Impact of the Coronavirus Pandemic on Family Well-Being: A Rapid and Scoping Review

The coronavirus disease of 2019 (COVID-19) has had a serious impact not only on the society, economy, and medical system, but also on the families and family members affected by it. This scoping review aimed to describe the effects of the COVID-19 pandemic on family well-being. Original articles in English published between January 2020 and August 2021 that examined the association between COVID-19 and family well-being, were searched on MEDLINE and CINAHL. The literature search was conducted using Mesh or CINAHL Subject Headings on COVID-19 and families. Of the 923 references extracted from MEDLINE and CINAHL, this review included 25 references based on exclusion criteria. The largest number of articles examined the impact of COVID-19 on family caregivers’ mental health, followed by its impact on family relationships. The pandemic reportedly worsened family relationships and functioning, increasing domestic violence. The increased burden of caregiving for children and older adults due to COVID-19 was a risk factor for poor physical, psychological, and social health among family caregivers. The workplace environments and health conditions of workers involved with COVID-19 patients affected their family members’ physical, psychological, and social health. The social and economic impact of the pandemic could change the internal family system and the permeability of its boundaries, ne-cessitating strategies to maintain an open family system. Additionally, family caregivers are at high risk for poor mental health and need a provision of psychosocial support. Moreover, devising strategies to improve workplace environments and alleviate health issues of workers involved with COVID-19 patients would be crucial for better mental health among their family members.


Introduction
A pneumonia of unknown cause, which was later identified as coronavirus disease of 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first diagnosed in Wuhan [1]. The World Health Organization declared COVID-19 a global pandemic on March 11, 2020 [2]. In the context of this pandemic, governments worldwide have taken measures to prevent and control COVID-19 infection [3], which has had a serious impact not only on the society, economy, and medical system, but also on individuals who are surrounded by these systems.
The COVID-19 pandemic is considered a type of Chemical, Biological, Radiological Nuclear, and high-yield Explosive (CBRNE) disaster [4]. A CBRNE disaster includes the uncontrolled release of hazardous chemicals, biological agents, or radioactive substances into the environment, potentially combined with explosions that cause widespread damage [5]. CBRNE disasters cause social disruption (e.g., discrimination, slander, bullying, increase in false rumors and misinformation, dissatisfaction, and discontent with the government and community), economic deterioration (e.g., job loss, decline in economic activities, and shortage of supplies), limitations and changes in individual behaviors (e.g., avoidance of travel and going out, and increase in alcohol and tobacco use), and poor public and individual health (e.g., damage to the medical system) [6] [7] showed that quarantine particularly deteriorated individual mental health (e.g., by increasing anxiety, depression, irritability, posttraumatic stress, and emotional exhaustion) [8].
Although previous studies have emphasized the psychological effects of infection outbreaks and their subsequent quarantine on individuals, they could also influence well-being in a family composed of individuals interacting with each other. According to the family systems theory, the family as a system exists in a hierarchical structure within society, with the family and its members falling at a lower level [9]. Thus, changes in a society consequently affect families and their members hierarchically [9]. During the H1N1 influenza pandemic, being a healthcare worker involved with a patient, or hospitalization of a family member infected with the virus complicated the relationship between family members due to its associated health risks [10]. Considering all the prior studies on similar topics, there has been no systematic report on the effects of the COVID-19 pandemic, including measures to prevent and control it, on family health and wellbeing.
This scoping review therefore aimed to clarify the impact of the COVID-19 pandemic on family well-being, while considering the various steps implemented to mitigate its impact.
( Figure 1). Of these, 11 duplicates were excluded. The titles and abstracts of the remaining 902 articles were screened for eligibility, and 783 articles were excluded for the following reasons: 237 articles included no abstract, 39 were published in non-English, 25 did not focus on the COVID-19 pandemic, 465 did not focus on family well-being, and 17 were reviews, recommendations, comments, and editorials. The full publication of the remaining 119 articles was assessed for eligibility, and 94 articles were excluded for the following reasons: one did not focus on the COVID-19 pandemic, 81 did not focus on family well-being, and 12 were reviews, recommendations, comments, and editorials. There was no additional article found through screening the reference lists of the excluded review articles. Finally, 25 articles were included in this scoping review.
-Pregnant women during the COVID-19 pandemic were more likely to report sleep disturbance, depression, anxiety, and somatization, compared to before the pandemic.
-Family cohesion was a protective factor for depression, anxiety, and somatization, whereas family conflict was a risk factor.

Families of COVID-19 patients and survivors
Beck et al. -Family members reported the following stressors: worry about an individual with ASD being home all the time (55%), concern about becoming ill or an individual with ASD becoming ill (52%), financial difficulties (31%), worry about lack of care other than myself for an individual with ASD (22%), and separation from an individual with ASD (5%).
-ASD severity increased stress caused by COVID-19 restrictions among family members. -Family members who were more worried about the safety of front-line rescue workers had sleep disturbance and more posttraumatic stress than those who were less worried.
-Family members who were more worried about physical condition of front-line rescue workers had sleep disturbance and more depressive symptoms than family members who were less worried.

Family Health and Happiness
All studies exploring family health and happiness were conducted in Hong Kong [23] [25] [26]. In the study by Wong et al. [25], families perceived certain benefits of COVID-19 in terms of physical health (e.g., improved family hygiene and T. Soejima improved family physical health), and harm to mental health (e.g., increased family negative emotion and decreased family happiness). In the studies by Sit et al. and Wong et al. that used the same items about family health and happiness, fear of COVID-19 was negatively associated [23], and personal preventive behaviors such as washing hands and wearing masks were positively associated with perceived family health and happiness among family members in Hong Kong [26].

Family Relations
Families reported that while family and parent-child relationships worsened during the COVID-19 pandemic, they also improved in certain instances [16] [17] [18] [25], with families reporting improved family relationships rather than worsened ones in some studies [16] [25]. Members of families that engaged in personal preventive behaviors perceived that their families were more harmonious than those who did not [26]. Telecommuting was associated with couple relationships in Spanish families [17]. In contrast, job loss and financial concerns caused by the COVID-19 pandemic, fear of infection with COVID-19, and stress that the pandemic exacerbates an existing mental health problem, worsened couple, parent-child, and family relationships (e.g., increased harsh words, conflicts and yelling/shouting) [16] [23].
Two qualitative studies exploring family relationships among families of Covid-19 patients were conducted in Iran [29] [30]. When family caregivers lived with and provided care to COVID-19 patients, they became more interested in and appreciative of each other [30]. Family members described that the death of a member, especially a father, had a very adverse effect on the stability of their family [29].

Family Functioning
Compared to before the pandemic, Chinese pregnant women reported less family cohesion and more family conflicts and independence during COVID-19 [27]. Similarly, family cohesion and expressiveness during the COVID-19 pandemic was lower than before among parents with typically developing children, children born very preterm, or children with congenital heart diseases in Switzerland [37].

IPV and CAN
No difference was found in the frequencies and severities of IPV and CAN before and during the lockdown among families with high risk of IPV and/or CAN in the Netherlands, but half of them reported frequent and serious violence during the containment [24]. Compared to before the lockdown, more than half of Bangladeshi mothers with experiences of IPV reported that emotional, sexual, and physical (moderate and severe) violence increased during the confinement [19].

Family Members' Physical Health
Chinese pregnant women reported sleep disturbance more frequently during the COVID-19 pandemic than before it [27]. Household chaos and stress related to the lockdown were negatively related to sleep time and physical activities among parents of preschoolers in the USA [20]. Family members providing care for COVID-19 patients at home reported sleep disturbance and fatigue as the most common physical problems [30]. Family caregivers of individuals with disabilities had more fatigue and sleep disturbance than non-family caregivers, and these symptoms worsened with increased caregiving burden related to COVID-19 [33].
More than half of the Chinese family members of front-line rescue workers had sleep disturbance with increased worry regarding the workers' physical condition and access to of supplies; a greater impact of front-line work on their daily lives was associated with more sleep disturbance [39].

Family Members' Mental Health
The COVID-19 pandemic and the subsequent lockdown increased psychological problems such as depression, anxiety, and somatic symptoms among pregnant women, and parents with infants or children aged < 18 years at home [16] [19] [27]. Among family members with nursing students, 26% indicated moderate to severe symptoms of depression after the first 10 days of lockdown associated with COVID-19 [21]. Eight percent of parents with children aged < 18 years at home reported suicidal ideation or self-harm during the pandemic, which was at a higher proportion than for parents without children at home (2%) [16]. Parenting for children, alongside caregiving and its increased burden for older adults during COVID-19 aggravated parents' and family caregivers' mental health [16] [22]. The belief that COVID-19 and the lockdown phase increased health problems influenced the worsening of depression among family members of nursing students [21]. Family cohesion perceived by pregnant women decreased their anxiety, depression, and somatization symptoms, while family conflict increased the perception of these symptoms [27].
Qualitative studies found that family members who had COVID-19 patients or experienced their deaths, described COVID-19 as difficult and terrifying, feeling fear, anxiety, worry, sadness, and hopelessness; they also reported negative preoccupation about patients' progress, feeling powerless to manage their symptoms and guilt that they may have transmitted the virus to their families, causing their deaths [29] [30]. Sixteen percent of family members with COVID-19 patients had anxiety, and 15% had depression [28]. The burden associated with COVID-19, such as the risk of infection and isolation from patients, and their death increased depression and anxiety [28].
Family members of individuals with disabilities reported aggravation of depression, anxiety, parenting stress, and psychological distress due to the COVID-19 pandemic and its subsequent lockdown [32] [33] [34] [35]. Increased severity of disabilities [32] [34], caregiving burden [33], and lack of support [32] for in-dividuals with disabilities were negatively related to mental health. In addition, during the COVID-19 pandemic and its subsequent lockdown, family caregivers of children with type 1 diabetes or kidney failure reported depression, anxiety, and pandemic-related emotional burden (e.g., feeling worried and afraid of being infected with the virus) [36] [38].
Among family members of workers involved with COVID-19 patients, 34% -49% reported anxiety, 12% -29% reported depression, 10% reported posttraumatic stress, and 8% reported suicidal ideation [39]. Worries about the safety and physical condition of workers, lack of supplies for workers, a greater impact of their job on their daily life, more time spent thinking about COVID-19, and longer working time of workers deteriorated psychological problems among family members [39] [40].

Family Members' Social Health
Family caregivers who had COVID-19 patients or experienced their deaths described that healthy people in the community were terrified of interacting with them, and would rather stay away from them, making them feel socially rejected and lonely [29] [30].
During the pandemic, family caregivers of individuals with disabilities reported less ability to participate in social activities than non-family caregivers.
Those who reported a greater impact of COVID-19 on their caregiving also had less social participation than family caregivers who reported less impact [33].

Family Members' QOL
Partners and family members of COVID-19 survivors reported that the poor dimension of the Family Reported Outcome Measure measuring their QOL was feeling worried, followed by the dimension of family activities, frustration, holiday, and sex life [31]. Partners and family members with a COVID-19 history experienced a greater impact on eating habits, work and study, family activities, holiday, sex life, and sleep than those with no history.

Discussion
This scoping review provides an overview of the current state of knowledge regarding the impact of the COVID-19 pandemic on family well-being. Twenty-five studies included in this review covered a variety of families, regardless of whether they had diseases and disabilities, and examined the association of COVID-19 with the health and well-being of whole families as well as individual members. This review suggested that due to the COVID-19 pandemic, families concurrently perceived deterioration of family relationships and experienced poor family functioning, and an increase in IPV and CAN. Family members also reported an impairment in physical, mental, and social health due to the pandemic, with an increase in caregiving burden for family members being negatively associated with physical, mental, and social health among family members.
Moreover, the work environment and condition of workers involved with Covid-19 patients worsened their family members' physical, mental, and social health.
From the viewpoint of the family systems theory [9], pandemic-related changes in a society as the higher system and a family member as the lower system would affect a family. Decline in economic activities due to COVID-19 could lead to job loss of family members, subsequently worsening the family's economic status. In addition, encouragement of telework and the closing of schools could make family members spend more time together at home, potentially altering the roles each individual plays in their families. Since family members of COVID-19 patients experienced isolation and bereavement, their family structure could change. Such changes in the family's internal system would negatively affect family relationships (e.g., conflicts and tension among family members) and family functioning (e.g., lower family cohesion), which may result in increased IPV and CAN.
The COVID-19 pandemic and its subsequent lockdown deteriorated interactions between family members and the community, such as health care providers and neighbors. This reduced exchange of information and support between family members and their community, indicating reduced permeability at the boundaries of the family system [41]. A closed family system, which implies low permeability at the boundaries of the family system, would make it more difficult to introduce support into a family during the COVID-19 pandemic, as compared to before it. Strategies maintaining an open family system are therefore needed to improve family relationships, functioning and happiness, even during a pandemic.
The COVID-19 pandemic is considered a CBRNE disaster, and its impact on individual mental health has received attention [4] [5] [8]. In this scoping review, the largest number of studies revealed a negative impact of COVID-19 on family members' mental health [16] [40]. In addition, caregiving for family members, and its increased burden due to COVID-19, were negatively associated with family caregivers' mental health [16] [22] [33] [39]. During the outbreak of an infectious disease, family members in caregiving roles would be at high risk for the deterioration of their mental health, requiring psychosocial support. Moreover, complex grief and posttraumatic stress were reportedly associated with poor social health in adults who lost a loved one infected with COVID-19, such as friends [42]. Thus, the deterioration of family members' mental health may spill over to poor physical and social health. Therefore, preventing deterioration in family members' mental health may be the first step in maintaining family well-being.
The families of workers involved with COVID-19 patients also had poor mental health [39] [40]. In addition, workplace environments and the health status of these workers affected their family members' physical, psychological, and social health [39] [40]. A CBRNE disaster has negative impacts on the health care system, such as shortage of human resources and supplies, which would place the workers involved with COVID-19 patients in harsh working conditions, compromising their health [6] [7]. Thus, appropriate allocation of medical resources by a government and monitoring condition of workers involved with COVID-19 patients by medical institutions could improve health condition of both workers and their family members.
This scoping review had some limitations. First, most studies included in this review conducted cross-sectional quantitative and qualitative research, while few used longitudinal quantitative research. This study insufficiently indicated evidence of the impact of the COVID-19 pandemic on family well-being. Second, the studies included in this review targeted a variety of families and investigated many types of outcomes on family well-being. Moreover, these studies were conducted in countries with different policies to prevent the COVID-19 pandemic and a variety of medical and social welfare systems. This made it difficult to compare the results of each study. Finally, all studies in this review were conducted in 2020, demonstrating only short-term effects of the pandemic on family well-being. Therefore, the long-term impact of COVID-19 on family well-being should be investigated in future research.
In conclusion, this scoping review suggested that the COVID-19 pandemic and its subsequent lockdown were negatively associated with family well-being, including family relations and their mental and physical health, among various types of families. Considering a future pandemic of infectious disease, nurses need to develop strategies to maintain families' open systems during lockdowns and social distancing measures, while improving family members' mental health.

Funding
This study was supported by a JSPS KAKENHI Grant-in-Aid for Young Scientists (Grant Number 19K19639).