Assessing the health, social, educational and economic impact of the COVID-19 pandemic on adolescents in low- and middle-income countries: a rapid review of the literature

Abstract

COVID-19 has caused profound health, social, educational and economic devastation around the world, especially among the lives of adolescents in low- and middle-income countries. This paper looks at a wide array of outcomes impacting adolescents’ daily lives including health (mental, physical, sexual and reproductive health, vaccine perceptions and overlap between these topics), social relationships (family and peer), education and socio-economic disparities. Both scientific and grey literature between December 2019 and February 2022 were sought from PubMed, Google Scholar and organisations conducting research among adolescents, and coded. A total of 89 articles were included, 73% of which were peer-reviewed; 37% of the articles were from WHO’s Western Pacific region; 62% of the articles were cross-sectional; 75% were quantitative. Three major topics emerged in more than half the articles: mental health (72%), education (61%) and socio-economic ramifications (55%). However, there were regional differences in topics and many of them overlapped. The results indicate that, where there has been research, almost all findings have been linked to worse mental health during the pandemic. Overall, remote education was seen as a negative experience. The ramification of school closures on future aspirations, in particular early school leaving, highlights the importance of prioritising education during future pandemics based on the situation within the country. Gender and other disparities have made marginalised adolescents vulnerable to the economic ramifications of containment measures. Given the risks identified, there is a pressing need to put adolescents at the centre of establishing priorities for their health agenda for post-pandemic recovery.

Introduction

Not since the Spanish Flu of 1918, has there been a greater public health crisis than COVID-19, that has caused profound health, social, educational and economic devastation.^1,2 Globally, over 6 million deaths have been estimated, though this is likely a gross underestimate.^3,4 Evidence also shows that inequalities have been exacerbated by disruptions and measures enacted to contain the virus’s spread, especially in low-resource settings.⁵ However, to our knowledge, there are no published reviews that examine the impact of COVID-19 containment measures on non-COVID-19 outcomes across different low- and middle-income countries (LMICs). The study focuses on LMICs because they have borne a greater economic burden of the containment measures in comparison to high-income countries.⁶ As a result of these inequalities, progress toward achieving a number of Sustainable Development Goals (SDG) may be adversely impacted including: (1) SDG 2: Zero hunger, (2) SDG 3:Good health and well-being; (3) SDG 4: Quality education, (4) SDG 5: Gender equality, (5) SDG 8: Decent work and economic growth.⁵ Adolescents have been affected by school closures and family financial stress, greater vulnerability to age- and gender-based violence and social isolation impacting physical and mental health.⁷ These inequalities have been exacerbated among those most vulnerable including refugees, adolescents with disabilities, married girls and those from the lowest socio-economic group.^7,8 However, there is a lack of evidence on the collective effect of all these consequences on adolescents’ daily lives.

With the government regulations to contain the virus, young people living in LMIC contexts have faced lengthier school closures and movement restrictions, altering their educational trajectories as well as their health and well-being. The literature shows that while adolescents⁹ have been spared much of COVID-19’s morbidity and mortality,¹⁰ the indirect impacts have altered life trajectories.^11,12 These include health, social relationships with family and peers, economic circumstances and educational disruptions.^2,11–18 A report on the impact of COVID-19 prevention measures on the sexual and reproductive health (SRH) and rights of older adolescents and youth in six countries additionally found that groups of young people who were already more vulnerable before the pandemic faced additional hardships and challenges.¹⁹ Examples include increased stigma and harassment for young Lesbian, Gay, Bisexual, Queer and Intersexual (LGBTQI) people, increased difficulties in accessing antiretroviral medicines for HIV-positive young people, increased harassment for transgender youth and sex workers, and increased difficulties for young people living with a disability to access remote learning as appropriate resources were often not in place.¹⁹

Although there have been some reviews focusing on the impact of COVID-19 on mental health^20,21 and SRH²² among adolescents, none of the reviews have synthesised the global evidence covering a range of types of impacts to understand the ramifications of the pandemic across different LMICs. The aim of this study is to carry out a rapid review of the published research on the health, social, educational and economic impact of COVID-19 among adolescents living in LMICs, so as to synthesise what is known. It reviews both published and grey literature and documents the pandemic impacts on health (mental, physical, SRH, vaccine perceptions and the overlaps between these topics), social relationships (family and peer), education and socio-economic disparities (economic ramifications, gender disparities and vulnerable/marginalised populations) among the adolescent population.

Methods

With new evidence emerging everyday regarding COVID-19, the authors decided to conduct a rapid review of the literature rather than a systematic review so that advocacy for attention to adolescent health and well-being was based on a sound body of evidence on a range of issues, and across different LMICs and not specific to one/some issues, one site, anecdotal evidence nor projections. A systematic review was not conducted because it would take time to complete, be specific to one topic and would entail a rigorous quality assessment which was not the purpose of the investigation. The lead author searched the databases between January 2022 and March 2022.

For the peer-reviewed literature, we searched PubMed and Google Scholar using the key terms outlined in Table 1. Key terms were associated with COVID-19, adolescents, physical health, mental health, SRH, access to healthcare, family relationships, peer relationships, education and socio-economic disparity. Two examples of how the keywords were entered are: (1) “COVID-19” AND “adolescents” AND “Physical health”; (2) “Corona” AND “Teenagers” AND “depression”:

Table 1.

Key terms used for the search strategy

COVID-19	Adolescents	Physical Health	Mental health	Sexual reproductive health	Access to healthcare	Family relationships	Peer relationships	Education	Socio-economic disparity
Corona	Teenagers	Exercise	Depression	Teenage pregnancy	vaccinations	Parent relationship	Friend relationships	School completion	Food insecurity
Coronavirus	Young people		Anxiety	Contraception	Access to health services	Physical Abuse	Bullying	Educational aspirations	Job loss
	Youth		Stress	Sexually transmitted infections	Access to mental health services	Sexual abuse	Social media	“Peer” and “school”	Family poverty
			Substance use	STIs	Telehealth	Family violence	Cyber bullying	School closures	Vulnerability
			Suicide	Family planning	Access to reproductive health services	Neglect	Interpersonal violence	Teacher relationships	Vulnerable populations
			Isolation	Abortion	Primary healthcare service utilization	ACEs	Peer-violence	Remote education	“health” + “disparity”
			Loneliness	Intimate partner violence		Adverse childhood experiences	Dating	School connectedness	“education” + “disparity”
			Distress	Gender-based violence		Family connectedness	Romantic relationships	School dropout	Child marriage
			Coping	HIV			Peer connectedness	Remote learning

For the grey literature, we searched from a specific list of organisations that focus on adolescents, including Gender and Adolescence: Global Evidence (GAGE), Population Council, Global Early Adolescent Study (GEAS), Young Lives, UNICEF, UNFPA, etc. We also used snowballing (perusing reference lists from included articles) to find articles that were relevant to our topic. Inclusion criteria included: (1) Reported results on adolescents aged 10–19 years or stratified results within this age band, (2) conducted in an LMIC based on the World Bank classification, (3) articles written in English, (4) published between December 2019 and February 2022, and (5) reported on original research. The decision to only include articles concerning the 10–19 years age range was made based on WHO’s definition of adolescents.²³

For the analysis, a spreadsheet was created which included the citation, the year in which the article was published, the type of article, the country on which the data were based, the WHO region, the study design (cross-sectional or longitudinal), the type of data collection method (quantitative, qualitative, or mixed methods), and the major topics (health, disparity, education, family relationships and peer relationships) and sub-topics. Sub-topics were coded inductively. The first author read the full text and categorised the topics into different sub-topics. Sub-topics included, for example, depression, anxiety, physical activity/exercise, remote learning, future aspirations, peer relationships, family relationships, socio-economic status, gender, vulnerable populations, etc.

Due to the narrative nature of the analysis, associated factors were determined if they were: (1) shown to be statistically significant within the article and reported repeatedly across different articles and settings for quantitative studies; (2) described as key themes from qualitative/ mixed methods studies and reported across different articles.

Findings

A total of 89 articles were extracted, analysed and coded as an annotated bibliography (Supplemental File 1). Supplemental File 2 highlights the articles on the different topics we investigate in this section. The findings are divided into three sub-headings: characteristics of the articles, differences in topic by region, and main topics covered across the articles:

Characteristics of the articles

Type of article

Overall, 73% (n = 65) of the documents were published as peer-reviewed journal articles. Reports (9%, n = 8), fact sheets (8%, n = 7), policy briefs (7%, n = 6) and working papers (3%, n = 3) comprised 27% (n = 24) of the total literature reviewed. When looking at the geographical region: China and Kenya were over-represented, comprising 44% of the total articles (n = 39). Regarding study design: 62% of the articles were cross-sectional (n = 55), 31% were longitudinal (n = 28) and 7% were comparative cross-sectional (n = 6). For the type of data collected: 75% of the articles were quantitative only (n = 67), 16% were mixed methods (n = 14) and 9% were qualitative only (n = 8). The main topics that evolved from these articles included mental health (72%, n = 64), education (61%, n = 54), socio-economic disparities (55%, n = 49), physical health (31%, n = 28), family relationships (30%, n = 27), peer relationships (20%, n = 18), SRH (18%, n = 16) and vaccine perceptions (2%, n = 2).

Differences in topics by regions

With the ability to compare data from six WHO regions, this section looks at the top three topics that emerged in each site. Figure 1 shows the region and the topics that emerged from the articles. Mental health, education and socio-economic disparities emerged as top topics across most of the regions. However, in the Western Pacific and Europe, physical health also appeared as a recurrent topic (Western Pacific: 42% of articles, Europe: 67% of articles). In Africa, SRH emerged as a topic in 63% of the articles. In the Eastern Mediterranean, peer relationships were highlighted in all their articles.

Figure 1.

Top three topics across the different regions

Main topics covered in the articles

Given the sample size differences in the articles across the regions, the rest of the results present findings on health, education, social relationships and socio-economic disparities at the overall level with all regions combined:

Mental health

A total of 64 articles looked at the mental health of adolescents across the Americas, Western Pacific, African, Southeast Asian, Eastern Mediterranean and European regions. In general, mental health conditions were the most reported topic. Sub-topics within mental health included anxiety and stress (65% of articles); depression, loneliness and suicidal ideation (63% of articles); social support, coping and resilience (28% of articles); and substance use (11% of articles).

Across the studies, the prevalence of anxiety and stress ranged from 5% to 54%^24–55:

“This education method has caused us severe stress and depression. We are given more lessons and homework than we usually get at school without explaining them to us and … with little support from our teachers.” (15-year-old girl, Palestine)⁵⁶

Figure 2 shows the anxiety proportions across different countries. In Brazil, the proportion was 49% in one study⁴⁴. There were a total of 11 studies in China showing proportions from 6.3% to 45.1%.^{24,25,28–31,35,40,45,50,57} In the Democratic Republic of Congo and Ethiopia, there were two studies that reported proportions of 24.5% and 22%, respectively.^49,53 In Indonesia, there were two studies with a range of 31–33%.^51,52 There was one study each in Nepal, Palestine and Turkey with proportions at 46.1%, 10% and 28%, respectively.^26,34,47

Figure 2.

Anxiety proportions across different countries

Prevalence of depressive symptoms ranged from 4% to 75% across Southeast Asia, America, Western Pacific, Africa, Eastern Mediterranean and Europe^{24–26,28–31,40,47,53,58–64}:

“Nothing would relieve my stress. I guess I haven’t accepted this situation yet. I want life to go back to normal. I want university to open again and I want everything to come back! They just started the distanced electronic learning yesterday, I still don’t accept it, I don’t want the distanced learning.” (19-year-old girl, Palestine)⁴⁷

Figure 3 shows the distribution of depressive symptoms across the countries. A total of 21 studies outlined proportions of depressive symptoms. In Bangladesh, depressive symptoms ranged from 4.4% to 75% across two studies.^62,63 In Brazil one study showed a proportion of 32%.⁴⁴ There were a total of 11 studies in China with proportions ranging from 12.3% to 60%.^{24,25,28–31,40,45,57,58,61} In Ethiopia and Kenya the proportion ranged from 5% to 50% across four studies.^53,55,59,64 In Jordan, Palestine and Turkey proportions were 19.3%, 5% and 37.6%, respectively.^26,47,60

Figure 3.

Depression proportions across different countries

Suicidal ideation was outlined across four studies in the Western Pacific and American regions. Three of them were in China (20.3–36.4%)^33,45,65 and one was in Mexico (21%).³⁹ Suicidal attempt was addressed in one study in China at 10.4%.³³ The factors that were associated with worsening mental health included the number of COVID-19 cases in the community,^{26,27,30,31,35,36,40,44,45,57,61,66–69} being an older adolescent,^{24,26,27,29,31,44,45,57,59,67,70,71} being female,^{24,26,31,34,37,40,42,45,56,57,60,61,69,72–76} experiencing school closures and challenges with online learning, peer social isolation and an overloaded burden of homework.^{30,31,35,44,45,58,69,77,78} Negative family relationships, including childhood trauma, conflicts within the household, emotional and physical violence by family members, were also associated with a greater risk of worse mental health.^{28,30,31,39,43,44,48,58–60,64–66,77} Factors that were associated with better mental health included sleep^{30,31,35,43,57} and any amount of physical activity.^{27,30,40,43,57,67,68,74,79} Coping mechanisms were categorised as both positive and negative. Positive coping mechanisms included social support, resilience, volunteering and adopting new hobbies,^{25,28,36,42,55,56,60,73,80,81} whereas negative coping included excessive screen time and substance use^{47,56,69,71,74,75}:

“Corona[virus]’s time made us explore our talents. I started to meditate by watching the sky and photographing it  …  When I started taking these pictures, it gave me a feeling of comfort as it is a beautiful view.” (18-year-old girl, Lebanon)⁵⁶

One study in Bangladesh looked at the types of support needed which included food, soap and medicine.⁶³

Physical health

Physical health was highlighted in 28 articles across all the WHO regions: Americas, European, Western Pacific, Eastern Mediterranean, African and Southeast Asian. Sub-topics within physical health included physical activity and food (57% of articles), sleep (46% of articles) and overall health (43% of articles). In general, adolescents qualitatively mentioned the amount of time spent on physical activity decreased^{47,77,82–84}:

“I used to do sports before corona[virus] but during the corona[virus] period I’ve gained a lot of weight as I can’t go anywhere to do any sports or exercise.” (15-year-old boy, Lebanon)⁵⁰

Physical activity was reduced especially among younger adolescents in one longitudinal study in Bosnia and Herzegovina.⁸³ Two studies also reported increased consumption of ultra-processed food, unhealthy snacking, and heavy late-night meals in South America and Turkey.^77,82 In terms of sleep, the results were mixed. Studies from China reported an increase in sleep duration during the pandemic^37,42,50 whereas others showed a decrease^47,77,84:

“[Remote school] can make our study really easy and we can get up later in the morning.” (Girl, China)⁵⁰

Factors associated with insomnia included: (1) being female, (2) parental migration (China), (3) having greater fear of COVID-19, (4) being older and (5) being adolescents in refugee host communities.^40,84 In terms of overall health, most articles said that the pandemic had a negative impact on their overall health^{32,46,47,49,51,53,54,76,84}:

“There were a lot of worries, fears that the disease might affect the family.” (Boy, Democratic Republic of Congo)⁴⁹

Eleven percent of adolescents in Palestine and 14% in Jordan stated that their health was worse than before the pandemic.^47,84 In Sub-Saharan Africa, there were two longitudinal studies in DRC and Ethiopia. In DRC, overall health levels decreased between 90% and 78% for boys and between 84% and 75% for girls. In Ethiopia, levels of subjective well-being fell by 17% during the pandemic in comparison to pre-pandemic times.^49,53 Overall health was worse for some ever-married girls and among young people with disabilities in two humanitarian settings (Bangladesh and Jordan).^46,84 A few studies reported an increase in overall health in Indonesia and China^50–52 or no change in Vietnam.⁸⁵

Sexual and reproductive health

A total of 16 articles focused on SRH in the African and Eastern Mediterranean regions. Sub-topics within SRH included access to and utilisation of health care including family planning and antenatal care (75% of articles), menstruation (50% of articles), teenage pregnancy (31% of articles) and HIV (19% of articles). Adolescents reporting not accessing healthcare ranged from 7% to 23% across four countries.^{47,55,64,84,86,87} Health services were not used due to COVID-19 stigma, restrictions in access to health facilities and financial cost.^{48,56,64,84,88} Forgoing health services was higher among females and those lost to follow up for routine HIV care^70,89,90:

“I was not able to go for my 7-month review when I know the sex of the baby and its condition, I was not even able to seek help at a private clinic. Everything was closed due to lockdown. It was more than three months I wasn’t able to see a doctor … Also although medications were available, I did not have enough money to buy it.” (19-year-old girl, Jordan)⁸⁴

Only one study in Uganda reported an increase in contraceptive visits and post-abortion care during the pandemic compared to pre-pandemic visits.⁹¹ This study showed that between 2019 and 2020 modern contraceptive prevalence increased among those who: (1) were 18–19 years old (58% higher); (2) were 15–19-year-old and married (68% higher); (3) completed primary education (64% higher); (4) were sexually active (81% higher); (5) lived in a rural area (43% higher); (6) were in the second poorest wealth quintile (159% higher) and (7) were exposed to family planning messages (33% higher).⁹¹ Reasons for an increase in post-abortion care included an increase in unintended pregnancies and abortion during COVID-19.⁹¹

For menstruation, 25–57% of adolescent girls stated they had difficulty accessing menstrual products or maintaining menstrual hygiene^{47,48,64,70,84,90}. In one study across three settings (Ethiopia, Lebanon and Cote d’Ivoire), this was reported to a greater extent by refugee girls compared with girls from host communities.⁵⁶ Not having the ability to manage their menstruation was reported to contribute to higher anxiety in Lebanon⁶⁰:

“For sure, it is a shame to tell [that I need menstrual supplies] to my brother or my father. We can’t talk about private girls’ issues with fathers, mothers or brothers.” (16-year-old girl, Jordan)⁶⁰

Figure 4 shows a graphical representation of the proportion of studies reporting difficulties in accessing health care and menstrual products by country. There were three studies in Kenya with 8.5–18% of adolescents reporting difficulties in accessing health services^55,64,90 and 45.5%–51.3%^64,70,90 reporting difficulties in accessing menstrual products. In general, adolescents reported more difficulties in accessing menstrual products in comparison to difficulties in accessing health services.

Figure 4.

Proportion of adolescents reporting difficulties in accessing health services and menstrual products

Reported teenage pregnancy ranged from 2.7% in Jordan to 4% in Kenya^64,84 with one study in Kenya suggesting that pregnancy risk before high school completion was double that before the pandemic.⁹² Factors influencing teenage pregnancy included economic constraints, school closure, peer pressure and lack of family planning⁶⁴:

“In one county, there are five villages that had school-going girls who are pregnant, one village has five girls and another three girls. All this is happening because of Corona.” (17-year-old boy, Kenya)⁶⁴

Vaccine perceptions

Two articles looked at vaccine perceptions in the Western Pacific Region, but the results were ambivalent. Both were conducted in China.^93,94 In general, vaccine acceptance was high (76%) in China and was positively associated with: (1) knowledge of the COVID-19 vaccine, (2) belief it would protect them from the infection, (3) encouraging family members and friends to get vaccinated, (4) belief that vaccines were safe, (5) being younger (12–15 years) versus older (16–19 years).⁹³ In Hong Kong, 39% of survey respondents planned on being immunised.⁹⁴ Factors associated with vaccine uptake included: (1) Having at least one parent vaccinated, (2) knowing someone diagnosed with COVID-19 and (3) having received the flu vaccine in the past. Reasons for vaccine hesitancy included concerns about safety and efficacy.⁹⁴

Education

A total of 55 articles reported on educational impacts across all the WHO regions. Twenty-five percent of the articles were published in 2020, 60% in 2021 and 15% in 2022. Most data collection was conducted whilst remote classes were ongoing but there were concerns about the problems with digital access. Experiences with education were generally negative and adolescents talked about reduced future aspirations, including school dropout. Sub-topics within education included remote education challenges (75% of articles) and future aspirations (49% of articles). Within remote education, articles described the proportions enrolled in school during the pandemic (64–92%).^{47,53,55,63,84,85,90,95} Figure 5 shows the range of adolescents enrolled in school by country. Across the countries, the educational contexts were different based on when and where the study was conducted. In Kenya, one study was conducted when schools were closed without any remote learning (95% said they were enrolled in school),⁵⁵ the other study was conducted when remote learning was being implemented (80% said they were enrolled).⁹⁰ In Palestine, Jordan, Bangladesh and India adolescents mentioned they were enrolled in remote learning during the survey.^47,54,63,84 In Ethiopia the survey was conducted when schools were open in-person after school closures and remote learning.⁵³ In Vietnam, there was a phased reopening, with some adolescents enrolled in in-person school and some continuing remote learning.⁸⁵

Figure 5.

proportion of adolescents enrolled in school during COVID-19 pandemic

Enrolment was lower among married girls, those with lower socio-economic status (SES), older adolescents, and those from smaller households.^46,84 Additionally, studies showed that among those who participated in remote learning during school closures, there was a significant decrease in those engaging in learning^53,77,96,97 with proportions ranging from 0.5% to 20.7% in South-East Asia and the Asia Pacific Regions^41,54 and 50% to 65% in Ethiopia.⁵³ There were two studies which showed a decrease in test scores during the pandemic.^98,99 One study in Bangladesh showed a decrease in test scores compared to the pre-pandemic period.⁹⁸ In Brazil, students who continued online education showed lower test scores in comparison to those who returned to school in person.⁹⁹ Lower learning ability was seen among those living in rural areas, highlighting girls (in particular married girls) due to expanded household chores, boys who were working, and adolescents with disabilities.^{78,81,84,90,95,97,100,101} Negative experiences with remote education included challenges to adapting to online teaching, lack of support from teachers, not getting appropriate material to learn, more time doing paid work, not having reliable internet connectivity and excessive homework^{47,48,56,64,70,77,84,88,97,102,103}:

“The school is sending us lessons on WhatsApp, but most of the time I cannot follow them because I do not have a mobile phone. I stopped studying because I could barely understand my lessons in class so how am I supposed to understand them on the mobile phone?” (15-year-old boy, Lebanon)⁴⁸

Learning ability was lower for those who were younger, female and those in the lower SES groups.^{62,70,76,81,104} Factors associated with better learning ability included a problem-based coping style (able to manage the problem), having a computer for learning, emotional competence (able to regulate the emotional reaction to the problem), online learning readiness and higher pre-COVID-19 academic performance.^103–105

Future aspirations focused on early school leaving (59% of articles), lower school and college aspirations (15% of articles), and lower confidence about completing the current grade (11% of articles). Adolescents were worried about how the pandemic would affect future school life.^38,48,49 They reported being forced to drop out of school because of: (1) limited or no access to remote learning, (2) not getting quality instructions from teachers, (3) household economic concerns pressurising adolescents to work and (4) inability to pay school fees^{48,56,99,101,106}:

“The anxiety is that this disease may cause many of us to lose hope about finishing school because we do not know when we will do our examinations because it is not known so we get confused.” (17-year-old girl, Kenya)⁶⁴

Two studies in Kenya and Brazil showed that the pandemic increased risk of early school leaving, especially during remote education because of becoming pregnant or because of patchy remote education.^92,99 School dropout was higher among older girls, those lost to follow up in healthcare services, those from lower SES households, those from rural areas and refugees.^{48,54,64,70,76,84,85,89,100} In Bangladesh, Peru, Indonesia and China, adolescents reported reduced college aspirations^81,95 and fears of current grade completion.^50–52 An impact of school closures included accelerated relationship timelines due to reduced future aspirations, pressure to marry and other friends getting married in two sub-Saharan African countries (Ethiopia and Kenya), Jordan and Indonesia^75,107,108:

“She was 13 years old and was pulled out of school … She ran away from home as she did not want to get married so young. She begged her family but they were not persuaded … She sheltered at my friend’s house and told us she was thinking to commit suicide. I asked my family to interfere but they [her family] said please do not interfere, she is our daughter … Now she stands by the window and thinks of suicide. She does not leave the house … she has a psychological illness.” (15-year-old girl, Syrian refugee in Jordan)⁷⁵

Family relationships

Family relationships were discussed in 27 articles from the Western Pacific, Eastern Mediterranean, African, American and Southeast Asian Regions; and were generally negative in nature. Sub-topics included negative family relationships including emotional and physical violence (60% of articles) and positive family relationships (19% of articles). Approximately 50% of the adolescents stated that the pandemic had moderate to severe impact on their family relationships and caring responsibilities in India,³² with 18–66% reporting an increase in household stress and violence during the pandemic^{47,60,63,64,84,109}:

“The tension has increased dramatically … We are all at home suffering from a bad psychological state. My father is very nervous, and we are all nervous and sad, we try to hide the nervousness but it shows on our faces. The reason  …  is the worry about tomorrow and surviving.” (17-year-old female, Syrian refugee in Lebanon)⁵⁶

Figure 6 shows how these proportions differed by countries. Palestine and Jordan reporting higher proportions of increased household tensions in comparison to Bangladesh and Kenya.^{47,60,63,64,70,84,90} Kenya had a total of three articles reporting proportions between 8% and 35.5%.^64,70,90

Figure 6.

Proportion of adolescents reporting increased household tensions

Adolescents reported quarrelling with others, experiencing physical violence, less communication with parents and siblings, lower parental support, less supervision, and detachment.^{28,30,31,39,58,65,77} Among married girls, adolescents reported higher levels of interpersonal violence and intra-household violence due to financial pressures^48,56,63:

“Life is hard already and it is becoming even harder with this pandemic. My conditions are becoming more intolerable with time. I am struggling with my first newborn and I do not know what to do when he cries. My mother is in Syria and cannot be with me to help with the baby due to the lockdown. My husband is out of work and always fighting with me because he is stressed over our financial situation. The prices of everything have become very high and we cannot buy anything. I worry about not being able to get milk and diapers for my son. I am so tired of life and I cannot get out of my depression. Life has become a black hole and we are trapped inside it.” (17-year-old girl, Syrian refugee in Lebanon)⁴⁸

Among unmarried girls, family economic problems led to child marriage being considered in some settings¹⁰⁸ as well as to girls experiencing violence at the hands of family members.^63,69 In another study in Kenya, 45% of adolescents reported there was less violence in the home but 8% still reported having experienced physical, emotional or sexual violence within the past month.⁷⁰ When asked about support, 20–28% of adolescents in China and Jordan said they received more support from family members,^42,84 65% in Palestine and Jordan said they could trust an adult in their life.^47,84 Positive family relationships included parent–child communication, security of attachment with family members, lower screen time and exercising. These factors had a protective association with mental health.^29,39,79

Peer relationships

Peer relationships were highlighted in 18 articles across all WHO regions. Seventy-two per cent of articles reported that adolescents perceived their relationships to have deteriorated during the pandemic, whereas 28% of articles reported that adolescents perceived their relationships to have improved during the pandemic:

“We used to go to school every day and see our friends and say hi to them and sit with them, see the teachers, see people and our neighbours. Now, we are alone, we can’t see anybody, and nobody can see us, so we feel nostalgia for our relatives, friends and school.” (16-year-old boy, Syrian refugee in Jordan)

Sixty-six per cent of adolescents were worried about the effect of COVID-19 on their future social life,^38,102 with peer relationship problems discussed by 38%.^75,110 This was especially true for girls who mentioned that their already limited spatial mobility was further constrained and that they had less time with friends resulting in a loss of peer-support networks.^{56,60,69,70,84} A study in Hong Kong China, showed an increase in peer-support (21%).⁴² Another study in Palestine showed that older girls reported receiving more support than boys through phone and social media.⁴⁷ Peer acceptance was associated with better mental health.¹¹¹ Not having any friends, missing friends and having fewer friends were associated with negative mental health and substance abuse in Indonesia and Brazil.^43,44,71

When considering peer romantic relationships in Kenya and Indonesia, adolescents reported that the pandemic negatively affected intimate relationships and forced adolescents to hasten their relationship stages due to economic hardships, peer pressure and more partner dependence.^107,108 In Kenya, during the lockdown, 55% reported having the same partners as before the pandemic, 76% said they spent less time with their partners and 42% said they received less emotional support¹⁰⁷:

“Now that people are at home and a lot of social distancing is observed, it has become hard to meet with my boyfriend who is in Uganda. It is really hard since we just converse on phone, and I’m forced to wait for him to come back.” (18-year-old girl, Kenya)¹⁰⁷

In terms of gender-based violence, 2% of girls in Kenya reported sexual violence by sexual partners.⁶⁴ Factors of GBV included: (1) parents not able to pay school fees and (2) feeling depressed in the past two weeks.⁶⁷

Economic ramifications

There were a total of 45 articles that looked at the economic ramifications of the pandemic across all WHO regions. Sub-topics included socio-economic instability (93% of articles) and household food insecurity (45% of articles). In relation to socio-economic instability, 59% of young people were worried about their family’s economic future,^38,101 between 23% and 93.5% said one of their parents experienced income loss and 81% reported worse household economic status compared with before the pandemic^{49–52,63,69,70,89,92,101}:

“There was a drought, we didn’t have any money left because our parents didn’t go to work.” (Girl, Kinshasa)⁴⁹

In general, it was seen that experiencing economic instability or coming from more economically depressed households was associated with worse mental health^{33,40,44,56,64,72,74}; poor adjustment to online learning and school dropout^{54,76,95,98,100,104}; reporting household violence/tensions^59,84; strained relationships¹⁰⁷; forgoing health services⁵⁹; finding paid work because of reduced household income despite the reduced opportunity to work^{48,70,75,88,101,112} and increased discussion of child marriage^97,108:

“My psychological status became bad because I stopped buying many things. The current conditions have affected us too much. My family started skipping many of our needs to be able to pay the rent and the internet fees. We are skipping a lot of food due to the increasing prices. We have a lot of fights and problems in our family because they [the parents] worry about how they can meet our needs. I no longer have the mood to do anything; I just sleep to escape these conditions.” (15-year-old girl, Lebanon)⁴⁸

Conversely, higher socio-economic status was associated with better physical health, mental health, time spent on exercise, support from friends and family and remote learning experience in China and Bangladesh.^42,81 In Jordan (among both Jordanians and Syrians), married girls had more future savings in comparison to never-married girls; in Bangladesh and Jordan (among refugee Rohingya and Syrian), ever-married girls also were more likely to report someone in their family had income/employment loss.⁴⁶

Continuing in the theme of socio-economic instability, many articles highlighted the topic of food insecurity. Most articles found that adolescents who came from economically unstable households had: an increased risk of being food insecure (4–59%)^{48–52,56,62,101} which manifested as skipping meals (63 times higher odds, 50–75%)^59,64,90; not having enough food (40–76%)^89,90 and feeling hungry (25–26%).^47,84 Food insecurity was higher among younger compared with older girls,⁷⁰ refugees,⁸⁴ adolescents with disabilities⁸⁴ and married girls⁴⁶:

“Now we don’t have money to buy any vegetables. After corona started, my father bought groceries only once and then our grandfather bought us some, and we told him we are sorry buy we don’t have money to repay you.” (12-year-old boy, Palestinian refugee in Jordan)

Figure 7 shows a graphical representation of the socio-economic ramifications of COVID-19 across countries.

Figure 7.

Socio-economic ramifications of COVID-19

Social disparities

Social disparities were separated into gender disparities (39 articles) and marginalised/vulnerable populations including adolescents who were married before the pandemic or pressured to get married during the pandemic (14 articles), refugees (4 articles) and adolescents with disabilities (3 articles). Gender disparities explored all the outcomes outlined above. Gender in all the articles was dichotomised as males and females, which limits the ability to make inferences about non-binary adolescents. Across the articles, females were more worried about their education,^32,41,50,69 were socially isolated including restrictions on mobility,^{32,41,47,56,60,63,69,75,84,88,97} had worse mental health,^{40,41,45,51,54,61,72,74,76} were doing more household chores,^{47,48,53,62,69,70,81,84,88,90,96,101,108} and experienced gender-based violence^56,64,69,92:

“We are ten people in the house, and I must help my mother-in-law with the housework. This additional work is really tiring.” (17-year-old girl, Syrian refugee girl in Jordan)⁸⁸

However, in some studies, notably in the Asia Pacific Region, females received more COVID-19 information from friends and family⁴¹ and more support in China (Hong Kong) and Palestine.^42,47 The concerns males reported included: higher substance abuse,^47,56,84 limited work opportunities^56,81,90,112 and economic poverty^48,88:

“We could earn money then [before COVID-19]. Now we can’t. My elder brother used to work [at Médecins Sans Frontières] … now he can’t … Depression comes as we can’t earn money now.” (18-year-old boy, Rohingya refugee in Bangladesh)

Males reported receiving COVID-19 information from the internet and phone,⁴¹ having access to learning apps, TV and radio for remote education,^81,90 and meeting friends in person.⁸⁴

Child marriage articles were of two kinds: (1) studies that pointed to pressure to marry due to COVID-19 and (2) studies among married adolescent girls in the pre-pandemic period. Among unmarried girls, the results were mixed regarding pressure to marry. In some settings, there was an increased pressure and in others, there was a decrease.^56,62,75,97 In Palestine and Jordan, 8–15% of girls said there was less pressure to get married from their family.^47,84 However, 3–12% also said they had more pressure to get married.^47,84 Among those who got married during the pandemic, reasons included: (1) escape from schoolwork, household chores, stress and boredom of studying and staying home during the pandemic¹⁰⁸; (2) economic problems,^75,108 (3) influence of the surrounding environment and peers getting married^75,108 and (4) being pregnant⁶⁴:

“Since learning had moved online, I felt under a great deal of pressure. The teachers kept giving assignments. That’s exactly what made me sad and frustrated. I had been venting my feelings and trusted my boyfriend. Since he paid more attention to me than my parents at home, I finally decided to get married.” (16-year-old girl, Indonesia)¹⁰⁸

Reasons for reduced pressure to marry included: household economic constraints and reduced remittances.^56,97 Some studies looked at the disparities between pre-pandemic married girls and unmarried girls. The proportion of pre-pandemic married girls across the studies ranged from 12% to 34%.⁴⁶ Married girls were poorer, had smaller households, were less likely to be enrolled in formal school and less economically stable in Bangladesh, Jordan and India.^46,54 Within the household, married girls reported higher relationship tensions and gender-based violence,^48,56,63 social isolation^46,75 and more domestic care responsibilities^46,48,84,88 during COVID-19, leading to worse mental health.^46,63 Married girls also had more challenges accessing health care (38%) during COVID-19 in Jordan.⁸⁴

Some articles highlighted results among vulnerable populations (refugees, adolescents with disabilities, adolescents with HIV) in the pre-pandemic period. During COVID-19, refugees faced higher community-level violence by the police,⁵⁶ lack of pedagogy during remote learning, increasing fears of dropping out of school,⁴⁸ higher food insecurity⁸⁴ and lower income/livelihood.⁷⁸ During COVID-19, adolescents with disabilities had less access to education,¹⁰⁰ lower voice and agency,⁴⁷ lower mobility,⁴⁷ lower overall health,⁸⁴ more food insecurity⁸⁴ and higher household stress.⁸⁴ One study in Kenya showed that adolescents who were lost to a HIV programme had greater difficulties with refilling medications and a higher proportion of not being engaged in school⁸⁹:

“The young people with a disability are more affected by corona[virus] because they used to go to the centres where they do activities together, communicate with other PWDs who are similar to us, but now they can’t! They feel alone and afraid!” (15-year-old girl, Palestine)⁴⁷

Conclusions

The COVID-19 pandemic upended the lives of adolescents and severely constrained the progress towards five SDG goals relating to zero hunger, quality education, gender equality, good health and well-being, and decent work and economic growth.⁵ This article looked at the health, social, educational and economic impacts of COVID-19 among adolescents living in LMICs, drawing upon both published and grey literature. This included effects on health, social relationships (family and peer), education and socio-economic disparities (economic ramifications, gender disparities and vulnerable/marginalised populations). When looking at the topics across regions, we found that mental health, education and socio-economic ramifications emerged as the three main topics across most. However, in some regions, SRH, physical health and peer-relationships also emerged as important. We should note that in most articles there was an interdependence of multiple themes and factors affecting the lives of adolescents. This allowed us to understand factors through a socio-ecological lens and realise that there is a mosaic of characteristics which create an individual, in this case an adolescent. Although there were few articles directly addressing adolescent SRH and rights, the issues discussed have profound consequences for SRH. For example, we know that depression, social isolation and anxiety all impact adolescent behaviours.¹¹³ So too, school closures precluded many young people from accessing comprehensive school-based sex education. And where both reproductive and sexual health services are available through schools, the pandemic-induced closures precluded accessing those services as well.²²

We believe this is the first paper that summarises the extant literature on the compounding impact of COVID-19 on adolescents’ lives during a pandemic. The results demonstrate how adolescents’ lives have been upended, and the serious ramifications of this on their mental health and education. Furthermore, we see that for all these impacts, there are disparities, with poor, marginalised and vulnerable populations being disproportionately affected. The results show that almost all domains have been linked to worsening mental health. Adolescents are susceptible to mental health problems because of rapid biological, psychological and social changes during this age.¹¹⁴ The COVID-19 containment measures further exacerbated mental health concerns due to school closures, separation from friends, forced contact with parents over an extended period and information overload.^115–119 A systematic review with 16 articles from predominantly high-income countries showed that during the COVID-19 pandemic, adolescents experienced higher levels of anxiety, depression, stress, and increased alcohol and cannabis use than before. However, social support, positive coping skills, home quarantine and parent–child discussions were associated with better mental health outcomes.¹¹⁶ Past literature has also shown the interdependence of various health outcomes to inform “good health and well-being”.¹²⁰ A systematic review among young people in humanitarian and LMIC settings found that mental health issues were compounded with poor SRH outcomes; this was especially true among those who were vulnerable and living in humanitarian settings.¹²¹ Adolescent girls were particularly vulnerable because they are more likely to experience depression, anxiety and sexual violence.¹²¹ This has had implications on contraceptive use and unwanted pregnancy.¹²¹ A systematic review on adolescent health in Sub-Saharan Africa showed that there were concerns around adolescent-friendly mental health services for pregnant adolescent girls and young women because of health worker attitudes, lack of confidentiality and lack of services to meet their needs.¹²² Our findings show that there is pressing need to take an interdisciplinary approach to addressing mental health problems, bearing in mind that the health of an adolescent is a complex collage of various socio-ecological characteristics, including and not limited to one health condition.

School closures have altered the way in which education is delivered and accessed. For more than 168 million children worldwide, schools were closed for an entire year or more.¹²³ For those who were able to access remote education, 65% of young people reported that they learned less since the start of the pandemic and 51% believed their completion of schooling would be delayed.²⁰ Our findings show that within LMICs, attitudes towards remote education were negative since there was a lack of resources to access it. The ramifications of school closures on future educational aspirations, in particular school dropout, were highlighted in our review. Between 2018 and 2020, a total of 5.9 million children dropped out of school, which was an increase compared with previous years.¹²⁴ With schools closed for so long, uncertainty about when they would reopen and economic shocks within the households, older adolescents were pressured to find work and support their households.¹²⁵ Younger adolescents on the other hand experienced an unprecedented amount of learning loss: 7 percentage point drop for each year of learning loss.¹²⁴ There is a need to change the way in which education is delivered.

The third topic that is crucial to post-pandemic efforts is reducing socio-economic disparities and therefore inequalities both within and between countries. Our results highlight how the pandemic has affected livelihoods of families and communities, resulting in income loss, food insecurity and economic shock. In 2020, approximately 1.2 billion children lived in multidimensional poverty which included lack of access to education, health, housing, nutrition and water. This was expected to increase by 100 million in 2021.¹²⁶ In relation to economic shocks, our results show this has been exacerbated among females and among the most vulnerable and marginalised, including married girls, refugees and adolescents with disabilities. In order to reduce these disparities, there is a need to pay particular attention to the problems and needs of marginalised adolescents.

Other topics that emerged in some of the regions included SRH outcomes. We found that during COVID-19 there was reduced access to health care. In particular, family planning services, antenatal care visits and lack of menstrual products were a recurring topic highlighted across the articles. In fact, some studies in Africa are showing that there is an increase in teenage pregnancy during COVID-19, partly due to difficulties in accessing services.^92,127,128 A report which highlighted the voices of adolescents and youth showed that health systems in developing countries were not prepared for the pandemic and therefore, access to essential SRH services was severely impacted during COVID-19, leading to likely increases in maternal deaths and unintended pregnancies.¹⁸ While none of the articles reviewed directly address the issues of menstrual hygiene and vaccine hesitancy, a systematic review showed that 52% of women had a menstrual problem after vaccination, with menorrhagia, metrorrhagia and polymenorrhagia ranging anywhere from 1% to 91%.¹²⁹ Factors affecting menstrual health problems included age, history of pregnancy, systemic side-effects of COVID-19, smoking and getting a second dose of the COVID-19 vaccine.¹²⁹ Likewise, there are numerous issues relevant to adolescent relationships during the COVID-19 pandemic (such as online relationships) which were not explicitly addressed in any of the literature reviewed. Future pandemics should ensure continuity of routine care and provide individualised care to vulnerable populations. There is also a need to reduce menstrual stigma and ensure availability of menstrual products to hygienically manage periods. A review of 36 case studies showed that innovative efforts to address SRH during COVID-19 included providing online modules, group sessions and radio edutainment lessons for comprehensive sexuality education.¹³⁰

The containment measures in place have forced adolescents to stay in close contact with their families and reduce interactions with peers. During adolescence, individuals try to step back in their relationship with their parents and lean toward peers for social and emotional support.¹³¹ These peer influences play an important role in both health and well-being. Our results show that most adolescents described negative family relationships including increased household stress and violence. The impact on peer relationships was worrying especially among girls who mentioned that their reduced spatial mobility was constrained. The pandemic deprived adolescents of peer resources which underlines the need to design interventions which acknowledge the importance of peers in adolescents’ lives.

Limitations

Our study had a number of limitations: (1) this was a rapid review of the literature, so it is likely that some published articles were missed. However, while coding the 89 articles, we believe we have reached saturation in terms of the information presented. (2) In comparison to mental health, education and economic ramifications, there were fewer articles on physical health, SRH, social relationships and vaccine perceptions. There is a need to conduct more research in these areas to draw conclusions on how the pandemic impacted them. (3) Since this is a literature review, it is susceptible to publication bias which leans towards findings which are statistically significant.¹³² (4) We were only able to include articles in English. However, we are somewhat reassured by the findings of a paper which noted that restricting reviews to English language had little to no impact on estimates and conclusions.¹³³ (5) Scales used to measure outcomes differed within and between regions. A quick analysis of 10 articles from China showed that mental health scales for depression and anxiety differed from study to study. There is a need for more multi-country studies using the same measures to understand the differences across regions. (6) Most of the studies were cross-sectional and quantitative in nature; thus there is a need to conduct more longitudinal research on the impact of COVID-19 over time and to utilise qualitative or mixed methods to understand how and why some outcomes occurred or evolved over time. (7) When outlining gender disparities, gender was dichotomised as male/female in all the articles. A study among youth in six countries showed that gender non-binary adolescents experienced increased vulnerability during COVID-19.¹⁹ For example, due to stay-at-home restrictions, many young people were forced to return to live with relatives who found their sexuality unacceptable, thereby increasing their mental health challenges and, in several cases, exposing them to stigma and violence. COVID-19 lockdown measures also restricted access to spaces where young gender non-conforming youth could safely meet and access information or services.¹⁹ More research is needed to understand the impact of COVID-19 among non-binary adolescents. (8) This review only included articles from LMICs with a large proportion from the Western Pacific. This limits the generalisability of the findings to those settings. There is a need to continue monitoring and examining the impact of COVID-19 across other regions to understand how factors compare.

We believe this is the first article that reviews the extant literature summarising the compounding impact of the different outcomes on adolescent lives during a pandemic. The results demonstrate how adolescent lives have been upended, and the ramifications for their mental health and education. Furthermore, we see that for all these impacts, there are disparities which further affect poor, marginalised and vulnerable populations. These results highlight the importance of interdisciplinary work by international agencies like the United Nations, governments and non-governmental organisations and, most importantly, adolescents themselves: to put adolescents at the centre of establishing the priorities for their health agenda and designing interventions which improve their sexual, mental and physical health and well-being.

Funding Statement

This work was funded by the UNDP, UNICEF, UNFPA and World Bank WHO Co-sponsored Human Reproduction Programme.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authorship contributions

AR, VCM and RWB conceptualised the study and determined the parameters with partners. AR conducted the literature search, coded the articles to create an annotated bibliography and wrote the first draft of the manuscript. RB, AG and SG aided in narrowing the parameters of the study and fine-tuning the methodology used for the annotated bibliography. All authors made significant contributions to the first draft of the manuscript.