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Researchers at Oxford Population Health’s Health Economics Research Centre, supported by the NIHR ARC OxTV, have shown that the COVID-19 pandemic was associated with a reduction in perceived health-related quality of life, especially related to incidences of anxiety and depression in younger people.

The impact of the COVID-19 pandemic on infection rates and deaths has been closely monitored, but data on the relationship between the pandemic and health-related quality of life is still quite limited. Other studies have mostly focused on single countries and used smaller sample sizes, making cross-country comparison difficult. The results from this multinational study help us to further understand and more accurately record the health burden of COVID-19 in diverse settings, health conditions, and populations, which may help to inform policies and interventions against the current COVID-19 pandemic and future public health shocks.

15,480 participants aged 18 years and over from across 13 different countries (Australia, Brazil, Canada, Chile, China, Colombia, France, India, Italy, Spain, Uganda, United States of America, and the United Kingdom) completed an anonymous online survey as part of the CANDOUR study between 24 November 2020 and 17 December 2020. The participants were asked questions about their sociodemographic characteristics, their health, and to rate their perceived health-related quality of life before and during the pandemic.

Key findings:

  • The study found an 8% reduction in perceived health-related quality of life overall;
  • The COVID-19 pandemic was associated with significantly worse self-reported health-related quality of life for more than one third of respondents, with anxiety and depression worsening the most, especially for people under the age of 35 and for women of all ages;
  • The deterioration of mental health was prevalent across all countries regardless of the level of economic development. For the other aspects of health that were measured by the study, including mobility, self-care, ability to carry out usual activities, and pain or discomfort, there was a clear association between lower levels of economic development and lower levels of health-related quality of life;
  • The number of perceived quality-adjusted life years (a way of measuring health that combines the quantity and quality of life lived) lost associated with COVID-19-related illness were much higher than the number of quality-adjusted life years lost because of premature death due to COVID-19; 
  • Government responsiveness to the pandemic at a national level, which varied between countries, was associated with a reduced likelihood of male survey respondents self-reporting worsened health;
  • Across all countries, on average, 43% of survey participants incurred a loss of income as a result of the pandemic. Income loss was found to be linked to significantly higher odds of worsened health irrespective of gender.

Dr Mara Violato, Associate Professor at Oxford Population Health and lead author of the study, said:

‘The results from the study suggest that the overall health burden may be substantially underestimated if we only consider the impact of deaths from COVID-19. By including data on the perceived health-related quality of life associated with COVID-19 related illness, we can more accurately capture the health burden of the COVID-19 pandemic. In turn, this information can help to guide public health measures and economic policies in the event of future pandemics.’

The researchers note that the participants were asked to complete some health-related questions referring to the pre-pandemic period retrospectively, which means that some of the results may be subject to ‘recall bias’, and that participants’ circumstances at the time of the survey may have had an impact on how they remembered events from the past. For example, the researchers note that some patients in previous studies have been found to recall their initial health-related quality of life as being better than it actually was, which may suggest that the differences observed in this study were larger than in reality.


The COVID-19 pandemic and health-related quality of life across 13 high- and low-middle-income countries: A cross-sectional analysis
Violato M, Pollard J, Lloyd A, Roope LSJ, Duch R, et al. (2023) The COVID-19 pandemic and health-related quality of life across 13 high- and low-middle-income countries: A cross-sectional analysis. PLOS Medicine 20(4): e1004146.

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