe globaleconomy,e.g.,whentheyfollowanopeninnovation

agendathattriestoleveragethemakers’ creativityforglobal manufacturingandfollowingprevailingeconomicgrowth businessmodels.Thus,wearewitnessingcontradictory developmentsofmakerspaces,wherewehaveopenspaces aimingfordemocratictransformationsnexttospacesthat adheretotraditionalmarket-drivenmodels(Unterfrauner etal.,2020).

Fromacriticalmakingperspective,thispathofenteringthe business-as-usualchainisnottheonetofollow,andmanymakers strikingasocialtransformativeordemocraticpathhavestarteda searchformoreparticipatorymodelsofproductiongenerally, andforthehealthcaresectorspecifically.DIYmanufacturing processesbasedonOpenSourcedesignmaybesocialinnovations thatrespondtocertainsocialneeds,buttheyalsorequirenew collaborativeand financialmodels. Ratto(2011) criticalmaking values,suchasthesocietalrelevanceofmakingandthepotential forlearningandgainingcriticalknowledgeduringthisprocessof materialwork,indicatethesocialandtransformativeinnovation potentialofDIYopenhealthcareproductioninmaker communities.

Asexplainedbysocialinnovationtheory,socialinnovations tacklesocialneedsandrespondtosocietalchallenges(Holtgrewe andMillard,2018).Accordingto BureauofEuropeanPolicy Advisers(BEPA)(2010) societallevelsmodelofsocial innovation,therearethreeinterconnectedlevels,namelythe socialneeds(microlevel),thesocietalchallenges(mesolevel), andthesystemicchange(macrolevel)(see Figure1).Atthe microlevel,socialinnovationsarerespondingtolocalsocial demands,tacklingspecificproblemsonthegroundthatare notmetbythemarketorpublicinstitutions.Theyrespondin abottom-upapproachtotheneedsofparticulargroups,often includingthebeneficiariesthemselves,suchasvulnerablepeople. Atthemesolevel,weseesocialinnovationsthataretackling societalchallengesatlargesocialscaleoracrosswholesectorsby combiningsocial,economic,environmental,andculturalfactors. Itusuallyrequiresnewformsofrelationsbetweenactors, includingadequateorganizations,networks,andmodesof collaborationforproducingrealanddesiredoutcomes.Atthe macrolevel,socialinnovationsgeneratesystemchange.Thiscan onlyhappenwhenfundamentaltransformationsinsocietyare takingplace,includingareformofunderlyingstructures,changes intherelationshipsandpowersinsociety.Itoftengoesalongwith organizationalandinstitutionchange,reformsofpublicpolicies, newgovernancearrangementsandachangingmindsetand cultures,allowingformoreparticipationandempowerment. Whilethisdistinctionofsocialinnovationsatthethreelevels ishelpfulforanalysisitisalsosimplisticinaway,implyinga somewhatlinearviewofsocietyandpossiblyignoringcomplex andunintendedconsequences(HoltgreweandMillard,2018). Forthepurposeofthiswork,itprovestobeausefulinstrument fordiscussingresultsofthemakers’ experiences.

TheDIYopenhealthcareactivitiesofprojectssuchas Careables arelocatedatthesocialdemandlevel,tackling specificproblemsofpeople,oftenfromvulnerablegroups,that arenotaddressedappropriatelybythemarketorinstitutions.The COVID-19PPEproductionstartedatamicrolevel,butwiththe enormousimpactthattheepidemichasonoursocial,political

andeconomicsystems,italsogetsattentionasamoresocietal challengeonamesolevel.Thethirdlevel,thesystemicchangeor transformationlevel,requiresfundamentalchangesin institutions,governanceandpolicies.Whileinthisanalysiswe willmostlystayatthemicrolevelwiththedescribedcases,we wanttoexplorehowtheactionsandnetworksaroundthe COVID-19responseofthemakermovementmayinfluenceat mesoandmacrolevel,contributingtotransformationsin healthcareinthefuture.

METHODOLOGY

Astheoverallmethodology,aqualitativecasestudyapproachwas chosensinceitrepresentsaversatileformofqualitativeinquiry thatissuitableforacomprehensiveandin-depthinvestigationof complexissuesandunclearboundaries(Harrisonetal.,2017). Representativesofmakerspacesfromthe Careables projectand theGIG(GlobalInnovationGathering)networkvolunteeredto participateinthiscasestudy.Theyarelistedasco-authorsandare referredtointhefollowingtextas “caserepresentatives,” sharing theirinsightsandexperiencesthroughaninteractivedialogue, guidedbyaself-reflectionexerciseandanonlinefocusgroup discussion.

InvolvedCaseRepresentativesand Researchers

Forthepurposeofthisstudy fivemakerspacesthathavebeenvery activeduringtheCOVID-19crisisinverydifferentcontextswere invitedtocontributetothisresearch.Threeofthese fiveare membersoftheGIGnetwork 4.Itisaglobalnetworkofsocialand technologicalinnovatorsthataimstofosterthesharingof knowledgeandexperienceamongstmembers.Two makerspacesarepartnersofthe Careables projectconsortium. Inthefollowinglistweintroducetherepresentativesofthe makerspaceswhocontributedtothisarticle.

-Brazil:RicardoRuizFreire(MemberoftheGIGSupervisory Board)

4https://www.globalinnovationgathering.org

FrontiersinSociology|www.frontiersin.org

FIGURE2| Stepsofdatacollectionandanalysis.

-Cameroon:NadineMowoh(MemberoftheGIGnetwork)

-Iraq:NawresArif(MemberoftheGIGSupervisoryBoard)

-Italy:EnricoBassi(DirectorofthemakerspaceOpenDot5)

-TheNetherlands:PaulienMelis(ProgrammeDeveloperofthe makerspaceWAAG6)

Inadditiontotheabove-mentionedcaserepresentativesfour researchersfromthe Careables researchteamparticipatedinthis research.ThreeofthemarefemaleacademicsattheCenterfor SocialInnovationinAustria,bringingininterdisciplinary perspectives,withanacademicbackgroundspanningthe disciplinesofpsychology,sociology,pedagogy,andeconomy. OneresearcherisafemalelegalexpertworkingfortheKU LeuvenCenterforIT&IPLawinBelgium.Thisdiversityin backgroundswasimportanttounderstandthecomplexityofthe casesandtoimprovetheintegrationofdiverseperspectives throughaseriesofdiscussionsandreflections.Thethree

5http://www.opendotlab.it/about/ 6https://waag.org

FIGURE1| Adaptionofthethree BureauofEuropeanPolicyAdvisers(BEPA)(2010) levelsofsocialinnovation.

researchersfromtheCenterofSocialInnovationwerealsothe oneswhodesignedthisqualitativestudyandtooktheleadin analyzingtheresult.

Ingeneral,theoverallcultureofthisresearchstudywas collaborativeandcooperative,sincenosingleresearcher imposedtheirinterpretation,andtheresultswereadditionally discussedwithallcontributorsofthepaper.

RESEARCHDESIGN

Twodatacollectioninstrumentswerepreparedtolearnaboutand analyzetheCOVID-19activitiesinthe fivecases:aself-reflection exerciseandanonlinefocusgroupdiscussion(Figure2).

Self-Re flection

Forthecollectionofthedata,theresearchteampreparedaselfreflectionexercise,whichguidedthecaserepresentativesintheir self-reflectionprocess.Theself-reflectionexercisewasbasedon thefollowingquestions,whichparticipantsansweredinrelation totheirtheCOVID-19responseactivitiesoftheirmakerspaces:

Casedescription: Pleasedescribewhatwere/areyourmain activitiesofCOVID-19response.Whatmotivatedyouto becomeactiveasCOVID-19responder?Whatpartnerships/ networks/collaborationshaveyouestablishedorareyou makinguseof?Howdo/didyou financetheproductionof PPE?Wheredo/didyougetthedesignsfrom?

Perceivedimpactandachievements: Pleasedescribethe perceivedimpactthatyouachievedsofarwithyour activitiesandwhathasbeenthepublic/politicalperception ofyouractivities.Hastherebeenanypublic/political recognitionofyourcontribution?Youmayalsoreporton theimpactachievedbyothermakersinyourcommunity.

Barriersandchallenges: Pleasereflectonthebarriersand challengesthatyouencounterduringyourCOVID-19 activities.

Futureimplications: Pleasereflectonthefuturepotential implicationsthatyouseefromyourexperienceswithregards topost-pandemiclocalproductionofhealthcareproducts.

Theself-re fl ectionreports,whichwere fi lledinbythecase representativesduringa3-weeksperiodinOctober2020, wereanalyzedbytheresearchteamina fi rstroundand providedthegroundforthestructureoftheonlinefocus groupdiscussion.

OnlineFocusGroup

TheonlinefocusgroupwasorganizedonNovember3,2020via thevideoconferencingplatformZOOMandlasted75min. RepresentativesfromthecasesinBrazil,Cameroon,andItaly, aswellasthefourresearchersintroducedabove,tookpartand aimedatelaboratingadeeperunderstandingofthedescribed casesandfuturescalingoptions.

Thestartingpointofthefocusgroupwasashortpresentation bytheresearchersofthethreedimensionsofsocialinnovation alsosharedonaGoogleJamboard-boardandpresentedin

FIGURE3| Scaleandsocialinnovationmatrix(adaptedfrom Unterfrauneretal.,2020).

Chapter3ofthisarticle.Afterthisintroduction,thecase representativeswereinvitedtoplacetheirCOVID-19response initiativesontherespectivedimensionofsocialinnovation (micro meso macro)andexplaintheirdecision.Inthenext step,aseconddimensionwasintroduced,thescaleand interactiondimension,asanindicatorforconnectedness (Figure3).Thisdimensionontheverticalaxisrefersontheone endtoasituationalawareness,wheresingleactorstendtowork relativelyisolated,unconnected,andfocusonthelocalareaworking onverylocalissues.Ontheotherendoftheaxis,wespeakabout distributedawareness,referringtoverystronglynetworked, interconnectedmakes,whoworkcollaborativelyoverlargeareas, orevenglobally.Thismatrixofscaleandsocialinnovation dimensionhasbeenappliedinpreviousstudiesandhasprovided valuableinsightsintothecharacteristicsofmakerinitiatives(e.g., Unterfrauneretal.,2020).

ThecaserepresentativesplacedagaintheirCOVID-19 responseinitiativesontherespectivex-andy-axesand discussedtheirpositioningwiththegroup.Afterthis introductionthecorediscussionfocusedontwoquestions:

-DocaserepresentativeswishthattheirCOVID-19activitiesin thedifferentcountriesscalefrommicro,tomeso,tomacro level?

-Ifnot,whynot?Ifyes,underwhichconditions?

Oneoftheleadingresearchersfacilitatedthediscussion, whilethesecondonesummarizedthemainaspectsofthe discussionontheJamboardtovisualizethekeypoints discussed.Thethirdresearchertookadditionalnotes.The discussionwasmoderatedtomakeparticipantsre fl ectontheir casesandtogainthemselvesnewinsightsintotheirspeci fi c situation.Inqualitativeresearchtheresearcherisnot necessarilytheinvisibleneutral,butmayalsocontributeto amoraldiscourseandsparktransformativeprocesses( Flick, 2018 ).Theonlinefocusgroupwasalsoaudiorecordedbased ontheinformedconsentgivenbyparticipants,asabasisfor thelateranalysis.

TABLE1| Overviewofcodes,subcodes,andtheirgrouping

Originalcodes Sub-codesGroupedcodes

Partnerships

Networks(local,regional,National,global)

Collaborationwithhealthcareprofessionals

Collaborationwitheducationalsector

Relationshipwithhealthcaresector

Nationalandinternationalcollaboration

Collaborationwithcompaniesandindustry

CollaborationWithspecifictargetgroups,e.g.police,army

CollaborationNetworks,partnerships,collaborations

CoordinationoflocalgroupsCoordination

Coordinationofnationalactivities

DecreasingvisibilityinlargenetworksChallengesinnetworks

Increasedcomplexityofstructurednetworks

Notlosingcontacttolocalcommunities

LackingCooperationwithgovernment

LocalContextadaptionLocalembedding

Localaspects

Localcoordinationgroups

Localneeds

Scaling ScaleValue,scale,infrastructures

Upscaling

Sharedprinciples,valuesValues

Voluntarycontributions,volunteers

Politicalsupport

Powerofnetworks

Fexibility Trust

Sustainability Sustainability Businessmodels

Funding Platforms Infrastructures

Localinfrastructure Communication Logistics

Localsupplychains Nationalcoordination StructuredNetworks

Overcomingbarriersintheproduction(material,legalandethicalaspects)Challengesofinfrastructures

Lackofresources,e.g.material Lackoffunding

Sensitization AwarenessEducation,training,skills,awareness

Localandinternationalawareness

Education Education Skills,experiences

Exchangeofknowledge Tackelingmisconceptions

Guidance Training Training

EmpowermentofcitizensSkills

Pushingmakerskillstowardsotherdomains,e.g.health-sector

Criticalthinkingofnegativeimpact

Safety SafetySafety,quality,legalaspects

Quality,certificationQuality

Prototypingandtesting

Legalaspects(NationalandInternational)Legalaspects

AnalysisandPresentationofData

Theanalysisofthecasestudiesisbasedontheself-reflectionreports ofthecaserepresentativesandthesummaryoftheonlinefocus

groupdiscussion.Qualitativecontentanalysisaccordingto Mayring (2014) wasselectedasasuitableapproachforthisexplorativestudy. Itcomprisesaholisticandsubjectiveprocedurethatisusedto

interpretandcategorizequalitativedata.Thisanalyticalprocess makessenseofthedata,itdescribesandhighlightsimportant findingsandallowstodrawclearlinksbetweentheresearch objectivesandthesummary findings.Theconventionalapproach tocontentanalysis(HsiehandShannon,2005)wasusedhere,where researchersavoidusingpre-conceivedcategories,allowingthe categoriestoemergefromthedata.

Theresearchmaterialwasanalyzedthroughtwoiterativephases, fromOctober29,2020toNovember11,2020bythethreefemale researchersfromtheCenterforSocialInnovation,whoalso figureas the firstauthorsofthismanuscript.Datawereanalyzedboth inductivelyanddeductivelyinthesetwophases.Specifically,two formsofdataanalysistriangulationwerecarriedoutbythe researcherstoensurearigorousandrobustapproach(Leechand Onwuegbuzie,2007).First,theself-reflectionreportswerecoded individuallybyeachresearcherindependentlyandprovidedinsights abouttheresearchmaterialthatweresharedanddiscussed. Preliminarycodeswerethenagreedandgroupedintosub-codes. The findingsfromthis firstcodingexperiencealsoservedasabasis forthefocusgroupdiscussion,wheretheywerecriticallyreflected withthecaserepresentatives.Inthesecondphaseoftheanalysisthe originalcodeswereappliedtothe summarytextofthefocusgroups, firstindividuallybyeachresearcherandthendiscussedjointly.At theendofthisprocessthefollowingcodes,subcodesanda final groupingofthecodeswasagreed(Table1).

Weareawarethatthisstudyisexploratoryinnatureandisgiving arichqualitativeviewonthereportedcases,butislimitedinitsscope. Thisistheverynatureofqualitativeresearch.Engagingthecase representativesinareflectivefocusgroupdiscussionandbeingpartof theauthoringteammightshedsomedoubtonthevalidityofthis research.However,webelievethatbydoingsowehaveguaranteed theauthenticityoftheexperiencesandour findingsareinternally coherent.Inparticularthefocusgroupdiscussionhashelpedto reflectontheconstructsemergingfromthe firstanalyticalphaseand hasallowedthethreemainresearcherstocapturedata “fromthe inside” andgainadeeperunderstandingofthephenomenaunder discussion(MilesandHuberman,1994).Thistransdisciplinary approachwasimportantforameaningfulknowledgecoproductionasdescribedby Thompsonetal.(2017).The integrativeandparticipatoryprocessesduringtheself-reflection reportingandthefocusgroupdiscussionopenedthecomplex contextofthemakermovementforthemainresearchers.The collaborationoftheactorsinvolvedinthisstudy,whotranscend disciplinaryandacademicboundaries,hasbeengrowingoverthe yearsandaccumulatesinthisstudy.Webeliefthatacertainlevelof mutualtrustamongstallco-researchersisimportantforthe transdisciplinaryco-production(Thompsonetal.,2017),leading tosociallyrobustknowledgeinthesenseof Nowotnyetal.(2001)

Thefollowingcasedescriptionsrepresentsummariesofthe self-reflectionreportswhilechapter6presentstheresultsfrom theonlinefocusgroup.

CASEDESCRIPTIONS

Thefollowing fi vecasesofmakerresponsestoCOVID-19 coverdifferentperspectivesandcontexts.Somefocusontheir

lab ’ sactivities,somerelatemoreonthenationalactivitiesall together,andoverall,theygiveagoodrepresentationofthe diversityofactionsencounteredinmakerspacesacross theglobe.

TheBrazilianCase(LabCOCO,CasaCriatura,Coletivo3D andLabProComum;Olinda)

InBrazil,beforetheoutbreakofthepandemic,fourmakerorientedorganizationshadestablishedcollaborationswiththe Careables projectandstartedtofunctionaslocalhubswhich connectlocalcommunitiesofpersonswith(physical) healthcareneeds,caregivers,andpublichealthcare professionalswiththecommunityofmakersandmedical herbalists.WiththeoutbreakofCOVID-19,theactivitiesof theselocalhubs,called CareablesOlinda ,completelyshiftedto producingPPEandothermedicalsuppliesinorderto fi ghtthe pandemic.Sofar,theyhaveproducedaround7,000faceshield unitsoutofwhichtheydonatedaround5,000piecesto differentinitiatives,tohospitalsandhealthauthoritiesin theRecifemetropolitanarea,citiesinthecountryside,and indigenousandAfro-Braziliancommunities.Theremaining productswereofferedviaane-Shopthatwasspeci fi callysetup forthatpurpose.TheBrazilianfablabspartlyreliedonshared OpenSourcedesignsoffaceshieldsandadaptedthemtothe localcontext.Besides,togetherwithhealthcareprofessionals, theydevelopedanopen-sourcemodelofanaerosolbox integratedintolocalnecessitiestouseatIntensiveCare Units(ICU)andreleaseditonline.Theaerosolboxisused intheprocessofintubationandextubationofpatients,to avoidthecontactofaerosolspraysofpatientswithdoctors. Theproductwasvalidatedwithdoctorsfromtwodifferent hospitalsintheMetropolitanRegionofRecife,whohave experienceinorotrachealintubation.Inaddition,a communityincludingprofessors,medicalstudentsand designersfromCasaCriaturawasestablishedtodevelopthe productfurtherandis,atthetimeofwritingthismanuscript, seekingcerti fi cationandregistrationofafreepatent,withthe fi nalaimofbringingtheaerosolboxtoaglobalmarket.

Partnershipsandnetworks,localandglobal,playedacrucial roleinthiscase.Sincethebeginningofitsactivities, Careables Olinda hadadialoguewiththeSecretaryofHealthofOlinda,who realizedtheimportanceofthemakercommunityinthelocal productionofPPEtokeepupthecity’shealthsystem.Later, collaborationwithhealthcareprofessionalsandhospitalsstarted asICUprofessionalsapproachedthemakerswitharequestfora betterversionofanaerosolboxandjointlytheydefinedthe specifications.Therelationshipwiththehealthsectorhasallowed CareablesOlinda toreviewitsareaofactivityandhasexpanded thescopeofitsinventivenesswhileatthesametimeitincreased localawarenessandknowledgeaboutopen-source,digital manufacturingandhealthcareacrosstheinvolved stakeholders,e.g.,physicists,designers,healthcare professionals,makers.Thelocalmakerhubsalsofeltlikebeing partofabiggerinitiative,notonlyfortheproducersofPPE.Their communicationcampaignwasasmallpartofabigoperationby differentsectorsinthecitiestosuppressthevirusandthe cooperationwiththeSecretaryofHealthhasalreadysplitover tootheractivitiesofopeninnovation,besidesCOVID-19.

Whiletheactivitiesclearlyshowedvaluableimpactinreducing thecurveofCOVID-19infectionsintheregions(contrarytothe figuresatnationallevel)andinpromotingthesocialvalueofopen innovation,theactorsclearlyrecognizethenegativeimpactof theiractions.Theenormousamountofplasticbeingproduced, theconsiderabledegreeofpollutionandcarbonemissionsrelated tothemakers’ activities,coupledwiththeenvironmental problemsofthelocalcommunitiestriggeredacommitment formoresustainablepracticesinthefuture.Someofthose havealreadystartedtoemerge,suchastheworkwithrecycled plasticorthecreationofabio-fermentationlabtoaddressthe foodscarcityinsomelocalcommunities.

TheCameroonianCase(Mboalab, Mbankomo)

Mboalabisacommunitybiologylabinthecentralregion YaoundeinCameroon,comprisingmolecularbiologists, biochemists,publiccommunicationsspecialists, microbiologists,andelectro-mechanictechnicians,whoactas educatorsinthelocalcommunitytoempowerthepopulation withtheskillstosolvetheirhealthandenvironmentalproblems. DuringtheCOVID-19pandemicoutbreak,thelabtriedto attacksomeofthelocalbottlenecksrelatedtothesanitary situation.TheinformationdepartmentatMboalabaccessed thelatestinformationandrecommendationsfromtheWorld HealthOrganization(WHO),theFoodandDrug Administration(FDA),andtheCentersforDiseaseControl andPrevention(CDC),lookingforsimpleformulaeformaking handsanitizersandinstructionsforfacemasksdesigns.With theirstrategytotargetthemostvulnerablegroupsand communities(healthcareworkersandthelocalpopulation) ofthesuburbancommunityofMbankomo,wherethelabis located,theystartedtheireducationalwork.Thelabteamwas abletopreparealcohol-basedhandsanitizersthatmettheFDA recommendationwithlocallyavailablecomponentsandstarted demonstratingsimpleformulaeforproducinghandsanitizers fromcheapandreadilyavailablecomponentsfromthelocal drugstores.

Thelabalsoproducedfacemasksusingappropriatelocal fabricandprototypedanautomaticgelandwaterdispenserto limitthespreadofthevirusandencouragefrequentwashingof hands.Educationalaspectswereembeddedinmostactivitiesof thelab.Throughtheuseoftheautomaticgeldispenserthelocal populationwastaughtabouttheimportanceofhandwashingand howaneffectivehandwashingexerciseshouldbecarriedout. Thesesensitizationsessionswerealsousedtoeducatethe populationabouttheCoronavirus,itsmodesoftransmission, waysofprevention helpingtodoawaywithcertainmythsabout thevirusthatcirculatedinthelocalcommunity.

Again,globalnetworkswereimportanttoconnectwithother populationstosharestories,knowledge,andapproachesusing platformslikeOpenairandWikifactory.Nationaland internationalcollaborationwasencounteredinthesearchof testingkits,andbyparticipatinginthedevelopmentand testingofsimple,easytoreplicatemethodsof fighting COVID-19inresourceconstraintsettings.

Inspiteofalltheseeffortsmade,somechallengeswere encountered.Upscalingwasanissue,duetoalackoffunds. Forinstance,theautomaticgeldispenserthatwasprototypedwas intendedtobekeptinatleast10majorcentersofthecommunity toencouragefrequentwashingofhandsanddemonstratean efficienthandwashingpractice.Thegeneralincreaseinpricesof allessentialandnon-essentialgoodsmadelifedifficultforthe commonlocalpopulation.ThewidelyspreadbeliefthatAfricans arenaturallyimmunetothevirusandthatsomeconcoctionscan providethemstrongerimmunityandprotectthemfrombeing infectedwasanotherhurdle.Partofthepopulationalsostrongly believedandwentaboutsayingthattheCoronavirusisnotreal andthatitwasonlyascamorsome “thing” createdtodeceiveand controlpeople’slives.

Giventhesensitizations,training,andcollaborationsachieved duringthisperiodofthepandemic,thepopulation,community biologists,andmakersstandachanceofindependentlyhandling futurepandemicsorepidemicsbyconfidentlyproducingPPEor othermaterialsthatmightberequiredto fightthepandemic.The approachistoeducateandequipthepopulationwiththeskillsto beabletohandlethecrisiswithoutdependingonthegovernment, non-profit-organisations,orforeignaiders.

TheDutchCase(WAAG,Amsterdam)

ThemakerspaceatWaagaimedtoprovidesupportinmaker research,productdevelopmentandprototypingduringthe first lockdownphase,teamingupwithanationwidegroupof TechnicalUniversities,theTechMedCenter(Universityof Twente),thepolice,theRoyalNetherlandsArmyandnational andglobalmakercommunities.

Inanattempttobetterunderstandtheneedswithinthe medical fieldeffortsweremostlydedicatedtocoordinating andbackchannelingwithinthenetwork.Viaonlinemeetings Waagfunctionedasacatalystinbringingdifferentmakergroups togetherandhasbeenconnectingstakeholdersthatweren’tin contactorcollaborationwitheachother.Itwasimportanttoget anoverviewofproductsorprototypesthatwereneededmost,but alsolookingintoexistingsolutionsorsolutionsthatwerebeing developed,andhowWaagcouldbeinvolvedinthis.Oneofthe mainconcernsandalsothemainchallengefortheWaagteam wastoensurethesafetyofthePPE.Also,gettingprototypestested bycertifiedbodieswasdifficult.Basedontheexperiencesfrom othermakerspacesintheNetherlandsandinternationally,door handlesandfaceshieldsweremostlyconsideredforproduction.

IncollaborationwiththepoliceWaagexploredthe prototypingofdoorhandles,whichpoliceofficerswoulduse whenenteringanunknownbuilding.Differentproduction methodswereexploredto findanalternativefortheprototype thepolicewereusing,whichwas3Dprintedandconsumedquite sometimeforlargescaleproduction.TheteamatWaagadjusted themodelsoitcouldbelasercut,andthusbeproducedatlarge scaleinashorttime.Theprototypewastestedandfunctional. However,withinthepoliceforcefewpoliceofficerswantedtouse adoorhandleintheirdailywork.So,theadapteddesignwasin theendnotproduced.Otherproductsthefablabwas experimentingwithincludeatransparentfacemaskanda DIYrespirator.

TherewasalotofmediaattentiononthelackofPPEfor healthcareprofessionalsintheNetherlands.Waagreachedouttothe medicalinstitutionswithintheMetropoleregionofAmsterdamto hearwhattheirneedsandwisheswere,butintheendthe first contactsendedinnospecificrequestforfurtherresearchor prototyping.Thus,thefablabatWaagstartedtoproduceface shieldsandopenedawebshoptosellthematminimalcoststo localhealthcareprofessionals,organizationsandpeopleworkingin contactjobs,suchashairdressers,cleaningservices,beauticians,nail salonsetc.Localresidentialcareorganizationsthatweredirectly offeredthesefaceshieldsdidnotshowanyinterest.

Overall,theimpactofWaag’sengagementhasbeenmainlyin coordinatingandpushingthenotionofmakerskillstowardsother domains,ratherthanorganizingandproducingPPE.Buildingona networkoflocal,nationalandinternationalorganizations,Waagwas abletopushtheaddedvalueofmakerskillsasadrivinginnovation force.However,whenitcomestotheproductionanddistributionof largenumbersofproductsWaagwasexpectingmorecollaboration withlargeenterprises,whichwasnotachieved.Accordingtotheir experiencecommercialcompaniesarereluctanttotakeuponthe innovativedesignsandknowledgestemmingfromthemaker communities.

Finally,itisworthmentioningthatthediscussionwithinthe nationalcoordinationgroup,includingtheNetherlandsRoyalArmy, alsotoucheduponthenotionofdistributedmanufacturing.Theidea ofsettingupaglobalnetworkofdecentralizedproductionfacilities, asanimmediateresponsetoahealthcarecrisis,gainedwider attentionandwillbefurtherdiscussedinthefuture.Currently thenetworkoffablabsmostlysharesknowledge,skillsand blueprints,butcoulditalsobeequippedtocoordinatealargescaleproductionofe.g.PPEinthefuture?

TheIraqiCase(ScienceCamp,Basra)

ScienceCamp,amakerspacebasedinBasra,southofIraq,is attachedtotheglobalmakermovementandusedtoprovide innovativesolutionsbyimplementingdigitalfabricationandDIY concepts,armedwiththequalifiedindustrialinfrastructure.This spacewasamongthe firstentitiesinthecountrythatrespondedto theCOVID-19crisiswithinnovativesolutions.Approximately 13,000protectivefaceshieldswereproducedanddistributedfor freetothefrontlinemedicalstaffandothermainhumanresources whoprovideessentialservicesforhealthcare,security,delivery services,etc.Incollaborationwithlocalindustry,localcivil society,andacademicians,aresponseinfrastructurewassetup takingcareofe.g.monitoringtheneedsofPPE,providingraw materials,communicatingwithhealthcareservices,PPEproduction, PPEdistribution,onlinedigitalstatisticsmonitoring,andresearch anddevelopment.Medicalstaffhighlyappreciatedtheeffortsdone bythemakercommunityandrequestedevenmorefaceshieldsand researchintoothertypesofPPE.

ThedesignandproductionprocessofPPEwasadaptedtothe localcontext,usinglocallyavailablerawmaterials,suchasPET plasticsheetsusedinwaterpackagingfactories.Also,thedesign wasadaptedtobeeasytoassemble,withnoneedforgluing, stapling,orsewing.Thedigitalfabricationtechniquesapplied madetheproductionprocessuseaminimalnumberofraw materials,andfast,withhighquality.

Alleffortswerecoveredbyvoluntarycontributionsfromall partners.Therawmaterialswereadonationfromthelocalwater factory.TheIraqigovernmentdid,however,notsupportthistype ofcommunityresponseandsomeinternationalNGOssuggested convertingthePPEproductionprocessintoabusinessrather thanacharitycrisisresponse,whichwasnotrealizedbythe makerspaceduetoethicalreasons.

Apartfromthe financialchallenges,theIraqimakerspacealso encounteredotherdifficulties,relatedtopublicadministration andlogistics.Travelpermissionformstoprocurerawmaterials, machinemaintenance,etc.werepartlyrefusedduringnational lockdownandbureaucraticbarriershinderedthedistributionof PPEviatheofficialchannelsofthehealthcareauthorities.

Inadditiontothehighrecognitioninlocalandglobalmedia, theinvolvedmakersgotexperienceinPPEproductionandlegal aspectsrelatedtoitaswellasbetterinsightintotheuseand availabilityofrawmaterialsandresourceslocations.Thefast responseactivitieshavealsoshownthatthebottom-upsocial responsecanworkindependentlyfromgovernmentalor internationalaidorganizations,avoidingpotentialconflicts betweentheseorganizations.

TheItalianCase(Opendot,Milan)

ItalywasEurope’ s firstandoneofthemostaffectednationsbeing hitbytheCOVID-19pandemic.Thecountry’smostefficient healthsystemsintheNorthernregionswereabouttocollapseand hospitalswererunningoutofsupplies,includingPPEsaswellas essentialpartsforventilatorsandotherrespiratorydevices. Triggeredbytheinitiativeofamakerwhoprovidedahospital witha3Dprinterandhelpedtoreproducemissingvalves,the valueofthemakercommunityforthelocalhealthinfrastructure becamevisible,andlocalsupplychainsofPPEforhealthcarestaff andotheressentialworkersstartedtoemerge.

Localcoordinationgroupsplayedanimportantroleinthe distributedproductionandsupplychains.Thesegroupswere almostallvolunteer-based,almostalwayswithinexisting communitiesofpeopleorfablabnetworkswhowerealready usedtoworkingtogether.The firstCOVID-19makernetworksin Italywereregional,andtheysucceededinrespondingtolocal needsastheyevolved.Thisteamworkatlocalandregionallevels pavedthewayfornationwidecoordinationacrossItaly.Inthe periodofjustafewdays,threedifferentinitiativesemergedwith similarandcomplementaryobjectives.Oneofthoseinitiatives alone, MakeinItaly7,collectedover500contactsfrommakers, smalllaboratories,startupsandfablabs.Theirwebsitecurrently listsover25,000itemsproducedanddonated.Opendot,afablab inMilano, Careables partnerandspecializedinworkingwiththe healthcaresector,wasinvolvedinthenationalcoordination activitiesfromtheonsetandcontributedtoovercomingthe localmedicalsupplyshortage.

Italy’sresponsetothehealthcrisiswasn’tlimitedtothe grassrootsmakermovementofhundredsofvolunteersand fablabs.ManyItaliancompaniesworkedcloselywithactive makers,andinsomecases,evenhelpedthemovementtotake

7http://www.makeinitaly.org/

off.Alsotheeducationalsectorwasinvolvedasthefaceshield productionmodelwasincludedinthetrainingofhighschool students,initiatedbytheMaker@Scuolaproject8

ThecaseinItalyhasshownsofarhownewlocalcollaborations fordigitalsocialinnovationscanbeestablished.Becauseofthe emergency,varioushospitalscontactedspecializedstudios, fablabs,smallbusinessesandstartupsinordertodevelopnew solutionstogether.Doctorshavestartedtobecomeco-designers, innovatorsandmakers.InItaly,we findsomeisolatedexamples wheretheseemergency-drivencollaborationshaveturnedinto establishedcollaborationswherehospitals,doctorsandtherapists recognizethevalueandpotentialofdigitalfabricationtoolsand distributedlocalproduction.However,theorganizationaland structuraldetailsofcooperationbetweenmakerspacesandthe publichealthcaresysteminamoresystematicwayarestilltobe explored.

FOCUSGROUPRESULTS

Inthefollowingchaptertheresultsfromthefocusgroup discussionwithcaserepresentativesfromBrazil,Cameroon, andItalyarepresented.

Ina firststep,focusgroupparticipantswereinvitedtorelate theirCovid-19activitiestooneofthelevelsofsocial innovation themicro,meso,ormacrolevel(see Figure4). Thetwocaserepresentativesnotpresentduringthefocus groupweregivenanindividualexplanationofthematrixand werelikewiseaskedforapositioning.

Allthreecaserepresentativespresentduringthefocusgroup meetingstatedthattheirCOVID-19relatedactivitieswerein transitionfrommicrotomesolevel.Thus,cooperationwithother organizationsbecameimportanttomeetthesocialneedandnot onlysocialbutalsoeconomicobjectiveswereaddressed.The Italiancaserepresentativesaidtohaveactedonamesolevel duringthe firstwaveofCOVID-19,establishingnetworks

betweenItalianfablabsandorganizationsintheneedfor fabricatedhealthdevices;butactedagainonamicrolevel whentheemergencysituationstopped.Connectionswith politicalactorshavebeenestablishedbutsustainablelinksare notinplaceyet.IntheBraziliancase, firstsustainablecontacts wereestablishedwithlocalpoliticians,whoshowedinterestinthe civicengagementtakingplaceinOlinda.Also,theclose cooperationwithhealthprofessionalsisstillinplace,afterthe firstwave.Ineconomicterms,thefablabsellsindividualface shields,fabricatedintheirfablab,orwholepackages,wheree.g.,a companyisdonating200faceshields.IntheCamerooncasethe activitieswereandstillareclosertothemesolevel,assustainable linkstootherorganizationshavebeenestablished,mostlyrelated totheeducationalpurposeofthelab.

Inasecondstep,thefocusgroupparticipantsdiscussedtwo keyquestions:1)IftheywouldwishfortheirCOVID-19activities tosustainablyscalefrommicro,tomeso,tomacrolevel;and2)if yes,underwhichconditions.

Allthreecaserepresentativessharedthesameopinion that scalingtheiractivitiesatleastfromthemicroleveltoamorestable macroleveliswishedfor,astherearepeopleintheneedofhelp andthisneedcanbemetbytheproductioncapacitiesinfablabs. However,scalingupshouldtakeplaceonlyundercertain conditionsandbuildingoncertainsharedprinciplesandvalues.

Scalinguponthesocialinnovationmodelshouldnotresemble thescalingupinbusinessterms.Itwasstatedthatcompaniestend tochangewhentheyscale,losingcontactwithlocalcommunities, introducingintermediatelayersofmanagement,andshiftingthe focusto financialaspectsandmaximizingincomes.Theriskis thatopeninnovationisnotopenanymore,butratherownedbya company,thushinderingtheinnovativegroundworkthatwas originallyaimedforbytheirinventors.Soit’sfundamentalto changethemodelsofscalingup.

Caserepresentativeswishtoscaletheapproachandspreadthe specificknowledgeonhowtoco-designandproduce (personalized)healthcaredeviceswithdigitalfabricationtools. Sotrainingotherfablabsinhowtosupporthealthandcareiskey here,butalsothetrainingoflocalpeople firstregardingCOVID19andhowtobestprotectthemselves,andsecondhowto cooperatewithandmakeuseoffablabstosupporttheirhealth andwell-being.

Participantsaimforestablishingconnectionsandcollaboration withotherfablabstoscaleresponsestohealthcareprofessionals andpeopleinneed.TheItalianexperienceinthisregardshowsthat creatingstructurednetworksofcooperationincreasescomplexity. Fablabsareheterogeneous,havedifferentunderlying organizationalmodelsandspecializations.Sonoteveryfablab wouldbeabletoproducemedicalequipmentthatmightwork properlyinahospitalcontext.Thequestionishowtodealwiththis complexityandalsoraisessomedoubtsthatstrongnetworksmight resultindecreasingvisibilityandimportanceofthesinglenodeof thisnetwork.

Legislationissueshavetobeaddressedcarefullyifmedical equipmentisthefocusofdigitalfabrication.Whenproducing healthcareproductsormedicalequipmentthemainaimistonot producemoreharmthangood.InCameroon,onlycertain institutionsareallowedtoproducemedicalequipment,thus

FIGURE4| Casepositioningonscaleandsocialinnovationmatrix.

Mboalabfocusedonproducingproductswherenostrict legislativemeasuresneedtobeaddressed,e.g.,producingand makingaccessibleproperdisinfectantsandprovidingthe knowledgeonhowtoprotectoneselffromCOVID-19.In Brazil,legislationismore flexible,andtheclosecooperation withhealthpersonnelallowedthefablabinOlindato successfullydevelopfaceshieldsusedinmedicalorganizations aswellasanopen-sourcemodelofanaerosolbox.Nevertheless, CareablesOlinda stressesthatworkingforothergroupsinthe needofhealthandcare,mightbeagoodwaytostrengthentheir approachwhileavoidingcomplexcertificationissues.Inthe Italiancase,theemergencysituationofthe firstCOVID-19 wavegaveroomforcertainlegislativeexceptions.Still, producingforhospitalsrequiresmeetinghighqualitycriteria anddemandsforadditionalaspectslikedocumentation,etc.In timesofcrisis,theofficialprocessesmightbetoolongand exclusiveto flexiblyreacttoemergencies,sothereisacallfor moreagilemechanismsthatareestablishedandtestedbeyondthe timesofcrisis.Itiswishedformore flexibilitytotestthe collaborationbetweenmedicalinstitutionsandlocal manufacturerstoco-designandproducemedicalequipment belowcertainrisksorcosts.Asmentionedabove,working withandfordisabledpeople,andofferingCOVID-19support thatisnotmedicalequipment(e.g.disinfection,etc.)aresomeof thesuggestedactivityareasthatcanstrengthensustainable cooperationbetweenlocalmanufacturersandpeopleand organizationsinneedofhealthandcaredevices.Alternative approachestosupportinghealthandcarearekeytospreadthe approach.

Additionally,stronglocalnodesarekeytospreadingthe approach.Workinginthehealthandcaresectorrequiresat theonehandtrustofpeopleandadiversesetoflocal organizations,ontheotherhanditaimstosuccessfully empowerlocalpeople.Thus,establishinganetworkoflocal nodesthatadapttolocalcontexts,linktolocalorganizations

andthelocalcommunityofpeopleinneed,isthebasisof spreadingdigitalfabricationforhealthandcare.

TheCOVID-19emergencysituationshowedhowpowerful thenetworkoflocaldigitalmanufacturerscanbein flexibly supportingsocietalneeds.Focusingthispowerofthenetworkto otheraspects,likeclimatechange,digitalfabricationinitiatives canplayakeyroleinsuccessfullysupportingsocialinnovation processes.Makeractivitiescaninthisregardcatalyzethe attentiontoawiderproblem,e.g.,theclimatechangeandthe scalingupshouldnottakeplaceatthecostoftheenvironment. Thus,producingtonsofplastics(e.g.,inthecaseoffaceshields) shouldbecriticallyreflectedandalternativewaysofmore environmentallyfriendlyproductionshouldbesought.

SUMMARYOFFINDINGS

Thetwomaindatacollectioninstrumentsbroughtforward complementary findings.Whiletheself-reflectionreporting focusedondescribingthepastandcurrentexperiencesmade duringtheCOVID-19responseactivitiesbythemakers,thefocus groupdiscussionbuiltontheseexperiencesandreflectedon futureimplicationsforthescalingofthemakers’ grassroots initiatives. Figure5 summarizestheexperiencesmadebythe casesandthelearningsandimplicationstheseexperiencesreveal forapotentialscalinginthefuture.

Fromthecollectedexperiencesweseehowfastthemaker communityreactedduringthehealthemergencybysupplying localhealthcareproviderswithurgentlyneededPPEandother medicaldevices.Such responsive behaviorwasstronglyenabled bythecommitmentoflocalstakeholdersontheonehandandthe globalconnectednessontheotherhand.Bydrawingfromtheir local,nationalandglobalnetworkstheactorsinthemakerspaces wereabletogetrapidaccesstodesigntemplates,material resourcesanddistributionchannels.Someoftheconnections

FIGURE5| COVID-19makerresponseandlearnings.

withrelevantstakeholders,suchasmedicalstafforlocal politicians,provedtoberatherfragilethough.Forscaling locallyembeddedmakeractivitiesthataddresslocalsocial needsastrengtheningofnetworks,locallyandglobally,is importantaccordingtoourcases.

TheCOVID-19responseofthemakerswasalso flexible in adaptingtothelocalcontexts.Thisresultedinlocalizeddesigns, suchastheBraziliantropicalfaceshield,whichwasalocal adaptationofaGermandesign,ortheuseoflocallyavailable materials,suchastheIraqiPETplasticsheet,whichareusually usedforwaterpackaging.InthecaseoftheCameroonmaker spacetheCOVID-19responseactivitiesincludedastrong educationalaspectacknowledgingthelocalneedformore informationaboutthevirus.Nexttotheimportanceof educationandtrainingonmakerskills,thecasesalsohighlight thestronglocalembeddingandconnectednesstothelocal communitiesasessentialfora flexibleandfastresponseto pressingsocialissues.Forafuturescalingofmakerspace activitiesthatrespondlocallytosocialneedsestablished cooperationwithlocalstakeholdershasbeenidentifiedasa keyelement.

Anotherimportantaspectaddressedintheself-reflectionandthe focusgroupdiscussionhasbeentheawarenessfora responsible practicefrommakers.Acrossthe fivecasesweobserveastrongsense ofsocialresponsibility.Thishasbeenmanifestedinacknowledgment ofqualitystandardsforhealthcareproductsaswellastheoverall commitmenttodoingnoharmandusersafety.Clearguidelinesand legalstructuresthatallowresponsiblemakingarethusbeing requestedbasedonthecurrent experiences.Whendiscussing ethicalaspects,thecaserepresentativesalsostresstheirgrowing awarenesstowardstheneedforecologicallysustainablemaker practices.

Finally,thecaserepresentativesareawareofthe limitations of theapproach.TheirCOVID-19responseactivitieswerelimitedin termsofcapacities,resources,andinfrastructures.Themakersthus recognizetheboundariesofwhatcanbeachievedwithintheir limitedspaces.Collaborationwithestablishedbusinessesand governmentsshouldbeenvisionedforthefuture.Thiswould allowforaneffectiveresponseatalargerscale.

DISCUSSION

The fivecasesrepresentedinthisstudyarelocatedacrossthree continentsandareembeddedinverydifferentcontexts, economically,politically,andsocially.WhentheCOVID-19 pandemicstartedtospread,thesemakerspacestookonthe challengeofcounteractingthePPEandmedicaldevice shortages.Intheircivicreactionstothefailuresofpublic healthcareprocurementandshortagesintheglobalsupply chains,theyallfacedsomesimilarchallengesandnew opportunities.Inthisanalysis,wewanttoconcentrateonfour mainperspectivesthatevolvedduringtheanalysisandturnedout toberelevantwhendiscussingthemakerCOVID-19response activitiesinthetheoreticalframeofthethreesocialinnovation levels:socialneeds(microlevel),societalchallenges(mesolevel), andsystemicchanges(macrolevel).

(1)ANetworkPerspective

Workingintranslocalnetworks,referringtonetworksatlocal andgloballevel,hasbeenacriticalaspectfortheoperationonthe ground.Wesawthatreflectedinallofthecases,withlocal networksplayingakeyroleinallphases,fromresearchand designtotheproduction,testinganddistributionoftheprovided COVID-19responsesolutions.Theestablishedlocalnetworks andtemporarypartnershipsincludestakeholdersfromacrossthe quadruplehelix,namelyacademia,government,civilsociety,and industry.Inaddition,inmostcases,thefastreactionfromthe makerspaceswasonlypossibleduetotheglobalopensharingof PPEdesigns.Beinggloballyconnectedoffersaccesstoawide rangeofresourcesandispossibleonlyinacultureofopenness andsharing,whichispropagatedalsobytheOpenDesignand OpenHardwaremovements.Thebenefitsofopennetworked collaborationsbecomevisibleimmediatelyintimesofcrisis,such astheCOVID-19pandemic.Insocialtransformativeinnovation theorytranslocalnetworksareanimportantelementcontributing toempowerment(Avelinoetal.,2019).Fromthereported experiencesinthe fivecases,wecanconsidermaker communitiesaslocalandglobalnetworksthatexchange resources,experiences,andknowledgeatgloballevel,butact atlocalleveltoadapttothespecificcontextsandreacttolocal needs.Thisabilityandcommitmentforopenglobalcollaboration andmutuallearningisdescribedasoneoftheuniquefeaturesof theglobalmakermovement(Smith,2017)andalsoimpliesa certainethicalcommitmentofthecontributingmakerspaces.The casescontributingtothisstudyconfirmtheirpotentialfor empowermentassuggestedby(Avelinoetal.,2019)and resilienceofthelocalactors,similartowhathasbeen encounteredby Wuytsetal.(2020).

Thesustainabilityoftheemergenttranslocalnetworksis howeververyfragile.TheItaliancaseshowedthathighly efficientandquicklyestablishednetworksmightbecomeloose whentheemergencysituationisover.Forthenetworksto continueandpossiblyleadtoatransformationalchangeas describedby Avelinoetal.(2017) newobjectivesfor collaborationthatfosterasustainablelinkagebetweennetwork membersareneeded.Forfutureemergencysituationsthese flexiblyemergingtranslocalnetworksandpartnerships,that havealreadybeeninstalledinprevioussituations,mighthelp toreactevenfaster.

(2)AValuePerspective

Anethicalcommitmentofthemakerspacesbecomes noticeablealsoinotheraspects.Whendiscussingwaystoscale theirpracticesaneedfornewtypesofbusinessmodelsandnew valuedefinitionswasexpressed.Transformativesocial innovationscannotbeachievedbyjustapplyingexisting innovationmodelsandcapabilitiestoissuesofsocialconcern (Smith,2017).Itneedsaredefinitionofvalues(Avelinoetal., 2017)andaredistributionofinnovationcapabilities.Globally distributedlocalmanufacturingprocessesneedtobeassessedon adifferentlevelthanlargeenterprises.Nexttothepurely economicvalue,whichisstilldominatinginthe

entrepreneurialcontextandalsopresentinmanymakerspace activities,weneedtoappreciateothervalues,oftensocialand ecologicalvalues,thatareassociatedwithlocalexperimentation andsmall-scaleproductioninmakerspaces.Theecological footprintofmanufacturingisaconcernformanymakersaswe haveseendocumentede.g.intheBraziliancase.Wecandeductthat we findwithintheactivistapproachesofmakersanenvironmental consciousreflectionandself-criticalviewontheirmaterial productiveengagementasconfirmedbyothers(e.g. Smith,2017; Richterich,2020). Wuytsetal.(2020) likewiserecognizethevalueof makeractivitiesduringthepandemicinmovingtowardsamore circulareconomyinthehealthcaresector.

Withthepresentedexperienceswearguethatenvironmentally andsociallyresponsiblemakingshouldbeassignedadditional value,nexttothecost-benefitcalculationsdominatingtoday’ s businessmodelsandmovetoaddedvalue-orientedmodels.The caserepresentativesinthisstudyfollowacommunity-driven approach,notabusiness-drivenapproach,whichneedshigher societalrecognition.Thereareattemptstoraisebroaderattention forthevaluesoftransformativesocialinnovationsinmeasurable terms,suchastheSocialReturnonInvestment(SROI),whichisa performancemeasurementtool,demonstratingthesocialvalue enterprisesgenerate.SROIishoweveranunderusedand undervaluedpracticedespitebeingacceptedasan internationallyrecognizedmeasurementtoolforsocial enterprise(MillarandHall,2012).Forcommunity-driven approachesinmakerspacesnewvaluemodelsforscalingare neededasthemakerspacesofthisstudyclearlydonotwantto followtheprevailingeconomicmodelofscaledominatedby monetaryvalue.

(3)AnEducationalPerspective

Makerspacesareoftencharacterizedasspacesforcollaboration, informationsharing,reflectionandlearning(Sheridanetal.,2014). Incidentalaswellasintentionallearningtakesplaceinthesesettings astheyareoftenlinkedwithcreativity,collaborativeproblem solving,digitalcompetence,andentrepreneurship(Vuorikari etal.,2019).Aneducationalagendawasstressedinthe Camerooncase,whereanimportantobjectiveofthelab’ s COVID-19responseactivitieswastoeducatethelocalpopulation intermsofhygienemeasures.Theothercaserepresentatives emphasizedtheimportanceofeducationintheiractivities generally,andspecificallyintermsofscalingsocialinnovations.

Also,learningbetweenmakerspacesandwithandfromother networkpartners,likehealthprofessionals,iskey.Wesee knowledgeexchangeonaglobalscalethataddresses overarchingtopics,liketheexchangeofcertified,provenPPE instructionguides,guidelinesonthedesignofco-creation processes,andtheefficientuseofdigitalfabricationtools.And wecanidentifycontextualizedknowledgethatemergesinthe diversesettings,likehowtoreacttothelocalavailabilityof material,howtoadaptproductionprocessestolocalcontexts, howtoaddressveryspecificlocalneeds.Undoubtedly,the learningtakingplaceinmakerspacesleadstoempowerment andresilience(Criadoetal.,2016; Unterfrauneretal.,2020). As Ratto(2011) identifiedlearningascoreinhiscriticalmaking

theory,wheretheprocessofmakingisasimportantastheresults, wealsosuggestthatmoresocietalrecognitioncouldbeaddedto theeducationalvaluecreatedinmakerspaces.Criticalskills acquiredduringthematerialexplorationcontributetothe empowermentoftheindividualsaswellasthecommunity. Again,weseesimilaritiesheretothecasesofempowerment analyzedindetailby Avelinoetal.(2017).Learningand practicingnewskillsinsocialspacesarekeyelementsfor empowermentandcontributetothetransformativepotential ofsocialinnovations.

(4)ALegalPerspective

Inorderforlocalmanufacturingtobecomerelevantatasystemic level,fundamentaltransformationsoftheunderlyingstructuresneed totakeplace.Inthecontextofopenhealthcare,currentlegal frameworksareoneofthekeystructuresthatwouldrequire adaptation.Assystemchangesaretypicallyslowandrequire long-termthinking,makersareexploringthecurrentboundaries intheirsupportofthehealthcaresector.Partofthecurrent boundariesbeingexploredbymakersrelatetothenatureofthe solutionstheyproduce.Insomestates(e.g.intheEuropeanUnion) theproductionofspecificsolutions suchasrespiratoryvalvesor breathingmasks requirescomplexprocessesandcompliance documentation.Thesearenecessaryasthesolutionsqualifyas medicaldevicesandimplytherespectoftherelevantlawsinthe matter(MedicalDevicesDirective,1993,intheEuropeanterritory). Whiletheroleoftheseregulationsistoensureahighlevelof patients’ safetyandprotection,theysetapprovalmechanismsand controlsthatarenotalwayscompatiblewithemergencysituations. Insomecountries,competentauthoritiesallowedforemergencyuse authorizationforcertaintechnologies(FoodandDrug Administration,2020).AsPearce(2020,p.12)noted,many regulatoryroadblocksremainacrossseveralcountries,whichmay needtobeimprovedtoallowrapidresponseandprovisionof medicalsuppliesinhealthcare emergencies.

Asecondkindofboundaryreliesonliabilitymechanismsfor makersinthecontextofemergencysituations.Asillustratedin theintroduction,inaknowncasesomemakersreverseengineeredthedesignofarespiratoryvalvetofaceaproduct shortageinanItalianhospital,whichledtheoriginal manufacturertothreatenbringinglegalactionagainstthem forintellectualpropertyinfringement.Thisexampleexplicates thedifficultvaluebalancebetweentheperceivedneedtoact(even “ethically”)bymakersvis-a-visthepossibleunintendednegative consequencesofsuchethicalacting.Asawayforward,so-called GoodSamaritanLaws whichofferprotectionfromliabilityfor thosewhomtheybelievetobeinperil,ill,orotherwise incapacitated-couldsetusefulmeasurestocounterbalance thisdichotomy.Thislegalperspectivecouldhelpreducethe barriersforcompaniesandmakershinderingthereleaseof healthcareprojects’ designsandtheirreplication.Thecaseof COVID19openednewscenariosfortheapplicationoftheselaws. Weareawareofthecomplexityofsysteminnovationastheyare “profoundtransformationsinsocialsystems” (Grinetal.,2010) andwebelievethatwearestillfarfromseeinginnovationsbeing fullyimplementedinourcurrentlegalsystems,buttherecent

experiencesduringCOVID-19havestartedtochallengethecurrent boundaries.Thus,futureexploration,bothinresearchandby policymakersisneeded(Pearce,2020)anditwouldbecapableof openingnewperspectivesforthemakerspacesandtheroleofmakers.

CONCLUSION

Theexperiencebroughtforwardinour fivecontextuallyvery differentcaseshasshownhowlocalproductionnetworkscan functionintimesofemergency.Theirlocaldesign,production, anddistributionofPPEandotherhealthcarerelatedproducts towardshealthprofessionalsandthegeneralpopulationhas provento flexiblycoveremergingneedsandstandinfor globalmanufacturers.Lookingatthemakers’ initiativesduring theCOVID-19crisisfromasocialandtransformativeinnovation perspective,weencounterawishtoscalefromworkingonthe socialneedsleveltoaddressingwidersocietaldemandsand,inthe future,eventriggeringsystemicchange.Networkingandsharing knowledgeandexperiencesacrossmultipleactorsarekeywith thisaim.Representativesfromthe fivecasesstresstheimportance ofemergenttranslocalnetworksfortheirCOVID-19responseto happen,whichincludeactorsofthequadruplehelixonlocalscale whileexchangingandlearningfromeachotherglobally.

Scalingtransformativepracticesofmakerspacesishowever envisionedonlyundercertaincircumstancesandfollowingaset ofprinciplesandvalues.Acommitmenttowardsopennessand sharing,suchasitispropagatedbytheopenhardwaremovement, requiresnewformsofbusinessandvaluemodels.Prototypinginthe healthcaredomain,withandforpatients,peoplewithdisabilities, andotheroftenvulnerablegroups,requiresanethicalcommitment andlegalbackinginordernottoproducemoreharmthangood. Educationalandenvironmentalconsiderationslikewisecomeinto play.Empowermentthroughteachingandcreatingonlysolutions thataddressrealpersonalproblemsorneedsarecoreprinciplesof responsiblemaking.Inthemakers’ futureendeavorstowardscodesigningandmakingopen,personalizedhealthcareand establishingtheseprocessesassocialinnovationsmoresocial valuepropositionsmaybeencountered,withimplicationsfor individuals,communitiesandsocietyatlarge.Whilewenotice signsofempowermentatindividualandcommunitylevel,we envisionastrengtheningofdemocraticprocessesatsocietylevel. Otherscholarslikewisespeakaboutthedemocraticvalueof makerspaces,whichthey findincertaingrassrootsactivitiesthat addresssocialissues(e.g. Tayloretal.,2016; Willingham,2017; Sipos etal.,2019).Atthesametime,weareawareofthecriticalviewssome scholarsexpresstowardsmakerspaces. Lindtneretal.(2016) challengethedemocratizationpotentialofthemakermovement andsuggestamoreself-criticalandreflexiveapproachforthewhole communityofmakers.Wehopethisstudycancontributetothe discussion.

Wehaveconsideredimplicationsthatgobeyondthemakers’ responseto fightingCOVID-19fromtheexperiencesmadein five contextuallydiversesettings.Weareawareofthelimitationsofour study,butseereasonablegeneralizationjustifiedbythecontextual heterogeneityofthecasescovered,thestrongembeddednessand

connectednessofthecaserepresentatives(andco-authors)withthe globalmakercommunity,andthesimilaritieswehavefoundon otherdocumentedcases,suchasthosedocumentedbyothers.Our case-basedsnapshotsresonatewellwithotherdocumented experiences(e.g. DiezandBaeck,2020; Richterich,2020).Nextto thisqualitativeapproachamoresystematicandquantitative assessmentoftheimpactthatthemakercommunitiesworldwide hadon fightingtheCOVID-19pandemicisneeded.Inhowfarhas theglobalmakerresponseduringtheCOVID-19emergency situationcreatedsustainableimpactandhavelonger-term linkagesbetweenlocalmanufacturersandhealthcareservices beencreated?Also,wewouldlovetoseemoreexplorationsof howandunderwhichconditionsmakerspacescontributeto addressingsocietalchallengesandhowthesemaytriggersystemic changeinthefuture.

DATAAVAILABILITYSTATEMENT

Therawdatasupportingtheconclusionsofthisarticlewillbe madeavailablebytheauthors,withoutunduereservation.

ETHICSSTATEMENT

Writteninformedconsentwasobtainedfromtheindividual(s) forthepublicationofanypotentiallyidentifiableimagesordata includedinthisarticle.

AUTHORCONTRIBUTIONS

BKisthemainauthorandaddedtheabstract,thestate-of-the-art sections,casestudydescriptions,discussionandconclusion, studydesignwasdonebyBK,TS,andCF;CFdescribedthe methodologyandpreparedtheimagesbasedondiscussionswith BK,TSdescribedthefocusgroupoutcomesandcontributedto thediscussionandconclusion,EnBprovidedthepartsofthelegal analysis,allotherscontributedwith fillingintheselfreflection reportsandElB,RR,NM,andEnBparticipatedinthefocus group,whichwasledbyBKandTS;CFwasthenotetaker.

FUNDING

Thisworkhasreceivedpartial financialsupportfromthe EuropeanUnion’sHorizon2020researchandinnovation programundergrantagreementNo.780298.

ACKNOWLEDGMENTS

Wewouldliketoacknowledgethecontributionsofthewhole Careables teaminthecontinuousefforttoestablish Careables asa globalreferencefortheco-design,makingandsharingofopen, personalizedhealthcareforeveryone.

REFERENCES

Ahmadi,M.,Weibert,A.,Wenzelmann,V.,Aal,K.,Gäckle,K.,Wulf,V.,etal. (2019). “ Designingforopennessinmaking:lessonslearnedfromadigital projectweek. ” inProceedingsofthe9thinternationalConferenceon CommunitiesandTechnologies-TransformingCommunities,New York,NY,UnitedStates:AssociationforComputingMachinery,June 3 7.2019,pp.160 171.

Avelino,F.,Dumitru,A.,Cipolla,C.,Kunze,I.,andWittmayer,J.(2019). Translocalempowermentintransformativesocialinnovationnetworks. Eur. Plann.Stud. 22,1 23.doi:10.1080/09654313.2019.1578339

Avelino,F.,Wittmayer,J.M.,Pel,B.,Weaver,P.,Dumitru,A.,Haxeltine,A., etal.(2017).Transformativesocialinnovationand(Dis)Empowerment. Technol.ForecastSoc.Change 145,195 206.doi:10.1016/j.techfore.2017. 05.002

BureauofEuropeanPolicyAdvisers(BEPA)(2010). Empoweringpeople,driving change.SocialinnovationintheEuropeanUnion.Luxembourg:Publications officeoftheEuropeanUnion.

Bosse,I.,Krüger,D.,Linke,H.,andPelka,B.(2019). “TheMakerMovement’ s potentialforaninclusivesociety.” in Atlasofsocialinnovation.2ndVolume:a worldofnewpractices EditorsJ.Howaldt,C.Kaletka,A.Schröder,and M.Zirngiebl(Munich:oekom),201 206.

Brown,D.(2020). “ Qualityassurance,validationofdesigns,copyrightsand patents:thevalidationofdesign. ” in Viraldesign:theCOVID-19crisisas aglobaltestbedfordistributeddesign .EditorDistributeddesign platform.Availableat:https://dis tributeddesign.eu/wp-content/ uploads/2020/11/DistributedDesign Book_2020-online.pdf(Accessed November6,2021).

Corsini,L.,Dammicco,V.,Bowker-Lonnecker,L.,andBlythe,R.(2020).The Makermovementanditsimpactinthe fightagainstCOVID-19.doi:10.17863/ CAM.60248

Criado,T.S.,Rodríguez-Giralt,I.,andMencaroni,A.(2016).Careinthe(critical) making.Openprototyping,ortheradicalisationofindependent-livingpolitics Lecaredanslefaire(critique).Prototypageouvertoularadicalisationdes politiquesdelavieindépendante. Alter 10(1),24 39.doi:10.1016/j.alter.2015. 07.002

Daly,A.(2016). Socio-legalaspectsofthe3DprintingRevolution.Berlin,Germany: Springer Diez,T.,andBaeck,P.(2020). “Introduction:theDIYandopenhardwareresponse totheCOVID-19crisis.” in Viraldesign:theCOVID-19crisisasaglobaltest bedfordistributeddesign.EditorsDistributeddesignplatform.Availableat: https://distributeddesign.eu/wp-content/uploads/2020/11/DistributedDesignBook_ 2020-online.pdf(AccessedNovember6,2021).

Diez,T.(2012).Personalfabrication:Fablabsasplatformsforcitizen-based innovation,frommicrocontrollerstocities. NexusNetw.J. 14(3),457 468. doi:10.1007/s00004-012-0131-7

Dougherty,D.(2012).Themakermovement. Innov.Technol.Governance, Globalization, 7(3),11 14.doi:10.1162/inov_a_00135

Fabfoundation(2020). FablabmanufacturingCOVID-19survey,June2020.Creative Commonslicense:CCBY(Attribution).Availableat:https://media2-production. mightynetworks.com/asset/13754195/FabMfgReportJune2020_Final.pdf(Accessed November6,2021).

Flick,U.(2017). TheSAGEhandbookofqualitativedataCollection.Thousand Oaks,CA,UnitedStates:SAGEPublications.

Flick,U.(2018). Managingqualityinqualitativeresearch 2nd.Edn.Thousand Oaks,CA,UnitedStates:SAGEPublicationsLtd.

FoodandDrugAdministration.(2020). Emergencyuseauthorisation.Emergency useauthorisation(EUA)information,andlistofallcurrentEUAs.SilverSpring: FDA.Availableat:https://www.fda.gov/emergency-preparedness-and-response/ mcm-legal-regulatory-and-policy-framework/emergency-use-authorization.

Grin,J.,Rotmans,J.,andSchot,J.(2010). Transitionstosustainabledevelopment: newdirectionsinthestudyoflongTermTransformativeChange.NewYork,NY: Routledge.

Harrison,H.,Birks,M.,Franklin,R.,andMills,J.(2017).Casestudyresearch: foundationsandmethodologicalorientations[34paragraphs]. ForumQual. Sozialforschung 18(1),1 17.

Holtgrewe,U.,andMillard,J.(2018). “ SocialInnovationaddressingsocietal needsandchallenges. ” in Atlasofsocialinnovation-newpracticesfora betterfuture .EditorsJ.Howaldt,C.Kaletka,A.Schröder,and M.Zirngibel(Dortmund,Germany:Sozialforschungsstelle,TU DortmundUniversity).

Hsieh,H.F.,andShannon,S.E.(2005).Threeapproachestoqualitativecontent analysis. QualHealthRes.,15,1277 1288.doi:10.1177/1049732305276687

Kamenjasevic,E.,andBiasin,E.(2018).Made4YouD6.1Legalandethical inventoryandin-depthanalysis.doi:10.5281/zenodo.4086150

Leech,N.L.,andOnwuegbuzie,A.J.(2007).Anarrayofqualitativedataanalysis tools:acallfordataanalysistriangulation. Sch.Psychol.Q. 22,557 584.doi:10. 1037/1045-3830.22.4.557

Lindtner,S.,Bardzell,S.,andBardzell,J.(2016). Reconstitutingtheutopianvisionof making:HCIafterTechnosolutionism.SanJose,CA,UnitedStates:CHI 2016#chi4good.

Marshall,D.R.,andMcGrew,D.A.(2017).Creativityandinnovationinhealth care:openingahospitalmakerspace. NurseLeader 15(1),56 58.doi:10.1016/j. mnl.2016.10.002

Mayring,P.(2014). Qualitativecontentanalysis:theoreticalfoundation,basic proceduresandsoftwaresolution.Klagenfurt,Germany:GESIS.Availableat: http://nbnresolving.de/urn:nbn:de:0168-ssoar-395173 MedicalDevicesDirective(1993).CouncilDirective93/42/EECof14June1993 concerningmedicaldevices(MedicalDevicesDirective).1 43.

Miles,M.B.,andHuberman,A.M.(1994). Qualitativedataanalysis:anexpanded sourcebook.2ndEdn.ThousandOaks,CA,UnitedStates:SagePublications. Millar,R.,andHall,K.(2012).SocialReturnonInvestment(SROI)and PerformanceMeasurement:theopportunitiesandbarriersforsocial enterprisesinhealthandsocialcare. PublicManagementReview 15(6), 923 941.doi:10.1080/14719037.2012.698857

Millard,J.,Sorivelle,M.N.,Deljanin,S.,Unterfrauner,E.,andVoigt,C.(2018).Is themakermovementcontributingtosustainability? Sustainability 10(7),2212. doi:10.3390/su10072212

Nowotny,H.,Scott,P.,andGibbons,M.(2001). Re-Thinkingscience:knowledge andthepublicinanageofuncertainty.Cambridge:PolityPres

OpenSourceMedicalSupplies(2020).OpensourceCOVID-19medical Su ppliesLo ca lresponseguide.Creat iveCommonsAttribution-ShareAlike 4.0InternationalLicense.Availableat:https://oscms.app.box.com/s/ zh0aynd8h fl xkfdaucs14ifs05z8d8dn?fbclid IwAR22mFmZ5oifL8LUNspZ3WCrzQ7qxyWNhOATzBqu1ZJMAsw70giUGlUdNI(AccessedNovember6, 2021).

Pearce,J.M.(2020).Distributedmanufacturingofopensourcemedical hardwareforpandemics. J.manuf.mater.Processing 4(2),49.doi:10. 3390/jmmp4020049

Peters,J.(2020).Volunteersproduce3D-printedvalvesforlife-savingcoronavirus treatments. TheVerge Availableat:theverge.com/2020/3/17/21184308/ coronavirus-italy-medical-3d-print-valves-treatments

Ranney,M.L.,Griffeth,V.,andJha,A.K .(2020).Critical supplyshortagestheneedforventilatorsandpersonalprotectiveequipmentduringthe covid-19pandemic. N.Engl.J.Med. 382(18),e41.doi:10.1056/ NEJMp2006141

Ratto,M.(2011).Criticalmaking:conceptualandmaterialstudiesin technologyandsociallife. Inf.Soc. 27(4),252 260.doi:10.1080/ 01972243.2011.583819

Richterich,A.(2020).Whenopensourcedesignisvital:criticalmakingofDIY healthcareequipmentduringtheCOVID-19pandemic. HealthSociol.Rev. 29 (2),158 167.doi:10.1080/14461242.2020.1784772

RuizFreire,R.,Costa,E.,Alves,J.L.,andDeSouzaBrito,C.(2019).Adialecticon innovationandsustainability. Int.J.InnovationSustainableDevelopment (IJISD) 13(3-4).doi:10.1504/ijisd.2019.100399

Sheridan,K.,Halverson,E.R.,Litts,B.,Brahms,L.,Jacobs-Priebe,L.,and Owens,T.(2014).Learninginthema king:acomparativecasestudyof threemakerspaces. Harv.Educ.Rev. 84(4),505 531.doi:10.17763/haer. 84.4.brr34733723j648u

Sipos,R.,Chinoy,S.,andRuiz,R.(2019). “ Thecriticalmakingmovement.How usingcriticalthinkingintechnologicalpracticecanmakeadifference. ” in 35C3 Refreshingmemories.EditorChaosComputerClube.V.Berlin:Chaos ComputerClube.V.,AchjeVerlag.

Smith,A.(2017).Socialinnovation,democracyandmakerspaces.SPRUworking papeseries(SWPS),1 18.ISSN2057-6668.Availableat:www.sussex.ac.uk/ spru/swps2017-10

Taylor,N.,Hurley,U.,andConnolly,P.(2016). “Makingcommunity:thewiderroleof makerspacesinpubliclife.” inProceedingsofthe2016CHIConferenceonhuman factorsinComputingsystems,May7-12.2016,SanJosé,California,US,p.1415 1425.

Thompson,M.A.,Owen,S.,Lindsay,J.M.,Leonard,G.S.,andCronin,S.J.(2017).Scientist andstakeholderperspectivesoftransdisciplinaryresearch:earlyattitudes,expectations, andtensions. Environ.Sci.Policy 74,30 39.doi:10.1016/j.envsci.2017.04.006

Unterfrauner,E.,Hofer,M.,Pelka,B.,andZirngiebl,M.(2020).Anewplayerfor tacklinginequalities?Framingthesocialvalueandimpactofthemaker movement. SocialInclusion 8(2).doi:10.17645/si.v8i2.2590

Vuorikari,R.,Ferrari,A.,andPunie,Y.(2019). Makerspacesforeducationand Training exploringfutureimplicationsforEurope,EUR29819EN Luxembourg:PublicationsOfficeoftheEuropeanUnion.

Willingham,T.(2017). Librarymakerspaces:thecompleteguide.Lanham,MD, UnitedStates:Rowman&Littlefield.

Wuyts,W.,Marin,J.,Brusselaers,J.,andVrancken,K.(2020).Circulareconomyas aCOVID-19cure? Resour.ConservationRecycling 162,105016.doi:10.1016/j. resconrec.2020.105016

Zastrow,M.(2020).Opensciencetakesonthecoronaviruspandemic. Nature 581, 109 110.doi:10.1038/d41586-020-01246-3

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialor financialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021Kieslinger,Schaefer,Fabian,Biasin,Bassi,Freire,Mowoh,Arif andMelis.Thisisanopen-accessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(CCBY).Theuse,distributionorreproductionin otherforumsispermitted,providedtheoriginalauthor(s)andthecopyrightowner(s) arecreditedandthattheoriginalpublicationinthisjournaliscited,inaccordance withacceptedacademicpractice.Nouse,distributionorreproductionispermitted whichdoesnotcomplywiththeseterms.

published:29March2021 doi:10.3389/fsoc.2021.642277

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: PiiaTint, TallinnUniversityofTechnology, Estonia MichalBeno, InstituteofTechnologyandBusiness, Czechia

*Correspondence: CeciliaBjursell cecilia.bjursell@ju.se

Specialtysection: Thisarticlewassubmittedto Work,EmploymentandOrganizations, asectionofthejournal FrontiersinSociology

Received: 15December2020 Accepted: 15February2021 Published: 29March2021

Citation: BjursellC,Bergmo-PrvulovicIand HedegaardJ(2021)Teleworkand LifelongLearning. Front.Sociol.6:642277. doi:10.3389/fsoc.2021.642277

TeleworkandLifelongLearning

CeciliaBjursell*,IngelaBergmo-PrvulovicandJoelHedegaard

Encell NationalCentreforLifelongLearning,SchoolofEducationandCommunication,JönköpingUniversity,Jönköping,Sweden

Theincreaseofteleworkduringthepandemicispredictedtoimpactworkinglife,notonlyin termsofalargernumberofemployeesworkingfromhome,butmoreimportantly,itmay transformthewayweconceptualisework.Thiswillinturnimpactsystemsforand participationinlifelonglearning.Thereisariskforincreasedsocialinequalities,as neitherteleworknorlifelonglearningisevenlydistributedamongworkers.Statisticson teleworkintheEUshowthattherearedifferencesbetweenagegroups,nations,sectors, andprofessions.Ifthesetrendswillsteerforward,thereisariskofwideninggapsbetween countries,companies,andworkers.Toestablishthecurrentknowledgebase,wehave gatheredliteraturereviewsfromseveraldisciplines.One findingisthattheprevious literatureonteleworkhasnotincludedlifelonglearninginanyform(formal,non-formal andinformal).Basedonareviewofpreviousstudies,wesuggestanumberofresearch questionsforfutureresearch.Thisisrelevantasresearchaboutteleworkandlifelong learninghasthepotentialtocontributetoasustainableworkinglifeintermsofproviding more flexiblearrangementsforemployeesandtosupportthelifelonglearningthattakes placeincontextssuchastheoffice,home,onlinemeetings,andvirtualreality. Keywords:lifelonglearning,sustainableworkinglife,socialinequality,telework,telecommuting

INTRODUCTION:INCREASEDTELEWORKANDINCREASED SOCIALINEQUALITIES

In2020,teleworkhasbecomethenewnormalinworkinglife.ConsideringemployeesintheEU betweentheagesof15and64,anaverageof5.4%workedfromhomein2019(Eurostat,2020).These numbershavebeensimilarfor10years.However,thenumberofpeoplewhoworkfromhomeafew daysaweekhasincreasedduringthesameperiod,from5.2%in2009to9%in2019.Amongtheselfemployed,almostonein fiveworkedfromhome.Therearedifferencesbetweenmenandwomenand betweendifferentages.Slightlymorewomenthanmenworkedfromhome(5.7vs.5.2%in2019). Moreover,theproportionofpeoplewhoworkfromhomeincreaseswithincreasingage.Among peopleinthe15 24agegroup,2.1%workedfromhome,whileamongpeopleinthe50 64agegroup, 6.6%workedfromhome.(Eurostat,2020).

However,allthese figuresarefromthetimebeforethepandemic,andtheproportionofpeople workingfromhomehasincreaseddisproportionately.InSweden,itincreasedtenfold,andamong whitecollarworkers,twothirdshaveworkedfromhomesincethepandemicstruckin2020 (Internetstiftelsen,2020).Mostpeoplewhohavebeenworkingfromhomearesatisfied,whilethose whohavestudiedatadistancearedissatisfied(ibid).Althoughworkingfromhomemaynotremain tothesameextentasthepandemicsubsides,itislikelythatwewillseeanincreasecomparedtothe figuresfrom2019.Notleast,theproportionwhowillcombineworkremotelywithpresenceinthe workplacemayincrease.However,theabilitytochooseandcombineworkplacesisnotevenly distributedbetweenprofessionsandpositions.Therapidchangesinworkinglifealsoraisethe questionofcompetence.InSweden,alandoftenrankedashighlydigitalised,asurveyshowedthat duringthelastyear,49%havefeltthattheyhaveinsufficientdigitalknowledgebothinthelabour

marketandprivately(SVT,2021).IntheWorldEconomic Forum’ s “Futureofjobsreport2020”,itisestimatedthat around40%ofworkerswillrequirereskillingofsixmonthsor fewer,andastaggering94%ofbusinessleadersexpectemployees topickupnewskillsonthejob,comparedto65%in2018.The neededskillsincludeanalyticalskillsaswellasskillsinselfmanagement,suchasactivelearning,resilience,stresstolerance and flexibility(WEF,2020).Self-managementskillsareinnately connectedtotelework,asitisasituationthatrequiresmore responsibilityfromtheemployeeintermsofmanagingthe physicalandpsychologicalworkaspects,aswellasperforming theworkitself.Tosupportasustainableworkinglife,inlightof thisyear’schangeslinkedtotelework,thefollowinginsights presentedbythe EuropeanCommission(2020) canguideefforts:

• Therearelargedifferencesintheprevalenceofteleworking betweenEUMemberStates,betweensectorsandbetween professions.

• Thereadinesstoimplementteleworkingonalargescaleis highinITandknowledge-intensivesectorsandforthe highlyeducated,buttherearelargedifferencesbetween countries.

• InmanyEUcountries,morethanhalfofthosewhonow workremotelyhadnottrieditbefore.

• Ifprevioustrendswillsteerforward,therisksofwidening gapsbetweencountries,companies,andworkersaregreat.

Althoughmostpeopleexpectthattheywillreturntothe workplaceafterthepandemic,itishighlyprobablethatthe numberofpeopleteleworkingwillincreasetosomeextent, andthiswillchangetheconditionsforworkinglifeinseveral ways.Notonlywillitchangethesocialdynamicsofworkplaces, butwealsoneedtodiscussthedissatisfactionamongpeoplein distancestudiesinconnectiontocompetencedevelopmentand upskilling.Thereisariskthateffortsofimprovement,suchasthe provisionof flexibilitythroughteleworkorlifelonglearning througheducationandtraining,willbeunevenlydistributed amongprofessionsandsectors.Thereis,becauseofthis,arisk forincreasedsocialgapsinsociety.Whenitcomestothe relationshipbetweenteleworkingandlifelonglearning,there areatleasttwowaystoapproachthisconnection.Firstly,one canfocusontheindividual’sperspectiveandhowteleworking affectsformal,informalandnon-formallifelonglearning. Secondly,thefocuscanbeonlifelonglearningaspolicy, whereanimportantmessageisthateveryoneshouldhavethe opportunitytoparticipateinsocietyonequalterms.

Basedontheassumptionthatteleworkwillincreasecompared tothefrequencyofteleworkersbeforethepandemic,andthefact thatthereisanurgentneedfornewskills,theaimofthepaperis toreviewpreviousresearchontelework.Thereviewisguidedby theresearchquestion:Whatcanbeconcludedabouttelework basedonpreviousresearch,withregardtoeffortsforcompetence developmentandupskillingaspartoftheindividual’slifelong learning?Inthispaper,wewillmakeasynthesisofreviews addressingteleworkto findoutwhatwealreadyknowaboutthe impactonlifelonglearning,includingcompetencedevelopment. Basedonthis,thediscussionaddressespossibleconsequences

thatteleworkingmighthaveforanindividual’slifelonglearning andproposesquestionsforfurtherresearch.Thepaperisbased onamultidisciplinaryandbroadunderstandingoftelework,as suggestedby Allenetal.(2015),tofullyunderstandthebenefits anddrawbacksofworkingfromhome.

TELEWORK:ANOVERVIEW

In1973,JackNilles’ book TheTelecommunicationsTransportationTradeoff introducedthetermtelecommutingto discussdistanceworkingasasolutiontotrafficcongestionand pollution.Adecadelater,companiessawteleworkasatoolto reducetheexpenseforofficespace,butthishasshiftedagaininto teleworkasastrategytoattractandretaintoppersonnel(Kurland andBailey,1999).Duringthepandemic,employeeshavecalled attentiontotheriskthatemployers(again)mightseeteleworkas atooltoreduceexpensesforofficespace.However,whathasbeen raisedinresearch,asdiscussedbelow,isthatteleworkmight requireinvestmentsfromtheemployertoachievethedesired benefits.Therefore,thecoststructuremightbedifferent,butit shouldnotnecessarilybeunderstoodasprimarilyacost-cutting strategy. KurlandandBailey(1999) definedfourtypesof telework:

• Home-basedtelecommuting referstowhenemployeesona regularbasisworkfromhome,buttheyarebasedatacentral officebelongingtoanemployer.

• Satelliteoffices refertoworklocationssituatedata convenientlocationallowingemployeestocutthetime theyspendcommuting.Thisbranchofficeisfurnished andequippedbytheemployer.

• Aneighbourhoodworkcentre islikeasatelliteoffice,withthe exceptionthatseveralemployerssharetheleaseofthe buildinganditmayhaveasiteownerresponsibleforthe location.

• Mobileworkers areemployeeswhoworkinanassortmentof locales,suchasfromhome,fromacar,fromaplane,orfrom ahotel.

Teleworkcanthustakeplaceindifferentcontexts,butwhen teleworkisresearched,thefocusisusuallyonhome-based telecommuting.Accordingtothefourtypesoftelework presentedby KurlandandBailey(1999),telecommutingisa formoftelework;inlaterpapers,however,thereisoftenno separationbetweentelecommutingandteleworkwhen addressingworkingfromhome.Theconceptstelecommuting andteleworkareusedinterchangeablyinthispaper.

Whenlookingatwhoparticipatesintelework,whytheydoit andwhathappenswhentheydo, BaileyandKurland(2002) find thatteleworkisacomplexconceptandphenomenon,althoughin research,thefocusisoftenononeorafewparameters.Intheir review,theyestablishedthattheindividualteleworkerwasa nearlyuniversalfocusofstudyandthattherewere assumptionsthatteleworktookplaceonafull-timebasis. Furthermore,BaileyandKurlandhighlightedthat,apartfrom methodologicalweaknesses,thestudieslackedawarenessof

TABLE1| Advantagesofteleworkontheindividualandtheorganizationallevel.

Advantageswithhome-basedtelework References

Individualadvantages:lesstimeconsuming,costsavings,lessstress,noneedforrelocation,moreautonomy,schedule flexibility,comfortableworkenvironment,fewerdistractions,absenceofofficepolitics,work/familybalance,workplace fairness,andmorejobsatisfaction.

Organizationaladvantages:greaterproductivity,lowerabsenteeism,bettermorale,greateropenness,fewerinterruptionsat office,reducedoverhead,widertalentpool,lowerturnover,andregulationcompliance(e.g.,disabilitiesact).

Individual:Higherjobsatisfaction,higherorganizationalcommitment,lesspressure,bettertimemanagement,reducedtravel time,balancedworkandhomelife,distraction-freeenvironment,lessinvolvementinofficepolitics,suitableforhomebound employees.

Organizational:increaseproductivity,lowercosts,lessofficespaceneeded,reducedabsenteeism,lowerturnover,donot havetohaveallemployeesinonelocation(aterroristconsideration),increasedrecruitmentoptions,andabletoadapttothe virtualorganization.

Teleworkisenvironmentallyfriendly,teleworkcancreatemore flexibleworkarrangementsandatthesametimehelptolower thecostsofrunningofficepremises,teleworkcanbeawayofraisingthecompany’scorporateimage,changeoverto teleworkhasimprovedjobcontrolandwell-beingattheindividuallevelandincreasedtheoverallefficiencyoforganizations.

Individual:Savingsbasedonlesstravellingandtypeofclothing,possibilitytocoordinateforwork-lifebalance,spatialmobility beyondcommutingdistance,increasedworkautonomy,increasedjobsatisfaction,andincreasedproductivity.

Organizational:Recruitmentandretention,increasedworkmorale,productivitygains,improvedagility,and financial advantagessuchascostsavingsforofficerent.

Increasedperceptionsofautonomyandlowerwork familyconflict;goodqualityofemployee supervisorrelationship;job satisfaction;lowerturnoverintentandrolestress;highersupervisorratings.Thesebene ficialconsequencesappearedtobe atleastpartiallymediatedbyperceivedautonomy.

TABLE2| Challengesofteleworkontheindividualandtheorganizationallevel.

KurlandandBailey(1999)

CrandallandGao(2005)

Pyöriä(2011)

Boelletal.(2013)

GajendranandHarrison(2007)

Challengeswithhome-basedtelework References

Individualchallenges:Socialisolation,professionalisolation,organizationalculture,reducedofficein fluence,work/family balance,informalinteraction,conducivehomeenvironment,focusingonwork,longerhours,accesstoresources,and technologicalcompetence.

Organizationalchallenges:Performancemonitoring,performancemeasurement,managerialcontrol,mentoring,jealous colleagues,synergy,informalinteraction,organizationculture,virtualculture,organizationloyalty,interpersonalskills, availability,schedulemaintenance,workcoordination,internalcustomers,communication,guidelines(e.g.,expenses),and technology.

Individual:Feelingsofisolationfromtheworkculture,lackofpromotionalopportunities,lossontheassignmentofgood projects,dissatisfactionwithpeerrelationships,lessinfluenceoverthepeopleandeventsatwork,work/familycon flict,and hardertotakeasickday.

Organizational:Moredifficulttosupervise,assessmentconcerns,speciallogisticsrequirements,sensitiveinformationcould becompromised,goesagainsttheconceptofteamwork,controloverhealthandsafety,andlackofinfrastructuresupport (secretary,etc.).

Theimportanceofagreeingonaframeworkfortelework,teleworkdoesnotsuiteveryone,theproblemofatraditional managementculture,teamwork,anddatasecurity.

Individual:Work-lifeblurring,lackofsocializingopportunities,questionsaboutcareer,lessworkplaceinvolvement,reduced trust,lackoftechnicalsupport,andunwantedinterruptions.

Organizational:Managementpracticesdonot fitthesituation,legalframeworkisnotsufficient,hindersteamworkand collaboration,lackofrelevantexpertiseandtraining,infrastructure,andtechnologyoutsidetheoffice,datasecurity,and investmentsinteleworkcosts.

High-intensitytelecommuting(<2.5daysaweek)harmedrelationshipswithco-workers.

issuesofstatusandpower.Althoughthedemographicsof teleworkersareelusive,theteleworkingpopulationmaybe dividedalongoccupationalandgenderlines.Laterreviewsand frameworksforstudiesonteleworklistsimilaradvantagesand challengesoftelework(CrandallandGao,2005; Pyöriä,2011; Boelletal.,2013).In Tables1, 2,listsofadvantagesand challengesfromreviewsofteleworkarepresented.The collectionisnotcomplete;forexample,thelistin Crandall andGao(2005) isbasedon Baruch(2001) and Danielsetal.

KurlandandBailey(1999)

CrandallandGao(2005)

Pyöriä(2011)

Boelletal.(2013)

GajendranandHarrison(2007)

(2001).Thisdescriptionofpreviousresearchwillprovidea backgroundtothediscussiononlifelonglearningandtelework.

Theadvantagesfortheindividualarethatteleworkprovides flexibilityandautonomy.Highautonomyisafactorsupporting evidenceforhome-basedtelecommutingasanemployeeorientedhumanresourcepractice(HornungandGlaser, 2009).Workerswhocanuseteleworktoadjusttaskstomeet theirneedsanddesiresaremorelikelytobesatisfied,and teleworkismorepositivelyrelatedto firmperformancethan

otherdimensionsoflabour flexibility(Martínez-Sánchez,etal., 2008).Lesstimespentcommutingprovidesmoretimeforother activities.Theindividualhasmorejobcontrolandopportunities tomanagethework-familybalance.Tobeincontrolcouldbeone explanationforotherpositiveoutcomes,suchaslessstress,job satisfaction,andwell-being.Fewerinterruptionswhenworking andcostsavingsarealsomentionedasadvantages.Anempirical studyof102employeesfromalargeUnitedStatesgovernment agencyreportedthatemployeesexperiencedmorejob-related positiveaffectivewell-beingwhenteleworkingcomparedtowhen workingintheoffice,buttheindividualdifferencesmoderated thisrelationship(Andersonetal.,2015).Thediscussionfocuses ontheneedtoconsidertheaffectiveconsequencesoftelework andthecharacteristicsthatdeterminewhowillbenefitfrom workingathome.Teleworkbeforethepandemicwasinsome casesregardedasareward,aperspectivethatcouldexplain positivenotionsoftelework(GajendranandHarrison,2007).

Theorganizationaladvantagesareincreasedproductivityand increasedworkmorale.Thatteleworkisperceivedtoimprove performance,increaseproductivity,andstrengthen organizationalcommitmentwassupportedinananalysisof empiricalstudiesonteleworkandorganizationaloutcomes (HarkerMartinandMacDonnell,2012).Fewerinterruptions andcostsavingsarealsomentionedasadvantagesforthe employer.Accesstoawidertalentpoolcreatesadvantagesfor recruitment,andretentionofpersonnelprovidesstabilityin operations.Regulationscomplianceissupported,andthe DisabilitiesActismentionedasanexampleofthis.Telework issometimespresentedasawayforemployerstoworkwith inclusionanddiversityperspectives,butthisisanareawhere moreresearchisneeded.Inaliteraturereviewwithafocuson work-lifebalanceforworkerswithdisabilitiesorworkerswho havefamilymemberswithdisabilities,theauthorsfoundatotalof only48articlesover20years(IgeltjørnandHabib,2020).The reviewindicatesthatalthoughseveralarticlesimplythatpolicies couldhavepositiveeffectsontheworkenvironmentofhomebasedteleworkers,theydonotdescribehowthiscouldbe achievedorwhetherexistingpolicieshaveyieldedthedesired effects.

Teleworkalsopresentschallenges,listedin Table2.Inreading thesechallenges,thereadershouldberemindedofthemetaanalysisofpsychologicalmediatorsandindividualconsequences performedby GajendranandHarrison(2007) thatprovided evidenceagainstthetelecommutingparadoxinvariableslisted asadvantagesANDchallenges(forexample,family-work conflict).Therearethuscontradictionsbetweenthestudies referencedinthispaper,andwewanttoraiseawarenessof themethodsusedandhowtheyimpactwhatisstudied,how findingsarepresented,andtherelevanceofresultsinrelationto practicalsituations.Therefore,continuedanalysesandvarious waystostudythedetailsofteleworkarestillneeded,nottheleast duringandafterthepandemicsituation.

Thechallengesfortheindividualwhenteleworkingcanbe socialandprofessionalisolation,withlessinfluenceand involvementinmattersthataredealtwithattheoffice.The negativeemotionalimpactofteleworkingcancomeintheformof emotionssuchasworry,irritability,guilt,andloneliness(Mann

etal.,2000; MannandHoldsworth,2003).Detachmentfrom workisdescribedasacareerrisk,astheindividualmightmissout onopportunitieswhennotbeingattheofficeinperson.Limited accesstoorganizationalresourcesandergonomicissuesinthe homeenvironmentareotherdrawbacks.Work familybalance wasanadvantage,butitcanalsobeachallenge,dependingonthe individual’ssituation.Thechallengesfortheorganization concernmanagementactivities,suchasmonitoring, measuring,andcontrollingemployees’ outcomes.This “problem” should,however,beviewedinthelightof findings statingthattelecommutingavailabilitywasdirectlyandindirectly relatedtoengagementviaperceivedsupervisorgoalsupport, andthattheoptiontotelecommutecouldincreaseemployee engagement(Masudaetal.,2017).Controloverhealthand safety,includingdatasecurity ,arechallengeswhenemployees workfromhome.Painordiscomfortstemmingfromtelework couldbeaddressedwithteleworkerergonomicstraining.A studyfoundthatalmosthalfoftheparticipantsexperienced physicalproblems,but85%oftheparticipantshadnotreceived ergonomicstraining(HarringtonandWalker,2004 ).A challengeforboththeorganizationandtheindividualislack ofinformalinteraction,whichhasconsequencesforthe developmentofinterpersonalskillsandmentoring opportunities.

CrandallandGao(2005) includedanoutlookonunresolved andemergingissuesthatarenecessarytoincludeforacomplete understandingofteleworkconditions.The firstunresolvedissue concernstheroleoftheorganizationandgovernmentin establishingemployeesafetywhenworkingfromhome.In manycountries,theemployerhasanobligationtomaintaina safeworkingenvironmentregardlessofwheretheworkactivityis performed.Whenitcomestoteleworksituations,questionsabout insurancecoverageandresponsibilitymayarisebecauseof blurredboundaries.Thesecondunresolvedissueaddresses whetherteleworkisawayfortheorganizationtoexploit workers.Twomaintargetshavebeenidentifiedinthisdebate: womenandlessskilledworkers.Theseconnectbacktoprevious research findingsthatitisrelevanttoincludeoccupationand gendertounderstanddifferencesinthe teleworking population (BaileyandKurland,2002).Whetherteleworkisaformof exploitationdirectedatwomenremainsspeculative;however, itishighlyprobablethatteleworkcancontributetoincreased polarizationinworkinglifeandthatthispolarizationcouldbe alonggenderlines(CrandallandGao,2005).Thethirdissuethat CrandallandGao(2005) suggestfordiscussionistheuseof technology,asthisisa fieldinrapiddevelopment.Accordingto thedesktopmetaphor,teleworkreliesonastandardsetof technologysuchasPC,e-mail,etc.,butthevirtualreality metaphorisemergingasanalternative.Virtualreality potentiallyoffersincreasedsocialrichnessandafeelingof “beingthere” (thatis,beingattheoffice).Technology,andthe emergentnewsocietyconnectedtotechnologicaldevelopment, enablesteleworkinnewways.However,intheinformation society,itisincreasinglydifficulttodefineordemarcate workinghoursandplacesofworkandtodistinguishbetween commodityandserviceproduction(Pyöriä,2011).Hybridwork set-upscallfornewhumanresourcesandmanagementpractices

withregardtohowsocialspaceandterritorialityplayout(Sewell andTaskin,2015).

Fromtheorganizationalpointofview,theindividualaswellas thetaskdimensionarerelevanttounderstandinghowtoplan telework.Thisrequiresconsideringprofessionaldifferencesas wellastaskdifferences.Writingamemocould fittelework, whereasactivitiesrequiringphysicalcoordinationbetween colleaguesrequireofficepresence.Thetypeofworkdonemay provideclearorblurredboundariesbetweenworklifeandprivate life,andthereforenotallprofessionshavethesamepotentialfor telework(HislopandAxtell,2007). BaileyandKurland(2002) suggestedthatfutureresearchshouldexpandthelensbeyond individualteleworkerstoincludethepracticethattelework affects,toconsiderwhypeopleworkawayfromtheofficeand includetheoptionthatteleworkmaybeawaytocopewiththe demandsofthemodernworkplace,andlastly,toemphasise theory-buildingandconnectlinkstoorganizationaltheories.

Theindividualdimensionofteleworkdiscussedaboveisonan overalllevel.Severalauthorspointedtothefactthatindividual differencesmayinfluencetheperceptionandoutcomeof telework.Factorssuchasfamilystructure,livingspaceand technologicalequipmentconstitutetheconditionsfortelework. Ageandexperiencecouldberelevanttounderstandingtelework andcouldbeconnectedtotheabilitytostructureworkeffortsat home.Whenworkersvaluethestatusassociatedwithtelework,or ifteleworksatisfiesneedsforachievementandstimulation,itmay beeasierfororganizationstoallowlargerproportionsoftheir workforcetotelework,asthesevaluescanmotivateteleworkersto performtheirtasksinlinewithorganizationalgoals(Petersetal., 2016). Pyöriä(2011) pointedoutthatteleworkissuitableforjobs thatrequirepeaceandconcentrationandinjobsthatrequire creativeproblem-solvingskills,wheretheoptiontowork flexibly accordingtoneedandinspirationisvital(Pyöriä,2011).Theidea ofthecreativeproblem-solvingprofessionalbeing flexibletolive andworkanywhereandanytimestandsincontrasttothe tendencyforknowledgeworkerstoconcentrateinandaround economichubs.Additionally,weareremindedthatthenotionof whattechnologycandoforusoftentakesonmythological dimensions:

“Theideaoftheempoweredteleworkerhasbecomehighly chargedsymbols,insomeinstancesaclearmyth,incorporating anovertlyoptimisticvisionofthealmostlimitlesspossibilities thatICTshavetooffer” (Pyöriä,2011,p.387).

Toimplementteleworkasapracticeinworkinglifeshould furthermoregiveattentiontotheproperrecognitionofinterests fromunions,aslabourrepresentatives.InEurope,tradeunions havediscussed,forexample,theburdenofcostswhenworking fromhome,occupationalsafety,ergonomics,andworkhour arrangements,aspartofformalframeworksfortelework. KurlandandBailey(1999) indicatedthatoneriskwith telecommutingisthatworkersolidaritydecreaseswhen telecommutersarephysicallydispersedandlessableto organizecollectively,whichmayaffecttheworkofunions. Thedecreasedorientationtowardsotherworkersmayalsobe aproblemforteamworkandtherebyforlearning:

“Additionally,managersmay finditdifficulttocreateteam synergyandtoovercometheabsenceofinformal,interactive

learning learningthattakesplacebythewatercooler,over lunch,orinthehallways” (KurlandandBailey,1999,p.59).

Theproblemwithteleworkisthatinteractionand communicationoftentakeplaceasscheduledmeetings,which doesnotsupportlearninginthesamewayastheinformal interactionintheofficedoes.Thisspontaneouslearning cannotbescheduled,butitisneverthelessanimportantpart oftheindividuals’ development,sometimescalled “inplacecareer development”.Aspecificpartofthislearningistomaster interpersonalskillsthatmaybeneededtointeract, communicate,andcooperatewithcolleagues,customers, students,andothersaspartofworking.Withasubstantial partoftheworkforceworkingforaconsiderableamountof timefromhome,thiscouldchangethenatureofsocial intercourseinunknownways. TaskinandBridoux(2010) havehighlightedthatteleworkingcouldendangeran organization’sknowledgebaseandcompetitiveadvantageas theknowledgetransferbetweenteleworkersandnonteleworkersisthreatened.Apartfrommentioningtheriskfor knowledgedrawbacks,lackofinformallearning,andtheneedfor ergonomicstrainingforteleworkers,theissueofcompetence developmentandlifelonglearningisabsentintheliteratureon telework,despitetherecognitionofnewwaystoconceptualise work,whichmaydemandlearningandrequirenewtheoretical frameworksaswellaspracticalknowledgeforindividuals, organizations,andsocieties.

TELEWORKDURINGTHEPANDEMICAND LIFELONGLEARNING

Thelackofresearchonhowteleworkaffectslifelonglearning, competencedevelopment,andupskillingisproblematic,andin additiontothis,wenowhavethecurrentsituationwitha pandemicchangingoureverydaylives,includinghowand wherewework.Whileteleworkusedtobeatooltomake employmentmoreattractive,ithascurrentlybecomea measuretostopinfection.Whenteleworkisperformedby peoplewhodonotwanttoworkfromhomeandmayhave limitedexperiencedoingso,thiswillmostlikelychangeour understandingoftelework.Similartohow9/11changedairport securityjobsacrosstheglobe,thepandemicwillchangejobsin waysthatwehaveyettounderstand(Lietal.,2020).Moreover, familiesarelockeduptogetherintheirhomes,raisingissuesof placesforthewholefamilytoworkandstudy,andwhetherthe internetconnectioncanhandleseveralvirtualmeetingstaking placeinthesamehome.Aspeoplewereforcedtoworkfrom homewhenthepandemichitin2020,theywereatthesametime forcedtolearn.Thismeantthatamassivedigitalcompetence boosttookplace,whichprovidedinsightsintotheneedforHR practitionersandmanagersingeneraltounderstandtheneedsof teleworkersandprovideadequatesupport.Asmentionedinthe introductionofthispaper,peoplealsolearnedthattheydidnot havesufficientdigitalskillstomanageeverydaytasksinlife andwork.

Furthermore,wehavenotseenthefulleffectsofactionstaken andtheimpactofchangesonourunderstandingofteleworkand

thetransformationofemployeesintoremoteworkers.Sofar,the premiseshavebeensimilarforall,regardlessofage,gender,and levelofexpertise,althoughthereisabigdifferencebetween peopleworkinginprofessionsthatcanbeperformedata distance,asopposedtothosewhohavetobeatworkto performtheirtasks.Comparedtothefewveteransalready workingfromhome,thenewbies,individualswithlimited experienceofworkingfromhome(Lietal.,2020),hadto mastervirtualmeetings,onlinesoftware,e-learningtools,and moreduringashortperiodoftime.

“Therealityisthatmostnewbieshavebeenforcedtolearnfast howtostayatthetopofthegameandensurethattheyhavethe knowledgetofollowtheveterans.Theyhavetoengagewith onlineforums,amendworkdocuments,undertakeonline meetings,shareresources,andmaketheargumentonline. Theysimplytryto figureoutwhattheyhavetodoand,in manycases,withoutanysupport” (Lietal.,2020,p.201).

Eventhoughsomelearningthattookplacecameintheformof competencedevelopmentcoursesthatwerequicklydevelopedby theorganizationsorbylearninginstitutions,thelion’sshareof thelearningthattookplaceconcernedinformallearningdriven byconcreteneedsforsolvingproblems.Totalkoflearning insteadofeducationisnotwithoutconsequencesbecauseit emphasisestheindividual’sdevelopmentinsteadofthe institutionalcontextwithinwhichitmaytakeplace.Thisalso entailsashiftfromthesubjectcontenttothehumanaspectsthat areinvolved;wemovefrommerelyteachingasubjectto consideringaperson’sdevelopment(Jarvis,2007).Thisideais basedontwofundamentalprinciplesforlifelonglearning:

• Learningmustbeunderstoodasacompletewholeandasan interactionbetweentheindividualandtheirsurroundings. Whenlifelonglearningispartofthepublicdebate,muchis spokenaboutwhattheindividualmustlearnintermsof specificcompetencies.Insuchacase,accordingtotheories aboutlifelonglearning,thereisalackofdialogueaboutwhat itisthatgetstheindividualtoengageinlearning.Incontrast topolicyinitiativesthatbasethisonexternaldrivingforces (forexample,ademandforcertaincompetencieswithina particularindustry),inlife-longlearning,thequestionthat isaskedis:Whatisitthatcreatesrealinterestinlearningin theindividual?

• Theindividual’sidentityprocessiscentraltolearning. Theoriesaboutlifelonglearningclaimthatthisincludesa newunderstandingofoneself.Inshort,learningentailsa renegotiationofone’sidentity.Forexample,formany adults,learningaboutthedigitalworld(thatwelivein) entailsasignificantadaptationwithrespecttotheiridentity. Anexampleofthisiswhenateacher,whomaybeanexpert intheclassroom,isamerebeginnerwithrespecttothe digitalworld.Tounderstandlearninginpractice,one shouldaskthefollowingquestion:Whateffectdoes participationinlearninghaveontheperson’sperception ofthemselves?

Thesetwopointsaretheoreticallygrounded( Wenger,1998 ; Illeris,2004; Jarvis,2004 , Jarvis,2007 , Jarvis,2012 ; Illeris,2017),

buttheyalsoprovidepracticaladvicewithregardsto arrangementsforadulteducationinitiatives.Whenthe labourmarketcallsforcompetencedevelopmentand upskilling,mostoften,itdoesnotconsidertheindividuals whoareaffectedbythis;instead,focusisplacedonthe bene fitsthattheemployerhopestoreapfromsuchefforts. Tomoveforward,onemightask:Whatisitthatcreatestrue enthusiasminpeople?Whatinternaleffectsdoeslearninghave onpeople?Aretherestructuralandmentalspaceswithinthe organizationfortheindividualwhoundergoeschangethrough education?Theseareimportantquestionsforthepersonwho wishestosupportlifelonglearning,andtheyareimportanttoset inrelationtotheteleworkcontext.Basedonthefoundationset outherebylifelonglearningtheories,thefollowingsection providesasetofquestionsandideastoguideresearchthatcould contributetotheoreticalaswellaspracticalknowledge.

FUTURERESEARCHONTELEWORKAND LIFELONGLEARNING

Thereviewssummarisedabovedonotspeci fi callyaddress competencedevelopmentorlifelonglearning. Kurlandand Bailey(1999) statedthatonechallengeformanagerswasthat teleworkledtoafocusonoutcomeratherthantheprocess. Teleworkoftenmeansthatamanagercannotseewhen employeesarestrugglingandstepinwithreliableand constructiveperformancefeedback.Thesituationofthe managerwhoworkswithformativefeedbackissimilarto thatofateacher,andthebalancebetweenfocusonoutput andprocessincompetencedevelopmentatworkshouldbe addressedinfuturestudies.Hybridformsofwork arrangementsmaybeconnectedtonewpowerstructures, andtherolesandresponsibilitiesofmanagersaswellas employeesmayevolve.Tounderstandcomplex entanglementsandtoapproachnew,visible,andnotvisible challengesandchangesintelework,socio-materialapproaches provideopportunitiesforinsights( Boelletal.,2013 ; Sewell andTaskin,2015 ).Spatialmobilityandtemporal fl exibility changethenatureofworkitself,workprocesses,andhuman engagement.Thedevelopmentofvirtualrealities(VR)isoften presentedasawaytoachieveincreasedsocialrichness ( CrandallandGao,2005 ),butwedonotyetknowwhatthe impactofvirtualrealitieswillbeonlearninginatelework setting.Suggestedresearchquestionsare:

RQ1:Howdoeschangedinteractionpatternsbetweenmanager andemployeeimpactformativefeedbackintheorganization?

RQ2:Howwillhybridformsofworkarrangementsinterplay withcompetencedevelopmentinorganizations?

RQ3:Whatdoesinformal,non-formalandformallearning meaninateleworkcontext?

RQ4:Howwillteleworkchangeinthea)natureofwork,b) workprocesses,andc)humanengagementinfluence individuals’ lifelonglearning?

RQ5:Howcanthesocialrichnessinvirtualrealities compensatefortherelationaldisadvantagesoftelework?

Intheteleworkliterature, flexibilityandautonomyofworkers areoftenpresentedaschallenges,astheystandopposedtothe needforteamworkandcollaborationintheorganization(Boell etal.,2013).Thiscontradictionbetweenautonomyand coordinationmay,however,beachimerabasedontheidea thatteamworkneedstobeledbyamanager.Self-organized teamworkcouldworkwellinmanyprofessionsandmayevenbe moreeffectivethantop-downmanagementinseveralcases. Contactbetweenteammembersbasedonemergentproblems intheworkprocesscouldbeconsideredastrongkeytoinformal learning,aslearningatworkisoftenproblembased.Thisisan areawhereweneedfuturestudiestovalidatethisproposition. Contextandinteractionaretwokeyconceptsinlifelonglearning theories,andthechallengeswithinteractionintelework, combinedwithcontextentanglements,proposethatwemay needtostudyteleworkininnovativewaystoobtainthefull picture.

RQ6:Howwillthebalancebetweenautonomyandteamwork influenceindividuals’ learningandcompetencedevelopment?

RQ7:Howdoindividualsengageintheself-organizationof learning,andwhatkindofsupportdotheyneedfromthe organization?

RQ8:Howcanproblem-solvinginitiativesintheindividual’ s dailyworkbeenrichedbyreflection,andhowisthisincluded inarelevantway?

Whenteleworksomedecadesagobecameanoptionformany duetothedevelopmentoftechnology,therewerehopesthat teleworkwouldhelporganizationsdecreaserealestatecosts, promoteahealthywork familybalance,aidcompliancewith DisabilitiesAct,andreduceairpollutionandtrafficcongestion (BaileyandKurland,2002).Whatwehaveobservedthroughthe literaturereviewresultsisthattheadvantagespresentedhavenot beenrealisedtotheextentthatwasexpected.Thecostfor teleworkisnotsimplyreduced,butinvestmentsinthehome officeareneededtoavoidnegativeeffectsontheemployees’ health.Asaformof flexibleworkarrangement,however, teleworkhasanaturalplaceintoday’sworkinglife.Rather thanconsideringteleworkandtelecommutingasanoptionto workingattheoffice,itshouldberegardedasapractical flexible arrangementthatcanboostproductivitywithoutresultingin socialexclusionorjeopardizingcrucialinteractionswith colleagues(Pyöria,2011)andthatcanbeuseddifferently dependingonthetaskandontheindividual.Theindividual’ s expectationsandpossibilitiescanbeastartingpointwhensetting upplans,buttheorganizationshouldhaveknowledgeaboutwhat ispossibleandwhytheyaredoingit.

RQ9:Howcanteleworksupportaninclusiveapproachto learningandcompetencedevelopment?

RQ10:Whatkindofinvestmentsareneededtoimproveskills forandthroughtelework?

RQ11:Howdoorganizationsembraceindividuals’ expectationsandpossibilitiestosupportlifelonglearningin telework?

RQ12:Whatkindoforganizationalstrategiesareemerging concerningtelework,andhowdotheyincludelearningand competencedevelopment?

Beforeendingthissection,itmightbeappropriateto rememberthatearlyresearchonteleworkproposedthat teleworkcouldbeawaytoreducetrafficcongestionand pollution theenvironmentalgainswhenpeopleworkfrom home.Thehopesofanimprovedenvironmentarestill relevant,andresearchduringandafterthepandemiccanshed somelightonwhetherteleworkhaschangedtheconditionofour naturalenvironment.Thispaperhas,however,highlightedthe needtorecognizeteleworkasanenvironmentforlearning.Thisis alsoimportant,asweneedknowledgeinthisareatobeableto supportasustainableworkinglifewherepeoplethriveandcan makerobustcontributionstocompaniesandsociety.

CONCLUSION

Thereareincreasedneedsforcompetencedevelopmentand upskillingduetothedigitalizationofoureverydaylives,but digitalizationalsoenablesteleworksolutionsofvariouskindsand withnewtools.Whileteleworkandlifelonglearningareusually discussedinpositiveterms,wewanttoraiseattentiontothefact thatparticipationinbothteleworkandlifelonglearningisnot evenlydistributedinthepopulation.Thishasbecomeobvious duringthepandemicwhere,forexample,professionswitha criticalsocietalfunction,suchasemployeesinhealthand socialcare,havenotbeenabletotelework.Thetransitionto, andappreciationof,teleworkisprobablyhighestamongeducated white-collarworkerswhoalreadymayhavehadsomeexperience ofteleworkandwhoareinterestedinparticipatinginfurther development.Differencesbetweenagegroups,nations,sectors, andprofessionsshouldbekeptinmindwhenformulating teleworkand/orlifelonglearningpracticesandpolicies.Ifnot, thereisariskofincreasedsocialinequalitiesbetweencountries andbetweenindividuals.

Thereviewinthispaperhasshownalackofresearchon lifelonglearninginallitsforms(formal,non-formaland informal)intelework.Researchaboutteleworkandlifelong learninghasthepotentialtocontributetoasustainable workinglifeintermsofprovidingmore flexiblearrangements foremployeesandtosupportthelifelonglearningthattakesplace indifferentcontexts(office,home,virtual,etc.).Asthereare expectationsofanincreaseintelework,full-timeorinhybrid solutions,afterthepandemichassubsided,itisrelevantto increasetheknowledgeaboutlifelonglearningpracticesin thisarea.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincludedin thearticle/SupplementaryMaterial,furtherinquiriescanbe directedtothecorrespondingauthor.

AUTHORCONTRIBUTIONS

Allauthorslistedhavemadeasubstantial,direct,andintellectual contributiontotheworkandapproveditforpublication.

REFERENCES

Allen,T.D.,Golden,T.D.,andShockley,K.M.(2015).Howeffectiveis telecommuting?assessingthestatusofourscientific findings. Psychol.Sci. PublicInterest 16(2),40 68.doi:10.1177/1529100615593273

Anderson,A.J.,Kaplan,S.A.,andVega,R.P.(2015).Theimpactofteleworkon emotionalexperience:when,andforwhom,doesteleworkimprovedaily affectivewell-being? Eur.J.WorkOrgan.Psychol. 24(6),882 897.doi:10. 1080/1359432X.2014.966086

Bailey,D.E.,andKurland,N.B.(2002).Areviewofteleworkresearch: findings, newdirections,andlessonsforthestudyofmodernwork. J.Organ.Behav. 23 (4),383 400.doi:10.1002/job.144

Baruch,Y.(2001).Thestatusofresearchonteleworkingandanagendaforfuture research. Int.J.Manag.Rev. 3(2),113 129.

Boell,S.K.,Campbell,J.A., Cecez-Kecmanovic,D.,andCheng,J.E.(2013). “Advantages,challengesandcontradictionsofthetransformativenatureof telework:areviewoftheliterature,” inHyperconnectedworld:anything, anywhere,anytime:proceedingsofthe19thAmericasconferenceon informationsystems,Chicago,Illinois,UnitedStates,August15 17,2013. Availableat:http://amcis2013.aisnet.org/(AccessedJanuary5,2021).

Crandall,W.,andGao,L.(2005).Anupdateontelecommuting:reviewand prospectsforemergingissues. SAMAdv.Manag.J. 70(3),30 37.

Daniels,K.,Lammond,D.,andStanden,P.(2001).Teleworking:frameworksfor organizationalresearch. J.Manag.Stud. 38(8),1151 1185.

EuropeanCommission(2020).TeleworkintheEUbeforeandaftertheCOVID-19. Sci.PolicyBriefs,JRC120945.

Eurostat(2020).Howusualisittoworkfromhome?.Availableat:https://ec. europa.eu/eurostat/web/products-eurostat-news/-/DDN-20200424-1(Accessed December11,2020).

Gajendran,R.S.,andHarrison,D.A.(2007).Thegood,thebad,andtheunknown abouttelecommuting:meta-analysisofpsychologicalmediatorsandindividual consequences. J.Appl.Psychol. 92(6),1524 1541.doi:10.1037/0021-9010.92.6. 1524

HarkerMartin,M.,andMacDonnell,R.(2012).Isteleworkeffectivefor organizations?Ameta-analysisofempiricalresearchonperceptionsof teleworkandorganizationaloutcomes. Manag.Res.Rev. 35(7),602 616. doi:10.1108/01409171211238820

Harrington,S.S.,andWalker,B.L.(2004).Theeffectsofergonomicstrainingon theknowledge,attitudes,andpracticesofteleworkers. J.Saf.Res. 35(1),13 22. doi:10.1016/j.jsr.2003.07.002

Hislop,D.,andAxtell,C.(2007).Theneglectofspatialmobilityincontemporary studiesofwork:thecaseoftelework. NewTechnol.WorkEmploy 22(1),34 51. doi:10.1111/j.1468-005X.2007.00182.x

Hornung,S.,andGlaser,J.(2009).Home-basedtelecommutingandqualityoflife: furtherevidenceonanemployee-orientedhumanresourcepractice. Psychol. Rep. 104(2),395 402.doi:10.2466/PR0.104.2.395-402

Igeltjørn, A.,andHabib,L.(2020). “Homebasedteleworkasatoolforinclusion?A literaturereviewoftelework,disabilities,andwork-lifebalance,” in14th Internationalconference,UAHCI2020,heldaspartofthe22ndHCI internationalconference,HCII2020,Copenhagen,Denmark,July19 24, 2020.EditorsM.AntonaandC.Stephanidis(NewYork,NY:Springer),420 436. Illeris,K.(2017).PeterJarvisandtheunderstandingofadultlearning. Int. J.LifelongEdu. 36(1 2),1 10.doi:10.1080/02601370.2016.1252226

Illeris,K.(2004). Thethreedimensionsoflearning.FrederiksbergUnitedKingdom: RoskildeUniversitet,272. Internetstiftelsen(2020). Svenskarochinternet2020.[Swedesandinternet] Stockholm,Sweden:ReportfromTheSwedishInternetFoundation,1 181. Jarvis,P.(2004). Adulteducationandlifelonglearning.Theoryandpractice.3rd Edn.London,NewYork:Routledge,352.

FUNDING

FundedbytheSchoolofEducationandCommunication, JönköpingUniversity,Sweden.

Jarvis,P.(2012). Teaching,learning,andeducationinlatemodernity.Theselected worksofPeterJarvis.NewYork,NY:Routledge,240.

Jarvis,P.(2007). “Towardsaphilosophyofhumanlearning.Anexistentialist perspective,” in Humanlearning.Anholisticapproach.EditorsP.Jarvisand S.Parker(NewYork,NY:Routledge),240.

Kurland,N.B.,andBailey,D.E.(1999).Telework:theadvantagesandchallengesof workinghere,there,anywhere,andanytime. Organ.Dyn. 28(2),53 68.doi:10. 1016/S0090-2616(00)80016-9

Li,J.,Ghosh,R.,andNachmias,S.(2020).InatimeofCOVID-19pandemic,stay healthy,connected,productive,andlearning:wordsfromtheeditorialteamof HRDI. Hum.Resour.Dev.Int. 23(3),199 207.doi:10.1080/13678868.2020. 1752493

Mann,S.,andHoldsworth,L.(2003).Thepsychologicalimpactofteleworking: stress,emotionsandhealth. NewTechnol.WorkEmploy. 18(3),196 211. doi:10.1111/1468-005X.00121

Mann,S.,Varey,R.,andButton,W.(2000).Anexplorationoftheemotional impactofteleworkingviacomputermediatedcommunication. J.Manag. Psychol. 15(7),668 690.doi:10.1108/02683940010378054

Martínez-Sánchez,A.,Pérez-Pérez,M.,Vela-Jiménez,M.J.,andde-LuisCarnicer,P.(2008).Teleworkadoption,changemanagement,and fi rm performance. J.Organ.ChangeManag. 21(1),7 31.doi:10.1108/ 09534810810847011

Masuda,A.D.,Holtschlag,C.,andNicklin,J.M.(2017).Whytheavailability oftelecommutingmatters:theeffectsoftelecommutingonengagementvia goalpursuit. CareerDev.Int. 22(2),200 219.doi:10.1108/CDI-05-20160064

Peters,P.,Ligthart,P.E.M.,Bardoel,A.,andPoutsma,E.(2016). ‘Fit’ fortelework’? Cross-culturalvarianceandtask-controlexplanationsinorganizations’ formal telework practices. Int.J.Hum.Resour.Manag. 27 (21), 2582 2603.doi:10. 1080/09585192.2016.1232294

Pyöriä,P.(2011).Managingtelework:risks,fearsandrules. Manag.Res.Rev. 34 (4),386 399.doi:10.1108/01409171111117843

Sewell,G.,andTaskin,L.(2015).Outofsight,outofmindinanewworldofwork? Autonomy,control,andspatiotemporalscalingintelework. Organ.Stud. 36 (11),1507 1529.doi:10.1177/0170840615593587

SVT(2021).Hälftenavallasvenskaransersighaotillräckligadigitala kunskaper[EveryotherSwedethinktheyhaveinsuf fi cientdigital knowledge].Availableat:https://www. svt.se/nyheter/inrikes/halften-avalla-svenskar-anser-sig-ha-otillrac kliga-digitala-kunskaper(Accessed February2,2021).

Taskin,L.,andBridoux,F.(2010).Telework:achallengetoknowledgetransferin organizations. Int.J.Hum.Res.Manag. 21(13),2503 2520.doi:10.1080/ 09585192.2010.516600

WEF(2020). Thefutureofjobsreport2020.WorldEconomicForum.Availableat: https://www.weforum.org/reports/the-future-of-jobs-report-2020+&cd 1&hl en&ct clnk&gl in(AccessedOctober20,2020).

Wenger,E.(1998). Communitiesofpractice.Learning,meaningandidentity Cambridge:CambridgeUniversityPress.

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialor financialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021Bjursell,Bergmo-PrvulovicandHedegaard.Thisisanopen-access articledistributedunderthetermsoftheCreativeCommonsAttributionLicense(CC BY).Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywith theseterms.

published:29April2021

doi:10.3389/fpubh.2021.638481

Editedby: AndrzejKlimczuk, WarsawSchoolof Economics,Poland Reviewedby: SubhasKhajanchi, PresidencyUniversity,India YuriyTimofeyev, NationalResearchUniversityHigher SchoolofEconomics,Russia

*Correspondence: MarthinusC.Breitenbach martin.breitenbach@up.ac.za

Specialtysection: Thisarticlewassubmittedto HealthEconomics, asectionofthejournal FrontiersinPublicHealth

Received: 06December2020 Accepted: 08March2021 Published: 29April2021

Citation: BreitenbachMC,NgobeniVand AyeGC(2021)GlobalHealthcare ResourceEfficiencyinthe ManagementofCOVID-19Deathand InfectionPrevalenceRates. Front.PublicHealth9:638481. doi:10.3389/fpubh.2021.638481

GlobalHealthcareResource EfficiencyintheManagementof COVID-19DeathandInfection PrevalenceRates

MarthinusC.Breitenbach 1*,VictorNgobeni 2 andGoodnessC.Aye 1

1 DepartmentofEconomics,UniversityofPretoria,Pretoria,SouthAfrica, 2 NationalTreasuryoftheRepublicofSouthAfrica, Pretoria,SouthAfrica

ThescaleofimpactoftheCOVID-19pandemiconsocietyandtheeconomyglobally providesastrongincentivetothoroughlyanalyzetheefficiencyofhealthcaresystemsin dealingwiththecurrentpandemicandtoobtainlessonstopreparehealthcaresystems tobebetterpreparedforfuturepandemics.Intheabsenceofaprovenvaccineorcure, non-pharmaceuticalinterventionsincludingsocialdistancing,testingandcontacttracing, isolation,andwearingofmasksareessentialinthefightagainsttheworldwideCOVID19pandemic.WeusedataenvelopmentanalysisanddatacompiledfromWorldometers andTheWorldBanktoanalyzehowefficienttheuseofresourcesweretostabilizethe rateofinfectionsandminimizedeathratesinthetop36countriesthatrepresented90% ofglobalinfectionsanddeathsoutof220countriesasofNovember11,2020.Thisis thefirstpapertomodelthetechnicalefficiencyofcountriesinmanagingtheCOVID19pandemicbymodelingdeathratesandinfectionratesasundesirableoutputsusing theapproachdevelopedbyYouandYan.Wefindthattheaverageefficiencyofglobal healthcaresystemsinmanagingthepandemicisverylow,withonlysixefficientsystems outofatotalof36underthevariablereturnstoscaleassumption.Thisfindingsuggests that,holdingconstantthesizeoftheirhealthcaresystems(becausecountriescannotalter thesizeofahealthcaresystemintheshortrun),mostofthesamplecountriesshowed lowlevelsofefficiencyduringthistimeofmanagingthepandemic;insteaditissuspected thatmostcountriesliterally“threw”resourcesatfightingthepandemic,therebyprobably raisinginefficiencythroughwastedresourceuse.

Keywords:pandemic,COVID-19,deathrates,infectionrates,recoveries,dataenvelopmentanalysis,healthcare systemsefficiency,technicalefficiency

INTRODUCTION

SinceitfirstemergedinChinainlateDecember2019,thenewcoronavirus(COVID-19)spread tonearlyeverycountryoftheworld(1).Within7months,ithadspreadto215countriesand regions.Atthetime ofproducingthispaper,onNovember11,2020,52millionpeoplewere knowntobeinfected(2),and ∼1.3milliondeathshadbeenrecordedsincetheoutbreak.Countries adoptedpandemicspreadmitigating interventionsreferredtoasnon-pharmaceuticalinterventions (NPIs),suchassocialdistancing,testingandcontacttracing,caseisolation,andpublichygieneat

anunprecedentedscale(3).Withoutaprovenvaccineorcure, non-pharmaceuticalinterventions includingsocialdistancing, testing,wearingofmasks,andcontacttracingareessentialtoend theworldwideCOVID-19(4).

Evenwiththese drasticNPIinterventions,thespreadof thepandemicexploded,especiallywithsurgesincontagion experiencedincountrieslikeItaly,France,theUK,andtheUSA. Thisputimmensestrainontheavailabilityofespeciallyintensive careunitfacilities,doctors,andnurses,andtheefficiencyof healthcaresystemswasalsoputunderthespotlight.Whatwe learnfromrecentexperiencesinthefightagainstthisdeadly diseasefromcountrieslikeSouthKoreaisthataccessibility tohealthcareservicescansignificantlyreducethenumberof deaths(5).Moreover,Sarkaretal.(4)usedamathematical modeltodemonstratethat theeliminationoftheongoingSARSCoV-2pandemicispossiblebycombiningrestrictivesocial distancingandcontacttracing.Theyconcludedthattheaccurate courseoftheepidemicheavilydependsonhowandwhen quarantine,isolation,andprecautionarymeasuresareenforced. ThisisalsosupportedbyBreitenbachetal.(6).Accordingto Khajanchiand Sarkar(7),intheabsenceofspecificantivirals orvaccines, mathematicalmodelingplaysanimportantrole inbetterunderstandingthediseasedynamicsandindesigning strategiestocontroltherapidlyspreadinginfectiousdisease. Samuietal.(8)usedacompartmentalmathematicalmodelto predictandcontrolthetransmissiondynamicsofCOVID-19 pandemicinIndiawithepidemicdatauptoApril30,2020. Theycomputedabasicreproductionnumber,R0,of1.7.This showedasubstantialoutbreakofCOVID-19inIndia.Their modelpredictedthat,forabout60days,thepeakwillbehigher forCOVID-19infectionsinIndiaandafterthatthecurvewill plateau,butthecoronavirusdiseasewillpersistforalongtime.

ItisforthisreasonandtheimpactofCOVID-19on societyandtheglobaleconomythattheefficiencyofhealthcare systemsneedstobethoroughlyexamined.Thiscouldinform appropriatepolicyresponsesandadequatelypreparehealth systemstorespondbettertofuturepandemics.Ourstudyis differentfromtypicalcompartmentalmodelsasweaddress theissueofmacro-efficiencyofpublichealthcaresystemsby applyingdataenvelopmentanalysis(DEA),anon-parametric andmathematicalmodeladepttoestimatethetechnical efficiencyofpublichealthcaresystems.Wealsouseextensive datacompiledfromWorldometers(2)andtheWorldBank (9 11).Specifically,weanalyzetheefficientuseofavailable resourcestostabilizetherateofinfectionsandminimizethecase fatalityratesinthetop36selectedcountriesrepresenting90% ofglobalinfectionsanddeathsin220countriesasofNovember 11,2020.Ourcontributiontotheliteratureis2-fold:first,this paperisthefirsttomodelthetechnicalefficiencyofcountries indealingwiththeCOVID-19pandemicbymodelingdeath ratesandinfectionratesasundesirableoutputsand,second, bymodelingcomparativescenariostotesttheaccuracyofour model.Modelingcontagioncurvesandestimatingefficiency ratesmaycontributetopoliciesandstrategiestoassistpublic healthcaresystemsinthefightagainstthispandemic.However, theroleofmediaisinvaluableineducatingthepopulation aboutthedangersofthepandemicandtheimportanceof

usingNPIs.Thiscanpotentiallychangethepublics’behavior andaffecttheimplementationofindividuals’interventionand controlstrategies(12).

LITERATUREREVIEW

DEAhas beenappliedextensivelytocomparetheefficiency ofhealthcarefacilitieswithincountriesandbetweencountries, andwebrieflydealwithsomeofthatliteraturehere.Wedo notdealwiththeliteratureoncountrystudiesbecauseour papercomparesefficiencybetweencountries.Forliteratureon efficiencystudiesamongdifferenthealthcarefacilitieswithina country,see,forexample,Ngobenietal.(13),Campanellaetal. (14),Alhassanetal.(15),Jarjueetal.(16),Chowdhuryetal.(17), Gannon(18),MarschallandFlessa(19),Akazilietal.(20),Masiye (21),Zereetal.(22),andKirigiaetal.(23, 24).

Althoughhealthcareisoneofthemostpopularareasof applicationforDEA(25),DEAstudiesonhealthcaresystems worldwidearestilllimited.Forexample,Bhat(26)usedDEAto measuretheimpactoffinancialandinstitutionalarrangements onnationalhealthcaresystemefficiencyin24OECDcountries. LoStortoandGoncharuk(27)appliedDEAtomeasurethe technicalefficiency of32European(EU)countries.AfonsoandSt Aubyn(28)usedatwo-stageDEAtoestimateasemi-parametric modelofthehealthcaresystemsin30OECDcountriesforthe years1995and2003.DeCosandMoral-Benito(29)estimated alternativemeasurementsofefficiencyusingDEAandstochastic frontieranalysisbetween1997and2009toascertainthemost importantdeterminantsofhealthcareefficiencyacross29OECD countries.Hadadetal.(30)comparedthehealthcaresystem efficiencyof31OECDcountries withtwomodelspecifications, oneincludinginputsundermanagementcontrolandtheother includinginputsbeyondmanagementcontrol.KimandKang (31)usedabootstrapDEAtoestimatetheefficiencyofhealthcare systemsinasampleof 170countries.

Althoughthechoiceofinputsissimilarinthesestudies, outputsselectiondependsmostlyonthepurposeoftheresearch. Forexample,Gonzalezetal.(32),inacross-sectionalstudy, measuredthetechnicalandvalueefficiencyofhealthsystemsin 165countries.Theyusedexpenditureonhealthandeducation asinputsanddataonhealthylifeexpectancyanddisability adjustedlifeyearsashealthoutcomes.Examiningtheefficiencyin healthcareservicesdeliverytothepopulation,Bhat(26)usesthe numberofpopulationsaged0–19, 20–64,and65yearsorolderas outputs.Santosetal.(33)examinetheefficiencyofcountriesin preventingthemother-to-childHIVtransmissionandusedthe numberofpregnantwomentestedforHIVandthenumberof HIVpregnantwomenreceivingantiretroviraldrugsasoutputs.

DEAstudiesfornewsettingssuchastherecentCOVID19outbreakmayhoweverneedtointroducenewoutputs. Shirouyehzadetal.(34)usesDEAtoanalyzetheefficiencyof contagionofCOVID-19and focusonthenumberofdeathsand recoveriesasoutcomes.Breitenbachetal.(6)analyzethe31most infectedcountriesduringthefirst100dayssincetheoutbreak oftheCOVID-19coronavirusfortheefficiencyincontaining thespreadofthevirusandfocusonflatteningthecurveasthe

mainoutput.Empiricalworkpivotsmostlyonhealthcaresystem performancebasedon technicalefficiencycalculatedasaratio ofsomequality-of-lifevariableasanoutputandphysicalhealth resourcesorexpenditureonhealthasinputs.Theinputsmostly usedwereexpenditure,doctors,andnurses,whiletheoutputs weredischargeorrecovery,prevalence,andmortalityrates.In thispaper,weusetests,doctors,andnursesasphysicalinputsand healthspendingasfinancialinputinmanagingtheCOVID-19 pandemic.Asoutputs,weusecasefatality(deaths)andinfection prevalencerates.

METHODOLOGY

Inthispaper,weusethevariablereturnstoscale(VRS) approachreportedbyGavurovaetal.(35)anddevelopedin 1984byBanker,Charnes,andCooper(BCCmodel)toallow forconsiderationofscaleefficiencyanalysis.Envelopmentin DEAreferstotheabilityoftheefficiencyproductionfrontier totightlyenclosetheproductiontechnology(inputandoutput variables).AccordingtoCooperetal.(36)andMcWilliams etal.(37),DEA wasdevelopedinamicroeconomicsetting andappliedtofirmstomeasuretheefficiencyofconverting inputsintooutputs.Intheanalysisofpublicinstitutions,firms arereplacedbythemoreencompassingdecision-makingunits (DMU).DEAisthereforeanappropriatemethodofcomputing theefficiencyofinstitutionsemployingmultivariateproduction technologies.Aristovnik(38)andMarti´cetal.(39)distinguish between inputminimizationandoutputmaximization DEA models.Theformerdeterminesthequantityofinputsthat couldbecurtailedwithoutreducingtheprevailinglevelof outputs,andthelatterexpandstheoutputsofDMUstoreach theproductionpossibilityfrontierwhileholdingtheinputs constant.However,theselectionofeachorientationisstudy specific.Inthispaper,weselectinputminimizationorientation, astheobjectiveofthestudyistomeasuretheefficiencyof resourcesused(minimizedinputs)atprevailinghealthoutput levels(recovery,death,andinfectionrates).Itisunwiseto selectanoutputmaximizationdispensationasitwouldbe tantamounttomaximizingdeathandinfectionratesasdesirable outputsalongsidetherecoveryrate.Whenundesirableoutputs areaninevitableby-productintheproductionprocess,theinput minimizationorientationisselectedasthepreferredDEA[also seeYouandYan(40)].

AccordingtoTaylorand Harris(41),DEAisacomparative efficiencymeasurementtoolthatevaluatestheefficiency ofhomogeneousDMUsoperatinginsimilarenvironmental conditions,forexample,DMUsdealingwithCOVID-19and wheretherelationshipbetweeninputsandoutputsisunknown. WefollowJoumardetal.(42)totreatthewholehealthcare systeminagivencountryasaDMUinordertoanalyzethe healthcaresystemattheaggregatelevel.WealsoadopttheVRS methodologyinthisstudybecauseofheterogeneityamongthe DMUsintermsoffactorslikecountrysizeandincome.Interms oftheDEAmethodology,thecurrentstudyusestheBCCmodel, withtheratioofDMUsbeingfourtimesthecombinednumberof inputsandoutputstoensurethestabilityoftheefficiencyresults.

ModelingUndesirableOutputs

DEAmodelshavefoundincreasinguseinefficiencyanalysis applicationswhereatleastoneoutputintheproduction processisanundesirableoutput,e.g.,pollution.Thereis considerableresearchpublishedontheundesirableaspectsof productionoutputs.However,YouandYan(40)havefound thattheeconomic implicationsandthesuitabilityofDEA modelsincorporatingtheundesirableoutputsshouldbecarefully consideredastheresultsmayeitherunder-oroverstateefficiency ifmodeledincorrectly.

Thefirstwaythatundesirableoutputsaredealtwith inthetraditionalDEAmodelistoignoretheundesirable output(43 46).Itisnot,however,appropriatetoignorethe realityof,e.g.,pollution duringproductionsinceundesirable outputsanddesirableoutputsaregeneratedsimultaneouslyin theproductionprocess.DyckhoffandAllen(47)dealtwith undesirableoutputsbymodeling themasinputs.However, treatingundesirableoutputsasinputsfailstoreflectthetrue productionprocess.Thereisaspecificproductiontechnology thatlinksinputstooutputs,andtakinganundesirableoutput asaninputintheproductionprocessleadstomisspecification andmisinterpretation,forexample,whenmodelingpollution asaninputusinganoutput-orientedmeasure,ecological inefficienciesremainundetected.GolanyandRoll(48)suggested adatatransformationapproachwhereanundesirableoutputis convertedintoa“normal”outputbyamonotonicdecreasing function.Theundesirableoutputs(carbonandnitrogen emissions)aretreatedasnormaloutputsbytakingtheir reciprocals.Althoughthepollutantistreatedasoutput,thescale andintervalsoftheoriginaldatagetlost,andtheproblemwith zerovaluesisthatitdoesnothaveareciprocalvalue.Thelinear monotonicdecreasingtransformationwassuggestedbySeiford andZhu(49).Asufficientlylargepositivescalar βi isaddedto thereciprocaladditivetransformationoftheundesirableoutput i sothatthefinalvaluesarepositiveforeachDMUk.Thismodel iscriticizedforitsinvariancetodatatransformationwithinthe DEAmodel(45, 46).Färeetal.(50)treatsundesirablefactors inanon-linearDEAmodel basedontheweakdisposabilityof undesirableoutputs(51).Weakdisposabilityassumesthat,to reduceundesirableoutputs,it iscostlybecausesimultaneouslyit increasestheinputsordecreasesdesirableoutputs(52).Ittends toincreasethe desirableandundesirableoutputconcurrently. Regardlessoftheformoftransformation,aslongasthefinalvalue ofundesirableoutputincludedintheDEAcalculationremains positive,itincreasestheefficiencyoftheDMU.Anundesirable outputshouldbringeitheranegativeorpositiveimpacttothe performanceoftheDMU;therefore,itisnotappropriateforthe undesirableoutputtosolelyfavortheefficiencyscore.

Aftercomparingtheperformanceofthemodelsdiscussed above,YouandYan(40)developedtheratiomodel,which outperformedallfiveofthesemodelsdevelopedfordealingwith undesirableoutputs.Wethereforeoptedtoadopttheratiomodel forthecurrentpaper.Theratiomodelisdifferentfromthe previousapproachesinthattheundesirableoutputisaggregated inaratioformwiththedesirableoutput.

FromtheconventionalBCCDEAmodelandassumingthat thereare R DMUr (r = l,2,..., R)thatconvert m inputsto

n outputs,DMUk isoneofthe R DMUs beingevaluated.Itis furtherassumedthatDMUk consumes m inputs Xk t (i = 1,2,..., m)toproduce n outputs Yk j (j = 1,2,..., n),andalltheseoutputs areassumedtobedesirable.ThemeasureofefficiencyofDMUk isthenobtainedby: min θ subjectto R r=1 λrXr i θXk i + si = 0 i = 1,2, ... , m (1) R r=1 λr Yr j s+ j = Yk j j = 1,2, ... , n (2) R r=1 λr = 1 λr, si , s+ j ≥ 0 r = 1, , R (3)

whereDMUr = the rthDMU, r = 1,2,..., R;DMUk = the kthDMUbeingevaluated; Xr i , Yr j = theinputsandoutputsof everyDMUr; i = 1,2,..., m,j = 1,2,..., n; θ = theefficiency ofDMUk; λr = thedualvariablecorrespondingtotheother inequalityconstraintoftheprimal; si , s+ j = theslackvariablesthatturntheinequalityconstraint intoanequalform; λ ∗ r, s ∗ i , s+∗ j = theoptimalsolutionswhenthe relativeefficiencyofDMUk is θ ∗ = 1and s ∗ i = s+∗ j = 0.

Intheratiomodel,theundesirableoutputanddesirable outputaredefinedas Oq (q = 1.2, , n1)and O+ p (p = 1,2, , n2),respectively(n1 + n2 = n).ForDMUk,the undesirableoutputs Oq (q = 1,2, ... , n1)aretreatedasa newvariable ψk,whichiscalledthepenaltyparameterandis writtenas:

ψk = ρ1O1k + ... + ρn1O n1k (4)

where ψk = penaltyparameterforDMUk; ρq = thepenalty forindividualundesirableoutput(q = 1,2, , n1); Oq = theundesirableoutput(q = 1,2, , n1).Since ρq isthe penaltychargedforproducingtheoutputs,the ψk obtainedfrom problem(10)givesameasureofthetotalmonetaryvalueof undesirableoutputs.Fromthedefinitionof ψk,thegreaterthe amountofundesirableoutput,thegreateristhevalueofthe penaltyparameter.Furthermore,therespectivevalueof ρq is associatedwiththeindividualundesirableoutput;therefore, ρq hasthesamevalueforeveryDMU.Withthismodel,desirable andundesirableoutputscanrelatetooneanother,regardless ofadisagreementinunits.Withthenewapproachoftreating theundesirableoutputsinEquation(10),thedesirableoutput p (p = 1,2, ... , n2)ofDMUk intheratiomodelismodifiedas:

Y ′ ρ = 1 ψk O+ p , p = 1,2, , n2 (5) where O+ p = thedesirableoutput p = 1,2, , n2 ,and Y ′ ρ = themodifiedoutput p = 1,2, , n2

Theratiomodelcomputesdesirableandundesirableoutputs asfractions,whereundesirableoutput Oq isthedenominator

anddesirableoutput O+ p isthenumerator.Herethevalueof theoutputisinterpretedasaratioofdesirabletoundesirable output.Usingratiosprovidesasimpleandeasywaytoexpose theimpactofundesirableoutputsinaDEA.Theratioformof theDEAmodelcansatisfytherestrictionsoftheconventional DEA,whichtheoutputvariablestatesmustbeapositivevalue. Moreover,theratioformprovidesamoredistinctwayforthe desirableandundesirableoutputtodescribethepresenceofan undesirableoutputonDMUefficiency.

Inordertocheckthestabilityofourmodelresults,weran threedifferentmodelspecificationsandcomparedtheresults.In modelI,weusethenumberoftestsandnumberofdoctorsand nursesasphysicalinputs,healthexpenditureasfinancialinput, andtheratioofrecoveriestoinfectionratesasoutput(ratioof desirabletoundesirableoutput).InmodelII,weusethenumber oftestsandnumberofdoctorsandnursesasphysicalinputs, healthexpenditureasfinancialinput,andtheratioofrecoveries todeathratesasoutput(ratioofdesirabletoundesirableoutput), andinmodelIII,weusethenumberoftestsandnumber ofdoctorsandnursesasphysicalinputs,healthexpenditure asfinancialinput,andthenumberofrecoveriesasoutput.In modelIII,wethereforeignoretheundesirableoutputs(43 46). Althoughitisnot goodtoignoretheundesirableoutputsof therateofnewinfectionsanddeathrates,wedothisinorder tocomparethedifferencethattheinclusionoftheundesirable outputsinourmodelhasontheefficiencyscores.

Data

Ourdataweregatheredfromdifferentsources.TheCOVID19-relateddata(i.e.,infectedcases,recoveredcases,deaths,and numberoftests)wereextractedfromextensivedatacompiled fromWorldometers(2).Theaggregateddataondoctorsand nursesper100,000of thepopulationandhealthcareexpenditure wereobtainedfromworlddevelopmentindicatorsprovided bytheWorldBank(9 11).Asreportedearlier,weanalyze theefficientuseofavailableresourcestostabilizetherateof infectionsandminimizethecasefatalityratesinthetop36 selectedcountries(see TableA1)representing90%ofglobal infectionsanddeathsin220countriesasofNovember11,2020.

Somedescriptivestatisticsofthevariablesreportedin Table1 indicatethatoursamplecountrieshave,onaverage,resources ofnearlysevendoctorsandnursesper1,000ofthepopulation, abudgetofabout8%ofgrossdomesticproduct(GDP)and 200,850testsperonemillionofthepopulationforitshealthcare system.ThenumberofinfectedcasesanddeathsfromCOVID19overthestudyperiodaveragedmorethan1,295,120and 32,821,respectively,andthemeannumberofpeoplerecovering fromtheinfectionwasaround974,487persons.Assumingthat thewholehealthcaresystemismobilizedtofighttheCOVID19outbreak,howefficientwasthemobilizationofresources? ThisissueisanalyzedwithourDEAmodel,andtheresultsare reportedinthenextsection.

RESULTS

Theresultsofthethreemodelvariantsaregraphicallyillustrated in Figure1,andtheresultsarepresentedin Table1 (TableA1). Asintimatedearlierinthispaper,itisimportanttoconsider

TABLE1| Descriptivestatisticsandvariablesusedin themodel.

Variables No.ofobservationsUnit

PhysicalInputs

MeanStandarddeviationMinimumMaximum

No.ofTests 36 permillion ofthepopulation200,849.78159,220.8115,033.00541,193.00 No.ofDoctors&Nurses 36 per1,000ofthepopulation7.00 5.00 1.00 22.00

FinancialInput

HealthExpenditure 36 %ofGDP 8.00 3.00 3.00 17.00

Desirableoutput RecoveryRate 36 No.ofPeople 974,486.671,844,065.4130,504.008,023,412.00

Undesirableoutput

DeathRates 36 No.ofPeople 32,820.67 50,619.93 1,174.00245,989.00 InfectionRates 36 No.ofPeople 1,295,119.312,265,355.91175,711.0010,575,373.00

Authors’calculationsbasedonWorldometers(2)andTheWorldBank(9 11).

theVRStechnical efficiencyscoresmotivatedbythedifferences inthesizeofhealthcaresystemsglobally,particularlybetween largedevelopedeconomiesandsmallless-developedeconomies. TheVRSTEscoresarealmostidenticalacrossthethreemodel variants.Thispointstotwothings:first,theinclusionof undesirableoutputsinourmodel(variantsIandII)doesnot haveanymaterialimpactonthemeantechnicalefficiencyof countryhealthcaresystemsand,second,itpointstothestability ofourresultsacrossthethreemodelvariants.Forthesake ofsimplicity,wethereforediscussonlytheresultsreflected inmodelI,whereourphysicalinputswerethenumberof tests/millionofthepopulationandnumberofdoctorsand nursesper100,000ofthepopulationandourfinancialinput healthcareexpenditureasapercentageofGDPandouroutput recoveries/infections.UndertheCRSassumption,therewere onlytwoefficienthealthcaresystemsindealingwithCOVID19, viz.,BangladeshandPakistan.WhentheVRSassumptionis considered,thefigurerisesasexpected,inthiscasetosix,with theadditionofBrazil,Chile,Indonesia,andMorocco.

Thesedifferences,regardingthefullsampleof36countries, arestatisticallysignificantunderaMann–Whitney–Wilcoxon’s test(Z = 5.271,p = 0.001).Itindicatestheroleofscaleefficiency inouranalysisbecauseitistheobjectiveofglobalhealthcare systemstoachievetheoptimaltechnicalcombinationofthe inputstoproducetheoutputs,buttheirscales(sizes)arenot optimalyet.Although21ofthe36countriesinoursample areoperatingunderincreasingreturnstoscale,thetechnical combinationofinputstoproducetheexistingoutputisstillnot optimal.Sixofthe36countriesoperateunderdecreasingreturns toscale(seethe TableA1),suggestingthattheycandouble theirinputswithoutdoublingtheiroutput.Thesecountries couldthereforerationalizetheirhealthcareresources/inputs bydownsizing(usingresources/inputsmoreefficiently)and, thereby,improvingthetechnicalefficiency,whiletheoutputscan stillstaythesame.Atfirstglance,itisoftendifficulttoenvisage acountrywithalargeundesirableoutputtobetechnically efficient.Brazil,forexample,hasaveryhighnumberofinfections anddeaths,yetourDEAresultsshowthatBrazilistechnically efficientandliesontheefficiencyfrontier.Togainfurtherinsight intothisnumberandtheassociatedDEAefficiencyscores,itis

helpfultocompareinputsandoutputsofabenchmarkcountry likeBrazilrelativetothatofothercountries.Wehavedone thisin Table2.

Forexample,incomparisontoBrazil,theUSAspends4.25 timesmoreasapercentageofGDPonhealthcare,has3.5times moredoctorsandnursesper100,000ofthepopulation,andhad 471%moreCOVID-19testsperformedrelativetoBrazil,yetit didnotsucceedtocontainitsundesirableoutputs(infections are185%higheranddeathsare151%higherthanBrazil)even thoughitperformedwellintheareaofthegoodoutput— recoveries.ThisresultclearlyexplainstherelativelylowVRS technicalefficiencyscoresoftheUSA,France,Germany,and Belgiumin Table2,whichcouldbelinkedtothespecificpolicy responsesoftheselectedcountries.Forexample,evidencenow suggeststhattheUKfailedtofighttheCOVID-19outbreakby followinga“herdimmunity”approach(53),andtheUSAwas veryslowtoactagainstCOVID-19(54).

CONCLUSIONS

Thispaperexaminedtheefficiencyof36healthcaresystems (whichrepresent90%ofcasesglobally)inmanagingthe COVID-19pandemic,giventheirresourceconstraints.We useanovelDEAapproach,developedbyYouandYan(40), whichaccountsfor bothdesirableoutputs(recoveredcases) andundesirableoutputs(infectionsanddeaths),andourresults indicatethattheaverageefficiencyofglobalhealthcaresystems inmanagingtheCOVID-19pandemicisverylow,withonlysix efficientsystemsoutofatotalof36underthevariablereturns toscaleassumption.Thisfindingsuggeststhat,holdingconstant thesizeoftheirhealthcaresystems(becausecountriescannot alterthesizeofahealthcaresystemintheshortrun),mostof thesamplecountriescouldnotimprovetheirefficiencyduring thistimeofmanagingthepandemic;insteaditissuspected thatmostcountriesliterally“threw”resourcesatfightingthe pandemic,therebyprobablyraisinginefficiencythroughwasted resourceuse.Inefficientcountriescouldlearnbestpracticesof managingpandemicsfromtheefficientcountriesinthesample, mostbeingdevelopingcountries.Thisindicatestotheglobal

COVID-19GlobalHealthcare

healthsectorthatitislessabouthealthresourceendowmentsbut moreaboutthe efficiencyofusingtheavailableresources.The studyalsoshowedthat,withoutpharmaceuticalinterventions likevaccines,theprevailinghealthcareresourcesandNPIsused incombatingmajorpandemicslikeCOVID-19appeartohelp fewercountries.Therefore,thehealthcaresectorshouldinvest moreinproactivethanreactivemanagementofpandemics, forexample,throughcontinuousresearchanddevelopmenton preventativemedication.Thestudyisconstrainedinseveral ways.TheDEAresultsareheavilydependentontheselection ofanalyticalvariables.Therefore,adifferentsetofindicators mayleadtoadifferentcollectionofresults.Thecredibility andaccuracyofstatisticsusedalsoaffecttheresultsofthe models—dataofthepandemicisgettingmorerefinedover time.Thisstudyaddstotheliteratureonmodelingthe efficientuseofresourcesinworldhealthcaresystemswith

REFERENCES

1.NeweyS,GullandA. WhatisCoronavirus,HowDidItStartandHow BigCouldItGet? TheTelegraph(2020).Availableonlineat:https://www. telegraph.co.uk/news/2020/04/28/what-is-coronavirus-covid-19-viruspandemic/(accessedApril28,2020).

2.Worldometers. COVID-19CoronavirusPandemic.Worldometer(2020). Availableonlnieat:https://www.worldometers.info/coronavirus/(accessed August08,2020).

3.CorreiaS,LuckS,VernerE. PandemicsDepresstheEconomy,PublicHealth InterventionsDoNot:Evidencefromthe1918Flu.DraftPaper.(2020). Availableonlineat:https://ssrn.com/abstract=3561560(accessedJuly01, 2020).

4.SarkarK,KhajanchiS,NietoJJ.ModelingandforecastingtheCOVID19pandemicinIndia. ChaosSolitFractals. (2020)139:110049. doi:10.1016/j.chaos.2020.110049

5.TangB,XiaF,BragazziNL,McCarthyZ,WangX,HeS. LessonsDrawnfrom ChinaandSouthKoreaforManagingCOVID-19Epidemic:Insightsfroma ComparativeModellingStudy.BulletinofWorldHealthOrganisation(2020).

6.BreitenbachMC,NgobeniV,AyeG.Efficiencyofhealthcaresystemsinthe firstwaveofCOVID-19-atechnicalefficiencyanalysis.In: MPRAPaper No.101440.(2020).Availableonlineat:https://mpra.ub.uni-muenchen.de/ 101440/(accessedOctober15,2020).

7.KhajanchiS,SarkarK.Forecastingthedailyandcumulativenumberof casesfortheCOVID-19pandemicinIndia. Chaos.(2020)30:071101. doi:10.1063/5.0016240

8.SamuiP,MondalJ,KhajanchiS.AmathematicalmodelforCOVID-19 transmissiondynamicswithacasestudyofIndia. ChaosSolitFractals.(2020) 140:110173.doi:10.1016/j.chaos.2020.110173

9.TheWorldBank. CurrentHealthExpenditure(%ofGDP).TheWorld Bank(2020).Availableonlnieat:https://data.worldbank.org/indicator/SH. XPD.CHEX.GD.ZS(accessedAugust08,2020).

10.TheWorldBank. NursesandMidwivesper1000Population.TheWorld Bank(2020).Availableonlnieat:https://data.worldbank.org/indicator/SH. MED.NUMW.P3(accessedAugust08,2020).

11.TheWorldBank. Physiciansper1000Population.TheWorldBank(2020). Availableonlnieat:https://data.worldbank.org/indicator/SH.MED.PHYS.ZS (accessedAugust08,2020).

12.KhajanchiS,SarkarK,MondalJ,PercM.Dynamicsofthe COVID-19PandemicinIndia.arXiv.(2020) arxiv:2005.06286. doi:10.21203/rs.3.rs-27112/v1

13.NgobeniV,BreitenbachMC,AyeG.Technicalefficiency ofprovincialpublichealthcareinSouthAfrica. Cost EffectResourAllocat. (2020)18:3.doi:10.1186/s12962-0200199-y

theinclusionofundesirableoutputs.Themethodologythat wedevelopedcan,atanytime,bereplicatedasnewdata becomesavailableasthepandemicprogressesorwhennew pandemicsdevelop.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle/supplementarymaterial,furtherinquiriescanbe directedtothecorrespondingauthor/s.

AUTHORCONTRIBUTIONS

Allauthorslistedhavemadeasubstantial,directand intellectualcontributiontothework,andapprovedit forpublication.

14.CampanellaP,AzzoliniE,IzziA,PeloneF,DeMeoC,LaMiliaCD,etal. Hospitalefficiency:howtospendlessmaintainingquality. AnnIstSuper Sanita.(2017)53:46–53.doi:10.4415/ANN_17_01_10

15.AlhassanRK,Nketiah-AmponsahE,AkaziliJ,SpiekerN,ArhinfulDK,De WitTFR.Efficiencyofprivateandpublicprimaryhealthfacilitiesaccredited bythenationalhealthinsuranceauthorityinGhana. CostEffectResourAllocat. (2015)13:23.doi:10.1186/s12962-015-0050-z

16.JarjueG,NorNM,GhaniJA,JalilSH.Technicalefficiencyofsecondaryhealth careservicedeliveryintheGambia. IntJEconManag. (2015)9:25–43.

17.ChowdhuryH,ZelenyukV,WodchisW,LaporteA. Efficiencyand TechnologicalChangeinHealthCareServicesinOntario(No.WP082010) SchoolofEconomics,UniversityofQueensland(2010).Availableonlnieat: https://economics.uq.edu.au/files/5235/WP082010.pdf(accessedJanuary01, 2019).

18.GannonB.TestingforvariationintechnicalefficiencyofhospitalsinIreland. EconSocRev. (2005)36:273–94.

19.MarschallP,FlessaS.AssessingtheefficiencyofruralhealthcentresinBurkina Faso:anapplicationofdataenvelopmentanalysis. JPublicHealth.(2009) 17:87.doi:10.1007/s10389-008-0225-6

20.AkaziliJ,AdjuikM,Jehu-AppiahC,ZereE.Usingdataenvelopmentanalysis tomeasuretheextentoftechnicalefficiencyofpublichealthcentresinGhana. BMCIntHealthHumRights.(2008)8:11.doi:10.1186/1472-698X-8-11

21.MasiyeF.Investigatinghealthsystemperformance:anapplicationofdata envelopmentanalysistoZambianHospitals. BMCHealthServRes. (2007) 7:58.doi:10.1186/1472-6963-7-58

22.ZereE,MbeeliT,ShangulaK,MandlhateC,MutiruaK,TjivambiB, etal.Technicalefficiencyofdistricthospitals:evidencefromNamibia usingdataenvelopmentanalysis. CostEffectResourAllocat. (2006)4:1. doi:10.1186/1478-7547-4-5

23.KirigiaJM,SamboLG,ScheelH.Technicalefficiencyofpublicclinicsin Kwazulu-NatalProvinceofSouthAfrica. EastAfrMedJ. (2001)78:1–14. doi:10.4314/eamj.v78i3.9070

24.KirigiaJM,LamboE,SamboLG.ArepublichospitalsinKwaZulu-Natal ProvinceofSouthAfricatechnicallyefficient? AfrJHealthSci. (2000)7:25.

25.LiuJS,LuLYY,LuWM,LinBJY.AsurveyofDEAapplications. OMEGA. (2013)41:893–902.doi:10.1016/j.omega.2012.11.004

26.BhatVN.Institutionalarrangementsandefficiencyofhealthcaredelivery systems. EurJHealthEcon. (2005)50:215–22.doi:10.1007/s10198-0050294-1

27.LoStortoC,GoncharukAG.Efficiencyvs.effectiveness:abenchmarking studyoneuropeanhealthcaresystems. EconSociol. (2017)10:102–15. doi:10.14254/2071-789X.2017/10-3/8

28.AfonsoA,StAubynM.Relativeefficiencyofhealthprovision:ADEA approachwithnon-discretionaryinputs.In: ISEG-UTLEconomicsWorking Paper (2006).

29.DeCosPH,Moral-BenitoE.Determinantsofhealth-systemefficiency: evidencefromOECDcountries. IntJHealthCareFinanceEcon. (2014) 14:69–93.doi:10.1007/s10754-013-9140-7

30.HadadS,HadadY,Simon-TuvalT.Determinantsofhealthcaresystem’s efficiencyinOECDcountries. EurJHealthEcon. (2013)14:253–65. doi:10.1007/s10198-011-0366-3

31.KimY,KangM. TheMeasurementofHealthCareSystemEfficiency:CrosscountryComparisonbyGeographicalRegion.(2014).Availableonlineat: http://s-space.snu.ac.kr/bitstream/10371/91911/1/02_Younhee_Kim.pdf (accessedJanuary01,2019).

32.GonzálezE,CárcabaA,VenturaJ.Valueefficiencyanalysisofhealth systems:doespublicfinancingplayarole? JPublicHealth.(2010)18:337–50. doi:10.1007/s10389-009-0311-4

33.SantosSP,AmadoCAE,SantosMF.Assessingtheefficiencyofmotherto-childHIVpreventioninlow-andmiddle-incomecountriesusing dataenvelopmentanalysis. HealthCareManagSci. (2012)15:206–22. doi:10.1007/s10729-012-9196-9

34.ShirouyehzadH,JouzdaniJ,Khodadadi-KarimvandM.Fightagainst COVID-19:aglobalefficiencyevaluationbasedoncontagioncontrol andmedicaltreatment. JApplResIndustEng. (2020)7:109–20. doi:10.22105/JARIE.2020.225087.1146

35.GavurovaB,KocisovaK,BelasL,KrajcikV.Relativeefficiencyof governmentexpenditureonsecondaryeducation. JIntStud.(2017)10:329–43.doi:10.14254/2071-8330.2017/10-2/23

36.CooperWW,SeifordLM,ToneK. DataEnvelopmentAnalysis:A ComprehensiveTextwithModels,Applications,ReferencesandDEA-Solver Software.NewYork,NY:Springer(2007).

37.McWilliamsA,SiegelD,VanFleetDD.Scholarlyjournalsasproducers ofknowledge:theoryandempiricalevidencebasedondataenvelopment analysis. OrgResMethods.(2005)8:185–201.doi:10.1177/10944281052 75377

38.AristovnikA. TheImpactofICTonEducationalPerformanceanditsEfficiency inSelectedEUandOECDCountries:ANon-ParametricAnalysis.Elsevier (2012).

39.MarticM,NovakovicM,BaggiaA.Dataenvelopmentanalysisbasicmodelsandtheirutilization. Organizacija.(2009)42:37–43. doi:10.2478/v10051-009-0001-6

40.YouS,YanH.AnewapproachinmodelingundesirableoutputinDEAmodel. JOperatResSoc.(2011)62:2146–56.doi:10.1057/jors.2011.1

41.TaylorB,HarrisG.Relativeefficiencyamongsouthafricanuniversities: adataenvelopmentanalysis. HigherEduc.(2004)47:73–89. doi:10.1023/B:HIGH.0000009805.98400.4d

42.JoumardI,AndréC,NicqC,ChatalO. HealthStatusDeterminants:Lifestyle, Environment,HealthCareResourcesandEfficiency.Elsevier(2008).

43.NakashimaK,NoseT,KuriyamaS.ANewapproachtoenvironmental performanceevaluation. IntJProdRes.(2006)44:4137–43. doi:10.1080/00207540600863522

44.HuaZ,BianY.DEAwithundesirablefactors.In:ZhuJ,CookWD, editors.ModellingDataIrregularitiesandStructuralComplexitiesinData EnvelopmentAnalysis.Boston,MA:SpringerScience(2007).p.103–21.

45.LuWM,LoSF.Abenchmark-learningroadmapforregional sustainabledevelopmentinChina. JOperatResSoc.(2007)58:841–9. doi:10.1057/palgrave.jors.2602229

46.LuWM,LoSF.Acloserlookattheeconomicenvironmentaldisparities forregionaldevelopmentinChina. EurJOperatRes.(2007)183:882–94. doi:10.1016/j.ejor.2006.10.027

47.DyckhoffH,AllenK.Measuringecologicalefficiencywithdata envelopmentanalysis(DEA). EurJOperatRes.(2001)132:312–25. doi:10.1016/S0377-2217(00)00154-5

48.GolanyB,RollY.AnapplicationprocedureforDEA. Omega. (1989)17:237–50.doi:10.1016/0305-0483(89)90029-7

49.SeifordLM,ZhuJ.Modellingundesirablefactorsinefficiencyevaluation. EurJOperatRes.(2002)142:16–20.doi:10.1016/S0377-2217(01) 00293-4

50.FäreR,GrosskopfS,LovellCAK,PasurkaC.Multilateralproductivity comparisonswhensomeoutputsareundesirable:anonparametricapproach. RevEconStat.(1989)71:90–8.doi:10.2307/1928055

51.ZhouP,AngBW,PohKL.Amathematicalprogrammingapproach toconstructingcompositeindicators. EcolEcon. (2007)62:291–7. doi:10.1016/j.ecolecon.2006.12.020

52.YangC,HsiaoC,YuM.Technicalefficiencyandimpactof environmentalregulationsinfarrow-to-finishswineproductionin Taiwan. AgricEcon. (2008)39:51–61.doi:10.1111/j.1574-0862.2008. 00314.x

53.StewartH,ProctorK,SiddiqueH. Johnson:ManyMorePeopleWillLoseLoved OnestoCoronavirus.(2020).Availableonlineat:https://www.theguardian. com/world/2020/mar/12/uk-moves-to-delay-phase-ofcoronavirus-~plan (accessedJune11,2020).

54.WattsJ. DelayisDeadly:WhatCovid-19TellUsAboutTacklingtheClimate Crisis.(2020).Availableonlineat:Governments-Coronavirus.https:// www.theguardian.com/commentisfree/2020/mar/24/covid-19-climatecrisis(accessedJune11,2020).

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021Breitenbach,NgobeniandAye.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice. Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththese terms.

APPENDIX

TABLEA1| Analyticalvariables andefficiencyscores.

Studied units ModelI ModelII ModelIII

DMU#CountryCRS efficiency score

VRS efficiency score

ScaleTypeof scale CRS efficiency score

VRS efficiency score

ScaleTypeof scale CRS efficiency score

VRS efficiency score

ScaleTypeof scale

1USA 0.120.180.67IRS 0.070.180.39IRS0.290.330.89DRS

2India 0.330.331.00 0.380.390.96DRS1.001.001.00–

3Brazil 0.831.000.83DRS 0.400.750.54IRS1.001.001.00–

4Russia 0.470.600.78IRS 0.370.600.62IRS0.180.640.29IRS

5France 0.030.270.11IRS 0.010.270.04IRS0.010.270.03IRS

6Spain 0.220.330.67IRS 0.110.330.33IRS0.070.340.19IRS

7Argentina0.330.331.00– 0.160.330.48IRS0.160.360.46IRS

8UK 0.200.300.67IRS 0.070.300.22IRS0.050.310.17IRS

9Columbia0.430.431.00DRS 0.220.430.50IRS0.160.450.34IRS

10Italy 0.150.330.44IRS 0.040.330.13IRS0.030.330.08IRS

11Mexico 0.670.770.87IRS 0.110.770.14IRS0.400.950.42IRS

12Peru 0.600.601.00– 0.210.600.35IRS0.150.620.24IRS

13SouthAfrica0.500.501.00– 0.300.500.61IRS0.130.540.24IRS

14Iran 0.260.330.78IRS 0.070.330.22IRS0.090.340.27IRS

15Germany0.180.270.67IRS 0.150.270.55IRS0.030.270.10IRS

16Poland 0.170.380.45IRS 0.150.380.41IRS0.030.380.07IRS

17Chile 0.671.000.67DRS 0.300.600.49IRS0.090.610.15IRS

18Iraq 0.600.601.00– 0.370.600.62IRS0.090.600.15IRS

19Belgium0.030.270.11IRS 0.010.270.03IRS0.000.270.01IRS

20Ukraine0.240.430.55IRS 0.160.430.36IRS0.030.430.07IRS

21Indonesia0.951.000.95IRS 0.441.000.44IRS0.231.000.23IRS

22Czechia0.290.430.67IRS 0.320.430.75IRS0.030.430.06IRS

23Bangladesh1.001.001.00– 1.001.001.00– 0.431.000.43IRS

24Netherlands0.180.270.67IRS 0.130.270.46IRS0.020.270.07IRS

25Philippines0.600.601.00– 0.460.600.77IRS0.080.600.14IRS

26Turkey 0.600.601.00– 0.270.600.45IRS0.050.600.09IRS

27SaudiArabia0.420.700.60DRS 0.330.400.83IRS0.040.380.10IRS

28Pakistan1.001.001.00– 0.821.000.82IRS0.161.000.16IRS

29Romania0.470.600.78IRS 0.230.600.38IRS0.030.600.05IRS

30Israel 0.420.500.83DRS 0.630.650.97IRS0.030.380.07IRS

31Canada0.270.300.89IRS 0.090.300.30IRS0.020.300.05IRS

32Morocco0.891.000.89IRS 0.881.000.88IRS0.021.000.02IRS

33Switzerland0.190.330.56IRS 0.190.330.58IRS0.010.330.03IRS

34Nepal 0.440.500.89IRS 1.001.001.00– 0.030.500.07IRS

35Portugal0.200.300.67IRS 0.160.300.52IRS0.010.300.02IRS

36Ecuador0.520.660.79DRS 0.100.460.21IRS0.050.460.11IRS

Mean 0.430.530.76 0.300.520.51 0.140.530.22 #ofefficientDMUs2 610 2 52 2 62 Basedondataenvelopmentanalysisefficiencycalculatedresults.

published:04June2021 doi:10.3389/fsoc.2021.638777

Editedby: DelaliA.Dovie, UniversityofGhana,Ghana

Reviewedby: HengLi, SouthwestUniversity,China

*Correspondence: LouSafra lou.safra@sciencespo.fr AnnabelleLever annabelle.lever@sciencespo.fr

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 07December2020 Accepted: 05May2021 Published: 04June2021

Citation: LeverAandSafraL(2021)Rethinking theEpidemiogenicPowerofModern WesternSocieties. Front.Sociol.6:638777. doi:10.3389/fsoc.2021.638777

RethinkingtheEpidemiogenicPower ofModernWesternSocieties

AnnabelleLever*andLouSafra*

SciencesPo CEVIPOF,CNRSUMR,Paris,France

Keywords:COVID-19,industrializedsocieties,epidemic,publichealth,non-pharmacologicalmeasures

INTRODUCTION

Inlessthanayear,COVID-19hasimposeditselfasoneofthemajorhealthcrisesinthehistoryof Westerndemocraciesalthough,aszoonoticdiseasesgo,itisnotespeciallydeadly,norareits symptomsespeciallyterrifying(HarvardHealth,2020; Ioannidis,2020).Facedwiththespreadof COVID-19,oneofthemostnoticeablereactionsofgovernmentshavebeentoimposelock-downs andimportantrestrictionsonfreedomofmovementandofassociation.Theseradicaldecisions causedsuchseverenegativeexternalities(unemployment,poverty,inequality,loneliness,anxiety, depression,violenceandthelossofschoolingformillionsofchildren)thattheycanonlybe temporary(Altman,2020; Arpinoetal.,2020; Banks,Karjalainen,andPropper2020; Benkeetal., 2020; Bonaccorsietal.,2020; Czymara2020; Green2020; Groveretal.,2020; Martinetal.,2020; Usheretal.,2020; Fountoulakisetal.,2021).Suchunparalleledrestraintsinpeace-timewere explicitlyconceivedastemporarymeasurestocontrol,ormitigate,thespreadoftheepidemicwhile waitingforaneffectiveandsafevaccinetobedeveloped(SeeforinstanceStellaKyriakides,EU commissionerforhealthandfoodsafety,declarationonApril2020 Day,2020).Evensofter measures,suchassocialdistancingandmask-wearing,wereseenasancillarytothemain weapon vaccination andtheassumptionwasthattheyhadnorelevancetohealthcarein “normal” times.

Thankstoanunprecededpharmacologicaleffort,thedevelopmentandroll-outofavarietyof safe,effectivevaccinesagainstCOVID19hasoccurred,offeringconcretemeanstoendthiscrisis (Zimmeretal.,2020).Nonetheless,thesepharmacologicalsolutionsshouldnotpreventthe considerationofthosefactors,endogenoustooursocieties,whichhelpedtocatalizethis pandemic.Indeed,thispaperargues,epidemicsreflectacombinationofexogenousand endogenousfactors.Attentiononlytotheformerrisksunderestimatingwhatwecall ’the epidemicogenic’ dimensionsofoursociety,attheriskofleavingusyetmorevulnerableto destructiveepidemicsinfuture.

ISSUESWITHPHARMACOLOGICALSOLUTIONS

TheEuropeanCommissionandtheWorldHealthOrganizationhavebothemphasizedthe importanceofensuringthatpharmacologicaltoolsagainstCovid-19aredeveloped collaborativelyandmadeaccessibletoallequally,inordertocounterthemedical,politicaland socialrisksofthepandemic(Riordan,2020; WorldHealthOrganization2020).Theyfear,rightly, thatotherwisescientificdevelopmentsonwhicheveryonedependswillbeinstrumentalizedbythose whoareabletomonopolisethem,andusedtoadvancesectarianpolitical,economicorideological agendas.Withincountries,notmerelyinternationally,differentialaccesstohealthcarecanbeusedto favoronesocialgroupsoverothers,andtodiscriminateonracial,religiousandethnicgrounds(asit hasalreadybeenthecaseforfooddistribution(TheNewHumanitarian,2002)andtheinternational contextmakessuchproblemspossible,ifnotprobable.InJuly,already,Putinannouncedthe

FrontiersinSociology|www.frontiersin.org

developmentofasafevaccineagainstCOVID-19byRussia (OfficialwebsitevaccineagainstcoronavirusSputnikV,2020). ThisannouncementplacesRussiaasaleaderintechnological developmentwithallitspotentialconsequences,includingthe militaryones.Thenameofthevaccineitself,SputnikV,reveals thereputational,diplomaticandpoliticalintentionsbehindthe announcement.

Besidesthesepoliticalandethicalconsiderations,thelongtermconsequencesofrelyingonpharmacologicalsolutionsfor epidemicsarenotpromising;scientistshaveindicatedthat pandemicsmaybemoreandmorefrequentinthefuture,due totheerosionofnaturalhabitatsexacerbatedbyglobalwarming, agriculturalintensificationandurbanareasextension(Dasgupta andAndersen2020; Epstein,2000; International,2020; Madhav etal.,2017).Specifically,bycausinganaveragetemperaturerise andincreasingcontactbetweenhumans,livestockandwildlife, thesepracticescreatetheidealconditionsforthedevelopment andspreadofzoonoticdiseases.However,vaccines,intheir nature,aredisease-speci fic,andthusaninefficientwayof protectingglobalpublichealth.Successfulvaccinesforglobal healththreatsofanyseverityandscalerequirethededicationof colossaldisease-specificresources,aswehaveseen,withthereal possibilityofextensiverestrictionsoncivillibertyinthe meantime.Considerableemphasishasbeenputonthe economicandmentalhealthconsequencesoftheCOVID-19 pandemic,butlittleattentionuntilnowhasbeenpaidtothe consequencesofmassdeathsforfamiliesandthegenerational balanceamongpopulations,althoughasknowfromtheHIV epidemicinAfrica,thesecanbesevere.Moreover,the psychologicaleffectsofacuteexposuretotheriskofinfectious diseasehavesignificantpoliticalandsocialconsequencesin themselves.Epidemicstendtoproducexenophobic scapegoatingandhostilityto ‘outsiders’ (Clissoldetal.,2020; Schaller,2011; White,2020) inthiscase,Asiancommunitiesin theWesthavebornethebruntofthathostilitysinceSpring2020. Suchempiricallyobservabletendenciesappearalsoin experimentalpsychologyresearch,whichshowsthatrealor perceivedexposuretoathreateningpathogenincreasesracist andxenophobicattitudesintestparticipants(Aarøeetal,2017; Faulkneretal.,2004; Millar,Fink-Armold,andLovitt2020).So insteadoflookingformadetomeasure,post-hoc,solutionsto eachlarge-scaleepidemic,itiscrucialto findwaystoprevent themand,wherethatisimpossible,tominimizetheirseverity.

DISEASESASEXTERNALENEMIES:THE EXOGENOUSDIALECTIC

Mainstreampoliticaldiscoursepresentsepidemicsasanexternal enemyandepidemicpreventionasaprocessofrepellingthis externalthreat.EmmanuelMacron’sreferencetowartime,inhis speechannouncingtheFrance’slockdowninMarch2020 exemplifiedthephenomenon(Macron,2020).The representationofepidemicsassomethingexternal fits naturallywithintuitiveWesternimagesofdiseaseasanalien threattothebody.Pathogenswormtheirwayintothepopulation andcauseanepidemicinjustthesamewaythattheyinsinuate

themselvesintoindividualbodiesandcausedisease(Napier, 2020).AlthoughwidelysharedinWesternsocieties,thisview isfarfromuniversal.Forexample,theBalineseviewofimmunity isbasedmoreontheideathathumansplayanactiveroleinthe circulationofvirusesthanontheideathattheyareexternal threatstotheself(Napier,2020).Importantly,theexogenous representationadoptedbyWesternersfacestwoproblems.First, itignoresthefactthatacuteinfectionsoftengiverisetochronic illnessand,evenwhencured,candamageone’sabilityto fight furtherinfectionsinfuturesomeillnesses,canleaveone vulnerabletonewinfectionsoverthelongterm,aswellasto thechronicillnessoveralifetimewhichacuteinfectionsoften entail,(e.g. Bonaccorsietal.,2020; Musher,Abers,andCorralesMedina2019; Sejvar,2007; Xiongetal.,2020).Inthecaseof COVID-19,specifically,anincreasingnumberofincapacitating long-termpathologieshavebeennotedbythemedical community,anditisquitepossiblethatthefullrangeoflongtermdamagefromCOVID19hasnotyetbeenappreciated (Carfì,Bernabei,andBermpohl; CDC2020; Fraser,2020). However,thesecondmainproblemwiththeideathatdisease, andparticularlyepidemics,canbeadequatelyconceptualizedas anexternalthreattoanotherwisehealthybody/societyisthatthis ignoresthesocialconditionsthatmakeepidemicspossible,and whichhelptodeterminewhowillsuffermostfromthem.

TheexponentialspreadofCOVID-19inWesterncountries, therefore,forcesustoconsiderthecausalroleofourstructuring institutions,habitsandnormsinturningwhatmighthavebeena relativelycontaineddiseaseintoanepidemicthathadhitusfull forcebyMarch2020.Indeed,inAutumnasinSpring2020,most Westerncountriesexperiencedexponentialrisesinthenumberof COVID-19cases(Roseretal.,2020).Thusevenifthisparticular epidemicemergedfromChina,andwasmadeworsebythe persecutionofjournalistsanddoctorsthere,(e.g. Waterson, 2021),Westernsocietieshaveclearlyplayedaroleinits propagationanddevelopment inpart,throughtheir reluctancetoacceptthattheepidemiccouldbecontrolled withoutaccesstoavaccine,asseemslargelytohavehappened inSouthEastAsia(AnandTang2020).As Ludovicetal.(2020) havehighlighted,integrationintoaglobalizedmarketeconomy hasbeenoneofthedriversoftheCOVID-19pandemic.Indeed, countrieswithhigherlevelsoftradealsoexperiencedahigher numberofCOVID-19casesinapril2020.Whiletheincreased circulationofpeoplebetweencountriesisundoubtedlyafactorin thisassociation,thequestionarisesastowhetherthiseffecthas notalsobeenmediatedbytheverystructureofmodernWestern societies.

THESTRUCTUREOFWESTERNMODERN SOCIETIESASEPIDEMICACCELERATORS

SignificantoutbreaksofCovid-19inslaughterhousesthroughout Europe(Académienationalede )haveremindedusofthe importanceofhealthyworkingandlivingconditionsin containinglethalepidemics,suchas tuberculosis,diptheria, andmeasleslongbeforetherewasavaccineforthem,or,as inthecaseofcholera,incontrollingdiseasesforwhichthereisno

vaccine(Porter,2005).Slaughterhousesarepoorlyventilatedand crowdedworkplacesandtheiremployeesoftensharecramped, unsanitaryhousingconditionsaswell.Whereastheimportance ofadequateventilationhasonlyrecentlybeenstressedasan essentialtoolincontrollingthespreadofCOVID-19(Connolly, 2020),itsimportancetothecontrolof tuberculosis wasknown sincethelate19thcentury(DubosandDubos,1987).More recently,theimportanceoffreshairandsanitaryconditionsto thehealthofnon-humananimalswashighlightedbytheroleof intensivelivestockfarminginthespreadofzoonoticdiseases. Intensivepoultryfarmssuffermorefromthedevelopmentof coccidiosis,apotentialfataldiseaseforchickens,duetotheovercrowdingofanimals(TewariandMaharana2011),and “madcow disease’”—lesscolloquiallyknownasBovineSpongiform Encephalopathy isthoughttohavearisenasaresultof feedingintensivelyfarmedcattlewithmeat-and-bone-meal (ColchesterandColchester2005).Itshumanform, Creutzfeldt-Jakobdiseaseisthoughttohavebeentransmitted byeatingcontaminatedcattle.Inshort,theimportanceoffresh air,lowdensityhousing,safedrinkingwater,foodsafetyand effectivewastecollectionwereallkeytothecontrolofepidemics beforetheadventofmoderntreatmentsforthem.However,it seemsthatrepeatedzoonoticepidemicsarenecessarytoremind usoftheircontinuingrelevancenowadays.

Acriticallookattheorganizationofmanyindustrialized societieshighlightsthecontrastbetweenclassicpublichealth measures,andcurrentwaysoflivinginoursocieties,withtheir highpopulationdensity,constantpopulationmovementsand life,workandtravelinlowventilationindoorareas.Evenin hospitalsanddoctors’ officesfreshaircanbehardtocomeby,and intheUnitedStates,notoriously,oneisnotsupposedtoopen windowsbecausecentralizedheatingandairconditioningmean thatthisotherwiseinnocentgesturerisksover-heatingorfreezing haplessco-workerselsewhereinthebuilding.

Moreover,thesocialorganizationofcontemporary industrializedsocietiesappearsatoddswiththeprimary principlesofpublichealth.While “caseisolation” hasbeen oneofthecentralelementsofthestrategyoftheWorld HealthOrganizationformanagingCOVID-19epidemic,this principlecannotbeimplementedgiventhecurrentconstraints onworkplaceorganization.Inadditiontothestatutoryand economicconstraintsonsickleave,suchastheexistenceof unpaiddaysduringpaidsickleave,Westernsocieties,createa moralandreputationalincentivetowork,evenwhenfeeling unwell,becauseoftheimportancethattheyattachtobeing “productive.” Moreover,healthinsuranceforcattleandcrops, aswellasforpeople,aregenerallyavailableonlyatsignificant personalcost,althoughifwidelyusedtheywouldpromotean importantpublicgood:therapidsharingofreliableinformation aboutinfectionsbeforetheybecomeepidemics.Assuch, industrializedsocietiesunitethematerialandpsychological characteristicsthatspreaddisease.Thissocialorganizationis atoddswiththenaturalbehaviorindividualsadoptwhen threatenedwithdisease.Psychologicalstudiesinexperimental settingsshowthatindividualstendtoavoidcontactwith potentiallyinfectiousindividuals(SchallerandPark2011; Park,VanLeeuwen,andChochorelou2013; Blackerand

LoBue2016).Suchindividuallyandcollectivelybeneficial behavior,unfortunately,ishardtoadoptinsocietieswhere peopleareforcedtoworkinclosecontactwithothers,andto commuteusingovercrowdedpublictransport.

UNDERSTANDINGTHEROOTSOFTHE EPIDEMIOGENICPOWEROFWESTERN SOCIETIES

However,ifthefactorsthatcontributetoepidemicsarewellknownand,inasense,partoffolkknowledge,wecanwonder whyindustrializedsocietiesaredesignedthewaytheyare.The riseofaproductivityandgrowth-centeredeconomysincethe SecondWorldWarisanimportantfactor.Twootherfactorsalso strikeusasessentialtocurrentvulnerabilitiestoepidemics, thoughsofar,theyhavenotreceivedattention.The first,is thecompartimentalizationofsociety,suchthatproblemsof humanhealtharelargelyseparatedfromthehealthofnonhumananimals,pollutionandthedesignofourphysicaland socialenvironment.Notonlydoesthismakeitdifficultto recognizechangesinpublichealthwhicharerelevantto epidemics,asinthecaseofpollution(FattoriniandRegoli 2020; Fronteraetal.,2020; Travaglioetal.,2021),butitmakes ithardertointegrateknowledgeacrosspublicpolicyareas.

Second,withthesuccessfuldevelopmentofvaccinesand antibioticssincetheSecondWorldWar,diseasessuchas diptheria,measles, tuberculosis,poliohavebecomedistant threatsformanyofus,ratherthanomnipresentthreatsto familiesand,especially,totheirmostvulnerablemembers. vulnerablemembers.Althoughthe21stcenturyisnotexempt fromlife-threateningtransmissiblediseases,inmost industrializedcountriesthesemainlyconcernspecific “at-risk” populationsratherthaneveryone:olderpeoplefortheseasonal flu,LGBTcommunitiesanddrugaddictsforAIDS,prisonersand deprivedurbanpopulationsfor tuberculosis.Inotherwords,mass infectiousdiseaseshavebecomelessandlessofaconcernfor publicpoliciesinmostcountries,andoutbreaksarepublicly treatedasisolatedandexceptionalevents.Inthiscontext,public healthprinciplesareincreasinglyignoredinthedevelopmentof contemporarysocieties,pavingthepathfortheexponential spreadofepidemics.

CONCLUSION

Inthispaper,wehighlightthestructural,epidemiogenicfactorsin industrializedsocietiesthatcontributetothedevelopment, intensificationandspreadofepidemics.Whilethesefactors aregenerallyacknowledgedwhendealingwithepidemicsin non-humanspecies,theirsignificanceforhumanswasonly slowlyrecognizedintheearlystagesoftheCOVID-19 pandemic.Reconsideringthestructuralfactorsthatplaceour societiesonacollisioncoursewiththemostbasiclessonsofpublic healthistheonlywaytodesignlong-termsolutionstocurrent epidemics,andtopreventfurtheronesinfuture.Recognizingand changingthosefactorsis,also,theonlywaytocombatthesocially

inegalitarianpatternsofriskandillness,whichCOVID-19has laidbare(Wolffandde-Shalit,2007; WilkinsonandKate,2009). Crowded,unsanitaryhousing;poorlyventilatedanddilapidated schools;poorlypaidwork,withnoentitlementtosickleaveor parentalleave,meansthattheburdensofCOVID-19fallhardest onsociallyvulnerablegroupswho,toooften,aretheoffspringof parentsandgrandparentswho,themselves,suffered discrimination,exploitationandneglect(Pateletal.,2020).In short,recognizingandcorrectingtheendogenousdeterminants

REFERENCES

Aarøe,L.,Petersen,M.B.,andArceneaux,K.(2017).TheBehavioralImmune SystemShapesPoliticalIntuitions:WhyandHowIndividualDifferencesin DisgustSensitivityUnderlieOppositiontoImmigration. Am.Polit.Sci.Rev. 111 (2),277 294.doi:10.1017/S0003055416000770

Académienationaledemédecine(2020). Slaughterhouses:AMajorTarget forCovid-19Prevention.Retrieved:https://www.academie-medecine.fr/ communique-de-lacademie-nationale-de-medecine-et-de-lacademie-veterinairede-france-les-abattoirs-une-cible-majeure-pour-la-prevention-de-la-covid-19/ ?lang en(AccessedDecember2,2020).

Altman,M.(2020).SmartThinking,LockdownandCovid-19:Implicationsfor PublicPolicy. J.Behav.Econ.Pol. 4(COVID-19SpecialIssue),12.

An,B.Y.,andTang,S.-Y.(2020).LessonsfromCOVID-19ResponsesinEastAsia: InstitutionalInfrastructureandEnduringPolicyInstruments. Am.Rev.Public Adm. 50(6 7),790 800.doi:10.1177/0275074020943707

Arpino,B.,Pasqualini,M.,Bordone,V.,andSolé-Auró,A.(2020).OlderPeople’ s NonphysicalContactsandDepressionduringtheCOVID-19Lockdown. The Gerontologist 61,176 186.doi:10.1093/geront/gnaa144

Banks,J.,Karjalainen,H.,andPropper,C..(2020).RecessionsandHealth:The Long-TermHealthConsequencesofResponsestotheCoronavirus*. Fiscal Stud. 41(2),337 344.doi:10.1111/1475-5890.12230

Benke,C.,Autenrieth,L.K.,Asselmann,E.,andPané-Farré,C.A.(2020). Lockdown,QuarantineMeasures,andSocialDistancing:Associationswith Depression,AnxietyandDistressattheBeginningoftheCOVID-19Pandemic AmongAdultsfromGermany. PsychiatryRes. 293,113462.doi:10.1016/j. psychres.2020.113462

Blacker,K.-A.,andLoBue,V.(2016).BehavioralAvoidanceofContagionin Childhood. J.Exp.ChildPsychol. 143,162 170.doi:10.1016/j.jecp.2015.09.033

Bonaccorsi,G.,Pierri,F.,Cinelli,M.,Flori,A.,Galeazzi,A.,Porcelli,F.,etal.(2020). EconomicandSocialConsequencesofHumanMobilityRestrictionsunder COVID-19. Proc.Natl.Acad.Sci.USA 117(27),15530 15535.doi:10.1073/ pnas.2007658117

Carfì,A.,Bernabei,R.,andLandi,F.(2020).PersistentSymptomsinPatientsafter AcuteCOVID-19. JAMA 324(6),603 605.doi:10.1001/jama.2020.12603

CDC(2020). CoronavirusDisease2019(COVID-19).Atlanta,GA:Centersfor DiseaseControlandPrevention.Retrieved:https://www.cdc.gov/coronavirus/ 2019-ncov/long-term-effects.html(AccessedDecember2,2020).

Clissold,E.,Nylander,D.,Watson,C.,andVentriglio,A.(2020).Pandemicsand Prejudice. Int.J.Soc.Psychiatry 66(5),421 423.doi:10.1177/ 0020764020937873

Colchester,A.C.,andColchester,N.T.(2005).TheOriginofBovineSpongiform Encephalopathy:TheHumanPrionDiseaseHypothesis. TheLancet 366(9488), 856 861.doi:10.1016/S0140-6736(05)67218-2

Connolly,K.(2020). GermansEmbraceFreshAirtoWardoffCoronavirus London,UnitedKingdom:TheGuardian.Retrieved.doi:10.1515/ 9780822393511https://www.theguardian.com/world/2020/sep/30/germansembrace-fresh-air-to-ward-off-coronavirus(AccessedDecember2,2020).

Czymara,C.S.(2020). CauseforConcerns:GenderInequalityinExperiencingthe COVID-19LockdowninGermany.London,UnitedKingdom:European Societies,15.

Dasgupta,P.,andAndersen,I.(2020). ‘ CoronavirusShowsWeMustChange OurEconomytoRecognisethatHumanWealthDependsonNature ’ sHealth ’ Lo ndon,UnitedK ingdo m:TheIndependent.Retrieved:https://www.

ofepidemicsisnotsimplyamatterofprudence,orofwisepublic policy.Itisalsoamatterofjustice,andofourdutyforfuture generations.

AUTHORCONTRIBUTIONS

ALandLSequallycontributedtotheconceptionandthe redactionofthemanuscript.

independent.co.uk/news/business/an alysis-and-features/biodiversityeconomy-coronavirus-covid-19-d asgupta-review-a9550156.html#gsc. tab 0(AccessedDecember2,2020). Day,M.(2020).Covid-19:EuropeanOfficialsWarnthatExitingLockdownWillBe “veryLong” andWillRequireCooperation. BMJ 369,m1549.doi:10.1136/bmj. m1549 Dubos,R.,andDubos,J.(1987). TheWhitePlague:Tuberculosis,Man,andSociety RutgersUniversityPress.

Epstein,P.R.(2000).IsGlobalWarmingHarmfultoHealth?. Sci.Am. 283(2), 50 57.doi:10.1038/scientificamerican0800-50

Fattorini,D.,andRegoli,F.(2020).RoleoftheChronicAirPollutionLevelsinthe Covid-19OutbreakRiskinItaly. Environ.Pollut. 264,114732.doi:10.1016/j. envpol.2020.114732

Faulkner,J.,Schaller,M.,Park,J.H.,andDuncan,L.A.(2004).EvolvedDiseaseAvoidanceMechanismsandContemporaryXenophobicAttitudes. Group Process.IntergroupRelations 7(4),333 353.doi:10.1177/1368430204046142

Fountoulakis,K.N.,Apostolidou,M.K.,Atsiova,M.B.,Filippidou,A.K.,Gousiou, D.S.,Katsara,A.R.,etal.(2021).Self-ReportedChangesinAnxiety,Depression andSuicidalityduringtheCOVID-19LockdowninGreece. J.AffectiveDisord. 279,624 629.doi:10.1016/j.jad.2020.10.061

Fraser,E.(2020).LongTermRespiratoryComplicationsofCovid-19. BMJ 370, m3001.doi:10.1136/bmj.m3001

Frontera,A.,Cianfanelli,L.,Vlachos,K.,Landoni,G.,andCremona,G.(2020). SevereAirPollutionLinkstoHigherMortalityinCOVID-19Patients:The “Double-Hit” Hypothesis. J.Infect. 81(2),255 259.doi:10.1016/j.jinf.2020. 05.031

Green,F.(2020). SchoolworkinLockdown:NewEvidenceontheEpidemicof EducationalPoverty.Colchester,UnitedKingdom:LLAKESResearch Paper,24.

Grover,S.,Sahoo,S.,Mehra,A.,Avasthi,A.,Tripathi,A.,Subramanyan,A.,etal. (2020).PsychologicalImpactofCOVID-19Lockdown:AnOnlineSurveyfrom India. IndianJ.Psychiatry 62(4),354.doi:10.4103/psychiatry. IndianJPsychiatry_427_20

HarvardHealth(2020). ‘COVID-19Basics’.Boston,MA:HarvardHealth. Retrieved:https://www.health.harvard.edu/diseases-and-conditions/covid-19basics(AccessedDecember3,2020).

International,W.W.F.(2020). ‘ProtectNature:PreventPandemics’.Gland, Switzerland:WWF.Retrieved:https://explore.panda.org/for-nature-for-us (AccessedDecember2,2020).

Ioannidis,J.(2020). TheInfectionFatalityRateofCOVID-19Inferredfrom SeroprevalenceData.Preprint.Stanford,CA:InfectiousDiseases(except HIV/AIDS).

Ludovic,J.,Bourdin,S.,Nadou,F.,andNoiret,G.(2020). EconomicGlobalization andtheCOVID-19Pandemic:GlobalSpreadandInequalities.Geneva, Switzerland:WorldHealthOrgan.

Macron,E.(2020). AdresseAuxFrançais,16mars2020.Paris,France:elysee.fr. Retrieved:https://www.elysee.fr/emmanuel-macron/2020/03/16/adresseaux-francais-covid19(AccessedDecember3,2020).

Madhav,N.,Oppenheim,B.,Gallivan,M.,Mulembakani,P.,Rubin,E.,and Wolfe,N.(2017). P a nd e m i c s:Risks,Impacts,andMitigation .Washington, DC:TheInternationalBankforReconstructionandDevelopment/The WorldBank.

Martin,A.,Markhvida,M.,Hallegatte,S.,andWalsh,B.(2020).Socio-Economic ImpactsofCOVID-19onHouseholdConsumptionandPoverty. EconDisCliCha 4(3),453 479.doi:10.1007/s41885-020-00070-3

Millar,M.,Fink-Armold,A.,andLovitt,A.(2020).DiseaseSalienceEffectson DesireforAffiliationwithIn-GroupandOut-GroupMembers:Cognitiveand AffectiveMediators. Evol.Psychol. 18(3),147470492093070.doi:10.1177/ 1474704920930700

Musher,D.M.,Abers,M.S.,andCorrales-Medina,V.F.(2019).AcuteInfection andMyocardialInfarction. N.Engl.J.Med. 380(2),171 176.doi:10.1056/ NEJMra1808137

Napier,D.(2020). ‘Nosconceptionsdesmaladiessontculturellementconstruites’ Paris,France:AOCmedia AnalyseOpinionCritique.Retrieved:https://aoc. media/entretien/2020/06/05/david-napier-nos-conceptions-desmaladies-sont-culturellement-construites/(AccessedDecember2,2020).

OfficialwebsitevaccineagainstcoronavirusSputnikV(2020). SputnikV theFirst RegisteredVaccineagainstCOVID-19.Retrieved:https://sputnikvaccine.com/ (AccessedDecember2,2020).

Park,J.H.,VanLeeuwen,F.,andChochorelou,Y.(2013).Disease-Avoidance ProcessesandStigmatization:CuesofSubstandardHealthArouseHeightened DiscomfortwithPhysicalContact. J.Soc.Psychol. 153(2),212 228.doi:10. 1080/00224545.2012.721812

Patel,J.A.,Nielsen,F.B.H.,Badiani,A.A.,Assi,S.,Unadkat,V.A.,Patel,B.,etal. (2020).Poverty,InequalityandCOVID-19:TheForgottenVulnerable. Public Health 183,110 111.doi:10.1016/j.puhe.2020.05.006

Porter,D.(2005). Health,CivilizationandtheState:AHistoryofPublicHealth fromAncienttoModernTimes .1sted.London,UnitedKingdom:Routledge. doi:10.4324/9780203980576

Riordan,L.(2020). ‘EUGlobalResponsetoCOVID-19’.Brussels,Belgium: InternationalCooperationandDevelopment EuropeanCommission. Retrieved:https://ec.europa.eu/international-partnerships/topics/eu-globalresponse-covid-19_fr(AccessedDecember2,2020).

Roser,M.,Ritchie,H.,Ortiz-Ospina,E.,andJoe,H.(2020). ‘CoronavirusPandemic (COVID-19)’.OurWorldinData.

Schaller,M.,andPark,J.H.(2011).TheBehavioralImmuneSystem(AndWhyit Matters). Curr.Dir.Psychol.Sci. 20(2),99 103.doi:10.1177/ 0963721411402596

Schaller,M.(2011).TheBehaviouralImmuneSystemandthePsychologyof HumanSociality. Phil.Trans.R.Soc.B 366(1583),3418 3426.doi:10.1098/rstb. 2011.0029

Sejvar,J.J.(2007).TheLong-TermOutcomesofHumanWestNileVirusInfection. Clin.Infect.Dis. 44(12),8.

Tewari,A.K.,andMaharana,B.R.(2011).ControlofPoultryCoccidiosis:Changing Trends. J.ParasitDis. 35(1),10 17.doi:10.1007/s12639-011-0034-7

TheNewHumanitarian(2002). ‘ViolenceandPoliticisationofFoodAidContinue’ Geneva,Switzerland:TheNewHumanitarian.Retrieved:https://www. thenewhumanitarian.org/fr/node/208471(AccessedDecember3,2020).

Travaglio,M.,Yu,Y.,Popovic,R.,Selley,L.,Leal,N.S.,andMartins,L.M.(2021). LinksbetweenAirPollutionandCOVID-19inEngland. Environ.Pollut. 268, 115859.doi:10.1016/j.envpol.2020.115859

Usher,K.,Bhullar,N.,Durkin,J.,Gyamfi, N.,andJackson,D.(2020). Family Violence andCOVID-19:IncreasedVulnerabilityandReducedOptionsfor Support. Int.J.Ment.HealthNurs 29(4):549 552.doi:10.1111/inm.12735

Waterson,J.(2021). ’OppressionofJournalistsinChina3mayHaveBeenFactorin CovidPandemic3.London,UnitedKingdom:TheGuardian.Retrieved:https:// www.theguardian.com/media/2021/apr/20/oppression-of-journalists-in-chinamay-have-been-factor-in-covid(AccessedApril20,2021).

White,A.I.R.(2020).HistoricalLinkages:EpidemicThreat,EconomicRisk,and Xenophobia. TheLancet 395(10232),1250 1251.doi:10.1016/S0140-6736(20) 30737-6

Wilkinson,R.D.,andKate,P.(2009). TheSpiritLevel:WhyMoreEqualSocieties AlmostAlwaysDoBetter.NewYork,NY,US:BloomsburyPublishing. Wolff,J.,andde-Shalit,A.(2007). Disadvantage.Oxford:OUP.doi:10.1093/acprof: oso/9780199278268.001.0001

WorldHealthOrganization(2020). FairAllocationMechanismforCOVID-19 VaccinesthroughtheCOVAXFacility.Retrievedhttps://www.who.int/ publications/m/item/fair-allocation-mechanism-for-covid-19-vaccines-throughthe-covax-facility(AccessedDecember2,2020).

Xiong,T.-Y.,Redwood,S.,Prendergast,B.,andChen,M.(2020).Coronaviruses andtheCardiovascularSystem:AcuteandLong-TermImplications. Eur.Heart J. 41(19),1798 1800.doi:10.1093/eurheartj/ehaa231

Zimmer,C.,Corum,J.,andSui-Lee,W.(2020). CoronavirusVaccineTracker.New York,NY:TheNewYorkTimes.doi:10.1051/978-2-7598-0305-7

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialor financialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021LeverandSafra.Thisisanopen-accessarticledistributedunder thetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse, distributionorreproductioninotherforumsispermitted,providedtheoriginal author(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublication inthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

REVIEW published:12July2021 doi:10.3389/fsoc.2021.647337

Editedby: AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

Reviewedby: KanakisLeledakis, PanteionUniversity,Greece LusyAsaAkhrani, UniversityofBrawijaya,Indonesia

*Correspondence: MohammadYaseenMir yaseencord36@gmail.com

Specialtysection: Thisarticlewassubmittedto SociologicalTheory, asectionofthejournal FrontiersinSociology

Received: 29December2020 Accepted: 24June2021 Published: 12July2021

Citation: HamidSandMirMY(2021)Global Agri-FoodSector:Challengesand OpportunitiesinCOVID-19Pandemic. Front.Sociol.6:647337. doi:10.3389/fsoc.2021.647337

andOpportunitiesinCOVID-19 Pandemic

SaimaHamid 1,2 andMohammadYaseenMir 1*

1CentreofResearchforDevelopment,UniversityofKashmir,Srinagar,India, 2DepartmentofEnvironmentalScience,Universityof Kashmir,Srinagar,India

COVID-19pandemichasbeencatastrophicforalmosteverythingincludingtheglobal economy.Amongmanysectors,thefoodandtheagriculturesectorwastheworsthit followingtheimmediatelockdownandmarketshutdowns.Thoughsomestabilitywas prevalentfromsupplysidetilldate,however,thesevererestrictionsputinplacetocurbthe spreadofpandemichaveendangeredthesupplyofagriculturalandfoodarticles contemporaneouslyacrossbordersandfrom fieldtofork.Whiletheincomedecline duetopricefallandsupplieschaindisruptionsduetopandemichaveescalatedthefood shortagesinseveralofdevelopinganddevelopedcountries.Neverthelesstheglobal demandforfooditemshasremainedmoreorlessunchangedowingtotheirinelastic demand.Evenwithinthegloballevel,thescenariooffoodsecurityandsupplychain stabilityhasbeensubstantiallydeplorableforemergingandlessdevelopingcountriesdue totheirlackofinsulationtotheglobalshocksorpandemics.Notably,thetechnological backwardness,excessiveknow-howdependenceanddeniedaccessibilityonseveral groundsleadtopovertyandfoodhungerinthesecountries.Atthepolicylevel,aholistic approachspecificallytargetedtowardsthedevelopingandlessdevelopedeconomiesis highlywarrantedtoensureanappreciableprogresstowardstheminimisationofsensitivity withregardtoagricultureandfoodsecurity.Apartfromthemeasurestoinsulatethemfrom globalshocks,additionalstepsneedtobetakentoalleviatetheirtechnological backwardnessanddeniedaccessibilityoncertainsocio-culturalnorms.

Keywords:globalpandemics,agriculturalcommodities,worldeconomy,routinedemands,underdeveloped nations,foodsecurity

INTRODUCTION

SARS-nCoV-2isanovelvirusknowntocauseCOVID-19diseasewhichisresponsibleto1.6million deathsinsixcontinentsoftheglobeasWorldHealthOrganization(WHO)declaredstateofhealth emergencyonMarch11,2020duetothispandemicdiseaseandsofarglobaltotalofcases71.6 millionareconfirmedtilldate(WHO,2020a; Hamidetal.,2020). WHO(2020a) issuedStrategic preparednessandresponseplantoimplementthemeasuresregardingcommunityparticipation, temporarytravelrestrictions,socialgatherings,closureofeducationalinstitutesandworkplaces. Workfromhomerecommendedforvarioussectorsbutitcannotbeappliedtofoodsectorthatneeds toworkintheirdailyroutine.Withregardstotheeconomy,thefoodindustryisaverysignificant fieldwhichislifesustainingthantherestofsectorslikeastourismandaviationafterapandemic,the foodindustryfacesvarioussetsofproblems.ThepandemiccouldleadtoanaviationlossofUS$113

billionandatourismindustrylossofUS$80billion(IATA,2020; FAOandWHO,2020).Preservingthewelfareoftheemployee andhavingenoughstaffinsteadofthosewhodonotchooseto workbecauseofpandemicremainedbigconcernsharedbyall foodcorporations.Inordertokeepfoodchainaliveitwas mandatoryforthemanagementtosupplyanddistributefood andtoworkoncontinuousmannerduringpandemics.Withthe contributionofallparties,themanagementofthedistributionof foodandservicesacrossthesupplychainshouldbeassured. Ensuringcustomerinterestisalsoimportantforfoodqualityand protection(UNTWO).Atthismomentofcrisis,food sustainabilityisrelatedtotheproximityofcustomerstofood ratherthanaccesstofood(OECD,2020d).Nostudyrevealsthat COVID-19hastodatebeenspreadthroughfoodintake,inview ofthelargesizeofthepandemic.HoweverinXinfandimarket, newinfectionshavebeenseenduetoprocessingofsalmon fishes whichcanbeinferredthattheriskofthevirusthatspreadby foodsislowerthantheperceivedrisk.SARS-CoV-2canbe dangeroussourceoffoodbornetransmissionwhiletaking considerationofitssurvivalinanumberofenvironments, suchasrubber,steelorcardboard,animaltissue(meat, fishor poultry).Foodbusinessoperators’ hygienecontrolsareintended toavoidfoodcontaminationbyanypathogenandwouldalsoaim topreventfoodcontaminationbytheCOVID-19virus (EuropeanCommission,2020a; FAO,2020b).Anycooking andeatinghabits,howevermaycontributetothereappearance ofcoronavirusfromanimalstohumans(Pressmanetal.,2020).

EffectsofPandemiconFoodSupplyChain

Agriculturalproduction,postharvesthandling,processing, distribution/retail/service,andconsumptioni.e., fieldtofork arethe5phasesofFoodsupplychain(FSC).Inthefood supplychain,twomechanismssurroundingfoodconsistency andprotectionareused.The firstisfocusedonrulesand legislationthatusecompulsoryrequirementsthatarereviewed bystatedepartments.Thesecondisfocusedonvoluntary principlesestablishedbybusinesslawsorinternational organisations(Rizouetal.,2020).AccordingtoRizouetal., (Pressmanetal.,2020),FSCinvolvescriticallaststageswhere peoplecangetinfectedeasily,henceforthesafehandling/ preparation/deliveryoffood,usingpersonalprotective equipmentssuchashelmetsandglove,sanitizationofsurfaces andworkingenvironments,eventhemaintenanceofsocial distancearesomeSafetymeasurestoensurethecontinuityof food flow.TheCOVID-19pandemicdoesnotspecificallyimpact development,unlikefootandmouthdisease,bird fluorListeria, sinceitdoesnotpropagatedirectlytoanimalsoragricultural products(RichardsandRickard,2020).Howeverasaresultofthe pandemic,policymakersaroundtheworldhaveplacedmajor limitsonthe flowofgoods(land,seaandairtransport)aswellas onlabormobility.Reportshaveindicatedthattheuseoffood deliveryvehicleshasreducedto60%aftertheconstraintsin Francewere30%beforethepandemic(IATA,2020; OECD, 2020c).Temporaryorseasonalsortofemploymentis commonindevelopingandunderdevelopedcountries, particularlywhenplanting,sorting,harvesting,refining,or transportingcropstomarkets.Therefore,duetothelackof

localortemporaryworkersduetoillnessortravelrestrictions enforcedbythelockdown,thesupplychainisgreatlyimpacted. Insituationswheretheillnessspecificallyimpactstheirhealthor activity,italsoweakensnotonlytheprocessingabilityofothers butalsotheirownfoodprotection(ILO,2020a).Thelackoflabor duetothepandemiccrisishasledtosignificantdisturbancesin certainindustries,suchaslivestockproduction,horticulture, planting,harvestingandcropprocessing,whicharerelatively laborintensive.Farmworkershortages,however,werealreadya significantconcernlongbeforetheCOVID-19epidemic(ILO, 2020b).The “PickforBritain” campaigninBritainwasplannedto locate70,000Britishworkinginthe fieldandthroughtheharvest (Dengetal.,2015).However,owingtothelackoflabordueto sicknessandthephysicaldistancetobesustainedduring production,thecrisisisweakeningtheopportunitytowork forfarmsandagriculturalundertakings.Theseconditions delayedthedeliveryofgrainandagriculturalinputsand produceddifficultieswiththecontinuedsupplyoffoodto markets(AuthorAnonymous,2020b).

EffectsofPandemiconGlobalFoodTrade

Whilethecurrentcircumstancesappearunprecedented,even beforetheCOVID-19crisis,foodsupplieswerevulnerableto climate-relatedanddisease-relatedissues.Foodmarketshave historicallybeenfragileduetonumerousincidentsandshocks, suchastheoilcrisisinthe1970s,theoutbreaksofSARSand Ebola,andthefoodcrisisfrom2006to2008.Onlyayearago, Africa’sSwineFeveroutbreakupsettheworldcommodity marketsandbecameaprogressiveepidemicinEasternEurope andAsia.Bytheendof2019,China,theworld’sbiggestpig manufacturer(1/3oftheglobalmarket)andlargestexporterhad lost37%ofitspigs(IPES,2020).IncertainAfricancountries,the production,marketing,andtradeeconomiesregarding agriculturewhereEbolacreatedhugedamages.Theongoing COVID-19crisishasmodifiedcertaingovernments’ food tradingpolicies,aimedatlimitingexportsandmakingimports simpler.Ensuringthepreservationofthenumberofgoodsinthe domesticmarketisthekeyreasonwhycountriesimplement exportrestrictions.Althoughthisoutcomeisusuallyproducedby anexportlimitationintheshortterm,itstillhassomenegative consequences.Banonexportresulteddomesticpricedropdueto whichfarmerseconomygothit via lowcropproductionand decreasedincentivesintheindustry.Aswellasexportcontrols leadtoareductionindomesticmarkets,triggeringa financial downturntoproducersandreducingbusinessincentives. Secondly,bylosingtheirpositiononforeignmarkets, countrieswouldlosetheireconomicedge.Thethird explanationisthatexportcontrolsdamagetheimageofthe exporterandallowimporterstodecreaseconfidenceintheglobal markets,thusreducingforeigntradingtrustandundermining potentialexportbusinessprospects(Espitiaetal.,2020).

ImpactonFoodProductionandDistribution

Inordertomonitortherateofinfection,mostnationshavetaken stepssuchashomeconfinement,travelrestrictionsandbusiness closure.Suchregulationshaveahugeeffectonthefooddeliveryat anypointofthefoodsupplychain.Itisestimatedthatworldtrade

ingoodswilldecreasefromCOVID-19by13 22%(FAO,2005). Differentareasofagriculturehavereceivedseriouspandemics, suchaswheat,livestockand fisheries.Withinadequateaccessto animalfeedandalackofwork,(WTO,2020),COVID-19in Chinahashadagreatereffectinlivestockproduction.Travelban haslimitedtheavailabilityofreproductivesuppliesofpoultryin manycountries.Prolongedrestrictionsontravelvanishedthe breedingstockandhatchingeggsasperreportsofThe InternationalPoultryCouncil(IPC)(Zhang,2020).Aswe knowthecheapsourceofproteinfor3millionpeoplethus accountingmorethan20%ofanimalproteinforthehuman consumption(Vorotnikov,2020).InvariouspartsofAsia,Africa andEurope,aquaculturesufferedhugelossesduetolabor shortage,inadequateinputsupplieswhentheothermain causesweresocialdistanceandlackoffeed(FAO,2020e). Farmersarerequiredtostoretheirunsoldproducefora longerperiodoftime,whichleadstoadecreaseinfood qualityaswellasariseinproductioncosts(FAO,2020e). COVID-19hasbeenstruckworstbythesupplyofmilkand dairyproducts.Afterasubstantialdeclineinmilkproductionand theclosingofthemilkmanufacturingbusiness,dairyfarmersare forcedtodumpmilkandmilkproducts.Dairyproducersin Americareportthatnearly4milliongallonsofmilkwerespilled everydaybyfarmersnationwide(Forstadt,2020).InNepal,2 billionNPRdairyproductshavebeendestroyedand5billion NPRdairyproductsinstoragetendtobeontheedgeof deterioration(NepaliSansar,2020).SincetheGreatRecession of1929tocurrentpandemicofcovd-19,worldissufferingfrom hugelossintermsofeconomy,socialandpsychologicalwhichset thecountriesonworstcrizesaccordingtoInternationalMonetary Fund(Marlow,2020)amongthepastepidemicsincludingthe 2002 2003SARS(SevereAcuteRespiratorySyndrome) epidemic;the2003NorthAmericanBSE(BovineSpongiform Encephalopathy)crisisandthe2003 2004H5N1avianinfluenza epidemic.Comparedto2019,a4.9%declineinglobalGross domesticproduct(GDP)hasbeenprojectedfor2020;the EuropeanUnion(10.2%,withpeaksforItalyandSpain,both 12.8%,andFrance,12.5%),theUnitedKingdom(10.2%),Canada (8.4%),andtheUnitedStatesareamongthemostsignificant economiesexperiencinglosses(8.0%).Inspiteofthefactthatthe coronavirusisextremelyinfectiousandthatanantidoteisnotyet availableonthemarket,theforcedshutdownofindustrialand businessoperationshascreatedchaosintheentireeconomic sector(CucinottaandVanelli,2020).Thepandemicwillshock thesupplyanddemandsidesofmarketdemand,many economistssay.Theformerappliestointerruptionsinthe provisionofgoodsandservices,whilethelatterreferstothe volumeofconsumptionandprocurementofproducts(OECD, 2020a).Standardfoodsupplychain(FSC)functionsareimpeded byCOVID-19includingfarmers,manufacturingplants, wholesalers,andretailers(ILO,2020a)formadiverseFSC. BreakdownsorbottlenecksinsomesectionoftheFSChave impactedothercomponentsupanddownthechainduringthe currentCOVID-19pandemic.The findingsofrecentanalyses haveshownthattheshockinthesupplyoflaborhasundergone thelargestdecrease(OECD,2020a; JohnsoandMuelle,2002), leadingtoinstabilityofthesupplychainanddumpingorwasteof

foodstuffsat fields.Thisinstabilityisduetotheabsenceofgrain harvesting,theaggregationoffarmgoods,andtheinterruptionof thedistributionnetwork(CucinottaandVanelli,2020).The shelvesofgrocerystores(supermarkets)wereoftenvacantasa resultofthisFSCdisturbance(alackofworkforceinpackaging andsellinggoodstoretailers),whichwasalsoattributedto hoardingandpanicbuying,whichinturncontributedtothe scarcityofessentialfoodstuffs(NepaliSansar,2020).Many policymakershavereducedthesellingandexportoffoodstuffs andboostedimportsofessentialproducts(CDC,2020a)toavoid suchashortage.Thelackofsupplyinretailstoresandthe growingdemandfromhouseholdshavehadasubstantial effectonthevolatilityofagriculturalproductprices(Cucinotta andVanelli,2020).Inthemeantime,amassivedemandshockhas beenreportedinthehotel,restaurant,andcatering(Ho.Re.Ca.) sectors,withabigeffectonthefoodsystem(CDC,2020b; WHO. HIV/AIDS,2020).Theglobalpandemicexpansionhasandwill continuetohaveanunparalleleddetrimentaleffecton householdsand firms ’ existingandfuturelivelihoods. Consumerconduct,asabuyingdecisionmechanism,isa behavioralprocess,asdescribedbyEngeletal.(Lopez-Ridaura etal.,2019),whichisobservedbeforeandafterpurchase.The actionofconsumersisverydynamic,requiringawidevarietyof activities, fromintaketodisposal(Zavatta, 2014). Several influencesincludingglobal,geographic,socialand demographicdiversity,aswellasconsumertastesand attitudes,whicharealloffeedintake(WorldBank,2019).

Agro-FoodConsumptionHabitsand Preferences

SincetheFSCandfoodsupplywereaffectedbytheeconomic crisisandtheoccurrenceoftheCOVID-19pandemic,manyhave resolvedthisdeviationfromnormalitybychangingtheirfood preferencereactionsandbehavior. Bree(2020) hasindicatedthat forminganewhabittypicallytakesapproximately3weeksto develop.Clearly,theCOVID-19crisislastedwelllongerthan 3weeks,butwhatbeganasatransitionincustomerbehaviorhas nowbecomeahabit.AccordingtotheEYFutureConsumer Indexby RogersandCosgrove(2020),28%ofcautiouslylavish consumers(25%ofthe4,859consumerssurveyedinthe UnitedStates,Canada,theUnitedKingdom,Franceand GermanyduringtheweekbeginningApril6,2020)will changetheireatinghabitsastheychangetheireatinghabits, accordingtotheEYFutureConsumerIndexbyRogersand Cosgrove(Hubbub,2020)ofthe fiveconsumersegmentstotake onprominenceastheCOVID-19crisiscanbesaidtohaveended. Sinceafterlockdownimplementationfrom16thMarch2020in UnitedKingdomchangedthecookingandeatingbehavior among90%ofarepresentativesampleof2,000adults surveyedasperresearchconductedbyHubbub(Datassential, 2020).Peopleremainedindoorsandspendlonghourstoprepare mealswhileenjoyingcookingathome(44%);and “sharing” virtualmealsoverZoom,Skype,Facetimeetc.,(40%)andwith neighbors(47%).Suchrecentlydiscovereddietarypatterns includebettermenupreparation,theuseofcupboardstaples, thefreezingoffood/mealsandtheincreaseduseofleftovers.As

FIGURE1| ImpactsonworldpricesonthebasisofPercentagedifferencefromthebaseline[Source: Ellebyetal.(2020)]. TABLE1| Showstheestimatedimpactsonglobalfoodpricesuntil2025on comparisonwithGDPbaselineshocks. Items202020212022202320242025Band(%)

Biodiesel 15.9 4.04.72.3 1.0 1.222.4 Butter 6.8 3.6 1.7 0.30.41.34.6

Skimmilkpowder 3.8 2.4 0.40.30.50.20.9 Rice 2.7 2.7 0.30.00.40.52.7 Wheat 3.2 4.9 2.6 0.40.70.73.9

Beefandveal 10.4 0.56.9 1.5 3.00.91.8

Vegetableoils 11.4 8.12.20.70.71.16.6

Poultry 7.0 4.20.7 0.30.51.13.2 Pork 17.64.77.2 4.3 0.82.93.7

Totalproteinmeal 4.7 7.5 1.72.51.6 0.54.5

perresearchconductedbyHubbub(Allen,2004)alsofoundthat manyindividualsdidnoteatasmuchfreshfruitandvegetablesas normal(31%),reducingtheirinteractionwithshops,whilesome alsodecreasedtheirmilk/eggconsumptionthroughoutthe lockdownera(15%)(Figure1).Shortagesandchallengesin obtainingstaplefoodingredientscausedmanytoattemptnew recipes(22%).Finally,therearesignsthattheseemerginghabits willpersistafterthelimitshavebeengreatlyremoved,albeittoa lesserdegree(Table1)(Ellebyetal.,2020).

GlobalGDPandPandemics

However,uncertaintyremainedastohowlongtheCOVID-19 recessionwilllastandwhatthemedium-termglobaleconomic effectswillbe.Itreliesonmanyfactors,includingagricultural commoditiesthataffectthesupplyanddemand.Theseinclude howfastmultinationalcompanieswillresorttolock-outs;whether secondarywaveswillcausepolicymakerstoimplementnewlockdownmeasures;howquicklytheSARS-CoV-2viruscanbe vaccinatedand/orsuccessfultreated,andhowanyofitaffects

markethabits.HowevertheCOVID-19effectontheirGDP estimatesalreadyrepresentsavarietyofglobaleconomic outlooks.TheprojectionsfortheglobalGDPreductionin2020 bytheIMF,WorldBankandOECDrangefrom3.0to7.5%and theforecastsfortheresultingglobalGDPrisein2021rangefrom 2.8to58%.(IMF,2020; WorldBank,2020a).TheInternational FoodPolicyResearchInstitute(IFPRI)forecaststhattheeconomic downturnin2020willincreasethenumberofpeoplelivingin severepovertybyawhopping20%or140millionpeople,resulting inexpandedfoodinsecurityinmanycountries,buildingonthe IMFprojection(Labordeetal.,2020).Incountriesdependenton seasonalmigrantworkersintheagro-foodindustry,asuddenloss ofmobilityacrossbordersandwithincountrieshastriggeredlabor shortages,whichinturnhasimpactedfoodsupplyandprices globally(Hernandezetal.,2020).Forexample,thepricesofsome mainstaplesinIndiaandinseveralAfricancountrieshave reportedlyrisenbymorethan15%frompre-COVID-19levels (OECD,2015).Thepandemichasalsoinfluencedtradeingoods by,forexampleadditionalbordercontrols,lackofshipmentsof freightandimprovedsanitarycontrols.Inaddition,thepandemic, analogoustothefoodcrisisof2007 2008,causedseveralcountries toenactexportbansinordertoprotecttheirdomesticcustomers (AuthorAnonymous,2020a).Thesetradefrictionsmayimpact globalfoodpricesaswell.TheOrganizationforEconomicCooperationandDevelopment(OECD)SecretariatandtheFoodand AgricultureOrganizationoftheUnitedNations(FAO)developed recursive-dynamicpartialequilibriummodelnamelyAglinkCosimowhichisanoutcomeoftheircollaboration(AraujoEncisoetal.,2015; EC.,2019).Inordertoprojectthebaseline forthemainagriculturalcommoditiesoverthemediumterm,this modelingapproachhasbeenusedtoproducetheOECD-FAOand EUMediumTermAgriculturalOutlooks(FAO.,2020f).Asingle scenario,augmentedbyEUfromthespring2020Economic PredictionbytheEuropeanCommission,isevaluatedbasedon

country-specificGDPgrowthprojectionsintheIMF,World EconomicOutlookdatabase(April2020).Thescenarioshocks aretheGDPgrowthratesexpectedbythe2020and2021,theGDP baselineandthe2021scenario.WebelievetheGDPscomebackto theircoreprinciplesfrom2022andbeyond.

GlobalImpacts

Astochastictheoreticalstudyhasbeenconductedonthe relationshipbetweenforeignoilpricesandtheagricultural productmarketsinadditiontothescenarioimpacts,expressed asarangeofpoint’sforecasts.Theagricultureandenergysectors areinterlinkedprimarilythroughtheoutputofbio-fuels(mainly mandated)andthecostofinput(e.g.,fertilisercosts).Atpresent, duetoamixtureofsupplyanddemandfactors,wearefacinga timeoflowoilprices.Asdiscussedbelow,however,foreignoil pricesinthemodelareexogenousandwehavenotmadeany conclusionsregardingtheirdivergencefromthebaselinetoretain astrictemphasisontheimpactofCOVID-19onproduction. Instead,basedonthehistoricalvolatilityofoilprices,wecalculate thejointdistributionofscenarioeffects,wherethevariation derivesfromalternateoilpriceprojections.Adecliningtrend hasbeenobservedforthepricesofvegetableoils,meatsandbiofuelsaswellassametrendwerefoundforagricultural commoditiesin2020.Oncomparisonwithbaselinedata,the priceswillbeunderneathin2021forsomelambandpork flesh. Theillustrationismoremixedfor2020,withthegrainsandbiofuelsaboveandbelowthebaseline.Allproductpricesarenear andclosetobaselinevaluesaswecometo2025.Untiltheendof the2030predictionera,thiswillcontinuetohappen.Mainly throughproductionofbio-fuels(managedtoasignificantdegree) andinputprices,agriculturalandenergymarketsinterconnect (e.g.,fertilisercosts).Atpresent,duetocombinedsupplyand demandconsiderations,wearefacedwithatimeoflowprice. Tradetiesinternationaleconomieswiththeglobaleconomy.Asa result,ariseininflationontheglobaleconomyisgenerallyoften responsibleforanincreaseininternalprices.

RecommendationstoMinimizetheEffectof Covid-19

TheoutbreakoftheCOVID-19severelyendangersfoodsecurity, nutritionandwelfare.The financialchaoscausedbythe pandemicriskstheaccesstofoodeconomicallyandphysically accessible.Disruptedmarketing,logisticsandcommercial networks,andpotentialproblemscouldlimitaccesstofoodin somepartsoftheworld(FAO,2020c).WorldFoodProgram studyhasindicatedthatby2020,COVID-19willincreasethe numberofindividualssufferingseriouspovertyto265million (WFP,2020a).AnotherresearchundertakenbyHeadeyetal. (WTF,2020a)foundthatCOVID-19contributestoariseof 14.3%intheincidenceoflackofhealthandsocialsecurityforlow ormiddle-incomechildrenundertheageof5yearsofage.

ActionsonGlobalTrade

Itisimportanttocontinuethemovementofagriculturalinputs betweencountries,eveninthecaseofquarantinerestrictionsor theclosureofborders.Actsshouldalsobetakenintheshortterm

toencouragetradeinagriculturalinputssuchasmachineryand fertilisers,astheseneedsareessentialforthesmoothcontinuityof plantingactivities(Headeyetal.,2020).Tradeandtaxpractises needtobediscussedtokeepfreetradeopen.Atthebeginningof theCOVID-19epidemic,someofthebigexportingcountries adoptedthe “beggarthyneighbor” approachthatrequires importercountriestocoverthecostsordangersofinsufficient supply.Thedistributionalconsequencesof “beggarthyneighbor” oftenincludefoodpricespikesandareductioninfoodsecurity (FAO,2020d).Countriesshouldalsoliftexportprohibitionsand importtaxesbecausethefoodpricescanbeavoidedbylowering importtariffsduetolowfoodsupply(Headeyetal.,2020).Asa result,theprotectionismoffoodtradingincludedvarioustypesof taxes,tariffs,non-tariffbarriersandrestrictions(Barichello, 2020).Howevertheintroductionofthesepolicieshasledtoa disparitybetweendemandandsupply,contributing,inthe mediumandlongterm,toasharpincreaseinglobalfood prices.Thereforethemostdisadvantagedgroupofthe remainingplayersinthesupplychainistheeconomically marginalizedclients.

SociologicalTheoriesforFoodSecurity

AttheendoftheColdWarandashakyglobalsurgein democracy,a floodofnewinformationtechnologiesthatbring theglobalcommunityclosertogetherandcontributetotherapid expansionofglobalization,theexplosionofaglobalHIV/AIDS pandemic,anda35%increaseintheworld’spopulationhaveall beenwitnessedbytheworld.Simultaneously,thereareconstants likeviolenceandwar,widespreadpovertyandinequality,and ongoingenvironmentalchallenges.Hungerpersistsinallofthis, andsociology’sroleinsolvingitrequiresfurtherandmore attention.AsperthereportsofFAO,(FoodandAgriculture OrganizationoftheUnitedNations,2008),and(FAO,2021),Less developedNationsarethehotspotwhichcomprisesofnearly96% oftheworld’stotalhungerpopulationasthese82nationshave beencategorized “low-incomefooddeficit” countrieswith chronicallypoor,netimportersoffoodandareproneto diseasesincludingcovid-19whiletheHotspotforhungerlies inSub-SaharanAfricaandSouthandSoutheastAsia.Children underage five,whoincludethehugemassoftheworld’sfood insecure,encompass18,000ofthe25,000peopleperdaywhodie ofhunger,addingtogethermorethan6.5millionperyear[U.N. (WorldFoodProgramme)].Foodinsecurityisdefinedby shortages,poverty,andsuffering,accordingto DeRoseetal., (1998).Foodinsecurityismostdirectlyconnectedtoinequality, withafocusondistributionandvariablesthataffectfoodaccess. Whenpeopleareunable “tosecuresufficientfoodtosatisfythe nutritionalneedsoftheirfamilymembersowingtoinsufficient income,limitedaccesstoproductiveresources,inabilitytobenefit fromprivateorgovernmentalfoodtransfers,orlackofother entitlementstofood,” theyaresaidtobeinfoodpoverty(Uvin andYverdon,1994).Thepresentglobalfoodcrisisduetocovid19pandemicisagoodillustrationofhowfoodinsecuritymay havefar-reachingconsequencesparticularlyforthepoorbutalso forpeoplewhoappeartobefoodsecuresuchasthoseinthe middleclasswhofeelthestingofrisingfoodprices.Food sovereignty,accordingto McMichael(2004),is “ a

community’sorcountry’ssocialrighttosetitsownpolicies surroundingfoodsecurity(enoughsupplyandacceptable cuisine)andthecultural,social,andecologicalcircumstances underwhichitissustained” (Menezes,2001).Foodinsecurityis asmuchafunctionofpoliticaleconomicsandtheglobal economicsystemasitisofpopulationandtechnology.Food insecurity’spersistenceunderscoresitsworldwiderelevance (Devereux,2007).Unlikepreviouscrizes,globalizationhas fosteredinterdependency,whereissuesinonepartofthe worldinfluencedifficultiesinanother.Thisisthesettingthat necessitatesanewsocialunderstandingoffoodsecurity/ insecurity.Asaresultofglobalization,governmentshave shiftedfromfeedingthemselvestoexportingcashcropstothe restoftheworld.Buyingfoodforconsumptioninthe “globalfood order” andbecomingnetfoodimportersonthemarket (Friedmann,1982).Inordertocompetewithglobalagribusiness,localmarketsandpricesaredisrupted,andpeasants whogrowcropsforlocaluseareevictedofftheirland.Ironically, manyofthepeoplewhocreatetheworld’sfoodsuppliesare hungrythemselves(Barkin,1982; McMichael,1995).InIndia,a shortageoflabor,storage,ortransportationchoicesresultedin lossesfor40%offarmerswhofacedaproductiondropinApril 2020.Smallandmarginalfarmersmadeuparound52%ofthe respondents,landlessfarmersmadeup6.7%,mediumfarmers madeup19.9%,andlargefarmersmadeup20.7%.Overhalfof thefarmersclaimedharvestingcostmorethisseasonthanthe previousseason,eithertoalackoflaborormachinery,ora greatercostofmachinery.Foodsecurity/insecurityispoliticalin termsofitstiestosocialmovementsandsocialtransformation,in additiontomacro-structural,globalpoliticaleconomyprocesses. Foodandhunger-relatedcollectiveactionhasawiderangeof applicationsincludingfoodriots(McMichael,2004)andfood justicemovements(WaltonandDavid,1994)inadditionto sustainability(Allen,2004; Wekerle,2004),cooperative(Buttel, 1997),foodsovereignty(DavidandMichael,2004),andlocal/ slowfoodsmovements(PetriniandGigi,2006; Schnell,2007). Thefreegansubculture,whichgleansfoodthathasbeenthrown away,includingdumpsterdivingasapoliticalact,drawsattention tofoodwasteandglobalconsumptionpatternsbygleaningfood thathasbeenthrownaway(EdwardsandMercer,2007).When manypeoplegohungry,freegans fighttheunfairnessof overconsumptionandinequity.Theactofeatingmayplainly bepolitical,andsociologyofpower,politics,andsocial movementshasalonghistoryofhelpingtograspits importanceforglobalfoodsecurityandinsecurity.Food insecurityislinkedtoavarietyoffactors,includingclass, ethnicity,andgenderaswellasdevelopment,landavailability, rural-urbaninequities,andage.Foodinsecurityismostlycaused byalackof financialresourcestopurchasefood.Thepoorarethe hardesthitamongthesepersons,resultinginasituationinwhich thecountryperformssignificantlyworsethanitscontemporaries intheindustrializedworld.Thisisespeciallytrueinlightofthe presenteconomicslump,whichhasresultedintheformationof newandspreading “fooddeserts” intheUnitedStates,where peopleareeitherjoblessorgoinghungryforthe firsttimeintheir lives.Accordingto Poppendieck(1995),insecurityoffood generatesascenarioof “heatoreat”.Peopleforgoeatingfor

rent,servicesormedicalcharges.InadditiontothesubstantialUS welfarereformin1996,theimportanceofstratificationforfood insecuritybecomesevenmoreapparent,combiningpovertywith genderandethnicdiscrimination.Moreover,despitetheirrolein allstagesoffoodproduction,distribution,andprocessing,food insecurityamongwomenandgirlsintheglobecontinuestobe pervasive.Extendingthistoracialdisparityworldwide demonstrateshowlaminationsystemsposeasobstaclesto fooddistributionandotherfundamentalnecessities.Among otherlocations,statefailuresinEritrea,Ethiopia,Indonesia, Somalia,SriLanka,andSudan(Messeretal.,1998) demonstratetheplagueofethnicdisparity for foodsecurity. Foodsecurityandinsecurityaddressingarecrucialto internationalpeacekeepingandsecurityeffortsinconflictareas (BryantandChristina,2005).Foodsecurityisacrucial componentofhowstable,sustainablesocietiesarecreated withthestronglinkstopovertyandunderdevelopment.

ApplicabilityofTheoryofAccesstoFood Security

AsdefinedbythetheoryofAccessdistinguishesbetweenone’ s righttoaccessresourcesandone’sabilitytoprofitfromthem. Peoplemayhavetherighttoaccessaresource,butduetoalackof structuralandrelationalmechanismssuchascapital,technology, labor,knowledge,authority,marketmechanisms,socialrelations, andidentitytheymaynotbeabletousetheresourceina productivewaytobenefitfromit(RibotandPeluso,2003).It hasalsobeenhighlightedbyUvin(Devereux,2007)thatfood insecurityincludesnumerouscomponents.Accordingto McKay andColque(2016),accessingresourcesrequiresproceduresthatgo beyondlegalnormsortitles,andthatalackofsuchprocessesleads toexclusion.Supposeafarmercouldhavetherighttoutilizethe landbutnotthelabororcashtorentit.Themostsignificant resourceforagriculturalproductivityforsmallholderfarmersis land,followedbyirrigationwater.Waterusedforirrigationaids agriculturalcropdevelopmentandmitigatestheimpactsof insufficientrainfall.Accesstoproductiveresourcesmayassist smallfarmers,throughimprovingproductionandadaptingto andmitigatingtheclimaticchanges,toimplementsustainableland managementmeasures,suchaswaterconservationmeasuresand nutrientmanagement.Foodsecurityisoneoftheprerequisitesor outcomesofalivelihood.Smallholderfarmersaresubjecttofood insecurityandhaveunsustainablelivelihoodsduetoalackof accesstoproductiveresources.Themajorityofpopulationinthe leastDevelopednationsincludingIndia,Somalia,Kenya,Pakistan andothercountrieswhoselivelihooddependsonAgricultureand livestockproduction.Inordertocheckthewideapplicabilityof TheoryofAccess,asmallstudyhasbeencarriedoutinnorthwesternslopesofMountKenya,coveringpartsofLaikipiaand Merucountries,asthistheoryholdsbroadersignificancewhile consideringdifferentvariables(SwindaleandBilinsky,2006).For householdswhichdependonagriculturalandlivestockproduction fortheirlivelihoods,accesstoproductionresources,suchasland andwaterisessential.Researchgenerallyassumesthatthetenure ofresourcesecurity(expressedasa “bundleofpropertyrights”)is favourableforagriculturaloutput,andconsequentlyfoodsecurity.

Howeverinthecategoryofbundleofrightsandpowers, followingvariableswhichformstateofartincludeAccessto Right,technology,Markets,knowledge,laborandlabor opportunities,capital,Accessthroughsocialidentityand throughsocialrelationships,Rights-basedaccesstoirrigation water.HouseholdDietaryDiversityScore(WorldFood programme,2008),FoodConsumptionScore(Maxwelland Caldwell,2008),CopingStrategyIndex(Coatesetal.,2007), HouseholdFoodInsecurityAccessScale(BilinskyandSwindale, 2010),andMonthsofInadequateFoodProvisioning(Mutea etal.,2020)wereusedtoestimatethefoodsecuritystatusof thetestedhomes.Muteaandco-workersin2020assessedintheir studywhethereachfamilyissatisfiedwiththefoodsecurity requirementsforeachofthe fiveindicatorstogetasenseoftheir overallfoodsecuritysituation.Inordertocategorizesafeand insecurefood,Muteaetal.(WorldFoodProgramme,2020a) utilizedthefoodsafetythresholdsfortherespectiveindices. HouseholdfoodsecurityviathelensoftheTheoryofAccess hasanapplicationthathasyettobefullyexploredfor industrializedcountriesinordertodeterminetheoptimal relationforeachvariable.Themajorityofthefarmersinthis researchhadpropertyrightstotheiragriculturalresourcesand wereabletoprofitfromthem.Instead,itindicatedthatthe fundamentalissuewasalackofaccesstothetechnologyrequired tounlockadditionaladvantagesfromhouseholds’ productive resources,leavingthesehouseholdsexposedtofoodinsecurity. Hence,greaternumberofvariablescanbeincludedevencan comparedfortheLeastdevelopedNationsinordertoframethe componentswhicharelackingorhaveputthepoorfamiliesor farmerslivelihoodintohaltasmakingthempronetohungerand foodsecurityandalsothistheorycanbeusedforcomparative analysisinordertodeterminechangingvariablesfoeallthe countrieswhichcomesunderthecategoryoffoodinsecurity.

StatisticalAnalysisOver45Developing NationsforFoodSecurity

Bytheendof2020,thenumberforacutehungerwilldoubleas per findingsofUnitedNationsWorldFoodProgram(WFP) (FoodandAgricultureOrganizationoftheUnitedNationsetal., 2020).ThepandemicCOVID-19willresultinadditionof83 132 millionpeopleintothecategoryofmalnutritionby2020 accordingtoestimatesofFoodandAgricultureOrganization (WorldTradeOrganization,2020).Whileadaptingmeasuresto abatetransmissionrates,TheWorldTradeOrganization(WTO) (FoodandAgricultureOrganizationoftheUnitedNations) reportedthatcountrieslikeEgypt,Thailand,North Macedonia,UkraineandKyrgyzstanstartedbanovercertain foodandagriculturalproducts.Somecountrieswhicharelargest suppliersofwheatlikeRussia,RicelikeVietnamimplemented export-restrictionswhilemajorityofcountriesputforthcustom restriction via cargoexportaspandemichasescalatedthe tensionsbetweentheUnitedStatesandChina,inwhichfood exchangetarishavebeenusedasaninstrumentofeconomic pressureintensively(ErokhinandGao,2020).

ErokhinandGao(WorldBank,2020b)triedtounderstandthe relationbetweenfoodsecurity,foodtrade,dynamicsofCOVID-

19cases,currencyvolatilitiesandfoodinflationbydividingthe45 developingnationsintothreegroupstudiesinordertocarryout statisticalanalysisusingYamamoto’scausalitytest,variance decomposition,autoregressivedistributedlagmethodonthe basisoflevelofincome.Withagrossnationalincome(GNI) percapitaof$1,025equalorlessaccordingtonormsofWorld Bank(Pumaetal.,2015)havekeptunderGroupIlikewiseGNI percapitabetween$1,026and$3,995comprisesGroupII countriesandGNIpercapitabetween$3,996and$12,375 includesGroupIII.Thisstudypertainstocheckthe dynamicityamongdifferentvariableswhichwereincludedas

1.Y Numberofpeoplewithinsufficientfoodconsumption (Unit-millionsofpeople),

2.X1 NumberofconfirmedCOVID-19cases(Unit-Number ofcases),

3.X2 Balanceoffoodtrade(USDmillion),

4.X3 Foodinflation(Percentage)and

5.X4 Currencyexchange(Unit-Monetaryunits)

Theirstudyexplainsthecumulativeeffectsofcovid-19 pandemiconoverallfoodsecurityin45developingnationby includingvariablesX(Hamidetal.,2020; IATA,2020; FAOand WHO,2020)aspertrendsofHungermapofWFP.Thefood tradebalance(X2)representedthecountry’srelianceonimports offoodandthusrevealedimprovementsintheavailabilityof food.Foodinflation(X3)andcurrencyexchange(X4)havebeen usedtodemonstratetheeffectonfoodsecurityofchangesin accesstofoodandagriculturalproducts(Figure2).Ithasbeen observedthatincountrieslikeEcuador,Pakistan,India,Turkey andPeru(primarilymiddle-incomeeconomies)wherethe numberofreportedCOVID-19casespercapitaishigh,the Y-X1linkageshowedsignificantresults.Lowerdeveloping countriesaredependentonimportforthestaplecropsasboth globalfoodchaindisruptionsandprotectionisttradepolicieslead togreateconomiclossescouldhaveseriousnegative consequencesforfoodsecurity[Puma(Woodetal.,2018)and Woodetal.(Frankenbergetal.,2019)].

Afterevaluatingtheresultsofvarioushypothesistesting, ErokhinandTianmingGao(SmithandGlauber,2020)put forththatacrossGroupI,numberofpeoplewithinsufficient foodconsumption(Y)isunidirectionallinkedtofoodtrade balance(X2)butthesignificanceofthelinkisloweveninthe countrieslikeTajikistan,HaitiandGuineawherefoodavailability largelydependsonimports.Forimport-dependent uppermiddle-income economies,thegreatestinfluenceofX2onYis seentobeincountrieslikeAlgeria,Botswana,Colombia,Jordan, Lebanon.Inmostlow-incomenations,alowerproportionoffood importsinexchangeiscorrelatedwithadeclineinthepercentage ofpeoplewithinadequatefoodintake.However, findingsofthis studyconcludedthatGroupIandGroupIIeconomiesdependon importslessdiversifiedthanGroupIIIcountriesthataremore tightlyintegratedintoglobalsupplychains.Inthelattersituation, greaterrelianceonimportsmeansthattheFoodTradeBalance, currencyexchange,andthereforethefoodsecuritypositionofthe peoplearemoreaffected.InNorthAfricaandtheMiddleEast countriesthatreliesonimportsoffoodandthereforerelyon

FIGURE2| SummaryofX(FAOandWHO,2020; Hamidetal.,2020; IATA,2020; WHO,2020a)effectsonYacrossthreegroupsofcountrieswhereGreen showingweakinfluence;yellowshowsmediuminfluenceandRedshowingstronginfluence(Source:ErokhinandGao(McMichael,2004).

currency fluctuationsinducedbythepandemic,UNCTAD[95] revealedincreasedrisksforfoodsafety.ThebestresultsofX2and X4onYonAlgeriaandTurkeyareseeninfavorofthisUNCTAD prediction.InanotherHypothesisthereisananticipationtrend ofanincreaseintheshareYoffoodtradeaswellasexchangesin currency,particularlyinthecountrieswiththehighestmiddle income.ThemostsignificantinfluenceofX2onYisexpectedin Libya,whererelianceonfoodimportsexceeds90%(18.03%).The X2inYproportionisalmost12%inMarch2021inNamibia, whichisanotherCategoryIIInationprimarilydependenton imports.Incountriescloselyembeddedintheglobalfoodsupply chains,theroleofthecurrencyexchangeinsecuringfoodsupply wouldincrease.InTurkey,forexample,X4describes15.21%ofY. Incontrastwiththoseinlowincomecountries,theeffectoffood inflationonthenumberofpeoplewithinadequatefoodintakein high-middleincomeeconomieshasbeenlower.Thisresult confirmsHypothesis3(theeffectsofX4andX2onYarethe highestamongtheeconomiesincludedinthestudy,whilethatof X3isthelowest)coincidesbothwithFrankenbergandThomas (Giordanietal.,2014)andSmithandGlauber(Andersonand Nelgen,2012)whoannouncethatelevatedfoodpricerateshave exacerbatedpoorhouseholds’ povertytraps,buthavenomajor impactontherelativelygoodfoodsafetystatus.Forexample,in Cambodiawesawthelimitedexportsofsomeagricultural producebetweenMarch April2020,whichresultedinthe reductioninthenumberofpeoplewithinsuccinatingfood intake,bothnegativebalancesoftradeinfoodandlow inflationinfoodstuffs.VietnamandTurkey,ontheother hand,havenotbeenveryactiveintheirdecisionstoreduce

foodexports.TheARDLstudyindicatesthata1%shiftinthe foodtradebalanceiscorrelatedwitha0.02%riseinfoodpoverty inVietnam.TheX2-Ypartnershipispoorerbutstilloptimisticin Turkey.ThisstudyshowedmajorcausalassociationbetweenX3 andYinbothcountries(5%!0.35%inTurkeyand5%!0.31%in Vietnam).This findingconfirmstheestimatesofAndersonand Nelgen(RudeandAn,2015),Giordanietal.(DaweandPeter Timmer,2012),andRudeandAn[68],whofoundthattrade protectionismcouldcausefoodinflationandthusintensifyfood insecurity.

CONCLUSION

Inthecurrentsituation,theglobalissueisfoodqualityandsafety. COVID-19,whichprovidesfoodcoverageforthemostvulnerable sectionofthepopulationatrisk,hasstruckthesupplychainthe hardest.Ingeneralfooddemandisveryinelasticandittakesmany yearsforsupplytocompletelyrespondtoashiftinprices,sothe shocksinGDPhaveonlyamarginaleffectonglobalproduction andconsumption.TheinabilitytocontaintheCOVID-19 pandemichashadfar-reachingconsequencesfortheworld economy,withglobalGDPexpectedtoplummetby3.3%by 2020.Despitethefactthattheglobaleconomyisexpectedto increaseby6%in2021,recoverywillbecontingentonfairvaccine distributionworldwide.AccordingtotheInternationalChamber ofCommerce,failuretodosomightcosttheglobaleconomyupto $9trillion,withlossessharedevenlybyrichandpoorcountries, wreakinggreatereconomichavocthanthe2008 financialcrisis.

Highvalueaddedgoodssuchasmeatandmilkaswellasbio-fuels arethecommoditieswhoseproductionchangesthemost.Inorder toensurethewelfareoffarmworkers,countriesshouldtake action.Healthcareworkersonstaffshouldmonitoremployees’ diseasestatus.Countriescancreatecollectioncentresfor agriculturalproductionatlocationseasilyreachedbysmallscalefarmerstominimizemobility.Collectioncentresfor agriculturalproductionshouldbebuilttoprovidehighcapacity storagefor(Beghin,2014;FAO,2020a).Inordertoreducethe depletionoffoodthroughoutthefoodsupplychain,enhancedand specializedstoragesystemsshouldalsobeused.Howeverwhen additionalcapitalinjectionisneedednewfacilitiesorimproved technologyincludehighermanufacturingcosts.Smalland medium-sizedagricultural firmsmayalsomaintaintheir operationsthroughgovernmentordonorcapitalinjections (Anangetal.,2015; WorldFoodProgramme,2020b).Food banksmayplayasignificantroleinconsideringthehorizontal andverticalcooperationstructureswithfarmerassociationsthat allowpledgedagricultureprocedure.Developingcountrieswill sufferthemostdespiteanyeconomicorfoodcrisismainlybecause oftheirlimitedresourcesandaresubjectedtothedeteriorationof themacroeconomicenvironment.Itisinterestingtonotethat beforethepandemicover2billionofthemostimpoverished peopleintheworldspent70%oftheirdisposableincomeonfood sothisreiteratestheimportanceoffoodsecurityandhowa disruptioninthesupplychaincanhaveseriousrepercussions

REFERENCES

Allen,P.(2004). TogetherattheTable:SustainabilityandSustenanceinthe AmericanAgrifoodSystem.PA:UniversityParkPennStateUniversityPress.

Anang,B.T.,Sipiläinen,T.,Bäckman,S.,andKola,J.(2015).FactorsInfluencing SmallholderFarmers’ AccesstoAgriculturalMicrocreditinNorthernGhana. Afr.J.Agric.Res. 10(24),2460 2469.doi:10.5897/AJAR2015.9536

Anderson,K.,andNelgen,S.(2012).TradeBarrierVolatilityand AgriculturalPriceStabilization. WorldDev. 40,36 48.doi:10.1016/ j.worlddev.2011.05.018

Araujo-Enciso,S.R.,PerezDominguez,I.,Santini,F.,andHelaine,S.(2015). DocumentationoftheEuropeanComission’sEUModuleoftheAglink-Cosimo ModellingSystem. EUR27138,ScientificandTechnicalReports.Institutefor ProspectiveTechnologicalStudies.

AuthorAnonymous(2020a). WTOExportProhibitionsandRestrictions: InformationNote.Geneva:WorldTradeOrganization.

AuthorAnonymous(2020b).NaturePlants.FoodinaTimeofCOVID-19. Nat. Plants 6,429.doi:10.1038/s41477-020-0682-7

Barichello,R.(2020).TheCOVID-19Pandemic:AnticipatingitsEffectson Canada’sAgriculturalTrade. Can.J.Agric.Economics/Revuecanadienne d’agroeconomie 68,219 224.doi:10.1111/cjag.12244

Barkin,D.(1982).TheImpactofAgribusinessonRuralDevelopment. Curr. Perspect.Soc.Theor. 3,1 25.

Beghin,J.C.(2014).TheProtectionismofFoodSafetyStandardsinInternational AgriculturalTrade. Agric.Pol.Rev. 2014(1),7 9.

Bilinsky,P.,andSwindale,A.(2010). MonthsofAdequateHouseholdFood Provisioning(MAHFP)forMeasurementofHouseholdFoodAccess: IndicatorGuide;FHI360/FANTAVersion4;FoodandNutritionTechnical AssistanceIIIProject.(Washington,DC,USA:FANTA).

Bree,A.HowWillCovid-19ChangeOurRelationshipwithFood?.Availableonline: https://nutritionconnect.org/resource-center/how-will-covid-19-change-ourrelationship-food.(Accessedon14April2020).

Bryant,C.,andChristina,K.(2005). ReducingPoverty,BuildingPeace.Bloomfield, CT:Kumarian.

onmorethanaquarteroftheworld’spopulation.Unless immediateactionistaken,thenumberofpeopleexperiencing acutefoodinsecurityisexpectedtodoubleto265millionby2020, asperthe WorldFoodProgramme(2020b).However,evenin Developednations,morevulnerablegroupssuchastheelderly, chronicallyill,andpoorerhouseholdsmaybeatdanger,and COVID-19hasexposedpre-existingsocialprotectiondeficiencies (OECD,2020b).Futurecomparativesociologicalresearchonfood safetycanbebuiltonrecentresearchwhichhasestablished sociologicalpositionsonthisarena.Itistraditionally dominatedbyresearchthatoverlyconcernsproductionand supplyandisnotsufficientlyconcernedwiththeconflicts, stratificationandinequalitymostessentialtostarvation.The EuropeanUnion’sFarmtoForkStrategydescribedfoodsystem conversionsystemtofocusonfutureresilience,healthand sustainability.Theirissuedstatementregardingframeworkwere focusedonthattherecanbeenvironmental,healthandsocial benefits,economicgainsandensuringthataresurgencefromthe crisiscanleadustothesustainableroute(EuropeanCommission, 2020b).

AUTHORCONTRIBUTIONS

Allauthorslistedhavemadeasubstantial,direct,andintellectual contributiontotheworkandapproveditforpublication.

Buttel,F.(1997).SomeObservationsonAgro-FoodChangeandtheFutureof AgriculturalSustainabilityMovements. inGlobalisingFood,344 365. CDC(2020a). 1957-1958Pandemic(H2N2Virus).Atlanta,GA,UnitedStates: CentersforDiseaseControlandPrevention(CDC). CDC(2020b). 1968Pandemic(H3N2Virus).Atlanta,GA,UnitedStates:Centers forDiseaseControlandPrevention(CDC).

Elleby,C.,PérezDomínguez,I,Adenauer,M.,andGenovese,G.(2020). “EnvironmentalandResourceEconomics,” in COVID-19Pandemiconthe GlobalAgriculturalMarkets,76,1067 1079.doi:10.1007/s10640-020-00473-6 Coates,J.,Swindale,A.,andBilinsky,P.(2007). HouseholdFoodInsecurityAccess Scale(HFIAS)forMeasurementofFoodAccess:IndicatorGuide;FHI360/ FANTAVersion3FoodandNutritionTechnicalAssistanceIIIProject (Washington, DC,USA:FANTA).doi:10.1037/e576842013-001

Cucinotta,D., andVanelli,M.(2020).WHODeclaresCOVID-19aPandemic. ActaBiomed. 91,157 160.doi:10.23750/abm.v91i1.9397

Datassential(2020). CoronavirusandtheImpactonEating.Availableonline:https:// datassential.com/wpcontent/uploads/2020/03/Datassential-Coronavirus-3-12-20. pdf(AccessedonMarch12,2020).

David,G.,andMichael,W.(2004).NewYork:Routledge.Mooney,PatrickH. “DemocratizingRuralEconomy:InstitutionalFriction,SustainableStruggleand theCooperativeMovement. RuralSociol. 69,76 98.doi:10.1526/ 003601104322919919

Dawe,D.,andPeterTimmer,C.(2012).WhyStableFoodPricesAreaGoodThing: LessonsfromStabilizingRicePricesinAsia. Glob.FoodSecur. 1,127 133. doi:10.1016/j.gfs.2012.09.001

Deng,Q.,Zinoviadou,K.G.,Galanakis,C.M.,Orlien,V.,Grimi,N.,Vorobiev,E., etal.(2015).TheEffectsofConventionalandNon-conventionalProcessingon GlucosinolatesanditsDerivedForms,Isothiocyanates:Extraction,Degradation, andApplications. FoodEng.Rev. 7,357 381.doi:10.1007/s12393-014-9104-9

DeRose,L.,Ellen,M.,andSara,M.(1998). Who’sHungry?andHowDoWeKnow? NewYork:UnitedNationsUniversity. Devereux,S.(2007). TheNewFamines:WhyFaminesPersistinanEraof Globalization.NewYork:Routledge. EC.(2019). EUAgriculturalOutlookforMarketsandIncome,2019 2030.Brussels: EuropeanCommission,DGAgricultureandRuralDevelopment.

Edwards,F.,andMercer,D.(2007).GleaningfromGluttony:AnAustralianYouth SubcultureConfrontstheEthicsofWaste. Aust.Geographer 38,279 296. doi:10.1080/00049180701639174

Erokhin,V.,andGao,T.(2020).ImpactsofCOVID-19onTradeandEconomic AspectsofFoodSecurity:Evidencefrom45DevelopingCountries. Ijerph 17, 5775.doi:10.3390/ijerph17165775

Espitia,A.,Rocha,N.,andRuta,M.(2020).Covid-19andFoodProtectionism:the ImpactofthePandemicandexportRestrictionsonWorldFoodMarkets.Policy ResearchWorkingPaper,No.9253,WorldBank.1 30.doi:10.1596/1813-94509253

EuropeanCommission(2020a). COVID-19andFoodSafety-Questionsand Answers.EuropeanCommission.Availableat:https://ec.europa.eu/food/ sites/food/files/safety/docs/biosafety_crisis_covid19_qandas_en.pdf(Accessed onApr10,2020).[Online]

EuropeanCommission(2020b). FarmtoForkStrategy.December.

FAO(FoodandAgricultureOrganizationoftheUnitedNations);WHO(World HealthOrganization)(2020).COVID-19andFoodSafety:GuidanceforFood Businesses:InterimGuidance.Availableat:http://www.fao.org/3/ca8660en/ CA8660EN.pdf(AccessedonApr17,2020).[Online]

FAO(FoodandAgricultureOrganizationoftheUnitedNations)(2005). DecentralizedDevelopmentinAgriculture,FoodandAgriculture Organization.Availableat:http://www.fao.org/docs/up/easypol/342/decen_ dev_in_agri_012en.pdf(AccessedonJul23,2020).[Online]

FAO(2020a).COVID-19andtheRisktoFoodSupplyChains:HowtoRespond?. http://www.fao.org/3/ca8388en/CA8388EN.pdf(AccessedonApr3,2020). [Online]

FAO(FoodandAgricultureOrganizationoftheUnitedNations)(2020b). ExtensionandAdvisoryServices:attheFrontlineoftheResponseto COVID-19toEnsureFoodSecurity.Availableat:http://www.fao.org/3/ ca8710en/CA8710EN.pdf(AccessedonApr24,2020).[Online]

FAO(FoodandAgricultureOrganizationoftheUnitedNations)(2020c).Impacts ofCoronavirusonFoodSecurityandNutritioninAsiaandthePacific:Building MoreResilientFoodSystems.Availableat:http://www.fao.org/3/ca9473en/ CA9473EN.pdf(AccessedonJun12,2020).[Online]

FAO(FoodandAgricultureOrganizationoftheUnitedNations)(2020d).Policy ResponsestoKeepInputMarketsFlowinginTimesofCOVID-19.Availableat: http://www.fao.org/3/ca8979en/CA8979EN.pdf(AccessedonMay8,2020). [Online]

FAO(2020e). HowIsCOVID-19AffectingtheFisheriesandAquacultureFood Systems.Rome,Italy:FoodandAgriculturalOrganizationoftheUnited Nations.

FAO;FoodandAgricultureOrganizationoftheUnitedNations(2021).Low-Income FoodDeficitCountries,” in FAOCountryProfilesandMappingInformation System2006a.Rome:FAO.Availableat:www.fao.org/countryprofiles/lifdc.asp? lang en(RetrievedJune11,2007).

FAO(2020f). MigrantWorkersandtheCOVID-19Pandemic.Rome,Italy:Food andAgricultureOrganizationoftheUnitedNations(FAO).

FoodandAgricultureOrganizationoftheUnitedNations;InternationalFundfor AgriculturalDevelopment;UnitedNationsChildren ’sFund;WorldFood Programme;WorldHealthOrganization(2020). TheStateofFoodSecurity andNutritionintheWorld2020TransformingFoodSystemsforAordable HealthyDiets.Rome,Italy:FAO.

FoodandAgricultureOrganizationoftheUnitedNationsNovelCoronaVirus (COVID-19).Availableonline:http://www.fao.org/2019-ncov/q-and-a/ impact-on-food-and-agriculture/en/(AccessedonJuly10,2020).

FoodandAgricultureOrganizationoftheUnitedNations(2008).Numberof HungryPeopleRisesto963Million.Rome:FAO.Availableat:www.fao.org/ news/story/en/item/8836/(RetrievedJanuary9,2009).

Forstadt,J.(2020). DairyIndustryUpendedbyCOVID-19.

Frankenberg,E.,andThomas,D.(2019). “HumanCapitalandShocks:Evidenceon Education,Health,andNutrition,” in TheEconomicsofPovertyTraps.Editors C.B.Barrett,M.R.Carter,andJ.-P.Chavas(Cambridge,MA,USA:National BureauofEconomicResearch),23 56.

Friedmann,H.(1982).ThePoliticalEconomyofFood:TheRiseandFallofthe PostwarInternationalFoodOrder. Am.J.Sociol. 88,S248 S286.doi:10.1086/ 649258

Giordani, P.E.,Rocha,N.,and Ruta, M.(2014). FoodPricesandtheMultiplierEect ofTradePolicy.Washington,DC,USA:IMF.

Hamid,S.,Mir,M.Y.,andRohela,G.K.(2020).NovelCoronavirusDisease (COVID-19):aPandemic(Epidemiology,PathogenesisandPotential Therapeutics). NewMicrobesandNewInfections 35,100679.doi:10.1016/ j.nmni.2020.100679

Headey,D.,Heidkamp,R.,Osendarp,S.,Ruel,M.,Scott,N.,Black,R.,etal. (2020).ImpactsofCOVID-19onChildhoodMalnutritionandNutritionRelatedMortality. TheLancet 396,519 521.doi:10.1016/s0140-6736(20) 31647-0

Hernandez,M.,Kim,S.,Rice,B.,andVos,R.(2020).IFPRI’sNewCOVID-19 FoodPriceMonitorTracksWarningSignsofStressinLocalMarkets. InternationalFoodPolicyResearchInstitute.Accessedfrom:https://www. ifpri.org/blog/ifpris-new-covid-19-food-pricemonitor-tracks-warning-signsstress-local markets.

Hubbub HowHasCovid-19ChangedOurEatingHabits? Availableonline:https:// www.hubbub.org.uk/blog/how-has-co vid-19-changed-our-eating-habits (AccessedonApril22,2020).

IATA(InternationalAirTransportAssociation)(2020). IATAUpdates COVID-19FinancialImpacts-ReliefMeasuresNeeded.Availableat: https://www.iata.org/en/pressroom/pr/2020-03-05-01/(AccessedonJul22, 2020).[Online]

ILO(2020a). ILOMonitorCOVID-19andtheWorldofWork.2ndedition.Genèva, Switzerland:InternationalLabourOrganization(ILO).

ILO(InternationalLabourOrganization)(2020b). COVID-19andtheImpacton AgricultureandFoodSecurity.Availableat:https://www.ilo.org/wcmsp5/ groups/public/ ed_dialogue/ sector/documents/brie fingnote/wcms_742023. pdf(AccessedonApr24,2020).[Online]

IMF(2020). WorldEconomicOutlook,April2020:TheGreatLockdown Washington,DC:InternationalMonetaryFund.

IPES(TheInternationalPanelofExpertsonSustainableFoodSystem)(2020). COVID-19andtheCrisisinFoodSystems:Symptoms,Causes,and Potentialsolutions.[Online].Availableat:http://www.ipes-food.org/_img/ upload/files/COVID-19_CommuniqueEN.pdf(AccessedonApr17,2020).

Johnso,n.N.P.A.S.,andMuelle,r.J.(2002).UpdatiNgTHeAccounts:Global Mortalityofthe1918-1920"Spanish"InfluenzaPandemic. Bull.Hist.Med. 76, 105 115.doi:10.1353/bhm.2002.0022

Laborde,D.,Martin,W.,andVos,R.(2020).PovertyandFoodInsecurity CouldGrowDramaticallyasCOVID-19Spreads.Washington,DC: InternationalFoodPolicyResearchInstitute(IFPRI).doi:10.2499/ p15738coll2.133762_02

Lopez-Ridaura,S.,Barba-Escoto,L.,Reyna,C.,Hellin,J.,Gerard,B.,andvanWijk, M.(2019).FoodSecurityandAgricultureintheWesternHighlandsof Guatemala. FoodSec. 11,817 833.doi:10.1007/s12571-019-00940-z

Marlow,S.(2020).COVID-19:EffectsontheFertilizerIndustry.IHSMarkit. Maxwell,D.,andCaldwell,R.(2008). “TheCopingStrategiesIndex,” in AToolfor RapidMeasurementofHouseholdFoodSecurityandtheImpactofFoodAid ProgramsinHumanitarianEmergenciesCooperativeforAssistanceandRelief Everywhere.2nded.(Washington,DC,USA:Inc.(CARE)).

McKay,B.,andColque,G.(2016).Bolivia’sSoyComplex:theDevelopmentof ’productiveExclusion’ J.PeasantStud. 43,583 610.doi:10.1080/ 03066150.2015.1053875

McMichael, P.(1995). FoodandAgrarianOrders in theWorldEconomy.Westport, CT:Praeger.

McMichael,P.(2004). DevelopmentandSocialChange.3rded.NewburyPark,CA: SAGE.

Menezes,F.(2001).FoodSovereignty:AVitalRequirementforFoodSecurityin theContextofGlobalization. Development 44,29 33.doi:10.1057/ palgrave.development.1110288

Messer,E.,Cohen,M.J.,andD’Costa,J.(1998). FoodfromPeace:Breakingthe LinksbetweenConflictandHunger.Washington,D.C;IFPRI.Availableat: www.ifpri.org/2020/dp/dp24.pdf(RetrievedJuly15,2008).

Mutea,E.,Rist,S.,andJacobi,J.(2020).ApplyingtheTheoryofAccesstoFood SecurityAmongSmallholderFamilyFarmersAroundNorth-WestMount Kenya. Sustainability 12,1751.doi:10.3390/su12051751

NepaliSansar(2020). COVID-19InflictsNPR2BnLossonNepalDairyIndustry! Irving,TX:NepaliSansar.

OECD(2015). OECDAglink-CosimoModelDocumentation.Tech.Rep.Seville, Spain:OECD-FAO.

OECD(2020a). Coronavirus:TheWorldEconomyatRisk.Paris.

OECD(2020b). “SupportingLivelihoodsduringtheCovid-19Crisis:Closingthe GapsinSafetyNets”.Availableat:http://www.oecd.org/coronavirus/en/ (AccessedonMay20,2020).

OECD(TheOrganisationforEconomicCo-operationandDevelopment)(2020c). COVID-19andInternationalTrade:IssuesandActions[Online].Availableat: http://www.oecd.org/coronavirus/policy-responses/covid-19-andinternationaltrade-issues-and-actions-494da2fa/(AccessedonJul24,2020).

OECD(TheOrganisationforEconomicCo-operationandDevelopment)(2020d). FoodSupplyChainsandCOVID-19:ImpactsandPolicyLessons.Availableat: http://www.oecd.org/coronavirus/policy-responses/food-supplychains-and-covid19-impacts-and-policy-lessons-71b57aea/(AccessedonAug5,2020).[Online]

Petrini,C.,andGigi,P.(2006). SlowFoodRevolution.NewYork:Rizzoli. Poppendieck,J.(1995). “HungerinAmerica:TypificationandResponse,” in In EatingAgendas:FoodandNutritionasSocialProblemsMaurerandSobal (New York:deGruyter),11 34.

Pressman,P.,Naidu,A.S.,andClemens,R.(2020).COVID-19andFoodSafety. Nutr.Today 55,125 128.doi:10.1097/nt.0000000000000415

Puma,M.,Bose,S.,Chon,S.Y.,andCook,B.(2015).AssessingtheEvolving FragilityoftheGlobalFoodSystem. Environ.Res.Lett. 10,024007.doi:10.1088/ 1748-9326/10/2/024007

Ribot,J.C.,andPeluso,N.L.(2003).ATheoryofAccess. RuralSociol. 68,153 181. doi:10.1111/j.1549-0831.2003.tb00133.x

Richards,T.J.,andRickard,B.(2020).COVID-19ImpactonFruitandVegetable Markets. Can.J.Agric.Economics/Revuecanadienned’agroeconomie 68, 189 194.doi:10.1111/cjag.12231

Rizou,M.,Galanakis,I.M.,Aldawoud,T.M.S.,andGalanakis,C.M.(2020).Safety ofFoods,FoodSupplyChainandEnvironmentwithintheCOVID-19 Pandemic. TrendsFoodSci.Technol. 102,293 299.doi:10.1016/ j.tifs.2020.06.008

Rogers,K.,andCosgrove,A.FutureConsumerIndex:HowCOVID-19IsChanging ConsumerBehaviors.Availableonline:https://www.ey.com/en_id/covid-19/ enterprise-resiliency-nine-areas-of-focus-for-covid-19-crisis-management. (Accessedon20June2020).

Rude,J.,andAn,H.ExplainingGrainandOilseedPriceVolatility:TheRoleof ExportRestrictions. FoodPolicy,2015 57,83 92.doi:10.1016/ j.foodpol.2015.09.002

Schnell,S.M.(2007).FoodwithaFarmer’sFace:Community-Supported AgricultureintheUnitedStates. GeographicalRev. 97,550 564. doi:10.1111/j.1931-0846.2007.tb00412.x

Smith,V.H.,andGlauber,J.W.(2020).Trade,Policy,andFoodSecurity. Agric. Econ. 51,159 171.doi:10.1111/agec.12547

Swindale,A.,andBilinsky,P.(2006). HouseholdDietaryDiversityScore(HDDS)for MeasurementofHouseholdFoodAccess:IndicatorGuide.FHI360/FANTA Version2,FoodandNutritionTechnicalAssistanceIIIProject.(Washington, DC,USA:FANTA).

UNTWO(WorldTourismOrganization). InternationalTouristNumbersCould Fall60 80%In2020.Availableat:https://www.unwto.org/news/covid-19international-tourist-numbers-could-fall-60-80-in-2020(AccessedonJul22, 2020).[Online]

Uvin, P.(1994). “TheStateof World Hunger,” in In theHungerReport.Editor Uvin.Yverdon(Switzerland:Gordon&Breach),1 47.

Vorotnikov,V.(2020). CoronavirusCouldDisruptPoultryproductionFAO.Qand A:COVID-19Pandemic ImpactonFoodandAgriculture.PoultryWorld. Walton,J.,andDavid,S.(1994). FreeMarketsandFoodRiots:ThePoliticsofGlobal Adjustment.Cambridge,MA:Blackwell.

Wekerle,G.R.(2004).FoodJusticeMovements. J.Plann.Educ.Res. 23,378 386. doi:10.1177/0739456x04264886

WFP(WorldFoodProgramme)(2020a).COVID-19WillDoubleNumberof PeopleFacingFoodCrisesunlessswiftActionIsTaken.https://www.wfp.org/ news/covid-19-will-double-number-people-facing-foodcrises-unless-swiftaction-taken(AccessedonAug5,2020).[Online]

WHO(WorldHealthOrganization)(2020a).2019NovelCoronavirus(2019nCoV):StrategicPreparednessandResponsePlan.Availableat:https://www. who.int/docs/default-source/coronaviruse/srp-04022020.pdf?sfvrsn 7ff55ec0_ 4&download true(AccessedonMar.13,2020).[Online]

WHO.HIV/AIDS(2020). WHO.CoronavirusDisease2019(COVID-19)Situation Report-92.2020

Wood,S.A.,Smith,M.R.,Fanzo,J.,Remans,R.,andDeFries,R.S.(2018).Trade andtheEquitabilityofGlobalFoodNutrientDistribution. Nat.Sustain. 1, 34 37.doi:10.1038/s41893-017-0008-6

WorldBank(2019). EmploymentinAgriculture(%ofTotalEmployment)(Modeled ILOEstimate).Washington,DC,UnitedStates:WorldBank.

WorldBank(2020a). GlobalEconomicProspects.Washington,DC:WorldBank. (AccessedfromJune2020).

WorldBank(2020b). WorldBankCountryandLendingGroups.Availableonline: (AccessedonJuly10,2020).

WorldFoodProgramme “HungerFacts.” Rome:WFP.Availableat:www.wfp.org/ aboutwfp/facts/hunger_facts.asp(RetrievedAugust1,2007).

WorldFoodprogramme(2008). FoodConsumptionScoreNutritionalQuality AnalysisGuidelines(FCS-N);UnitedNationsWorldFoodProgramme,Food SecurityAnalysis(VAM).Rome:Italy.

WorldFoodProgramme(2020a).COVID-19WillDoubleNumberofPeople FacingFoodCrisesunlessSwiftActionIsTaken.Availableonline:https:// www.wfpusa.org/news-release/covid-19-will-double-number-of-peoplefacingfood-crises-unless-swift-action-is-taken/(AccessedonJuly6,2020).

WorldFoodProgramme(2020b). COVID-19WillDoubleNumberofPeopleFacing FoodCrisesunlessswiftActionIsTaken”.Availableat:https://www.wfp.org/ news/covid-19-will-double-number-peopl e-facing-food-crises-unless-swiftaction-taken.

WorldTradeOrganization.TheCOVID-19PandemicandTrade-Related DevelopmentsinLDCs.Availableonline:https://www.wto.org/english/ tratop_e/covid19_e/ldcs_report_e.pdf(AccessedonJune29,2020).

WTO(2020).WTO|FrequentlyAskedQuestions:TheWTOandCOVID-19. Genèva,Switzerland:WorldTradeOrganization.

Zavatta,G.(2014). AgricultureRemainsCentraltotheWorldEconomy.60%ofthe PopulationDependsonAgricultureforSurvival.Milan,Italy:ExpoMilano. Zhang,X.(2020).ChineseLivestockFarmsStruggleunderCOVID-19 Restrictions,” in IFPRIBlog:ResearchPost.(Washington,DC,UnitedStates: InternationalFoodResearchInstitute).doi:10.2499/p15738coll2.133762_19

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialor financial relationshipsthatcouldbe construed asa potentialconflictofinterest.

Copyright©2021HamidandMir.Thisisanopen-accessarticledistributedunder thetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse, distributionorreproductioninotherforumsispermitted,providedtheoriginal author(s)andthecopyrightowner(s)arecreditedandthattheoriginalpublication inthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse, distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

published:15July2021 doi:10.3389/fpsyg.2021.627833

Editedby: DelaliA.Dovie, UniversityofGhana,Ghana

Reviewedby: JoniTzuchenTang, NationalTaiwanUniversityofScience andTechnology,Taiwan AndrzejKlimczuk, WarsawSchoolofEconomics,Poland

*Correspondence: YaWen ywen1133@126.com

Specialtysection: Thisarticlewassubmittedto EducationalPsychology, asectionofthejournal FrontiersinPsychology

Received: 10November2020 Accepted: 14June2021 Published: 15July2021

Citation: ChenH,LiuF,WenY,LingLand GuX(2021)Compilation andApplicationoftheScale ofSustainableKnowledgeSharing WillingnessinVirtualAcademic CommunityDuringtheTimesofthe CoronavirusPandemic(COVID-19). Front.Psychol.12:627833. doi:10.3389/fpsyg.2021.627833

CompilationandApplicationofthe ScaleofSustainableKnowledge SharingWillingnessinVirtual AcademicCommunityDuringthe TimesoftheCoronavirusPandemic (COVID-19)

HuaruoChen1,2 ,FeiLiu1,3 ,YaWen4* ,LingLing5 andXueyingGu1

1 SchoolofEducationScience,NanjingNormalUniversity,Nanjing,China, 2 CenterforResearchandReforminEducation, JohnsHopkinsUniversity,Baltimore,MA,UnitedStates, 3 SchoolofEducationScience,HuaiyinNormalUniversity,Huaian, China, 4 SchoolofTeacherEducation,NanjingXiaozhuangUniversity,Nanjing,China, 5 InstituteofMathematicsandPhysics, BeijingUnionUniversity,Beijing,China

WiththeoutbreakofCOVID-19,manyofflineacademicactivitieshavebeenturned online,andvirtualacademiccommunitieshavebeenfurtheremphasized.Basedonthis situation,thisstudytooktheEaglyandChaiken’sHeuristic-SystemModelofPersuasion andthegeneralrulesofbehavioraldecisionasatheoreticalbasis,establisheda theoreticalmodelofsustainableknowledgesharingwillingnessinvirtualacademic communities.Firstly,thisstudydevelopedthescaleofwillingnesstosharesustainable knowledgebasedontheheuristicsystemmodelofpersuasion.Afteranalyzingthe dataof62participants,thescalewasrevised.Secondly,256validdatawerecollected fromChina,theUnitedStates,Singapore,andIndonesia.Finally,theconceptualmodel andtheoreticalhypothesisweretestedbasedonthedata.Theresultsshowthat knowledgesharingsatisfactionisaffectedbyheuristicfactors(knowledgesharing quantity,knowledgesourcecredibility)andsystemfactors(knowledgesharingquality, knowledgesharingusefulness),andhasasignificantpositivecorrelationwithsustainable knowledgesharingwillingness.

Keywords:Heuristic-SystemModel,academicvirtualcommunity,COVID-19,sustainableknowledgesharing, willingness

INTRODUCTION

Withtherapiddevelopmentofmoderninformationtechnologyandthepopularizationand applicationoftheInternet,newdigitalscientificresearchenvironmentssuchasE-Learning areincreasinglyformedandmature.EspeciallyundertheinfluenceofcurrentCOVID-19,new knowledgesharingmodewithanvirtualacademiccommunityasthecarrierhasemergedand receivedextensiveattention(CastanedaandCuellar,2020).Thevirtualacademiccommunitywill gatherresearcherswithcommonorsimilarresearchintereststogethertoreleasequestions,discuss questions,provideanswersandshareknowledgearoundthesametopic,torealizeknowledge

sharing(Marquezetal.,2016).Thevirtualacademiccommunity hasbrokenthroughthetime,space,anddisciplinerestrictions changedtheknowledgeproductionmodebasedondisciplines anddocuments,compliedwiththeneedsofreal-timescientific research,interactivescientificresearch,openscientificresearch, andcollaborativescientificresearchinthenetworkera, whichbecomeanimportantplatformforresearcherstoshare knowledge(Cantor,2019).

Inrecentyears,withtherapiddevelopmentofvirtual academiccommunity,thescaleofcommunityuserssuchas Academia,ResearchGATE,Mendeley,etc.hasbeenexpanding, whichnotonlyallowsuserstoshareandviewthelatest scientificresearchresultsintimebutalsohelpsuserstoestablish communityrelations,tomakeacademicexchangesmoresmooth andknowledgesharingmoreefficient.Butatthesametime, therearealsosomeacademicvirtualcommunitieswithlow userparticipation,lessknowledgesharingactivities,andusers’ sustainableuseintentiondeclining.Theestablishmentsoon begantodecline,whichdidnotachievethepurposeofacademic exchange.Fromtheperspectiveofknowledgemanagement, virtualacademiccommunityconstructsanewparadigmof knowledgeproduction,storage,sharing,andutilization,which providestheresources,technology,andenvironmentneededfor knowledgesharing,whileknowledgesharingprovidespowerand guaranteeforthesustainabledevelopmentofthevirtualacademic community(Chengetal.,2018).Therefore,thesustainable participationofusersinknowledgesharingisthekeytothe successofthevirtualacademiccommunity(Chandranand Alammari,2020).Inthispaper,theHeuristic-SystematicModel ofPersuasion(HSMPP)(Chaikenetal.,1989)andthegeneral rulesofhumanbehaviordecision-makingareusedtoconstructa heuristicforsustainableknowledgesharinginvirtualacademic communityandthescalewasformed.Thesystematicmodel explorestheinfluenceofheuristicvariablesandsystematic variablesonthewillingnessofsustainableknowledgesharing andanalyzestheobstaclesandcountermeasuresofsustainable knowledgesharinginvirtualacademiccommunity.

LITERATUREREVIEW

SustainableKnowledgeSharinginVirtual AcademicCommunity

Thesustainabledevelopmentofvirtualacademiccommunity dependsonwhetherusersarewillingtoshareknowledge sustainably.Themainchallengeisthatknowledgeinthevirtual academiccommunityisnon-competitiveandnon-exclusive, whichisusuallyregardedas“publicgoods”(Riceetal.,2018). CabreraandCabrera(2002) believedthatallpeopleinan organization,whethertheyhavecontributedknowledgeornot, canobtainsharedresources,andtheuseofknowledgeresources byeachpersonwillnotreducetheuseoftheseresources byothers(CabreraandCabrera,2002).Thepublicgoods attributeofknowledgetendstoleadtotheimbalanceofsharing. Peoplearealwayswillingtoobtainandusefreeknowledge resources,ratherthancontributetheirownknowledge,which leadsto“free-riding”behavior.However,accordingtoSimon’s

“limitedrationality”theory,everyoneislimitedrationality, andcommunitymembersmayshareknowledgebecauseof irrationalfactorssuchasinterpersonalrelationshipsandemotion (Cristofaro,2017).Therefore,therearemanyfactorsinfluencing knowledgesharingandsustainablewillingness.

Atpresent,theresearchmainlyfocusesontheendogenous factorssuchasemotionalfactors,psychologicalcognition, individualmotivation,ortheexternalvariablessuchastechnical function,socialimpact,situationalenvironmenttostudythe sustainablewillingnessinknowledgesharingofvirtualacademic community. RanjbarfardandSureshjani(2018) constructed aframeworkforknowledgesharinginvirtualacademic communitybetweenteachersandstudents,andstudiedtherole ofpartnershiprequirements,collaborativelearningservices,and socialnetworksonthewillingnesstosustainableknowledge sharing(RanjbarfardandSureshjani,2018). CheungandLee (2007) pointedoutthatinternalmotivationhasastrong correlationwithknowledgeself-efficacy,whichhasasignificant positiveimpactonthewillingnesstocontinueknowledgesharing (CheungandLee,2007). Chiuetal.(2011) constructeda modelbasedonexpectationrecognitiontheoryandfairness theory,pointedoutthattheuncertaintyofself-worth,fairness ofdistribution,andfairnessofinteractionsignificantlyaffectthe satisfactionandwillingnessofmembersofvirtualcommunity (Chiuetal.,2011).Theexistingresearcheshavemadefruitful resultsbyusingtheinherentmodelofclassicaltheory,butthey havenotdistinguishedtheheuristicbehaviorandsystematic behaviorofknowledgesharing,andhavenotyetstudiedthe rationalandirrationalfactorsandtheirmechanismofknowledge sharingbehavior.

ApplicationofHSMP

TheHSMPisadualprocessingtheoreticalmodelproposed bypsychologistChaikentoexplaintheprocessofindividual informationbehavior(Chaikenetal.,1989).Chaikenbelieved thathumansocialactivitieshavetwokindsofinformation processingmodes:heuristicandsystematic(Chaikenetal.,1989). Theheuristicbehaviorbasedonintuitionmeansthatpeoplepay lesscognitiveeffortandmakeasimplejudgmentaccordingtothe externalcluesofinformation(Chaiken,1980).Forexample,the implicationofsourcecredibilitymaytriggertherulethattrust meansright,makingpeoplemorewillingtoacceptinformation sentbypeoplewithhightrust.Systematicbehaviorbasedon rationalitymeansthatpeopleuseenoughcognitiveresourcesto systematicallyevaluaterelevantinformationcontent(Chaiken, 1980).Users’evaluationofinformationqualitymainlyconsiders theinformationcontentitself(suchasdiscussionqualityand discussionintensity),notonlythenon-contentfactorssuchas informationsourcereliabilityandinformationquantity.

HSMPprovidesanin-depththeoreticalexplanationforhow individualsdealwithinformation,evaluateinformation,use information,andformdecision-makingindifferentsituations, whichiswidelyusedtoexploretheinfluencingfactorsand situationalconditionsofheuristicandsystematicinformation behavior(ChandranandAlammari,2020). Wirthetal.(2007) proposedthatinformationsearchbehaviorcanbedividedinto heuristicandsystematicpatterns,andtheimportanceofsearch

experienceandsearchresultsisthemainfactortodistinguish thetwobehaviorpatterns(Wirthetal.,2007). Lucassenetal. (2011) pointedoutthatforWikipedia,studentswithahigh degreeoftrusttendtoadoptheuristicinformationbehavior mode,andpaymoreattentiontothequantityofinformation. Onthecontrary,theytendtoadoptsystematicinformation behaviormodeandpaymoreattentiontothequalityof information(Lucassenetal.,2011). Zhangetal.(2014) believed thatconsumers’acceptanceofonlinecommentinformationis adualprocess,includingheuristicandsystematicbehaviors, informationsourcereliabilityandcommentquantitycognition areheuristicvariables,commentqualityissystematicvariables, andbothvariableshaveasignificantimpactonconsumers’ behaviorattitude(Zhangetal.,2014).

Atpresent,therearelittleresearchesonknowledgesharing usingHSMP.Comparedwiththetechnologyacceptancemodel andusersatisfactionmodel,theadvantagesofHSMPliein thatthemodelisnotafixedtheoreticalmodelcomposedof severalspecificvariables,butageneralframeworkandbehavior paradigmofbehaviordecision-makingresearch,whichhasa strongtheoreticalexpansionandexplanatorypower.Using HSMPtostudythesustainableknowledgesharingofvirtual academiccommunitycanidentifythekeyinfluencingfactorsand mechanismofknowledgesharingsatisfactionandsustainable willingnessfromthegeneralruleofbehaviordecision-making, withoutthelimitationofintrinsicvariablesandtheirrelations.

RESEARCHMODELANDHYPOTHESIS

HypothesesinSatisfactionModel

Satisfactionreferstotherecognitiondegreeofusersforproducts, services,andbehaviorprocesses,includingtheevaluationafter adoptionandthefeelingstateformedintheuseprocess (ChangchitandKlaus,2020).Satisfactionhasastablepositive correlationwiththeuser’sintentiontocontinuetouse,whichcan predicttheuser’sintentiontocontinuetouse(Bae,2017).Forthe virtualacademiccommunity,usersatisfactionisthepremiseofits sustainabledevelopment.Iftheuserisnotsatisfied,itwillreduce communityactivitiesandevencanceltheaccount(Borcsaand Pomini,2017).Therefore,inthevirtualacademiccommunity, thesatisfactionofknowledgesharinghasapositiveimpacton sustainablewillingness,andtherelationshipbetweenthemisas follows:

• H1:thereisapositivecorrelationbetweensatisfaction ofknowledgesharingandsustainableknowledgesharing willingnessinvirtualacademiccommunity.

RelevantHypothesesofHSMP

Knowledgesharingbehaviorinvirtualacademiccommunity isacomplexdualprocessandhastwokindsofbehaviors: heuristicandsystematic,whichareaffected,respectively.The directmeasurementofheuristicandsystematiccuesistosee theamountofinformationprocessedandthedegreeoffine processing,whichisdifficulttooperate.Somescholarstrytouse indirectmeasurementtoexploretwokindsofclues,thatis,to

investigatepeople’sprocessingmethodsofinformationcontent characteristicsandexternalcharacteristics. Zhangetal.(2014) regardedthequantityperceptionandsourcecredibilityofonline reviewsascluesofheuristicbehavior,andthecognitionand discussionintensityofinformationdegreeascluesofsystematic behaviortostudytheimpactofonlinereviewsononline shopping(Zhangetal.,2014).Thebehaviorpatternregardsthe topofthepageasaheuristicbehaviorandthemiddleposition asthesystembehavioraccordingtothelocationwheretheuser clicksonthesearchpage(Kimetal.,2014; Ghosesetal.,2018).

BecausetheHSMPdoesnotputforwardspecificcriteria fordividingheuristicandsystematicbehaviors,theacademic communityhasnotformedaunifiedviewonthemeasurement scaleofthetwobehaviors(Schemeretal.,2008).Accordingto theresearchof Chaiken(1980),explicitfactorssuchasexternal cuesofbehaviorandformalcharacteristicsofinformationare regardedasheuristicvariables,potentialfactorssuchascentral cuesofbehaviorandinternalcharacteristicsofinformation areregardedassystematicvariables,andreliabilityandquality arethemostimportantinfluencingfactorsofinitiatingand systematicbehaviors,respectively(Chaiken,1980).Intheprocess ofknowledgesharinginvirtualacademiccommunity,knowledge qualityandusefulnessjudgmentneedmorecognitiveresources toanalyzethecontentandvalueofknowledgesharing,soit canbeusedastheinfluencingfactorofsystematicbehavior. Thejudgmentofknowledgequantityandcredibilityisrelatively simplethinkingofexternalavailableclues,whichconsumes relativelylesscognitiveresources,andcanbeusedasan influencingfactorofheuristicbehavior.

RelevantHypothesesofSystematicVariables

Thequalityandusefulnessofknowledgesharingaretwomain indicatorstomeasurethelevelofknowledgesharing,which reflectthevalueofknowledgesharingamongmembersof virtualacademiccommunity.Manystudiesshowthatquality, usefulness,andsatisfactionofknowledgesharingarerelated. BounckenandAslam(2019) pointedoutthatthehigherthe qualityofsharedknowledge,themoreexpecteditis,thehigher theusersatisfaction(BounckenandAslam,2019). Gangand Ravichandran(2015) pointedoutthatusefulnessisanimportant factoraffectingcommunitysatisfaction(GangandRavichandran, 2015).Therefore,ifthevirtualacademiccommunitycanprovide userswithtimelyandhighlyrelevantknowledgetodiscuss topics,andincreaseusers’usefulawarenessofknowledgesharing, thenusers’satisfactionwiththeknowledgesharingprocesswill beimproved.Basedonthis,thispaperproposesthefollowing assumptions:

• H2:thereisapositivecorrelationbetweenquality andsatisfactionofknowledgesharinginvirtual academiccommunity.

• H3:thereisapositivecorrelationbetweentheusefulness andsatisfactionofknowledgesharinginvirtualacademic community.

RelatedHypothesesofHeuristicVariables

Thecredibilityofknowledgesourcereferstotheusers’overall perceptionofthecredibilityofknowledgesource,includingthe

reliabilityandprofessionalismofknowledgesource,inwhichthe reliabilityisrelatedtothefamiliarityofcommunitymembers toknowledgecontributorsandtherecognitionofknowledge. Professionalismisrelatedtotheprofessionalexperience, academicinfluence,andsocialidentityofknowledgecontributors inrelevantfields.Whenpeopleadoptheuristicbehavior,they usuallyregardsourcecredibilityasthemainbasisfordecisionmakingandjudgment,andthinkthat“expertopinioniscorrect” and“expertmeansauthorityandreliability”(Bonneretal.,2006). Borattoetal.(2016) showedthatpersuasiveinformationwith highsourcereliabilitycanstimulateusers’positiveevaluation (Borattoetal.,2016).Therefore,thispaperholdsthatthereis thefollowingrelationshipbetweenthecredibilityofknowledge sourceandthesatisfactionofknowledgesharinginvirtual academiccommunity:

• H4:thereisapositivecorrelationbetweenthecredibility ofknowledgesourceandsatisfactionofvirtualacademic community.

Quantityofknowledgesharingisanotherimportantheuristic clue,whichplaysanimportantroleinusersatisfaction evaluation(Altmanetal.,2018).Thispaperstudiesthenumbers ofknowledgesharingfromfouraspects:totalknowledge, theinformationcontained,updatefrequency,andseveral participants.Whenpeopletakeheuristicevaluationtothe satisfactionofknowledgesharing,theyoftenjudgethesignificant characteristicsandexternalperformanceofknowledgesharing simplyaccordingtoexperienceandintuition.Manystudies alsousequantityasaheuristicvariable. Chaiken(1980) took theamountofinformationandthepreferencesofinformation recipientsastheinfluencingfactorsoftheevaluationofthe informationreceptioneffect(Chaiken,1980). Gaoetal.(2012) foundthatthemoretheamountofreferenceinformation,the moreconducivetoreducingthedifferencesinusers’expectations ofproductsandimprovingusers’satisfaction(Gaoetal.,2012). Accordingly,thefollowingassumptionsareproposed:

• H5:thereisapositivecorrelationbetweenthequantity ofknowledgesharingandsatisfactionofvirtualacademic community.

HypothesesBetweenHeuristicVariables andSystematicVariables

AccordingtotheHSMP,heuristicbehaviorandsystematic behaviorcanoccuratthesametime,andthetwobehaviors interactwitheachother,resultinginacertaindeviationin thefinalbehavior.Specifically,ifthetwobehaviorresultsare similar,userbehaviorhasthecharacteristicsofbothheuristicand systematicbehaviorpatterns.Thebehaviorresultsareintuitive andrational,andthetwobehaviorshaveanadditiveeffect.Ifthe resultsofthetwobehaviorsaredifferent,theyneedtofurther investigatethespecificsituation.Ifthesituationinformationis clearandtheconditionsareclear,thenthesystematicbehavior hasaweakeningeffectontheheuristicbehavior.Peopletendto adoptthesystembehaviorbasedonrationaljudgment,otherwise, theheuristicbehaviorisdominant,peopletendtoadoptthe

heuristicbehaviorbasedonintuitivejudgment,andproduce irrationaldeviation.

Intheprocessofsatisfactionevaluationanddecision-making ofknowledgesharinginvirtualacademiccommunity,the credibilityofknowledgesourceandquantityofknowledge sharingcanstimulateusers’cognitionoftheusefulnessof knowledgeandactivelyinferthesharingresults.Chinnand Rinehartpointedoutthatthecredibilityofknowledgesources hasanimportantimpactonperceivedusefulness(Chinnand Rinehart,2016).Whenitisdifficultforcommunitymembersto judgethevalueofsubjectknowledge,ifthecredibilityofthese knowledgesourcesishigh,andtheamountofknowledgeshared islarge,thenthemembersarelikelytothinkthatknowledgeis ofhighusefulness.Therefore,thispaperproposesthefollowing assumptions:

• H6:thereisapositivecorrelationbetweenthecredibility ofknowledgesourceandperceivedusefulnessinvirtual academiccommunity.

• H7:thereisapositivecorrelationbetweenthequantity ofknowledgesharingandperceivedusefulnessinvirtual academiccommunity.

RelevantHypothesesofSocialImpact Variables

Virtualacademiccommunityisasocialorganizationbasedon anetwork.Knowledgesharingamongcommunitymembersis asocialexchangeactivity.Itsprocessandresultsareaffectedby socialcapitalfactors.Accordingtothetheoryofsocialexchange, peoplefollowtheprincipleofinterestexchangeintheprocess ofknowledgesharing,exchangeotherpeople’sknowledgeby contributingknowledgeorexpectsimilarhelpinthefuture, toachievemutualbenefit(Parketal.,2015).Theexpectation basedonmutualbenefitrepresentstheinvisiblenormof“mutual debt,”whichcanbeunderstoodasastrongsenseoffairness coexistingingivingandacquiring.Onlywhenknowledge contributionisrewarded,cancommunitymemberseffectively stimulatetheirwillingnesstocontinuouslycontributetheir knowledge? Gangulyetal.(2019) showedthatreciprocityhas animportantimpactonthequalityandquantityofknowledge sharing,andknowledge-collectorsmustreturnequalormore knowledgetotheircontributorstomaintainknowledgeexchange activities(Gangulyetal.,2019).Asanimportantrelationalsocial capital,reciprocitycanhelppeoplerealizethepotentialvalue ofknowledgesharing,andpromoteknowledgeexchangeand knowledgesharingbyimprovingpeople’sunderstandingand satisfactionoftheirpotentialneeds.Thestrongerthereciprocal beliefofmembersofvirtualacademiccommunity,themore willingtheyaretoparticipateinknowledgeacquisitionand exchangeactivities,andthemorewillingtheyaretosharemore high-qualityknowledgewithothers.Therefore,thispaperholds thatreciprocityhasthefollowingrelationswiththequantityand qualityofknowledgesharing:

• H8:thereisapositivecorrelationbetweenthereciprocity amongmembersofvirtualacademiccommunityandthe quantityofknowledgesharing.

• H9:thereisapositivecorrelationbetweenthereciprocity amongmembersofvirtualacademiccommunityandthe qualityofknowledgesharing.

Insocialorganizations,socialconnectionisanimportant contentofsocialcapitalstructure,andalsoanimportant channelforinformationexchangeandknowledgeacquisition, representingthestrengthofatwo-wayrelationshipbetween members.Closesocialconnectionmeansstability,trust,and cooperation,whichcanpromotemembers’understandingofthe overallobjectivesandbehaviorsoftheorganization,stimulate members’efforts,andreduceconcernsabouttheeffectiveness ofknowledgesharing,toensurethetransferandsharing ofhigh-qualityknowledge.Manystudieshaveconfirmedthe importantinfluenceofsocialcontactoninformationexchange andknowledgesharing.Researchontheevaluationofsocial e-commerceword-of-mouthindicatesthatsocialcontactcan effectivelypromoteusercommunication,whichhasasignificant impactonthequantityandqualityofonlineword-of-mouth (Gorayaetal.,2019). HallandMerolla(2020) measuredsocial connectionfromthreeaspects:communicationfrequency,time, andcloseness,whichshowedthatsocialconnectioncanstimulate theexternalmotivationofcommunitymembersandimprove thequalityofknowledgesharing(HallandMerolla,2020).In thevirtualacademiccommunity,thecloselyrelatedcommunity membersarewillingtosharemoreknowledgeandhigherquality. Accordingly,thefollowingassumptionsareproposed:

• H10:thereisapositivecorrelationbetweenthesocial connectionandthequantityofknowledgesharingamong membersofvirtualacademiccommunity.

• H11:thereisapositivecorrelationbetweenthesocial connectionamongmembersofvirtualacademic communityandthequalityofknowledgesharing.

Basedontheaboveassumptions,thisstudyproposesthe followingresearchmodel,asshownin Figure1.

MATERIALSANDMETHODS

SelectionofExperimentalPlatform

ThisstudymainlychooseResearchGATEandMendeleytocollect experimentaldata,see Figure2.ResearchGateisaprofessional networkcomposedofscientistsandresearchers.Atpresent,more than20millionmembersfromallovertheworldhaveusedit toshare,discoveranddiscussresearch.Itsmainfunctionsare toupdateresearchconsultationatanytime,communicatewith researchersinprofessionalfieldsintime,andprovidesustainable learningapproaches.Atthesametime,theplatformisfreeto openresearchtoallpeople,andhasstrictprivacyprotection technologyandserviceaimstoensurethesafetyofdataand sharedknowledge.Mendeleyisafreereferencemanagerand sharingplatform,whichhasbeenusedbymorethanonemillion users.Itsmainfunctionistohelpstore,organize,record,share, andquotereferencematerialsandresearchdata.Themain advantageofMendeleyisthatitcaneasilycollaboratewithother researchersonline,obtainliteratureandshareopinionsfrom

multiplesources.Basedontheaboveintroductionofthetwo platforms,itcanbeknownthatbothplatformsareopentothe outsideworldfreeofchargeandhavealargenumberofusers, whichisconvenientforlatersampleselectionanddatacollection. Atthesametime,thesetwoplatformsaretheinternational mainstreamacademicvirtualcommunityplatforms,whichhave beenrecognizedbyresearchers,soitisrepresentativetochoose thesetwoplatforms.

SampleSelection

Firstly,duringtheCOVID-19period,thispapercollected 500demographicinformationfromChina(includingTaiwan ProvinceandHongKong),theUnitedStates,Singaporeand Indonesiabyusingthevirtualacademiccommunityplatform. Allparticipantswereinformedofthepurposeofthisstudy andtheconfidentialityofdataatthebeginning,andonce theyfilledoutthequestionnaireofthisstudy,theyagreedto participate.Secondly,thisstudyrandomlyselected100people toconductpre-surveywithself-designedscale(see TableA1), itsmainpurposeistotestwhetherthereisanylanguage expressionorunclearmeaninginthequestionnaire.Atotal of62validquestionnaireswerecollectedinthepre-survey, andtheresearchersadjustedthemaccordingtothefeedback resultsofthepre-survey.Finally,because100peoplehave beenfilledoutandinterviewedinthepre-surveystudy,in ordertoensurethereliabilityandaccuracyofthedata,this studyexcludedtheseparticipantsintheformalsurvey,andthe remaining400peoplewereformallyinvestigatedinthisstudy, and256validquestionnaireswererecovered.Intermsofgender, 62%oftherespondentsweremaleand38%werefemale.In termsofprofessionaltitles,professorsaccountfor21%,associate professorsaccountfor32%,andlecturersandgraduatestudents accountfor47%;Asfarasagestructureisconcerned,82%are aged29–45,8%areover45,and10%areunder29.Interms ofsubjectbackground,thenaturalsciencesaccountedfor64%, andthesocialsciencesandhumanitiesaccountedfor36%.The studywasconductedbytheDeclarationofHelsinki(2002)and MeasuresforEthicalReviewofBiomedicalResearchInvolving Humans,MinistryofHealth,China.Theprotocolwasapproved bytheEthicsCommitteeofNanjingNormalUniversity.

Procedure

Inordertobetterdiscussandmeasuretheknowledgesharing willingnessofresearchersinvirtualacademiccommunity,this studyconductedacross-sectionalsurveyof500researchersfrom February2020toJune2020.Themainexperimentaldesign includesfourparts:firstly,gettingthescalefactorstructure andresearchhypothesisaccordingtotheresultsofHSMPand literaturereview.Secondly,100researcherswereselectedfor pre-surveyandinterviewtoensuretheaccuracyofthescale. Thirdly,theremaining400researcherswerefinallyfilledoutwith questionnairesandcollectedwithdata.Finally,SPSSandAmos areusedtoanalyzethedataanddrawaconclusion.Itisworth mentioningthatthereasonwhythisstudyadoptsonlinesurvey isthatitisdifficultforresearcherstocollectdatafacetofacedue totheoutbreakofepidemic.

System variable Quality of knowledge sharing

Reciprocity Social connection Satisfaction Of knowledge sharing

Usefulness of knowledge sharing

Sustainable knowledge sharing willingness

Credibility of knowledge source

Quatityof knowledge sharing

FIGURE1| Researchmodel.

FIGURE2| HomepagesofResearchGateandMendeley.

DataProcessing

Inordertodeterminewhetherthemeasurementhassatisfactory psychometricattributes,SPSS25.0andAmos24.0wereused toanalyzethedata.Firstly,descriptivestatisticsareusedto analyzethedatadistributionandCronbach α coefficientisused toevaluatethereliabilityofthescale,soastojudgewhetherthe sampledistributionissuitableforthenextanalysis.Secondly, analyzethecorrelationamongthevariablesandjudgewhether themodelcanbeconstructed.Finally,thestructuralequation modelisconstructedbyusingAmos24.0,andtherelationship amongthevariablesisdiscussed.

RESULTS

CommonMethodDeviationTest

Inthisstudy,thetestscaleisusedtoinvestigate,andallofthem areconductedinaunifiedway.Thecontentofthequestionnaire, thecharacteristicsoftheparticipantsandtheenvironmentof thetestmaycausecovariationbetweentheefficacystandard

andtheprediction,whichmayleadtodeviationoftheresearch results.Inordertoeffectivelyverifytheexistenceofcommon methoddeviation,Harmansinglefactortestwasadoptedinthis study,andexploratoryfactoranalysiswasmadeforallitems. Throughanalysis,whentheeigenvaluerootisgreaterthan1, thevarianceexplainedbythefirstfactoris17.43% < 40%. Therefore,thereisnoseriouscommonmethodde-viationamong thevariablesinthisstudy.

ReliabilityandValidityTestofthe MeasurementModel

Thereliabilityofthemeasurementmodelwasmeasuredby averagevarianceextracted(AVE),compositereliability(CR),and CronbachAlpha,withthelowestvaluesof0.5,0.7,and0.7, respectively.Asshownin Table1,theAVEvalueofallvariablesis greaterthan0.7,theCRofallvariablesisgreaterthanorequalto 0.886,andtheCronbach’sAlphaofallvariablesisgreaterthan orequalto0.777,indicatingthatthemeasurementmodelhas goodreliability.

Thevalidityofthemeasurementmodelincludescontent validityandconstructvalidity.Contentvalidityexaminesthe comprehensivenessandrepresentativenessofthecontentof themeasurementindicators.Asthemeasurementitemsofall variablescomefromexistingresearchandarepreinvestigatedin advance,theclarityandrelevanceofthemeasurementvariables areguaranteed.Constructionvalidityincludesaggregation validityanddifferentiationvalidity.Aggregationvalidityis measuredbyAVE,andthethresholdvalueofAVEis0.5. Accordingto Table1,allAVEvaluesarebetween0.711and0.901, indicatingthataggregationvalidityisgood.Itcanbeseenfrom Table2 thatthesquarerootofthemean-varianceofallvariables isgreaterthanthecorrelationcoefficient,sothediscrimination validityisgood.

TABLE1| Reliabilitytestofthemodel.

VariableNumbersAVECRCronbach’sAlpha

Sustainableknowledge sharingwillingness 30.8380.9410.922 Usefulnessof knowledgesharing 40.7980.9040.910 Qualityofknowledge sharing 40.7110.8860.876

Quantityofknowledge sharing 40.8120.9210.933

Reciprocity40.8610.9570.945 SatisfactionOf knowledgesharing 30.9010.9610.955 Socialconnection40.8910.9590.948 Credibilityofknowledge source 40.7210.8920.777

TABLE2| Correlationcoefficient.

Variable12345678

1.Sustainable knowledge sharing willingness

2.Usefulnessof knowledge sharing

3.Qualityof knowledge sharing

4.Quantityof knowledge sharing

0.922

0.6560.910

0.5330.5950.876

0.5010.4980.6220.933

5.Reciprocity0.6120.6880.5210.5670.945

6.Satisfaction ofknowledge sharing

0.7010.5990.5340.6960.5890.955

7.Social connection 0.3330.4210.3830.3330.3470.4660.948

8.Credibilityof knowledge source

FitAnalysisoftheStructuralModel

Partialleastsquaremethodisusedtoanalyzethestructural model,includingpathcoefficientamongvariables,significance degreeofthepath(allsignificantpathsaremarkedwith ∗ mark), andvarianceofvariableinterpretation(R2).Theanalysisresults areshownin Figure3.

Theresultsofthestructuralmodeltestshowthat50.1%of thedifferenceofsustainablewillingnessofknowledgesharing iscausedbythesatisfactionofknowledgesharing,andR2 (explainedvariance)ofsatisfactionofknowledgesharingis 54.6%,thatistosay,54.6%ofthevarianceofsatisfactionof knowledgesharingisexplainedbyvariousheuristicfactorsand systematicvariables,whichshowsthatthestructuralmodel hasbetterpredictioneffect.Besides,allhypothesesareverified. Thesatisfactionofknowledgesharinghasasignificantpositive effectonthesustainablewillingnessofknowledgesharing (β =0.701, P < 0.001).HypothesisH1isverified.Systematic factorsandheuristicfactorsarethekeypredictorsofsatisfaction ofknowledgesharing.Systematicfactorsincludethequalityof knowledgesharingandtheusefulnessofknowledgesharing, andtheirinfluencecoefficientsare0.121(P < 0.05)and 0.274(P < 0.001),respectively.Heuristicfactorsincludethe quantityofknowledgesharingandthecredibilityofknowledge sources,andtheirinfluencecoefficientsare0.444(P < 0.001) and0.141(P < 0.0),respectively1)(β =0.444, P < 0.001), assumingthatH2,H3,H4,H5areallverified.Thequantity ofknowledgesharingandthecredibilityofknowledgesource havesignificantpositiveeffectsontheusefulnessofknowledge sharing,theinfluencecoefficientsare0.374(P < 0.001)and 0.322(P < 0.001),respectively,assumingthatH6andH7 aretenable.Inaddition,thetwosocialinfluencevariablesof reciprocityandsocialconnectionhaveasignificantinfluence onsomeheuristicvariables(quantityofknowledgesharing) andsystematicvariables(qualityofknowledgesharing),and reciprocityhasasignificantinfluenceonthequalityofknowledge sharing(β =0.553, P < 0.001).Andthequantityofknowledge sharing(β =0.501, P < 0.001)hadagreaterimpact.Thesocial connectionhadasmallerimpactonthequalityofknowledge sharing(β =0.221, P < 0.001)andthequantityofknowledge sharing(β =0.218, P < 0.001),assumingthatH8,H9,H10,H11 werealltenable.

DISCUSSION

0.4890.4870.5240.4100.5870.4810.3670.777

WiththecontinuousdevelopmentofCOVID-19,itwill inevitablyleadtoanincreaseintheproportionofonline academicexchangesinthefuture.Duetovariousdiscomforts causedbytheinitialonlinesharing,thepublicationofa largenumberofrelatedstudiesfrom2019to2021canshow thatresearchersattachimportancetothisissue.However,the existingliteratureisdifficulttoprovideareliabletheoretical basistoensurethescientificnatureoftheresearch.Therefore,

Reciprocity

System variable Quality of knowledge sharing

0.553*** 0.501***

0.221*** 0.218***

Usefulness of knowledge sharing Credibility of knowledge source

R2=0.366 R2=0.324 R2=0.278

Social connection Satisfaction Of knowledge sharing

0.322* 0.374***

0.121* 0.274*** 0.141** 0.444***

Quatityof knowledge sharing

Heuristic variable

FIGURE3| Modelresults.*p < 0.05,**p < 0.01,***p < 0.001.

althoughHSMPismoreandmoreappliedtotheresearchof networkinformationbehavior,itislessappliedinthefieldof knowledgesharinginvirtualacademiccommunity,whichisan innovation.Inthispaper,thesatisfactionofknowledgesharing andsustainablewillingnessofknowledgesharingisregardedasa dualprocess,includingheuristicandsystematicbehaviors,which areaffectedbyheuristiccues(includingtwoheuristicvariables ofreliabilityofknowledgesourceandquantityofknowledge sharing)andsystematiccues(includingtwosystematicvariables oftheusefulnessofknowledgesharingandqualityofknowledge sharing).Twoheuristicvariableshaveasignificantimpactonthe usefulnessofknowledgesharing,whichisasystemvariable.The deviationeffectoftheHSMPisverified.Itcanbeseenthatthe applicationofHSMPfromthegeneralrulesofhumanbehavior decision-makingtoexploresatisfactionofknowledgesharingand sustainablewillingnessofvirtualacademiccommunitycanreveal theinfluenceandmechanismofvariousrationalandirrational factorsonthesatisfactionofknowledgesharingandsustainable willingnessofvirtualacademiccommunity.Itcanalsoprovide anovelandinterestingresearchperspectiveformorestudieson epidemicsituationandeducationinthefuture.

PracticeVerifiestheInfluencingFactors ofSustainableKnowledgeSharing

Inpractice,managersofvirtualacademiccommunitycan makeeffortstoimprovesatisfactionofknowledgesharingand sustainablewillingnessofvirtualacademiccommunitythrough fouraspects:

QualityandUsefulnessofKnowledgeSharing

Qualityandusefulnessofknowledgesharingaretwo systematicvariablesofsatisfactionevaluation,whichhavean importantimpactonsatisfaction.Forneworunfamiliarvirtual

0.734***

Sustainable knowledge sharing willingness

R2=0.546 R2=0.501

communities,usersusuallyadoptsystematicbehaviormodein theprocessofknowledgesharingandsatisfactionevaluation, mainlybasedonthequalityandusefulnessofknowledgesharing fordecision-making,whichconsumesmorecognitiveabilityand resources.Becausethevirtualacademiccommunityisaloose organizationformedbyself-organization,thereisnomandatory constraintmechanism,andtheremaybeintellectualproperty disputes,timelinessisnotstrong,innovationisnotenough, andtherelevancewiththediscussiontopicisnotstronginthe processofknowledgesharing.Atthesametime,theamount ofcommunityknowledgeislargeandgrowingconstantly,and communitymembersareinconvenienttoobtainhigh-quality knowledge,thusreducingtheusefulnessofknowledgesharing. Inviewofthis,thevirtualacademiccommunitycanidentify thepotentialhigh-qualitycontentbyusingthecombination ofmachinealgorithmandartificialscreening,useknowledge miningandsemanticretrievaltechnologytoachievetherapid acquisitionofcommunityknowledge,andcarryoutsemantic analysisanddeep-seatedaggregationofcommunityknowledge, buildaknowledgenavigationsystemwithinterrelatedcontent, multi-dimensionalandmulti-level,andprovidedeep-seated knowledgeservicesToimprovetheeffectivenessandusefulness ofknowledgesharing.

TheCredibilityofKnowledgeSourceandQuantityof KnowledgeSharing

Thecredibilityofknowledgesourceandquantityofknowledge sharingaretwoimportantheuristicvariables.Forvirtual communitieswithacertaindegreeofsocialrecognition,inthe processofsatisfactionevaluationandsustainablewillingness formationofuserknowledgesharing,communitymembers usuallyfollowtheprincipleofminimumeffortandtendto adoptheuristicbehaviormode,mainlybasedonthesource

(credibility)andsurfacecharacteristics(quantityofknowledge sharing)Itcostslesscognitiveeffortandresourcestojudge. Therefore,themanagersofvirtualacademiccommunitycan reducethecognitiveburdenofusersbyincreasingthecredibility ofknowledgesourcesandthenumberofknowledge:first,adopt thereal-namesystemtoimprovethecredibilityofusersand buildahigh-qualitycommunity;second,usePageRank,hitsand otherlinkalgorithmsforreference,comprehensivelyconsider theacademicauthorityandcommunityinfluenceofusers,and calculatetherankingvalueofcommunityusercredibility(Person Rank,PR);thethirdistomeettheuser’shumanneedstoshare knowledgeandbuildprestigeasmuchaspossible,learnfromthe experienceofcommunity,improvethepossibilityofnewusers beingrecognized,andencourageuserstocontinuetoparticipate inknowledgesharingactivities.

TheSatisfactionofKnowledgeSharingand SustainableWillingness

Heuristicbehaviorandsystematicbehaviorcanoccurat thesametime.Theprocessofsatisfactionofknowledge sharingevaluationandsustainablewillingnessformationhasthe characteristicsofbothheuristicandsystematicbehaviorpatterns, makingtheresultsbothintuitiveandrational.Community membersdeterminebehaviorpatternsmainlyaccordingto themotivationandabilityfactorsinspecificsituationsand seektherelativeoptimalsolutionintheprocessofweighing theminimumcognitiveeffortandthemaximumbenefit.In thisregard,managersofvirtualacademiccommunityneed toconsiderthebalancebetweenknowledgesharingbenefits andcognitivecosts,payattentiontocollectingandsaving knowledgesharingbehaviortracksandrelevantdata,and usebigdatatechnologyandmethodstodeeplyminethe professionalcharacteristics,researchpreferencesandbehavior habitsofcommunitymembers,soastoprovideanintelligent recommendationofknowledgesharing,sothatcommunity memberscanhavetheminimumcognitivecostgetthemostfrom knowledgesharing.

ReciprocityandSocialConnection

Heuristiccuesandsystematiccuesareaffectedbyexternalsocial capital.Reciprocityandsocialconnectionhaveasignificant influenceonthequantityandqualityofknowledgesharing, andtheinfluenceofreciprocityisgreaterthanthatofsocial connection.Knowledgesharinginvirtualacademiccommunity isacollectiveexchangebehavioramongmembers,andthe pursuitofinterestsisthekeyfactortopromotetheexchange behavior.Theinterestshereincludenotonlymaterialrewards, butalsopsychologicalrewardssuchasself-esteem,approval, support,andprestige,andpsychologicalrewardsareusually moreimportantthanmaterialrewards.Becauseofthis,the managersofvirtualacademiccommunityneedtotakeeffective measures.Forexample,establishaweakrelationshipbasedon interest,holdofflineactivities,promotemutualcommunication andrecognition,improvetrustamongmembers,enhancesocial contactandcommunityactivityamongmembers,andimprove theknowledgesharingeffectofvirtualacademiccommunity.

KnowledgeSharingUnderEpidemic SituationHelpsOnlineAcademic Development

Withtheoutbreakoftheepidemic,moreandmoreonlinetools havebeendeveloped.Themaingoalistoallowuserstocreate andparticipateinacademicactivitiesthroughcommunication, sharing,collaboration,publishing,managementandinteraction. Amongthesekeyfunctions,sharinghasalwaysbeenregarded asanimportantcomponentofsocialmedia,andthesustainable sharingwillaffectitsfuturedevelopmenttrend.Asoneofthe mainstreamsocialmediatoolsforacademiccommunication,the sharingofknowledgeandinformationhasbecomeoneofits basicfunctions.Knowledgesharingisdefinedastheprocess ofindividualsspreadingknowledgetoothers,whichessentially showsthatknowledgesharingneedssocialinteraction.However, knowledgesharinginvolvesthebehaviorthatindividualsmake othershavetheirownproprietarytechnologyandinformation sources,soitisveryimportanttopromotepersonalwillingness toshareknowledge.

Theresultsofthisstudyshowthatresearchersareoptimistic aboutknowledgesharinginvirtualacademiccommunities. Onlineknowledgesharingmakesiteasyforresearchersto obtaincutting-edgeknowledgeandencourageeachotherfrom otherresearchers,whilecutting-edgeknowledgeandfriendly interpersonalrelationshipscanenableresearcherstoactively considerthevalueofknowledgesharingasanacademicactivity, andalsohelpthemtoconductacademicresearchbetterunder manydifficultiescausedbytheepidemic.However,thissocial effectdependsonwhetherresearchersregardtheplatformasa sharedplatform,becausedifferentindividualsmayperceivethe sametechnologydifferently,whichmaysubsequentlyaffectthe waytheyinteractwiththetechnology.Therefore,theextentto whichresearchersthinkthattheplatformprovideseasyonline knowledgesharingmayalsodeterminethepossibilityoreven thesustainabilityoftheirwillingnesstoregardtheplatformasa valuableacademictool.Thisisalsoameaningfulfocusforfurther investigationinfutureresearch.

HowtoEffectivelyBuildaVirtual AcademicCommunityandHelpLearning

Withtheoutbreakoftheepidemic,onlinelearningplatformand onlineeffectivelearninghavebeenwidelyconcerned.Forawide rangeofacademicresearchers,acompleteandeffectiveacademic communityplatformhasbecomeanindispensabletoolfor futureresearch.Howtocreateacompleteacademiccommunity platformandimprovetheuseeffectofonlinelearningshouldbe discussedfromthreeaspects:researchers’sustainablewillingness toparticipate,academiccommunitymanagers’attentionand inputsupport,andthequalityofonlinelearningproducts.

Firstly,theresultsofthisstudyshowthatresearchers’ sustainablewillingnesstoshareknowledgeisatahighlevel, whichreflectsthatthereasonwhyaplatformisusedforalong timeisinfluencedbyresearchers’willingnesstouseit.Therefore, inthedevelopmentofacademiccommunity,itisnecessaryto paycloseattentiontousers’usefeelingsandproblemfeedback

atanytime,andtimelyhandleandsolveproblemstoensurethat researchers’usefeelingswillnotbegreatlyaffected.

Secondly,theorientationandfunctionofacademic communityneedtokeeppacewiththetimestoensurethe forefront,whichisconsistentwiththeneedsofresearchers. Therefore,itinvolvesthemanagementandmaintenanceof academiccommunitiesbymanagers,whomustensurethe smoothuseofplatformfunctions,updateandexpandthe resourcesneededbyresearchersinatimelymanner,andstrictly controltheprotectionofresearchdataandscientificresearch achievements.That’swhythisresearchchoosesResearcheGate andMendeleyasresearchplatforms,becausetheydowellenough toensurethattherearemillionsofusers.

Finally,ifindividualswanttoensureeffectiveonlinelearning, theyshouldbeclearaboutwhytheylearn.Onlinelearning requiresahigherlevelofself-control.Therefore,researchers shouldmakeacompletestudyplanbeforestudying.Inthe processoflearning,theacademiccommunitycanprovide researcherswithprofessionalsinthesameprofessionalfield, fromwhichyoucandiscussandsharetheconfusionand experienceoflearning,whichwillhelpyoudeepenunderstanding ofthecontentandmaintaincontinuousenthusiasmforlearning. Mendeley,forexample,cancommentontheliteratureread onlineandshareitwiththestudygroupintime.Inaddition tostudying,itisdifficultforustocommunicatefacetoface duetotheepidemicsituation,andtheonlinevirtualacademic communityprovidesuswiththefunctionofonlinemeeting. Therefore,researchersshouldkeepanoptimisticattitudetoward learningandacorrectwillingnesstoshareinordertoensurethat everyonecanobtainaccurateinformation.

LIMITATIONS

Therearesomelimitationsinexplainingthecurrentstudy.First, duringtheperiodofCOVID-19,datawereavailableonlythrough onlinetools.Althoughthescaleofthisstudyissubmittedto thevirtualacademiccommunityuserstofillinandretrievein time,theremaybesomedeviationinthedatabasis.Secondly, thesamplesizeofthisstudyislimited.Perhapsalargersample sizewillmakethisstudymoreeffective.Finally,althoughthe resultsofthisstudyconfirmtherelationshipbetweensustainable shareknowledgewillingnessandsomevariables,isthisresult moreseriousduringtheoutbreakthanbefore?Sincethisstudy cannotobtainpreepidemicdata,itisimpossibletocompare

REFERENCES

Altman,M.,Wood,A.,O’Brien,D.R.,andGasser,U.(2018).Practicalapproaches tobigdataprivacyovertime. Int.DataPrivacyLaw 8,29–51.doi:10.1093/idpl/ ipx027/4930711

Bae,M.(2017).Understandingtheeffectofthediscrepancybetweensought andobtainedgratificationonsocialnetworkingsiteusers’satisfactionand continuanceintention. Comput.Hum.Behav. 79,137–153.doi:10.1016/j.chb. 2017.10.026

Bonner,B.L.,Baumann,M.R.,Lehn,A.K.,Pierce,D.M.,andWheeler,E.C. (2006).Modelingcollectivechoice:decision-makingoncomplexintellective tasks. Eur.J.Soc.Psychol. 36,617–633.doi:10.1002/ejsp.305

andanalyzethewillingnesstoshareknowledgebeforeandafter theoutbreak,butthisstudycanexplorethefuturedataafter theepidemicsituationisstable.Therefore,thefutureresearch focusofthispaperwillalsoexplorewhetherthesustainable knowledgesharingwillingnessofvirtualacademiccommunity willbedifferentfromthatduringtheepidemicandwhether thereisamoredirectrelationshipwithotherfactorswhenthe epidemicisover,offlineacademicexchangesandknowledge sharingactivitiesarefullyrestored.

DATAAVAILABILITYSTATEMENT

Theoriginalcontributionspresentedinthestudyareincluded inthearticle/supplementarymaterial,furtherinquiriescanbe directedtothecorrespondingauthor/s.

ETHICSSTATEMENT

Thestudiesinvolvinghumanparticipantswerereviewed andapprovedbytheEthicsCommitteeofNanjingNormal University.Thepatients/participantsprovidedtheirwritten informedconsenttoparticipateinthisstudy.

AUTHORCONTRIBUTIONS

Allauthorslistedhavemadeasubstantial,directandintellectual contributiontothework,andapproveditforpublication.

FUNDING

ThisresearchwasfundedbyaJiangsuGraduateInnovation Project,grantno.“KYCX20_1145,”JiangsuProvince BasicEducationProspectiveTeachingReformExperiment Project,ChinaNationalFundforStudyAbroad,grantno. “202006860031,”andJiangsuProvinceUniversity’sAdvantageous DisciplineConstructionProject,grantno.“PAPD.”

ACKNOWLEDGMENTS

Thisstudywouldliketoextendoursinceregratitudetoreviewers.

Boratto,L.,Carta,S.,Fenu,G.,andSaia,R.(2016).Usingneuralwordembeddings tomodeluserbehavioranddetectusersegments. Knowl.BasedSyst. 108,5–14. doi:10.1016/j.knosys.2016.05.002

Borcsa,M.,andPomini,V.(2017).Virtualrelationshipsandsystemicpractices inthedigitalera. Contemp.Fam.Ther. 39,239–248.doi:10.1007/s10591-0179446-6

Bouncken,R.,andAslam,M.M.(2019).Understandingknowledgeexchange processesamongdiverseusersofcoworking-spaces. J.Knowl.Manag. 23, 2067–2085.doi:10.1108/JKM-05-2018-0316

Cabrera,A.,andCabrera,E.F.(2002).Knowledge-sharing dilemmas. Organ.Stud. 23,687–710.doi:10.1177/01708406022 35001

Cantor,F.(2019).Constructionofpublicpolicyofhighereducationwith participationoftheacademiccommunity,Colombian,caseforrecognitionof virtualanddistancelearningprograms. J.Phys.Conf.Ser. 1161:12001.doi: 10.1088/1742-6596/1161/1/012001

Castaneda,D.I.,andCuellar,S.(2020).Knowledgesharingandinnovation:a systematicreview. Knowl.ProcessManag. 27,159–173.doi:10.1002/kpm.1637

Chaiken,S.(1980).Heuristicversussystematicinformationprocessingandtheuse ofsourceversusmessagecuesinpersuasion. J.Pers.Soc.Psychol. 39,752–766. doi:10.1037/0022-3514.39.5.752

Chaiken,S.,Liberman,A.,andEagly,A.H.(1989). HeuristicandSystematic InformationProcessingWithinandBeyondthePersuasionContext.NewYork, NY:Guilford.

Chandran,D.,andAlammari,A.M.(2020).Influenceofcultureonknowledge sharingattitudeamongacademicstaffineLearningvirtualcommunitiesin saudiArabia. Inf.Syst.Front. 8,1–10.doi:10.1007/s10796-020-10048-x

Changchit,C.,andKlaus,T.(2020).Determinantsandimpactofonlinereviewson productsatisfaction. J.Int.Commer. 19,82–102.doi:10.1080/15332861.2019. 1672135

Cheng,H.,Zhang,N.,andYuan,Q.(2018).Researchprogressofknowledge exchangeinacademicvirtualcommunities. J.Mod.Inf. 5,158–163.doi:10. 3969/j.jssn.1008-0821.2018.05.025

Cheung,C.,andLee,M.(2007).“Whatdrivesmemberstocontinuesharing knowledgeinavirtualprofessionalcommunity?Theroleofknowledgeselfefficacyandsatisfaction,” KnowledgeScience,EngineeringandManagement eds Z.Zhang,andJ.Siekmann(Berlin:Springer)472–484.doi:10.1007/978-3-54076719-0_46

Chinn,C.A.,andRinehart,R.W.(2016).Commentary:advancesin researchonsourcing—sourcecredibilityandreliableprocessesforproducing knowledgeclaims. Read.Writ. 29,1701–1717.doi:10.1007/s11145-0169675-3

Chiu,C.M.,Wang,E.T.G.,Shih,F.J.,andFan,Y.W.(2011). Understandingknowledgesharinginvirtualcommunities:anintegrationof expectancydisconfirmationandjusticetheories.1,134–153.doi:10.1108/ 14684521111113623

Cristofaro,M.(2017).Herbertsimon’sboundedrationality:itshistoricalevolution inmanagementandcross-fertilizingcontribution. J.Manag.Hist. 2,170–190. doi:10.1108/JMH-11-2016-0060

Gang,K.,andRavichandran,T.(2015).Exploringthedeterminantsofknowledge exchangeinvirtualcommunities. IEEETrans.Eng.Manag. 62,89–99.doi: 10.1109/TEM.2014.2376521

Ganguly,A.,Talukdar,A.,andChatterjee,D.(2019).Evaluatingthe roleofsocialcapital,tacitknowledgesharing,knowledgequalityand reciprocityindetermininginnovationcapabilityofanorganization. J.Knowl.Manag. 23,1105–1135.doi:10.1108/JKM-03-20180190

Gao,J.,Zhang,C.,Wang,K.,andBa,S.(2012).Understandingonlinepurchase decisionmaking:theeffectsofunconsciousthought,informationquality,and informationquantity. Decis.SupportSyst. 53,772–781.doi:10.1016/j.dss.2012. 05.011

Ghoses,A.,Ipeirotis,P.G.,andLi,B.(2018).Modelingconsumerfootprintson searchengines:aninterplaywithsocialmedia. Manag.Sci. 65,1363–1385. doi:10.1287/mnsc.2017.2991

Goraya,M.A.S.,Jing,Z.,Shareef,M.A.,Imran,M.,andMalik,A.(2019). Aninvestigationofthedriversofsocialcommerceande-word-of-mouth intentions:elucidatingtheroleofsocialcommerceinE-business. Electronic Mark. 31,181–195.doi:10.1007/s12525-019-00347-w

Hall,J.A.,andMerolla,A.J.(2020).Connectingeverydaytalkandtimealoneto globalwell-being. Hum.Commun.Res. 46,86–111.doi:10.1093/hcr/hqz014

Kim,S.,Qin,T.,Liu,T.,andYu,H.(2014).Advertiser-centricapproachto understanduserclickbehaviorinsponsoredsearch. Inf.Sci. 276,242–254. doi:10.1016/j.ins.2014.02.058

Lucassen,T.,Noordzij,M.L.,andSchraagen,J.M.(2011).“Referenceblindness: theinfluenceofreferencesontrustinWikipedia,”in ProceedingsoftheACM WebScienceConferenceGermany,(NewYork,NY:ACM)1–4.

Marquez,J.,Villanueva,J.,Solarte,Z.,andGarcia,A.(2016).IoTineducation: integrationofobjectswithvirtualacademiccommunities. Adv.Intell.Syst. Comput. 444,201–212.doi:10.1007/978-3-319-31232-3_19 Park,J.,Lee,H.,andLee,J.(2015).Applyingsocialexchangetheoryin ITservicerelationships:exploringrolesofexchangecharacteristicsin knowledgesharing. Inf.Technol.Manag. 16,193–206.doi:10.1007/s10799-0150220-x

Ranjbarfard,M.,andSureshjani,M.H.(2018).Offeringaframeworkforvaluecocreationinvirtualacademiclearningenvironments. Interact.Technol.Smart Educ. 15,2–27.doi:10.1108/ITSE-08-2017-0040

Rice,R.E.,Heinz,M.,andVanZoonen,W.(2018).Apublicgoodsmodel ofoutcomesfromonlineknowledgesharingmediatedbymentalmodel processing. J.Knowl.Manag. 23,1–22.doi:10.1108/jkm-06-2018-0360

Schemer,C.,Matthes,J.,andWirth,W.(2008).Towardimprovingthevalidity andreliabilityofmediainformationprocessingmeasuresinsurveys. Commun. MethodsMeas. 2,193–225.doi:10.1080/19312450802310474

Wirth,W.,Böcking,T.,Karnowski,V.,andvonPape,T.(2007).Heuristicand systematicuseofsearchengines. J.Comput.Mediat.Commun. 12,778–800. doi:10.1111/j.1083-6101.2007.00350.x

Zhang,K.Z.K.,Zhao,S.J.,Cheung,C.M.K.,andLee,M.K.O.(2014).Examining theinfluenceofonlinereviewsonconsumers’decision-making:aheuristic–systematicmodel. Decis.SupportSyst. 67,78–89.doi:10.1016/j.dss.2014. 08.005

ConflictofInterest: Theauthorsdeclarethattheresearchwasconductedinthe absenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasa potentialconflictofinterest.

Copyright©2021Chen,Liu,Wen,LingandGu.Thisisanopen-accessarticle distributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY). Theuse,distributionorreproductioninotherforumsispermitted,providedthe originalauthor(s)andthecopyrightowner(s)arecreditedandthattheoriginal publicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.No use,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms.

APPENDIX

TABLETA1| Scaleofsustainableknowledgesharinginvirtualacademiccommunity.

Serialnumber Topic 1

Iliketohelpothersbysharingmyknowledge. 2 IamconfidentthatIcanprovidevaluableknowledgetoothers. 3 Ihavetheabilitytoprovidevaluableknowledge. 4 Ibelievethatasolidknowledgebaseiseasiertoacceptnewknowledge. 5 Iamgoodatsharingnewknowledgetoworkorstudy. 6 Iamgoodatapplyingnewmethodsofknowledgesharingtoworkorstudy. 7 Sharedknowledgeishelpfultomyworkorstudy. 8 Sharedknowledgeisrelatedtothetopic. 9 Sharedknowledgeisrigorousandaccurate. 10 Sharedknowledgeiscomplete. 11 Sharedknowledgeistimely. 12 Richknowledgetopicsprovidedbyvirtualcommunity. 13 Sufficientknowledgeprovidedbyvirtualcommunity. 14 Theknowledgesharedbyvirtualcommunitycontainsabundantinformation. 15 Theknowledgetopicofvirtualcommunityupdatingandsharing. 16 Iamwillingtoshareknowledge. 17 Iamnotwillingtoshareknowledge. 18 Iwouldliketoparticipateinthediscussionofvirtualcommunity. 19 Iwouldliketorespondtothetopic. 20 Iamsatisfiedwithvirtualcommunityproducts. 21 Iamsatisfiedwithvirtualcommunityservice. 22 Iamsatisfiedwiththeuseofvirtualcommunities. 23 Icanfindthesameprofessionalinthevirtualcommunity. 24 Ihavepeopleinclosecontactwiththevirtualcommunity. 25 Icanbuildfriendshipsinvirtualcommunities. 26 Ibelongtoatopicorganizationofvirtualcommunity. 27 Theknowledgesharedbyvirtualcommunityisbasedonmywillingness. 28 Theknowledgesharedbyvirtualcommunityisauthoritative. 29 Knowledgerecognitionofvirtualcommunitysharingishigh. 30 Theknowledgesharedbyvirtualcommunityshouldbetrusted.