In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
Re iew
E ec o COVID-19 on Heal h-Rela ed Quali y o Li e in
Adolescen s and Child en: A Sys ema ic Re iew
Hadi Noba i 1,2,3,*,† , Mohamad Fashi 4,*,† , A ezoo Eskanda i 5, San os Villa aina 6,
Ál a o Mu illo-Ga cia 6and Jo ge Pé ez-Gómez 3


Ci a ion: Noba i, H.; Fashi, M.;
Eskanda i, A.; Villa aina, S.;
Mu illo-Ga cia, Á.; Pé ez-Gómez, J.
E ec o COVID-19 on
Heal h-Rela ed Quali y o Li e in
Adolescen s and Child en: A
Sys ema ic Re iew. In . J. En i on.
Res. Public Heal h 2021,18, 4563.
h ps://doi.o g/10.3390/ije ph
18094563
Academic Edi o : S e an Nilsson
Recei ed: 31 Ma ch 2021
Accep ed: 21 Ap il 2021
Published: 25 Ap il 2021
Publishe ’s No e: MDPI s ays neu al
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Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
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A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
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1Depa men o Physical Educa ion and Spo s, Uni e si y o G anada, 18010 G anada, Spain
2
Depa men o Exe cise Physiology, Facul y o Spo Sciences, Uni e si y o Is ahan, Is ahan 81746-7344, I an
3HEME Resea ch G oup, Facul y o Spo Sciences, Uni e si y o Ex emadu a, 10003 Cáce es, Spain;
[email p o ec ed]
4
Depa men o Biological Sciences in Spo s, Facul y o Spo Sciences and Heal h, Shahid Behesh i Uni e si y,
Teh an 198396-3113, I an
5Depa men o Exe cise Physiology, Facul y o Physical Educa ion and Spo s Science, Teh an Uni e si y,
Teh an 1417935840, I an; [email p o ec ed]
6Physical Ac i i y and Quali y o Li e Resea ch G oup (AFYCAV), Facul y o Spo Sciences,
Uni e si y o Ex emadu a, A . De Uni e sidad s/n, 10003 Cace es, Spain; [email p o ec ed] (S.V.);
[email p o ec ed] (Á.M.-G.)
*Co espondence: [email p o ec ed] (H.N.); [email p o ec ed] (M.F.)
† Au ho s con ibu ed equally o his s udy.
Abs ac :
The aim o he p esen sys ema ic e iew was o assess and p o ide an up- o-da e analysis
o he impac o co ona i us disease 2019 (COVID-19) pandemic on he heal h- ela ed quali y o li e
(HRQoL) o child en and adolescen s. Thus, an elec onic sea ch o he li e a u e, in wo well-known
da abases (PubMed and Web o Science), was pe o med un il Feb ua y 2021 (wi hou da e es ic ion).
PRISMA guideline me hodology was employed and da a ega ding he HRQoL we e ex ac ed om
eligible s udies. A icles we e included i hey me he ollowing inclusion c i e ia: (a) child en
and/o adolescen popula ion (4 o 19 yea s old); (b) HRQoL as a main assessmen ; (c) Ge man,
Spanish, Po uguese, F ench, and English language; and (d) p e-pandemic and du ing pandemic
HRQoL da a. Following he ini ial sea ch, 241 possible ela ed a icles we e iden i ied. A o al o
79 a icles we e iden i ied as duplica es. Mo eo e , 129 a icles we e emo ed a e eading he i le
and abs ac . O he emaining 33 a icles, 27 we e emo ed since hey we e no ocused on child en
o adolescen s (n= 19), a icles did no epo p e- and pos - pandemic HRQoL alues (
n= 6
), a icles
we e no ocused on HRQoL (n= 6), and one a icle was an edi o ial. Finally, six s udies ul illed he
inclusion c i e ia and, he e o e, we e included in he sys ema ic e iew. A o al o 3177 child en
and/o adolescen s du ing COVID-19 we e included in his sys ema ic e iew. Th ee a icles showed
ha COVID-19 pandemic signi ican ly impac ed he HRQoL o child en and adolescen s, and ano he
did no epo compa ison be ween p e- and du ing COVID-19 pandemic, al hough a educ ion in he
HRQoL can be obse ed. Ne e heless, wo a icles did no ind signi ican changes and ano he one
did no epo p- alues. Rega ding sex di e ences, only wo s udies analyzed his opic, obse ing
no di e ences be ween gi ls and boys in he impac o COVID-19 pandemic on HRQoL. Taking in o
accoun hese esul s, his sys ema ic e iew migh con i m ha COVID-19 has a nega i e impac on
he HRQoL o child en and/o adolescen s.
Keywo ds: adolescen ; COVID-19; child en; HRQoL; li es yle; wellbeing
1. In oduc ion
Heal h- ela ed quali y o li e (HRQoL) has been de ined as he le el o wellbeing con-
sequen om he e alua ion ha a pe son makes o di e se domains o his li e, conside ing
he impac hese ha e on his heal h s a us. I is cha ac e ized as subjec i e, mul idimen-
sional, and changing o e ime [
1
]. The HRQoL assessmen inco po a es a ea ly ages
In . J. En i on. Res. Public Heal h 2021,18, 4563. h ps://doi.o g/10.3390/ije ph18094563 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 4563 2 o 12
he pe cep ion o physical, psychological, and social wellbeing acco ding o e olu iona y
de elopmen and indi idual di e ences, wi hin a speci ic cul u al con ex , and conside s
he abili y o ully pa icipa e in he ac i i ies and he physical, social, and psychosocial
unc ions app op ia e o hei age. Child en wi h poo HRQoL a e less likely o de elop
no mally and ma u e in o heal hy adul s [2].
Many child en and adolescen s in de eloped coun ies lead seden a y li es yles, e-
duced ac i e leisu e ac i i ies, and inc eased eliance on seden a y li es yles [
3
]. Be o e he
COVID-19 pandemic, a p e ious s udy s a ed ha 81% o s uden s aged 11–17 yea s we e
insu icien ly physically ac i e [
4
]. Independen ly o physical ac i i y le els, seden a y
ac i i ies, especially hose based on he use o elec onic de ices, a e associa ed wi h an
inc eased isk o obesi y, a educ ion in physical condi ion, sel -es eem, and p osocial
beha io [
5
]. In his ega d, he COVID-19 pandemic has inc eased he amoun o sc een
ec ea ional ime [
6
,
7
]. This is qui e ele an since a p e ious sys ema ic e iew o e-
iews indica ed ha he e idence ha sc een ime was associa ed wi h poo e HRQoL was
mode a e [8].
In addi ion o inac i i y, s ess ul si ua ions such as co ona i us disease 2019 (COVID-
19) pandemic ha e a ec ed he HRQoL o child en. Home qua an ine condi ions and he
use o he In e ne o mobile phones ha e also been e ec i e in c ea ing hese condi ions.
The COVID-19 pandemic has led o apid, unp eceden ed changes o he li es o billions o
child en and adolescen s [9,10].
The impac o pandemic COVID-19 on HRQoL is no ye unde s ood su icien ly
well. Child en and adolescen s ace massi e changes in hei daily li es, including school
closu es, home con inemen , and social dis ancing ules, which can bu den hem sub-
s an ially [
11
,
12
]. Managing wi h he cu en si ua ion and complying wi h he cu en
es ic ions on op o his can be especially di icul o child en and adolescen s since
hese ci cums ances can be expe ienced as being incong uen wi h hei de elopmen al
asks. The challenges and consequences o COVID-19 migh he e o e ha e a emendous
impac on hei HRQoL [
13
]. In his ega d, p e ious o COVID-19 pandemic, anxie y was
he main men al diso de in bo h, child en, and adolescen s, wi h mo e han 15% o his
popula ion a ec ed by his diso de [14].
Fu he mo e, as commen ed be o e, es ic ion in mobili y, social dis ancing, o school
closu es ha e been inc eased seden a y beha io . Thus, i is expec ed ha HRQoL would
be educed in child en and adolescen s. P e ious s udies ha e indica ed ha HRQoL ha e
been educed due o COVID-19 [
15
,
16
] whe eas o he s did no ind di e ences [
17
,
18
].
Howe e , o he bes o ou knowledge, no sys ema ic e iew has syn hesized he exis ing
esul s in o de o cla i y his di e gence. To aim o he p esen sys ema ic e iew was
o assess and p o ide and up- o-da e analysis o he impac o he co ona i us disease
2019 (COVID-19) pandemic on he heal h- ela ed quali y o li e (HRQoL) o child en
and adolescen s.
2. Ma e ials and Me hods
The p esen sys ema ic e iew was conduc ed ollowing he guidelines included in
he P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses Guidelines
(PRISMA), o sea ch p ocedu es, s udy selec ion, and da a collec ion and analysis [
19
].
To achie e he objec i e o his esea ch we sys ema ically e iewed he li e a u e o
analyze obse a ional s udies which compa ed he HRQoL da a o he same child en and
adolescen s p e and pos /du ing COVID-19 pandemic. This would allow us o analyze i
COVID-19 pandemic had a nega i e e ec on HRQoL in child en and adolescen s.
2.1. Da a Sou ces and Sea ches
Two well-known da abases, PubMed and Web o Science (whe e Cu en con en s
connec , De wen inno a ions index, Ko ean jou nal da abase, Medline, Russian science
ci a ion index, and SciELO ci a ion index a e included), we e used o iden i y all he
obse a ional s udies, published un il 8 Feb ua y 2021, e alua ing HRQoL du ing COVID-
In . J. En i on. Res. Public Heal h 2021,18, 4563 3 o 12
19 pandemic in child en and/o adolescen s. The sea ch s ing used in all da abases was
(“co ona i us”[MeSH Te ms] OR “co ona i us”[All Fields] OR “co ona i uses”[All Fields]
OR (“sa s co 2”[MeSH Te ms] OR “sa s co 2”[All Fields] OR “co id”[All Fields] OR
“co id 19”[MeSH Te ms] OR “co id 19”[All Fields])) AND “Quali y o li e”[All Fields] AND
(“child”[MeSH Te ms] OR “child”[All Fields] OR “child en”[All Fields] OR “child s”[All
Fields] OR “child en s”[All Fields] OR “child ens”[All Fields] OR “childs”[All Fields] OR
(“adolescences”[All Fields] OR “adolescency”[All Fields] OR “adolescen ”[MeSH Te ms]
OR “adolescen ”[All Fields] OR “adolescence”[All Fields] OR “adolescen s”[All Fields] OR
“adolescen s”[All Fields])).
Th ee esea che s (M.F., A.E., and H.N) independen ly conduc ed he sea ch. Disc ep-
ancies we e sol ed by a discussion wi h a ou h in es iga o (A.D).
Figu e 1shows he a icle selec ion p ocess. The s udies we e included i hey me he
ollowing inclusion c i e ia: (a) child en (0–10 yea s-old) and/o adolescen s (10–19 yea s-
old) popula ion [
20
]; (b) HRQoL as a main assessmen ; (c) Ge man, Spanish, Po uguese,
F ench, and English language; and (d) p e-pandemic and du ing pandemic HRQoL da a.
Exclusion c i e ia we e (a) abs ac s, edi o ials, commen s, e iews, and guidelines, and (b)
pa icipan s we e su e ing om a majo heal h condi ion such as cance o disabili ies.
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 3 o 13
2.1. Da a Sou ces and Sea ches
Two well-known da abases, PubMed and Web o Science (whe e Cu en con en s
connec , De wen inno a ions index, Ko ean jou nal da abase, Medline, Russian science
ci a ion index, and SciELO ci a ion index a e included), we e used o iden i y all he ob-
se a ional s udies, published un il Feb ua y 8, 2021, e alua ing HRQoL du ing COVID-
19 pandemic in child en and/o adolescen s. The sea ch s ing used in all da abases was
(“co ona i us”[MeSH Te ms] OR “co ona i us”[All Fields] OR “co ona i uses”[All
Fields] OR (“sa s co 2”[MeSH Te ms] OR “sa s co 2”[All Fields] OR “co id”[All Fields]
OR “co id 19”[MeSH Te ms] OR “co id 19”[All Fields])) AND “Quali y o li e”[All
Fields] AND (“child”[MeSH Te ms] OR “child”[All Fields] OR “child en”[All Fields] OR
“child s”[All Fields] OR “child en s”[All Fields] OR “child ens”[All Fields] OR
“childs”[All Fields] OR (“adolescences”[All Fields] OR “adolescency”[All Fields] OR “ad-
olescen ”[MeSH Te ms] OR “adolescen ”[All Fields] OR “adolescence”[All Fields] OR
“adolescen s”[All Fields] OR “adolescen s”[All Fields])).
Th ee esea che s (M.F., A.E., and H.N) independen ly conduc ed he sea ch. Dis-
c epancies we e sol ed by a discussion wi h a ou h in es iga o (A.D).
Figu e 1 shows he a icle selec ion p ocess. The s udies we e included i hey me
he ollowing inclusion c i e ia: (a) child en (0–10 yea s-old) and/o adolescen s (10–19
yea s-old ) popula ion [20]; (b) HRQoL as a main assessmen ; (c) Ge man, Spanish, Po u-
guese, F ench, and English language; and (d) p e-pandemic and du ing pandemic HRQoL
da a. Exclusion c i e ia we e (a) abs ac s, edi o ials, commen s, e iews, and guidelines,
and (b) pa icipan s we e su e ing om a majo heal h condi ion such as cance o disa-
bili ies.
Figu e 1. Flow cha o he selec ion p ocess in his sys ema ic e iew.
2.2. Risk o Bias
The E idence P ojec isk o bias ool [21] has been used o assess he isk o bias. This
scale consis ed o eigh i ems, assessed as no, yes, no applicable, o no epo ed. The
Figu e 1. Flow cha o he selec ion p ocess in his sys ema ic e iew.
2.2. Risk o Bias
The E idence P ojec isk o bias ool [
21
] has been used o assess he isk o bias.
This scale consis ed o eigh i ems, assessed as no, yes, no applicable, o no epo ed.
The eigh i ems a e: (1) coho ; (2) con ol o compa ison g oup; (3) p e-pos in e en ion
da a; (4) andom assignmen o pa icipan s o he in e en ion; (5) andom selec ion o
pa icipan s o assessmen ; (6) ollow-up a e o 80% o mo e; (7) compa ison g oups
equi alen on sociodemog aphic; and (8) compa ison g oups equi alen a baseline on
ou come measu es. Two au ho s (A.M. and A.D.) e alua ed he isk o bias independen ly,
and disag eemen s we e sol ed by a discussion wi h ano he au ho (J.P.-G.).
In . J. En i on. Res. Public Heal h 2021,18, 4563 4 o 12
2.3. Da a Ex ac ion
We de eloped a da a ex ac ion shee (based on he s udy design, sample size, coun y,
popula ion—child en o adolescen s, ins umen o assessing HRQoL, p e and du ing
HRQoL alues). One e iew au ho (S.V) ex ac ed he ollowing da a om included
s udies and a second au ho checked he ex ac ed da a (A.M.-G). Disag eemen s we e
esol ed by a discussion wi h ano he au ho (J.P.-G.).
2.4. E idence Syn hesis and Da a Analysis
Syn hesis o esul s a e p esen ed wi h an ini ial desc ip ion o he s udy popula ion
(child en o adolescen s), including o al sample size and age ange, as well as he s udy
design o included s udies. Then, ins umen s used o assess he HRQoL and a gene al
summa y o COVID-19 impac on HRQoL o child en and adolescen s included in each
s udy will be p esen ed. A e ha , o each s udy a simple summa y wi h main esul s will
be ex ac ed. Due o he s udy design and he e ogenei y o included a icles, an es ima ed
e ec ac oss s udies wi h a con idence in e al could no be calcula ed.
3. Resul s
3.1. S udy Selec ion
Figu e 1 epo s he PRISMA low diag ams o he s udy selec ion. Following he
ini ial sea ch, 241 possible ela ed a icles we e iden i ied. A o al o 79 a icles we e
iden i ied as duplica es. Mo eo e , 129 a icles we e emo ed a e eading he i le and
abs ac (see Figu e 1 o easons). O he emaining 33 a icles, 27 we e emo ed since
hey we e no ocused on child en o adolescen s (n= 19), a icles did no epo p e- and
pos - pandemic HRQoL alues (n= 6), a icles we e no ocused on HRQoL (n= 6), and
one a icle was an edi o ial. Finally, six a icles we e included in he sys ema ic e iew (see
Figu e 1). De ails and cha ac e is ics o hese a icles a e also p o ided in Table 1.
Table 1. Risk o bias o included a icles using he E idence P ojec isk o bias ool.
S udy 1 2 3 4 5 6 7 8
Abawi (2020) Yes No Yes No No No NA NA
D agun (2020) Yes No Yes No No No NA NA
Ma os (2020) Yes No Yes No No Yes NA NA
Ra ens-Siebe e (2021)
Yes No Yes No No Yes NA NA
Vallejo-Slocke (2020) Yes No Yes No No No NA NA
Syzmanski (2018) Yes No Yes No No Yes NA NA
The eigh i ems a e (1) coho ; (2) con ol o compa ison g oup; (3) p e-pos in e en ion da a; (4) andom assignmen o pa icipan s o he
in e en ion; (5) andom selec ion o pa icipan s o assessmen ; (6) ollow-up a e o 80% o mo e; (7) compa ison g oups equi alen on
sociodemog aphic; and (8) compa ison g oups equi alen a baseline on ou come measu es. NA: non applicable.
3.2. Risk o Bias
The E idence P ojec isk o bias ool was employed in he p esen s udy (see
Table 1
).
This ool e alua ed he isk o bias o he six a icles included in his sys ema ic e iew.
A e e alua ing all o hem, six a icles ul illed c i e ia one and h ee (coho and p e-pos
measu emen s). Th ee a icles ul illed he c i e ia ela ed o he ollow-up a e o 80%
o mo e. Howe e , he mos c i ical conce ns a e ela ed o he andom assignmen o
pa icipan s o he in e en ion and he andom selec ion o pa icipan s o assessmen .
Two c i e ia, he compa ison g oup’s equi alen on sociodemog aphic measu es, and he
compa ison g oups equi alen a baseline on ou come measu es, we e no assessed due o
he obse a ional design o he s udies included in his sys ema ic e iew.
3.3. Syn hesis o Resul s
Table 2summa izes he impac o he COVID-19 pandemic on he HRQoL o child en
and adolescen s. A o al o 3177 child en and adolescen s ha e been included in his
sys ema ic e iew. The age anged be ween 4 o 18 yea s.
In . J. En i on. Res. Public Heal h 2021,18, 4563 5 o 12
Table 2. Main indings o child en and/o adolescen s HRQoL p e- and du ing COVID-19 pandemic.
Au ho Coun y S udy Design Sample Size
(Gi ls) Age (Yea s) Ques ionnai e HRQoL p-Value
P e-Pandemic Du ing-Pandemic
Abawi 2020 Ne he lands C oss-Sec ional 40 10.5 (7.6–15.2) PedsQL 66.2 (17.7) Change o
−6.3 (29.9) 0.26
D agun (2020) C oa ia C oss-Sec ional 531 (384) 18 (6.0) Like scale 8.0 (2.0) 7.0 (2.0) <0.001
Ma os (2020) B azil C oss-Sec ional 25 child en (10)
44 adolescen s (25)
9.56 (1.47)
16.3 (1.67) SF-36 - - <0.001 a
Ra ens-Siebe e
(2021) Ge many C oss-Sec ional 793 (396) 12.25 (3.30) KIDSCREEN-10
Low HRQol in Boys:
10.4%
Low HRQol in Boys:
35.7 % <0.001
Low HRQol in Gi ls:
20.4%
Low HRQol in Gi ls:
44.7 % <0.001
Low HRQol in Boys
and gi ls: 15.3%
Low HRQol in Boys
and gi ls: 40.2 % <0.001
P oxy esul s o 7- o
10-yea s-olds: 7.4%
P oxy esul s o 7- o
10-yea s-olds: 26.8% <0.001
P oxy esul s o 11- o
13-yea s-olds: 12.8%
P oxy esul s o 11- o
13-yea s-olds: 14.5% <0.001
Vallejo-Slocke
(2020) Spain C oss-Sec ional 33 8–18 KIDSCREEN-10 50 (10) 50.4 (10.1) 0.4
Wunsch (2021) Ge many C oss-Sec ional 1711 4–10
11–17 KIDSCREEN-10
Male child en
44.89 (3.92)
Male child en
40.68 (4.33)
Female child en
45.49 (4.88)
Female child en
41.27 (4.34)
Male adolescen s
43.87 (4.19)
Male adolescen s
40.77 (4.70)
Female adolescen s
43.15 (4.32)
Female adolescen s
40.83 (4.27)
a
: The e was a signi ican dec ease in all aspec s o quali y o li e analyzed by he SF-36 (Func ional capaci y, Limi a ion by physical aspec , Gene al Heal h S a us, Vi ali y, Social Aspec s, Emo ional Aspec s, and
Men al Heal h) in bo h child en and adolescen s. Da a can be checked in he o iginal a icle. HRQoL: heal h- ela ed quali y o li e. COVID-19: co ona i us disease 2019. PedsQL: Pedia ic Quali y o Li e
In en o y Ques ionnai e.

In . J. En i on. Res. Public Heal h 2021,18, 4563 6 o 12
Rega ding he ins umen s used o e alua e he HRQoL, ou di e en scales we e
used o e alua e he HRQoL o child en and adolescen s: KIDSCREEN-10 index, he
SF-36, he Pedia ic Quali y o Li e In en o y Ques ionnai e, and a Like Scale (0–10).
Th ee a icles explici ly s a ed ha used language alida ed e sions [
16
,
22
] whe eas
he o he h ee a icles only desc ibed he ques ionnai e in hei a icle [
15
,
17
,
18
]. To
summa ize, h ee a icles epo ed ha COVID-19 signi ican ly educed he HRQoL o
child en and adolescen s [
15
,
16
], wo a icles did no ind a signi ican impac [
17
,
18
], and
one a icle did no epo s a is ical compa ison be ween p e- and pos -pandemic da a.
Di e ences be ween gi ls and boys we e explo ed in wo a icles [
16
,
22
] and non-signi ican
di e ences we e obse ed in he e ec o he COVID-19 pandemic on he HRQoL. The
impac o COVID-19 on he di e en dimensions o HRQoL was only analyzed in one
s udy [
16
], showing ha COVID-19 has nega i ely a ec ed unc ional capaci y, physical
aspec , gene al heal h s a us, i ali y, social aspec s, emo ional aspec s, and men al heal h
in bo h child en and adolescen s. Howe e , nei he o he s udies analyzed whe he he
COVID-19 pandemic has equally impac ed he HRQoL o child en and adolescen s.
The KIDSCREEN-10 index co e s he physical, social, and psychological sphe es o
heal h, p o iding a global HRQoL sco e [
23
]. I s en i ems (e.g., “Ha e you el ull o
ene gy?”) we e p esen ed wi h 5-poin esponse scales (0 = “ne e ” o 4 = “always” o
0 = “no a all”
o 4 = “ex emely”), ha ing a mean sco e anging om 0 o 4. The SF-36
measu es he pa icipan s’ sel - epo ed opinion abou hei physical and men al well-
being [
24
]. I has eigh domains o HRQoL: gene al heal h, ene gy/ i ali y, body pain,
physical unc ioning, emo ional well-being, ole limi a ions due o physical heal h, ole
limi a ions due o emo ional p oblems, and social unc ioning. Responses o each ques ion
wi hin a domain a e combined o gene a e a sco e om 0 o 100, whe e 100 indica es “good
heal h”. The 23-i em PedsQL
™
4.0 Gene ic Co e Scales [
25
] con ain ou dimensions wi h
di e en i ems: (1) Physical Func ioning (8 i ems), (2) Emo ional Func ioning (
5 i ems
),
(3) Social Func ioning (
5 i ems
), and (4) School Func ioning (5 i ems). A i e-poin e-
sponse scale is in he pa en p oxy- epo (0 = ne e a p oblem;
1 = almos ne e a p oblem
;
2 = some imes a p oblem
; 3 = o en a p oblem; 4 = almos always a p oblem). I ems a e
e e se-sco ed and linea ly ans o med o a 0–100 scale. The Like scales, wi h a
0–10 scale
,
which was used o measu e he HRQoL, ep esen ed he 0 as he absence o heal h and
10 ep esen ing comple e heal h. In his sys ema ic e iew, h ee a icles employed he
KIDSCREEN-10 index o assess he quali y o li e o child en and adolescen s [
13
,
18
,
22
],
one a icle used he SF-36 [
16
], ano he he Pedia ic Quali y o Li e In en o y Ques ion-
nai e [17], and ano he used a Like Scale (0–10) [15].
Th ee a icles epo ed ha COVID-19 signi ican ly educed he HRQoL o child en
and adolescen s [
15
,
16
]. D agun, Veˇcek, Ma endi´c, P ibisali´c, Ði i´c, Cena, Polašek and
Kolˇci´c [
15
] analyzed a o al o 531 adolescen s. Thei esul s showed ha lockdown
signi ican ly a ec ed HRQoL, happiness, op imism (p< 0.001), as well as pe cei ed s ess.
In e es ingly, he Medi e anean die adhe ence posi i ely co ela ed o HRQoL p e and
du ing COVID-19 lockdown. The e o e, his s udy concludes ha gi en he nume ous
bene icial e ec s associa ed wi h he Medi e anean die adhe ence, modi ica ion o li es yle
h ough applica ion o li es yle medicine dese es a p io i y app oach. In he s udy o de
Ma os, Aida , Almeida-Ne o, Mo ei a, Souza, Ma çal, Ma cucci-Ba bosa, Ma ins Júnio ,
Lobo and dos San os [
16
], a o al o 69 child en and adolescen s pa icipa ed in an online
su ey, based on he SF-36, in o de o e alua e he HRQoL. Resul s showed ha HRQoL
signi ican ly dec eased in all aspec s o quali y o li e analyzed by he SF-36 in bo h
adolescen s and child en. Au ho s concluded ha he scena io o social isola ion nega i ely
impac ed he le el o physical ac i i y, quali y o li e, and s ess le el in B azilians. Thus,
implemen ing an adap ed physical aining p og am a home du ing he pe iod o he
pandemic may help o dec ease he nega i e physiological and psychological impac
o inac i e beha io s. Ra ens-Siebe e , Kaman, E ha , De ine, Schlack and O o [
13
]
analyzed a o al o 793 child en and adolescen s using he KIDSCREEN-10 ques ionnai e.
This s udy showed de ailed da a ega ding he educ ion o HRQoL due o he COVID-19
In . J. En i on. Res. Public Heal h 2021,18, 4563 7 o 12
pandemic. In his ega d, au ho s poin ed ha be o e he pandemic, 15.3% (n= 146; based
on weigh ed da a o he BELLA s udy) o child en and adolescen s epo ed low HRQoL
whe eas, du ing he pandemic, 40.2% o he child en and adolescen s epo ed low HRQoL
(n= 418; based on weigh ed sel - epo ed da a o he COPSY s udy). Fu he mo e, a gende
s a i ied analysis showed ha a highe p opo ion o gi ls epo ed low HRQoL, when
compa ed o hei male pee s bo h be o e and du ing he pandemic. In e es ingly, younge
child en we e a ec ed signi ican ly mo e han olde ones. Fo ins ance, he pe cen age o
child en epo ing low HRQoL anged om 7.7% o 41.3% in 11- o 13-yea -old child en
and om 17.1% o 39.3% in 14- o 17-yea -olds. Taking in o accoun all hese esul s,
au ho s concluded ha heal h p omo ion and p e en ion s a egies a e needed o main ain
child en’s and adolescen s’ men al heal h, as well as o imp o e hei HRQoL, and mi iga e
he bu den caused by COVID-19, pa icula ly o child en who a e mos a isk.
Two a icles did no ind a signi ican impac [
17
,
18
] o COVID-19 pandemic on
HRQoL. A o al o 40 child en and adolescen s pa icipa ed in he s udy o Abawi, Welling,
an den Eynde, an Rossum, Halbe s ad , an den Akke and an de Voo n [
17
]. The
23-i em Paedia ic Quali y o Li e in en o y (PedsQL) 4.0 (pa en s’ p oxy- epo e sion)
was egis e ed. The mean PedsQL o al sco e be ween baseline and COVID-19 ou b eak
dec eased in child en, al hough he change was no s a is ically signi ican (mean change
−
6.3
±
29.9; p= 0.26). Ne e heless, au ho s also s udy anxie y and showed a bigge
dec ease in child en o whom anxie y was epo ed s. hose who did no (mean change
−
10.3
±
36.5 s.
−
3.3
±
24.4). Howe e , i was also no s a is ically signi ican . Thus,
au ho s concluded ha heal hca e p o essionals should add ess possible COVID-19 ela ed
anxie y in child en. Mo eo e , in he s udy o Vallejo-Slocke , F esneda and Vallejo [
18
], a
o al o 33 child en and adolescen s comple ed he KIDSCREEN-10 ques ionnai e in o de
o assess he HRQoL. Resul s showed ha no signi ican di e ences we e de ec ed be ween
p e- and du ing COVID-19 pandemic in he HRQoL. In e es ingly, au ho s analyzed he
possible di e ences be ween sexes. In his ega d, gi ls sco ed highe (n= 223, M = 3.8;
SD = 2.46
) han males (n= 236, M = 2.9, SD = 2.17) in emo ional p oblems, indica ing wo se
unc ioning. In he same line, using he KIDSCREEN-10 o al index, boys ob ained highe
esul s (n= 236, M = 51.04; SD = 9.89) han gi ls (n= 223, M = 48.89; SD = 10.01), indica ing
highe HRQoL. Thus, au ho s concluded ha i is necessa y o moni o he men al heal h
s a us o child en and adolescen s in o de o p e en possible p oblems.
Las ly, in he s udy o Wunsch, Nigg, Niessne , Schmid , O iwol, Hanssen-Doose,
Bu cha z, Eichs elle , Kolb and Wo h [
22
], a o al o 1711 child en and adolescen s we e
sc eened using he KIDSCREEN-10 ins umen o assess hei HRQoL. In his s udy, au-
ho s did no p esen a - es o compa e p e and du ing HRQoL, bu epo ed whe he
physical ac i i y, sc een ime, and HRQoL be o e COVID-19 p edic ed physical ac i i y,
sc een ime, and HRQoL du ing he COVID-19 pandemic. This analysis e ealed ha
physical ac i i y du ing-COVID-19 was posi i ely p edic ed by p e-COVID-19 HRQoL
(s anda dized es ima e = 0.07; p= 0.003) and nega i ely p edic ed by p e-COVID-19 sc een
ime (s anda dized es ima e =
−
0.21; p< 0.001). Mo eo e , when he in o ma ion we e
s a i ied by gende , sc een ime p e- COVID-19 nega i ely p edic ed du ing-COVID-19
physical ac i i y (s anda dized es ima e =
−
0.24; p< 0.001), bu no s a is ically signi ican
ela ionship be ween HRQoL and physical ac i i y was obse ed (p= 0.112). Fo emales,
physical ac i i y du ing-COVID-19 was posi i ely p edic ed by HRQoL p e-COVID-19
(s anda dized es ima e = 0.09, p= 0.007) and nega i ely by leisu e sc een ime p e-COVID-
19 (s anda dized es ima e =
−
0.18, p< 0.001). Ne e heless, au ho s compa ed hei esul s
wi h Eu opean no ms and Ge man child en, obse ing a dec ease. Fo ins ance, p io o he
COVID-19 lockdown, mean T-Sco es we e 44 poin s a he 27 h pe cen ile, and du ing he
lockdown, sco es dec eased o 41 poin s, e lec ing he 18 h pe cen ile. The e o e, au ho s
concluded ha policies o imp o e he HRQoL, especially in child en aged 4 o 10 yea s
and emales, should be p omo ed in o de o inc ease esilience. Mo eo e , due o he
nega i e associa ion be ween p e-COVID-19 sc een ime and wi hin-COVID-19 physical
In . J. En i on. Res. Public Heal h 2021,18, 4563 8 o 12
ac i i y, heal h policy mus implemen coun e measu es o educe sc een ime in child en
and adolescen s.
4. Discussion
The pu pose o his sys ema ic e iew was o p o ide an up- o-da e analysis o he
impac o COVID-19 pandemic on he HRQoL o child en and adolescen s. Thus, a icles
ha analyzed p e and pos /du ing pandemic HRQoL alues we e included. Findings
sugges ha child en and/o adolescen s expe ienced a educ ion in he HRQoL due o he
COVID-19 pandemic.
The COVID-19 pandemic, due o he high unce ain y and s ess, has dec eased
psychological heal h [
26
]. P e ious s udies ha e ound a signi ican impac o COVID-19
con inemen on s ess, dep ession, o anxie y [
27
,
28
]. This dec emen in psychological
heal h has also been obse ed in child en and adolescen s [
29
,
30
]. Fu he mo e, child en
and adolescen s expe ienced massi e changes in hei daily li es, such as school closu es,
social dis ancing, o home con inemen , signi ican ly dec easing he HRQoL [
12
,
31
]. In his
ega d, p e ious s udies ha e indica ed ha HRQoL has been educed due o he COVID-
19 pandemic [
16
,
32
,
33
]. The esul s o his sys ema ic e iew a e in he same line, wi h h ee
a icles showing a signi ican educ ion o HRQoL in child en and adolescen s. Mo eo e ,
wo s udies independen ly explo ed he impac o COVID-19 in gi ls and boys [
13
,
22
].
Resul s showed ha indi e en ly o hei sex, HRQoL was educed. Howe e , a p e ious
s udy showed ha gi ls we e mo e likely o expe ience dec eased men al heal h han boys
du ing COVID-19 pandemic [
29
]. In he same line, p e ious s udies showed ha gi ls
a e mo e ulne able o psychological dis ess han boys [
34
]. The e o e, u u e s udies
should explo e sex-based di e ences on he impac o he COVID-19 pandemic in child en
and adolescen s.
No ably, due o he go e nmen s’ social isola ion and he measu es o con ol he
sp ead o COVID-19, p e ious s udies ha e de ec ed a signi ican dec ease in physical
ac i i y le el [
35
,
36
]. These measu es ha e limi ed he oppo uni y o s ay physically ac i e.
Due o his ac , Cos a, e al. [
37
] showed ha du ing he pandemic, B azilians’ le el o
physical ac i i y was signi ican ly educed, becoming ha m ul o he heal h o he popula-
ion [
37
]. Sus ained physical inac i i y is usually associa ed wi h dec eased physical and
men al wellbeing and ele a ed disease-speci ic beha io and all-cause mo ali y isk [38].
As commen ed be o e, social isola ion can lead o a educ ion in social con ac and
longe pe iods o immobili y. This would lead, di ec ly o indi ec ly, o inc ease he use o
in e ac i e de ices, such as TV, compu e s, and mobile phones [
39
]. P e ious s udies ha e
ound ha he o al amoun o ec ea ional sc een ime has inc eased du ing he COVID-19
pandemic [
6
,
7
]. In his ega d, a p e ious s udy showed ha child en and adolescen s
inc eased a o al o 61.2 minu es pe day o ec ea ional sc een ime due o he COVID-19
pandemic [
40
]. This s udy also ound ha boys spend mo e ec ea ional sc een ime pe
day han gi ls, 66.2% and 56.3%, espec i ely. In e es ingly, his a icle showed ha a o i e
ec ea ional sc een ac i i y is TV whe eas, o adolescen s, he In e ne ’s use was p edomi-
na ely chosen. This is qui e ele an , especially in adolescen s whe e sex ing (exchange o a
message con aining sexual con en ia in e ne ) has been shown o be p e alen among
ju eniles [
41
]. Inc eased ime on ec ea ional in e ne could ha e inc eased his beha io
wi h nega i e consequences on child en’s men al heal h and HRQoL.
Social isola ion can enhance loneliness and abandonmen , igge ing ad e se beha -
io al ela ionships (i.e., agg essi eness, c ying, emo ional pain, e c.) [
42
]. Mo eo e , he
absence o social in e ac ion can a ec he emo ional pe cep ion ha will in luence he
eeling o i ali y and he pe cep ion o gene al heal h. This has a di ec in luence on men al
heal h, and all hese in e connec ed eac ions can be ha m ul o he physical aspec s, which
can educe he unc ionali y and inc ease he pe cep ion o physical pain [
43
]. The e o e,
he sel -pe cei ed quali y o li e ends o su e nega i e changes du ing he isola ion
pe iod o he COVID-19 pandemic [
44
]. Siebe e e al. showed ha lowe HRQoL and mo e
In . J. En i on. Res. Public Heal h 2021,18, 4563 9 o 12
men al heal h p oblems du ing pandemic COVID-19 and heal h p omo ion and p e en ion
s a egies need o be execu ed [13].
P e ious s udies ha e explo ed he bene i s o physical exe cise o comba he nega i e
impac o he COVID-19 pandemic [
45
]. In his ega d, a p e ious s udy ound ha hose
who we e no en olled in physical exe cise du ing COVID-19 con inemen showed a highe
le el o s ess, anxie y, and dep ession [
9
]. In he same line, a p e ious andomized con-
olled ial which ocused on he e ec s o wo home-based physical exe cise in e en ions
(using high-in ensi y in e al aining and mode a e-in ensi y aining) showed ha bo h
g oups educed s ess, anxie y, and dep ession as well as inc eased esilience. Howe e ,
he g oup who pe o med high-in ensi y in e al aining signi ican ly ob ained he g ea -
es educ ion o dep ession when compa ed o mode a e-in ensi y aining. Rega ding
esilience, he signi ican e ec on esilience is qui e impo an o ace he s ess ul and
unce ain si ua ion caused by he COVID-19 pandemic [
46
,
47
]. Acco ding o a sys ema ic
e iew, child en should pe o m 60–180 min o daily mode a e o igo ous physical ac i i y
and use hei own bodyweigh o ligh weigh s du ing s eng h aining [
48
]. Howe e , in
child en and adolescen s who we e no in ol ed p e ious o he COVID-19 pandemic, i is
ecommended o con inue mode a e-in ensi y exe cise e e y day o 10 o 15 min [49].
Fu he mo e, ano he ele an ac o which should be conside ed in he dec ease o
HRQoL in child en and adolescen s a e pa en s. In his ega d, a p e ious s udy has shown
how iolence agains child en has inc eased unde home con inemen lea ing child en
a isk o abuse and auma [
50
], pa icula ly in hose amilies wi h a low socioeconomic
s a us [
51
]. Fu he mo e, poo e amilies a e less inancially esilien and a e mo e ex-
posed o job and ea nings losses while hei child en a e likely o be disp opo ionally
disad an aged by school-closu es [
52
]. Mo eo e , g owing up in poo e neighbo hoods
inc eases he isk o ca ching he i us [
52
]. Addi ionally, he COVID-19 ou b eak has
inc eased he likelihood o inancial and social insecu i y o low-income g oups, which
could hypo he ically con ibu e o low HRQoL o child en and adolescen s [
52
]. Thus, a
p e ious s udy showed ha pa en al job and income losses a e associa ed wi h pa en s’
dep essi e symp oms, s ess, diminished sense o hope, and nega i e in e ac ions wi h
child en [53,54].
The p incipal limi a ion o his e iew is he small numbe o a icles abou HRQoL
ha compa e p e and du ing pandemic alues. In addi ion, he a icles analyzed a e om
child en and adolescen s om di e en coun ies. This can be a limi a ion because each
coun y has had di e en ime and con inemen es ic ions. This conside a ion may be
a u u e line o esea ch when mo e s udies appea on his opic. Addi ionally, a icles in
languages o he han English, Spanish, Ge man, F ench, o Po uguese we e no included
in his sys ema ic e iew. Thus, i is plausible o suppose ha some impo an pedia ic
coho s we e no included in ou sys ema ic e iew. Fu he mo e, one a icle included a
Like scale [
15
], while ano he included he SF-36 ques ionnai e o assess he HRQoL. In
o de o measu e HRQoL in child en and adolescen s, o he ques ionnai es such as PedsQL
and KIDSCREEN-10 can be use ul. Fu u e s udies should explo e i COVID-19 has equally
a ec ed gi ls and boys, as well as adolescen s and child en. Addi ionally, s udies should
explo e, in a deepe way, which aspec s o he HRQoL ha e been mo e a ec ed by he
COVID-19 pandemic in child en and adolescen s.
Despi e he limi a ion, his s udy has some s eng hs which should be acknowledged.
Fi s , his is he i s sys ema ic e iew which analyzes he impac o COVID-19 pandemic
on he HRQoL o child en and adolescen s. Addi ionally, mo e han 3100 child en and
adolescen s we e included in his s udy. Las ly, his s udy showed how COVID-19 has neg-
a i ely impai ed he HRQoL o child en and adolescen s, so in e en ions a e encou aged
o eco e he HRQoL le el p e-pandemic.
5. Conclusions
The COVID-19 pandemic could ha e signi ican ly dec eased he HRQoL o child en
and adolescen s. Rega ding sex di e ences and HRQoL dimensions, s ong e idence was