COVID-19 has uprooted healthcare as we know it . To date, COVID-19 has claimed over 20.4 million confirmed cases and 745,000 deaths worldwide , leaving the world scrambling and struggling to find a solution [5–7]. Similar to the severe acute respiratory syndrome or SARS and Middle East respiratory syndrome or MERS, coronavirus disease 2019 or COVID-19 is a pandemic that has caused fear and uncertainty across continents [8–10]. Different from SARS and MERS, COVID-19 has greater transmissibility [11–13]. This, in turn, fuels its adverse impacts on societies at large as it leaves little time for governments across the world to develop an effective plan to tackle the pandemic. While SARS, MERS, and COVID-19 share similar virus characteristics [11–13], the epidemiological attributes of COVID-19 make it more difficult to contain and control as the virus evolves [11–13], further allowing it to continue wreaking havoc across the globe.
Mounting evidence shows that women are among the hardest hit populations during the pandemic [14–18], especially non-white racial or ethnic communities such as black and Hispanic women [19, 20]. A preliminary literature review indicates that factors influencing women’s increased vulnerability to COVID-19 can be grouped into five primary contributors: (1) pronounced exposure to COVID-19, (2) issues related to women’s reproductive health, (3) elevated domestic violence, (4) increased mental health challenges, and (5) lack of access to healthcare services. A detailed illustration can be found in Fig. 1.
Related to the first, primary contributor studies have shown that older adults, especially older nursing home residents and healthcare workers (e.g., nurses), have the most pronounced exposure to COVID-19 [1, 2]. Women make up the majority of both these populations [1, 21–23] leading them to an increased probability and disproportionate risk of contracting COVID-19. It is estimated that, worldwide, women make up 55% of the older adult (≥ 65 years old) population, whereas over 61% of the 80 years and older population are women . In the U.S., data show recent reports indicate that approximately 70.6% of nursing home residents are women . Nursing home residents often live with frailty and underlying conditions , which makes them particularly susceptible to COVID-19 infection and deaths. Repeated research indicates that nursing homes are ground zero in COVID-19 . As of July 30, 2020, 44% of all COVID-19 deaths in the U.S. occurred in nursing homes, which translates into 62,925 lives lost in total . Research also indicates that between 61.3–90.0% frontline healthcare professionals are women [1, 23, 26] and, in addition to an elevated risk of direct exposure to confirmed cases of COVID-19, most of these healthcare professionals often face substantial mental health issues, such as anxiety, insomnia, and depression [27, 28].
The other primary factors that contribute to women’s pronounced vulnerability to COVID-19 are gender-specific [29–31] and are rooted in the historical and cultural social power imbalances that result from being a patriarchal society, which disproportionately affects women, such as lower incomes and job loss and violence against women [18, 32, 33]. Research indicates that women’s employment is 1.8 times more likely to be in jeopardy due to COVID-19 compared to men. Even though women make up approximately 39% of the employed population globally, they count for 54% of all COVID-19-induced job losses . Domestic violence victims are also disproportionately impacted by COVID-19. Violence against women, or domestic violence, could be understood as “all behaviors which are based on gender, hurt, and damage, resulted or possibly resulted in physical, sexual and mental damage and cause to oppress on women in social or private life and arbitrary restrict the freedom of women” . Domestic violence constituted a health pandemic before the coronavirus outbreak [36–39]. Reports from the World Health Organization indicate that, globally, 1 in 3 women is or will become a victim of physical or sexual violence at some point in their relationship . COVID-19 only serves to escalate this reality for women .
Mounting evidence shows that both incidence and death rates related to violence against women have soared during the COVID-19 outbreak [32, 41–45]. In Australia, even though there was a 40% drop in overall crime rates during the outbreak, domestic violence calls have increased 5% . Available evidence from European countries further indicates that there is a 60% spike of emergency calls from female domestic violence victims during the COVID-19 outbreak . Disturbing reports from the United Kingdom (U.K.) suggest that between 23 March and 12 April, 2020, female deaths due to domestic violence almost doubled compared with average rates in the past decade . Compounding this effect is that, citing COVID-19 infection risks, Governors in the U.S. have largely released perpetrators in jail for misdemeanors , a categorization under which most domestic cases fall. This, in turn, may further heighten the burden of fear and uncertainty some women shoulder amid COVID-19, if not increase their odds of physical harm as well.
Undoubtedly, both health issues related to reproductive health and elevated domestic violence women face can have a grim effect on women’s health during COVID-19, especially their mental health conditions [30, 46, 49–52]. Repeated evidence indicates that women who are subject to domestic violence often suffer from traumatic brain injuries (TBI) [53–55], which could have a long-term effect on their mental health as well . Examining the prevalence of TBI among a group of domestic violence victims, researchers found that 88% of the women studied experienced more than one injury, and 81% of them had experienced loss of consciousness due to their injuries . Mounting research indicates that mental health challenges domestic violence victims face may be even more disheartening [57–59]. Results from a meta-analysis of 207 studies show that depression, anxiety, posttraumatic stress disorder, antisocial personality disorder, and borderline personality disorder are common among domestic violence victims . However, due to spatial distancing measures and COVID-19 medical resources rationing policies, many traditional venues of help, such as face-to-face consultation, have either been delayed or cancelled [46, 50, 60–62]. In addition, it is well-documented that most domestic violence cases remain underreported or unreported, because a considerable number of women do not seek help [32, 46, 50, 62, 63].
It is not clear whether and to what degree women may benefit from the increasing number of technology-based health solutions proposed during the time of COVID-19. Older adults, the majority of whom are women , often face issues associated with cognitive decline [64, 65], making them highly dependent on physically-based healthcare services [66–68]. Furthermore, many older women face concurrent issues, like visual impairment, hearing difficulties, or dual sensory loss [69, 70]. The majority of existing technology-based health solutions fail to address these challenges given that they are primarily delivered or hosted on websites and mobile applications [71–73].
Situations may be even worse for older domestic abuse victims. Research suggests that, amongst those who have experienced concussions, a symptom common among domestic abuse victims, females are more likely to develop computer-screen intolerance due to brain-related photosensitivity issues. In other words, though technology-based solutions exist, due to lack of tailored design and consideration of older users [74–76], these solutions may have limited utility and functionality for older females. All of these barriers, in turn, can contribute to the most vulnerable of the population left with little to no access to services [2, 46, 50, 62], especially factoring in the digital divide experienced by people who face both health disparities and economic hardships which may further exacerbates these individuals’ unmet healthcare needs [77–79]. These combined insights indicate that, while women face substantial health issues amid COVID-19, most of these issues may remain unsolved for a prolonged period of time due to lack of available health solutions [46, 50, 62]. This, undoubtedly will further worsen the dire situations women face on a daily basis [46, 50, 62].
Overall, there is dearth of research that examines health solutions that have the potential to address health issues people face amid COVID-19 , particularly for women. Available evidence indicates that corollary interventions have the potential to address women’s health issues. Take the case of interventions for human immunodeficiency virus (HIV). Researchers found that educator-led programs based on the Health Belief Model yielded significantly more positive behavioral outcomes for females living with HIV when compared to standard talk therapy . One way to determine potentially effective interventions for women during COVID-19 is to systematically review literature in the context of infectious disease pandemics [80, 82, 83] as they share attributes such as unpredictability (e.g., when, where, and how the crises unfold and fade) and destructiveness (e.g., uprooted lives and livelihoods) [11–13]. Communicable disease pandemics often share similar disaster preparedness procedures as well, like social distancing measures [84–87]. Thus, interventions designed for women in the context of pandemics like SARS and MERS may be able to shed light on solutions women can use amid COVID-19 as well.
To bridge this gap in literature, we aim to systematically review the literature to: (1) identify interventions designed for women in the context of pandemics, (2) describe the characteristics and effects of these interventions concerning the distinctive traits of women and pandemics, and (3) present evidence-based and practical health solutions for women to mitigate challenges they face amid and beyond COVID-19. Findings of this study will fill an important void in the literature. Considering that women are often subject to grim health disparities, the need for evidence-based health solutions that could address the unique challenges women face during COVID-19 is of paramount importance. A comprehensive understanding of the characteristics and effects of health solutions available to women in the context of pandemics can also help researchers identify areas of improvement regarding intervention design and development.