essay on online education in covid 19

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Students’ experience of online learning during the COVID‐19 pandemic: A province‐wide survey study

Lixiang yan.

1 Centre for Learning Analytics at Monash, Faculty of Information Technology, Monash University, Clayton VIC, Australia

Alexander Whitelock‐Wainwright

2 Portfolio of the Deputy Vice‐Chancellor (Education), Monash University, Melbourne VIC, Australia

Quanlong Guan

3 Department of Computer Science, Jinan University, Guangzhou China

Gangxin Wen

4 College of Cyber Security, Jinan University, Guangzhou China

Dragan Gašević

Guanliang chen, associated data.

The data is not openly available as it is restricted by the Chinese government.

Online learning is currently adopted by educational institutions worldwide to provide students with ongoing education during the COVID‐19 pandemic. Even though online learning research has been advancing in uncovering student experiences in various settings (i.e., tertiary, adult, and professional education), very little progress has been achieved in understanding the experience of the K‐12 student population, especially when narrowed down to different school‐year segments (i.e., primary and secondary school students). This study explores how students at different stages of their K‐12 education reacted to the mandatory full‐time online learning during the COVID‐19 pandemic. For this purpose, we conducted a province‐wide survey study in which the online learning experience of 1,170,769 Chinese students was collected from the Guangdong Province of China. We performed cross‐tabulation and Chi‐square analysis to compare students’ online learning conditions, experiences, and expectations. Results from this survey study provide evidence that students’ online learning experiences are significantly different across school years. Foremost, policy implications were made to advise government authorises and schools on improving the delivery of online learning, and potential directions were identified for future research into K‐12 online learning.

Practitioner notes

What is already known about this topic

• Online learning has been widely adopted during the COVID‐19 pandemic to ensure the continuation of K‐12 education.
• Student success in K‐12 online education is substantially lower than in conventional schools.
• Students experienced various difficulties related to the delivery of online learning.

What this paper adds

• Provide empirical evidence for the online learning experience of students in different school years.
• Identify the different needs of students in primary, middle, and high school.
• Identify the challenges of delivering online learning to students of different age.

Implications for practice and/or policy

• Authority and schools need to provide sufficient technical support to students in online learning.
• The delivery of online learning needs to be customised for students in different school years.

INTRODUCTION

The ongoing COVID‐19 pandemic poses significant challenges to the global education system. By July 2020, the UN Educational, Scientific and Cultural Organization (2020) reported nationwide school closure in 111 countries, affecting over 1.07 billion students, which is around 61% of the global student population. Traditional brick‐and‐mortar schools are forced to transform into full‐time virtual schools to provide students with ongoing education (Van Lancker & Parolin,  2020 ). Consequently, students must adapt to the transition from face‐to‐face learning to fully remote online learning, where synchronous video conferences, social media, and asynchronous discussion forums become their primary venues for knowledge construction and peer communication.

For K‐12 students, this sudden transition is problematic as they often lack prior online learning experience (Barbour & Reeves,  2009 ). Barbour and LaBonte ( 2017 ) estimated that even in countries where online learning is growing rapidly, such as USA and Canada, less than 10% of the K‐12 student population had prior experience with this format. Maladaptation to online learning could expose inexperienced students to various vulnerabilities, including decrements in academic performance (Molnar et al.,  2019 ), feeling of isolation (Song et al.,  2004 ), and lack of learning motivation (Muilenburg & Berge,  2005 ). Unfortunately, with confirmed cases continuing to rise each day, and new outbreaks occur on a global scale, full‐time online learning for most students could last longer than anticipated (World Health Organization,  2020 ). Even after the pandemic, the current mass adoption of online learning could have lasting impacts on the global education system, and potentially accelerate and expand the rapid growth of virtual schools on a global scale (Molnar et al.,  2019 ). Thus, understanding students' learning conditions and their experiences of online learning during the COVID pandemic becomes imperative.

Emerging evidence on students’ online learning experience during the COVID‐19 pandemic has identified several major concerns, including issues with internet connection (Agung et al.,  2020 ; Basuony et al.,  2020 ), problems with IT equipment (Bączek et al.,  2021 ; Niemi & Kousa,  2020 ), limited collaborative learning opportunities (Bączek et al.,  2021 ; Yates et al.,  2020 ), reduced learning motivation (Basuony et al.,  2020 ; Niemi & Kousa,  2020 ; Yates et al.,  2020 ), and increased learning burdens (Niemi & Kousa,  2020 ). Although these findings provided valuable insights about the issues students experienced during online learning, information about their learning conditions and future expectations were less mentioned. Such information could assist educational authorises and institutions to better comprehend students’ difficulties and potentially improve their online learning experience. Additionally, most of these recent studies were limited to higher education, except for Yates et al. ( 2020 ) and Niemi and Kousa’s ( 2020 ) studies on senior high school students. Empirical research targeting the full spectrum of K‐12students remain scarce. Therefore, to address these gaps, the current paper reports the findings of a large‐scale study that sought to explore K‐12 students’ online learning experience during the COVID‐19 pandemic in a provincial sample of over one million Chinese students. The findings of this study provide policy recommendations to educational institutions and authorities regarding the delivery of K‐12 online education.

LITERATURE REVIEW

Learning conditions and technologies.

Having stable access to the internet is critical to students’ learning experience during online learning. Berge ( 2005 ) expressed the concern of the divide in digital‐readiness, and the pedagogical approach between different countries could influence students’ online learning experience. Digital‐readiness is the availability and adoption of information technologies and infrastructures in a country. Western countries like America (3rd) scored significantly higher in digital‐readiness compared to Asian countries like China (54th; Cisco,  2019 ). Students from low digital‐readiness countries could experience additional technology‐related problems. Supporting evidence is emerging in recent studies conducted during the COVID‐19 pandemic. In Egypt's capital city, Basuony et al. ( 2020 ) found that only around 13.9%of the students experienced issues with their internet connection. Whereas more than two‐thirds of the students in rural Indonesia reported issues of unstable internet, insufficient internet data, and incompatible learning device (Agung et al.,  2020 ).

Another influential factor for K‐12 students to adequately adapt to online learning is the accessibility of appropriate technological devices, especially having access to a desktop or a laptop (Barbour et al., 2018 ). However, it is unlikely for most of the students to satisfy this requirement. Even in higher education, around 76% of students reported having incompatible devices for online learning and only 15% of students used laptop for online learning, whereas around 85% of them used smartphone (Agung et al.,  2020 ). It is very likely that K‐12 students also suffer from this availability issue as they depend on their parents to provide access to relevant learning devices.

Technical issues surrounding technological devices could also influence students’ experience in online learning. (Barbour & Reeves,  2009 ) argues that students need to have a high level of digital literacy to find and use relevant information and communicate with others through technological devices. Students lacking this ability could experience difficulties in online learning. Bączek et al. ( 2021 ) found that around 54% of the medical students experienced technical problems with IT equipment and this issue was more prevalent in students with lower years of tertiary education. Likewise, Niemi and Kousa ( 2020 ) also find that students in a Finish high school experienced increased amounts of technical problems during the examination period, which involved additional technical applications. These findings are concerning as young children and adolescent in primary and lower secondary school could be more vulnerable to these technical problems as they are less experienced with the technologies in online learning (Barbour & LaBonte,  2017 ). Therefore, it is essential to investigate the learning conditions and the related difficulties experienced by students in K‐12 education as the extend of effects on them remain underexplored.

Learning experience and interactions

Apart from the aforementioned issues, the extent of interaction and collaborative learning opportunities available in online learning could also influence students’ experience. The literature on online learning has long emphasised the role of effective interaction for the success of student learning. According to Muirhead and Juwah ( 2004 ), interaction is an event that can take the shape of any type of communication between two or subjects and objects. Specifically, the literature acknowledges the three typical forms of interactions (Moore,  1989 ): (i) student‐content, (ii) student‐student, and (iii) student‐teacher. Anderson ( 2003 ) posits, in the well‐known interaction equivalency theorem, learning experiences will not deteriorate if only one of the three interaction is of high quality, and the other two can be reduced or even eliminated. Quality interaction can be accomplished by across two dimensions: (i) structure—pedagogical means that guide student interaction with contents or other students and (ii) dialogue—communication that happens between students and teachers and among students. To be able to scale online learning and prevent the growth of teaching costs, the emphasise is typically on structure (i.e., pedagogy) that can promote effective student‐content and student‐student interaction. The role of technology and media is typically recognised as a way to amplify the effect of pedagogy (Lou et al.,  2006 ). Novel technological innovations—for example learning analytics‐based personalised feedback at scale (Pardo et al.,  2019 ) —can also empower teachers to promote their interaction with students.

Online education can lead to a sense of isolation, which can be detrimental to student success (McInnerney & Roberts,  2004 ). Therefore, integration of social interaction into pedagogy for online learning is essential, especially at the times when students do not actually know each other or have communication and collaboration skills underdeveloped (Garrison et al.,  2010 ; Gašević et al.,  2015 ). Unfortunately, existing evidence suggested that online learning delivery during the COVID‐19 pandemic often lacks interactivity and collaborative experiences (Bączek et al.,  2021 ; Yates et al.,  2020 ). Bączek et al., ( 2021 ) found that around half of the medical students reported reduced interaction with teachers, and only 4% of students think online learning classes are interactive. Likewise, Yates et al. ( 2020 )’s study in high school students also revealed that over half of the students preferred in‐class collaboration over online collaboration as they value the immediate support and the proximity to teachers and peers from in‐class interaction.

Learning expectations and age differentiation

Although these studies have provided valuable insights and stressed the need for more interactivity in online learning, K‐12 students in different school years could exhibit different expectations for the desired activities in online learning. Piaget's Cognitive Developmental Theory illustrated children's difficulties in understanding abstract and hypothetical concepts (Thomas,  2000 ). Primary school students will encounter many abstract concepts in their STEM education (Uttal & Cohen,  2012 ). In face‐to‐face learning, teachers provide constant guidance on students’ learning progress and can help them to understand difficult concepts. Unfortunately, the level of guidance significantly drops in online learning, and, in most cases, children have to face learning obstacles by themselves (Barbour,  2013 ). Additionally, lower primary school students may lack the metacognitive skills to use various online learning functions, maintain engagement in synchronous online learning, develop and execute self‐regulated learning plans, and engage in meaningful peer interactions during online learning (Barbour,  2013 ; Broadbent & Poon,  2015 ; Huffaker & Calvert, 2003; Wang et al.,  2013 ). Thus, understanding these younger students’ expectations is imperative as delivering online learning to them in the same way as a virtual high school could hinder their learning experiences. For students with more matured metacognition, their expectations of online learning could be substantially different from younger students. Niemi et al.’s study ( 2020 ) with students in a Finish high school have found that students often reported heavy workload and fatigue during online learning. These issues could cause anxiety and reduce students’ learning motivation, which would have negative consequences on their emotional well‐being and academic performance (Niemi & Kousa,  2020 ; Yates et al.,  2020 ), especially for senior students who are under the pressure of examinations. Consequently, their expectations of online learning could be orientated toward having additional learning support functions and materials. Likewise, they could also prefer having more opportunities for peer interactions as these interactions are beneficial to their emotional well‐being and learning performance (Gašević et al., 2013 ; Montague & Rinaldi, 2001 ). Therefore, it is imperative to investigate the differences between online learning expectations in students of different school years to suit their needs better.

Research questions

By building upon the aforementioned relevant works, this study aimed to contribute to the online learning literature with a comprehensive understanding of the online learning experience that K‐12 students had during the COVID‐19 pandemic period in China. Additionally, this study also aimed to provide a thorough discussion of what potential actions can be undertaken to improve online learning delivery. Formally, this study was guided by three research questions (RQs):

RQ1 . What learning conditions were experienced by students across 12 years of education during their online learning process in the pandemic period? RQ2 . What benefits and obstacles were perceived by students across 12 years of education when performing online learning? RQ3 . What expectations do students, across 12 years of education, have for future online learning practices ?

Participants

The total number of K‐12 students in the Guangdong Province of China is around 15 million. In China, students of Year 1–6, Year 7–9, and Year 10–12 are referred to as students of primary school, middle school, and high school, respectively. Typically, students in China start their study in primary school at the age of around six. At the end of their high‐school study, students have to take the National College Entrance Examination (NCEE; also known as Gaokao) to apply for tertiary education. The survey was administrated across the whole Guangdong Province, that is the survey was exposed to all of the 15 million K‐12 students, though it was not mandatory for those students to accomplish the survey. A total of 1,170,769 students completed the survey, which accounts for a response rate of 7.80%. After removing responses with missing values and responses submitted from the same IP address (duplicates), we had 1,048,575 valid responses, which accounts to about 7% of the total K‐12 students in the Guangdong Province. The number of students in different school years is shown in Figure  1 . Overall, students were evenly distributed across different school years, except for a smaller sample in students of Year 10–12.

The number of students in each school year

Survey design

The survey was designed collaboratively by multiple relevant parties. Firstly, three educational researchers working in colleges and universities and three educational practitioners working in the Department of Education in Guangdong Province were recruited to co‐design the survey. Then, the initial draft of the survey was sent to 30 teachers from different primary and secondary schools, whose feedback and suggestions were considered to improve the survey. The final survey consisted of a total of 20 questions, which, broadly, can be classified into four categories: demographic, behaviours, experiences, and expectations. Details are available in Appendix.

All K‐12 students in the Guangdong Province were made to have full‐time online learning from March 1, 2020 after the outbreak of COVID‐19 in January in China. A province‐level online learning platform was provided to all schools by the government. In addition to the learning platform, these schools can also use additional third‐party platforms to facilitate the teaching activities, for example WeChat and Dingding, which provide services similar to WhatsApp and Zoom. The main change for most teachers was that they had to shift the classroom‐based lectures to online lectures with the aid of web‐conferencing tools. Similarly, these teachers also needed to perform homework marking and have consultation sessions in an online manner.

The Department of Education in the Guangdong Province of China distributed the survey to all K‐12 schools in the province on March 21, 2020 and collected responses on March 26, 2020. Students could access and answer the survey anonymously by either scan the Quick Response code along with the survey or click the survey address link on their mobile device. The survey was administrated in a completely voluntary manner and no incentives were given to the participants. Ethical approval was granted by the Department of Education in the Guangdong Province. Parental approval was not required since the survey was entirely anonymous and facilitated by the regulating authority, which satisfies China's ethical process.

The original survey was in Chinese, which was later translated by two bilingual researchers and verified by an external translator who is certified by the Australian National Accreditation Authority of Translators and Interpreters. The original and translated survey questionnaires are available in Supporting Information. Given the limited space we have here and the fact that not every survey item is relevant to the RQs, the following items were chosen to answer the RQs: item Q3 (learning media) and Q11 (learning approaches) for RQ1, item Q13 (perceived obstacle) and Q19 (perceived benefits) for RQ2, and item Q19 (expected learning activities) for RQ3. Cross‐tabulation based approaches were used to analyse the collected data. To scrutinise whether the differences displayed by students of different school years were statistically significant, we performed Chi‐square tests and calculated the Cramer's V to assess the strengths of the association after chi‐square had determined significance.

For the analyses, students were segmented into four categories based on their school years, that is Year 1–3, Year 4–6, Year 7–9, and Year 10–12, to provide a clear understanding of the different experiences and needs that different students had for online learning. This segmentation was based on the educational structure of Chinese schools: elementary school (Year 1–6), middle school (Year 7–9), and high school (Year 10–12). Children in elementary school can further be segmented into junior (Year 1–3) or senior (Year 4–6) students because senior elementary students in China are facing more workloads compared to junior students due to the provincial Middle School Entry Examination at the end of Year 6.

Learning conditions—RQ1

Learning media.

The Chi‐square test showed significant association between school years and students’ reported usage of learning media, χ 2 (55, N  = 1,853,952) = 46,675.38, p  < 0.001. The Cramer's V is 0.07 ( df ∗ = 5), which indicates a small‐to‐medium effect according to Cohen’s ( 1988 ) guidelines. Based on Figure  2 , we observed that an average of up to 87.39% students used smartphones to perform online learning, while only 25.43% students used computer, which suggests that smartphones, with widespread availability in China (2020), have been adopted by students for online learning. As for the prevalence of the two media, we noticed that both smartphones ( χ 2 (3, N  = 1,048,575) = 9,395.05, p < 0.001, Cramer's V  = 0.10 ( df ∗ = 1)) and computers ( χ 2 (3, N  = 1,048,575) = 11,025.58, p <.001, Cramer's V  = 0.10 ( df ∗ = 1)) were more adopted by high‐school‐year (Year 7–12) than early‐school‐year students (Year 1–6), both with a small effect size. Besides, apparent discrepancies can be observed between the usages of TV and paper‐based materials across different school years, that is early‐school‐year students reported more TV usage ( χ 2 (3, N  = 1,048,575) = 19,505.08, p <.001), with a small‐to‐medium effect size, Cramer's V  = 0.14( df ∗ = 1). High‐school‐year students (especially Year 10–12) reported more usage of paper‐based materials ( χ 2 (3, N  = 1,048,575) = 23,401.64, p < 0.001), with a small‐to‐medium effect size, Cramer's V  = 0.15( df ∗ = 1).

Learning media used by students in online learning

Learning approaches

School years is also significantly associated with the different learning approaches students used to tackle difficult concepts during online learning, χ 2 (55, N  = 2,383,751) = 58,030.74, p < 0.001. The strength of this association is weak to moderate as shown by the Cramer's V (0.07, df ∗ = 5; Cohen,  1988 ). When encountering problems related to difficult concepts, students typically chose to “solve independently by searching online” or “rewatch recorded lectures” instead of consulting to their teachers or peers (Figure  3 ). This is probably because, compared to classroom‐based education, it is relatively less convenient and more challenging for students to seek help from others when performing online learning. Besides, compared to high‐school‐year students, early‐school‐year students (Year 1–6), reported much less use of “solve independently by searching online” ( χ 2 (3, N  = 1,048,575) = 48,100.15, p <.001), with a small‐to‐medium effect size, Cramer's V  = 0.21 ( df ∗ = 1). Also, among those approaches of seeking help from others, significantly more high‐school‐year students preferred “communicating with other students” than early‐school‐year students ( χ 2 (3, N  = 1,048,575) = 81,723.37, p < 0.001), with a medium effect size, Cramer's V  = 0.28 ( df ∗ = 1).

Learning approaches used by students in online learning

Perceived benefits and obstacles—RQ2

Perceived benefits.

The association between school years and perceived benefits in online learning is statistically significant, χ 2 (66, N  = 2,716,127) = 29,534.23, p  < 0.001, and the Cramer's V (0.04, df ∗ = 6) indicates a small effect (Cohen,  1988 ). Unsurprisingly, benefits brought by the convenience of online learning are widely recognised by students across all school years (Figure  4 ), that is up to 75% of students reported that it is “more convenient to review course content” and 54% said that they “can learn anytime and anywhere” . Besides, we noticed that about 50% of early‐school‐year students appreciated the “access to courses delivered by famous teachers” and 40%–47% of high‐school‐year students indicated that online learning is “helpful to develop self‐regulation and autonomy” .

Perceived benefits of online learning reported by students

Perceived obstacles

The Chi‐square test shows a significant association between school years and students’ perceived obstacles in online learning, χ 2 (77, N  = 2,699,003) = 31,987.56, p < 0.001. This association is relatively weak as shown by the Cramer's V (0.04, df ∗ = 7; Cohen,  1988 ). As shown in Figure  5 , the biggest obstacles encountered by up to 73% of students were the “eyestrain caused by long staring at screens” . Disengagement caused by nearby disturbance was reported by around 40% of students, especially those of Year 1–3 and 10–12. Technological‐wise, about 50% of students experienced poor Internet connection during their learning process, and around 20% of students reported the “confusion in setting up the platforms” across of school years.

Perceived obstacles of online learning reported by students

Expectations for future practices of online learning – RQ3

Online learning activities.

The association between school years and students’ expected online learning activities is significant, χ 2 (66, N  = 2,416,093) = 38,784.81, p < 0.001. The Cramer's V is 0.05 ( df ∗ = 6) which suggests a small effect (Cohen,  1988 ). As shown in Figure  6 , the most expected activity for future online learning is “real‐time interaction with teachers” (55%), followed by “online group discussion and collaboration” (38%). We also observed that more early‐school‐year students expect reflective activities, such as “regular online practice examinations” ( χ 2 (3, N  = 1,048,575) = 11,644.98, p < 0.001), with a small effect size, Cramer's V  = 0.11 ( df ∗ = 1). In contrast, more high‐school‐year students expect “intelligent recommendation system …” ( χ 2 (3, N  = 1,048,575) = 15,327.00, p < 0.001), with a small effect size, Cramer's V  = 0.12 ( df ∗ = 1).

Students’ expected online learning activities

Regarding students’ learning conditions, substantial differences were observed in learning media, family dependency, and learning approaches adopted in online learning between students in different school years. The finding of more computer and smartphone usage in high‐school‐year than early‐school‐year students can probably be explained by that, with the growing abilities in utilising these media as well as the educational systems and tools which run on these media, high‐school‐year students tend to make better use of these media for online learning practices. Whereas, the differences in paper‐based materials may imply that high‐school‐year students in China have to accomplish a substantial amount of exercise, assignments, and exam papers to prepare for the National College Entrance Examination (NCEE), whose delivery was not entirely digitised due to the sudden transition to online learning. Meanwhile, high‐school‐year students may also have preferred using paper‐based materials for exam practice, as eventually, they would take their NCEE in the paper format. Therefore, these substantial differences in students’ usage of learning media should be addressed by customising the delivery method of online learning for different school years.

Other than these between‐age differences in learning media, the prevalence of smartphone in online learning resonates with Agung et al.’s ( 2020 ) finding on the issues surrounding the availability of compatible learning device. The prevalence of smartphone in K‐12 students is potentially problematic as the majority of the online learning platform and content is designed for computer‐based learning (Berge,  2005 ; Molnar et al.,  2019 ). Whereas learning with smartphones has its own unique challenges. For example, Gikas and Grant ( 2013 ) discovered that students who learn with smartphone experienced frustration with the small screen‐size, especially when trying to type with the tiny keypad. Another challenge relates to the distraction of various social media applications. Although similar distractions exist in computer and web‐based social media, the level of popularity, especially in the young generation, are much higher in mobile‐based social media (Montag et al.,  2018 ). In particular, the message notification function in smartphones could disengage students from learning activities and allure them to social media applications (Gikas & Grant,  2013 ). Given these challenges of learning with smartphones, more research efforts should be devoted to analysing students’ online learning behaviour in the setting of mobile learning to accommodate their needs better.

The differences in learning approaches, once again, illustrated that early‐school‐year students have different needs compared to high‐school‐year students. In particular, the low usage of the independent learning methods in early‐school‐year students may reflect their inability to engage in independent learning. Besides, the differences in help seeking behaviours demonstrated the distinctive needs for communication and interaction between different students, that is early‐school‐year students have a strong reliance on teachers and high‐school‐year students, who are equipped with stronger communication ability, are more inclined to interact with their peers. This finding implies that the design of online learning platforms should take students’ different needs into account. Thus, customisation is urgently needed for the delivery of online learning to different school years.

In terms of the perceived benefits and challenges of online learning, our results resonate with several previous findings. In particular, the benefits of convenience are in line with the flexibility advantages of online learning, which were mentioned in prior works (Appana,  2008 ; Bączek et al.,  2021 ; Barbour,  2013 ; Basuony et al.,  2020 ; Harvey et al.,  2014 ). Early‐school‐year students’ higher appreciation in having “access to courses delivered by famous teachers” and lower appreciation in the independent learning skills developed through online learning are also in line with previous literature (Barbour,  2013 ; Harvey et al.,  2014 ; Oliver et al.,  2009 ). Again, these similar findings may indicate the strong reliance that early‐school‐year students place on teachers, while high‐school‐year students are more capable of adapting to online learning by developing independent learning skills.

Technology‐wise, students’ experience of poor internet connection and confusion in setting up online learning platforms are particularly concerning. The problem of poor internet connection corroborated the findings reported in prior studies (Agung et al.,  2020 ; Barbour,  2013 ; Basuony et al.,  2020 ; Berge,  2005 ; Rice,  2006 ), that is the access issue surrounded the digital divide as one of the main challenges of online learning. In the era of 4G and 5G networks, educational authorities and institutions that deliver online education could fall into the misconception of most students have a stable internet connection at home. The internet issue we observed is particularly vital to students’ online learning experience as most students prefer real‐time communications (Figure  6 ), which rely heavily on stable internet connection. Likewise, the finding of students’ confusion in technology is also consistent with prior studies (Bączek et al.,  2021 ; Muilenburg & Berge,  2005 ; Niemi & Kousa,  2020 ; Song et al.,  2004 ). Students who were unsuccessfully in setting up the online learning platforms could potentially experience declines in confidence and enthusiasm for online learning, which would cause a subsequent unpleasant learning experience. Therefore, both the readiness of internet infrastructure and student technical skills remain as the significant challenges for the mass‐adoption of online learning.

On the other hand, students’ experience of eyestrain from extended screen time provided empirical evidence to support Spitzer’s ( 2001 ) speculation about the potential ergonomic impact of online learning. This negative effect is potentially related to the prevalence of smartphone device and the limited screen size of these devices. This finding not only demonstrates the potential ergonomic issues that would be caused by smartphone‐based online learning but also resonates with the aforementioned necessity of different platforms and content designs for different students.

A less‐mentioned problem in previous studies on online learning experiences is the disengagement caused by nearby disturbance, especially in Year 1–3 and 10–12. It is likely that early‐school‐year students suffered from this problem because of their underdeveloped metacognitive skills to concentrate on online learning without teachers’ guidance. As for high‐school‐year students, the reasons behind their disengagement require further investigation in the future. Especially it would be worthwhile to scrutinise whether this type of disengagement is caused by the substantial amount of coursework they have to undertake and the subsequent a higher level of pressure and a lower level of concentration while learning.

Across age‐level differences are also apparent in terms of students’ expectations of online learning. Although, our results demonstrated students’ needs of gaining social interaction with others during online learning, findings (Bączek et al.,  2021 ; Harvey et al.,  2014 ; Kuo et al.,  2014 ; Liu & Cavanaugh,  2012 ; Yates et al.,  2020 ). This need manifested differently across school years, with early‐school‐year students preferring more teacher interactions and learning regulation support. Once again, this finding may imply that early‐school‐year students are inadequate in engaging with online learning without proper guidance from their teachers. Whereas, high‐school‐year students prefer more peer interactions and recommendation to learning resources. This expectation can probably be explained by the large amount of coursework exposed to them. Thus, high‐school‐year students need further guidance to help them better direct their learning efforts. These differences in students’ expectations for future practices could guide the customisation of online learning delivery.

Implications

As shown in our results, improving the delivery of online learning not only requires the efforts of policymakers but also depend on the actions of teachers and parents. The following sub‐sections will provide recommendations for relevant stakeholders and discuss their essential roles in supporting online education.

Technical support

The majority of the students has experienced technical problems during online learning, including the internet lagging and confusion in setting up the learning platforms. These problems with technology could impair students’ learning experience (Kauffman,  2015 ; Muilenburg & Berge,  2005 ). Educational authorities and schools should always provide a thorough guide and assistance for students who are experiencing technical problems with online learning platforms or other related tools. Early screening and detection could also assist schools and teachers to direct their efforts more effectively in helping students with low technology skills (Wilkinson et al.,  2010 ). A potential identification method involves distributing age‐specific surveys that assess students’ Information and Communication Technology (ICT) skills at the beginning of online learning. For example, there are empirical validated ICT surveys available for both primary (Aesaert et al.,  2014 ) and high school (Claro et al.,  2012 ) students.

For students who had problems with internet lagging, the delivery of online learning should provide options that require fewer data and bandwidth. Lecture recording is the existing option but fails to address students’ need for real‐time interaction (Clark et al.,  2015 ; Malik & Fatima,  2017 ). A potential alternative involves providing students with the option to learn with digital or physical textbooks and audio‐conferencing, instead of screen sharing and video‐conferencing. This approach significantly reduces the amount of data usage and lowers the requirement of bandwidth for students to engage in smooth online interactions (Cisco,  2018 ). It also requires little additional efforts from teachers as official textbooks are often available for each school year, and thus, they only need to guide students through the materials during audio‐conferencing. Educational authority can further support this approach by making digital textbooks available for teachers and students, especially those in financial hardship. However, the lack of visual and instructor presence could potentially reduce students’ attention, recall of information, and satisfaction in online learning (Wang & Antonenko,  2017 ). Therefore, further research is required to understand whether the combination of digital or physical textbooks and audio‐conferencing is appropriate for students with internet problems. Alternatively, suppose the local technological infrastructure is well developed. In that case, governments and schools can also collaborate with internet providers to issue data and bandwidth vouchers for students who are experiencing internet problems due to financial hardship.

For future adoption of online learning, policymakers should consider the readiness of the local internet infrastructure. This recommendation is particularly important for developing countries, like Bangladesh, where the majority of the students reported the lack of internet infrastructure (Ramij & Sultana,  2020 ). In such environments, online education may become infeasible, and alternative delivery method could be more appropriate, for example, the Telesecundaria program provides TV education for rural areas of Mexico (Calderoni,  1998 ).

Other than technical problems, choosing a suitable online learning platform is also vital for providing students with a better learning experience. Governments and schools should choose an online learning platform that is customised for smartphone‐based learning, as the majority of students could be using smartphones for online learning. This recommendation is highly relevant for situations where students are forced or involuntarily engaged in online learning, like during the COVID‐19 pandemic, as they might not have access to a personal computer (Molnar et al.,  2019 ).

Customisation of delivery methods

Customising the delivery of online learning for students in different school years is the theme that appeared consistently across our findings. This customisation process is vital for making online learning an opportunity for students to develop independent learning skills, which could help prepare them for tertiary education and lifelong learning. However, the pedagogical design of K‐12 online learning programs should be differentiated from adult‐orientated programs as these programs are designed for independent learners, which is rarely the case for students in K‐12 education (Barbour & Reeves,  2009 ).

For early‐school‐year students, especially Year 1–3 students, providing them with sufficient guidance from both teachers and parents should be the priority as these students often lack the ability to monitor and reflect on learning progress. In particular, these students would prefer more real‐time interaction with teachers, tutoring from parents, and regular online practice examinations. These forms of guidance could help early‐school‐year students to cope with involuntary online learning, and potentially enhance their experience in future online learning. It should be noted that, early‐school‐year students demonstrated interest in intelligent monitoring and feedback systems for learning. Additional research is required to understand whether these young children are capable of understanding and using learning analytics that relay information on their learning progress. Similarly, future research should also investigate whether young children can communicate effectively through digital tools as potential inability could hinder student learning in online group activities. Therefore, the design of online learning for early‐school‐year students should focus less on independent learning but ensuring that students are learning effective under the guidance of teachers and parents.

In contrast, group learning and peer interaction are essential for older children and adolescents. The delivery of online learning for these students should focus on providing them with more opportunities to communicate with each other and engage in collaborative learning. Potential methods to achieve this goal involve assigning or encouraging students to form study groups (Lee et al.,  2011 ), directing students to use social media for peer communication (Dabbagh & Kitsantas,  2012 ), and providing students with online group assignments (Bickle & Rucker,  2018 ).

Special attention should be paid to students enrolled in high schools. For high‐school‐year students, in particular, students in Year 10–12, we also recommend to provide them with sufficient access to paper‐based learning materials, such as revision booklet and practice exam papers, so they remain familiar with paper‐based examinations. This recommendation applies to any students who engage in online learning but has to take their final examination in paper format. It is also imperative to assist high‐school‐year students who are facing examinations to direct their learning efforts better. Teachers can fulfil this need by sharing useful learning resources on the learning management system, if it is available, or through social media groups. Alternatively, students are interested in intelligent recommendation systems for learning resources, which are emerging in the literature (Corbi & Solans,  2014 ; Shishehchi et al.,  2010 ). These systems could provide personalised recommendations based on a series of evaluation on learners’ knowledge. Although it is infeasible for situations where the transformation to online learning happened rapidly (i.e., during the COVID‐19 pandemic), policymakers can consider embedding such systems in future online education.

Limitations

The current findings are limited to primary and secondary Chinese students who were involuntarily engaged in online learning during the COVID‐19 pandemic. Despite the large sample size, the population may not be representative as participants are all from a single province. Also, information about the quality of online learning platforms, teaching contents, and pedagogy approaches were missing because of the large scale of our study. It is likely that the infrastructures of online learning in China, such as learning platforms, instructional designs, and teachers’ knowledge about online pedagogy, were underprepared for the sudden transition. Thus, our findings may not represent the experience of students who voluntarily participated in well‐prepared online learning programs, in particular, the virtual school programs in America and Canada (Barbour & LaBonte,  2017 ; Molnar et al.,  2019 ). Lastly, the survey was only evaluated and validated by teachers but not students. Therefore, students with the lowest reading comprehension levels might have a different understanding of the items’ meaning, especially terminologies that involve abstract contracts like self‐regulation and autonomy in item Q17.

In conclusion, we identified across‐year differences between primary and secondary school students’ online learning experience during the COVID‐19 pandemic. Several recommendations were made for the future practice and research of online learning in the K‐12 student population. First, educational authorities and schools should provide sufficient technical support to help students to overcome potential internet and technical problems, as well as choosing online learning platforms that have been customised for smartphones. Second, customising the online pedagogy design for students in different school years, in particular, focusing on providing sufficient guidance for young children, more online collaborative opportunity for older children and adolescent, and additional learning resource for senior students who are facing final examinations.

CONFLICT OF INTEREST

There is no potential conflict of interest in this study.

ETHICS STATEMENT

The data are collected by the Department of Education of the Guangdong Province who also has the authority to approve research studies in K12 education in the province.

Supporting information

Supplementary Material

ACKNOWLEDGEMENTS

This work is supported by the National Natural Science Foundation of China (62077028, 61877029), the Science and Technology Planning Project of Guangdong (2020B0909030005, 2020B1212030003, 2020ZDZX3013, 2019B1515120010, 2018KTSCX016, 2019A050510024), the Science and Technology Planning Project of Guangzhou (201902010041), and the Fundamental Research Funds for the Central Universities (21617408, 21619404).

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• Published: 25 January 2021

Online education in the post-COVID era

• Barbara B. Lockee 1  

Nature Electronics volume  4 ,  pages 5–6 ( 2021 ) Cite this article

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The coronavirus pandemic has forced students and educators across all levels of education to rapidly adapt to online learning. The impact of this — and the developments required to make it work — could permanently change how education is delivered.

The COVID-19 pandemic has forced the world to engage in the ubiquitous use of virtual learning. And while online and distance learning has been used before to maintain continuity in education, such as in the aftermath of earthquakes 1 , the scale of the current crisis is unprecedented. Speculation has now also begun about what the lasting effects of this will be and what education may look like in the post-COVID era. For some, an immediate retreat to the traditions of the physical classroom is required. But for others, the forced shift to online education is a moment of change and a time to reimagine how education could be delivered 2 .

Looking back

Online education has traditionally been viewed as an alternative pathway, one that is particularly well suited to adult learners seeking higher education opportunities. However, the emergence of the COVID-19 pandemic has required educators and students across all levels of education to adapt quickly to virtual courses. (The term ‘emergency remote teaching’ was coined in the early stages of the pandemic to describe the temporary nature of this transition 3 .) In some cases, instruction shifted online, then returned to the physical classroom, and then shifted back online due to further surges in the rate of infection. In other cases, instruction was offered using a combination of remote delivery and face-to-face: that is, students can attend online or in person (referred to as the HyFlex model 4 ). In either case, instructors just had to figure out how to make it work, considering the affordances and constraints of the specific learning environment to create learning experiences that were feasible and effective.

The use of varied delivery modes does, in fact, have a long history in education. Mechanical (and then later electronic) teaching machines have provided individualized learning programmes since the 1950s and the work of B. F. Skinner 5 , who proposed using technology to walk individual learners through carefully designed sequences of instruction with immediate feedback indicating the accuracy of their response. Skinner’s notions formed the first formalized representations of programmed learning, or ‘designed’ learning experiences. Then, in the 1960s, Fred Keller developed a personalized system of instruction 6 , in which students first read assigned course materials on their own, followed by one-on-one assessment sessions with a tutor, gaining permission to move ahead only after demonstrating mastery of the instructional material. Occasional class meetings were held to discuss concepts, answer questions and provide opportunities for social interaction. A personalized system of instruction was designed on the premise that initial engagement with content could be done independently, then discussed and applied in the social context of a classroom.

These predecessors to contemporary online education leveraged key principles of instructional design — the systematic process of applying psychological principles of human learning to the creation of effective instructional solutions — to consider which methods (and their corresponding learning environments) would effectively engage students to attain the targeted learning outcomes. In other words, they considered what choices about the planning and implementation of the learning experience can lead to student success. Such early educational innovations laid the groundwork for contemporary virtual learning, which itself incorporates a variety of instructional approaches and combinations of delivery modes.

Online learning and the pandemic

Fast forward to 2020, and various further educational innovations have occurred to make the universal adoption of remote learning a possibility. One key challenge is access. Here, extensive problems remain, including the lack of Internet connectivity in some locations, especially rural ones, and the competing needs among family members for the use of home technology. However, creative solutions have emerged to provide students and families with the facilities and resources needed to engage in and successfully complete coursework 7 . For example, school buses have been used to provide mobile hotspots, and class packets have been sent by mail and instructional presentations aired on local public broadcasting stations. The year 2020 has also seen increased availability and adoption of electronic resources and activities that can now be integrated into online learning experiences. Synchronous online conferencing systems, such as Zoom and Google Meet, have allowed experts from anywhere in the world to join online classrooms 8 and have allowed presentations to be recorded for individual learners to watch at a time most convenient for them. Furthermore, the importance of hands-on, experiential learning has led to innovations such as virtual field trips and virtual labs 9 . A capacity to serve learners of all ages has thus now been effectively established, and the next generation of online education can move from an enterprise that largely serves adult learners and higher education to one that increasingly serves younger learners, in primary and secondary education and from ages 5 to 18.

The COVID-19 pandemic is also likely to have a lasting effect on lesson design. The constraints of the pandemic provided an opportunity for educators to consider new strategies to teach targeted concepts. Though rethinking of instructional approaches was forced and hurried, the experience has served as a rare chance to reconsider strategies that best facilitate learning within the affordances and constraints of the online context. In particular, greater variance in teaching and learning activities will continue to question the importance of ‘seat time’ as the standard on which educational credits are based 10 — lengthy Zoom sessions are seldom instructionally necessary and are not aligned with the psychological principles of how humans learn. Interaction is important for learning but forced interactions among students for the sake of interaction is neither motivating nor beneficial.

While the blurring of the lines between traditional and distance education has been noted for several decades 11 , the pandemic has quickly advanced the erasure of these boundaries. Less single mode, more multi-mode (and thus more educator choices) is becoming the norm due to enhanced infrastructure and developed skill sets that allow people to move across different delivery systems 12 . The well-established best practices of hybrid or blended teaching and learning 13 have served as a guide for new combinations of instructional delivery that have developed in response to the shift to virtual learning. The use of multiple delivery modes is likely to remain, and will be a feature employed with learners of all ages 14 , 15 . Future iterations of online education will no longer be bound to the traditions of single teaching modes, as educators can support pedagogical approaches from a menu of instructional delivery options, a mix that has been supported by previous generations of online educators 16 .

Also significant are the changes to how learning outcomes are determined in online settings. Many educators have altered the ways in which student achievement is measured, eliminating assignments and changing assessment strategies altogether 17 . Such alterations include determining learning through strategies that leverage the online delivery mode, such as interactive discussions, student-led teaching and the use of games to increase motivation and attention. Specific changes that are likely to continue include flexible or extended deadlines for assignment completion 18 , more student choice regarding measures of learning, and more authentic experiences that involve the meaningful application of newly learned skills and knowledge 19 , for example, team-based projects that involve multiple creative and social media tools in support of collaborative problem solving.

In response to the COVID-19 pandemic, technological and administrative systems for implementing online learning, and the infrastructure that supports its access and delivery, had to adapt quickly. While access remains a significant issue for many, extensive resources have been allocated and processes developed to connect learners with course activities and materials, to facilitate communication between instructors and students, and to manage the administration of online learning. Paths for greater access and opportunities to online education have now been forged, and there is a clear route for the next generation of adopters of online education.

Before the pandemic, the primary purpose of distance and online education was providing access to instruction for those otherwise unable to participate in a traditional, place-based academic programme. As its purpose has shifted to supporting continuity of instruction, its audience, as well as the wider learning ecosystem, has changed. It will be interesting to see which aspects of emergency remote teaching remain in the next generation of education, when the threat of COVID-19 is no longer a factor. But online education will undoubtedly find new audiences. And the flexibility and learning possibilities that have emerged from necessity are likely to shift the expectations of students and educators, diminishing further the line between classroom-based instruction and virtual learning.

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Lockee, B.B. Online education in the post-COVID era. Nat Electron 4 , 5–6 (2021). https://doi.org/10.1038/s41928-020-00534-0

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The COVID-19 pandemic has changed education forever. This is how 

With schools shut across the world, millions of children have had to adapt to new types of learning. Image:  REUTERS/Gonzalo Fuentes

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Farah lalani.

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Stay up to date:, education, gender and work.

• The COVID-19 has resulted in schools shut all across the world. Globally, over 1.2 billion children are out of the classroom.
• As a result, education has changed dramatically, with the distinctive rise of e-learning, whereby teaching is undertaken remotely and on digital platforms.
• Research suggests that online learning has been shown to increase retention of information, and take less time, meaning the changes coronavirus have caused might be here to stay.

While countries are at different points in their COVID-19 infection rates, worldwide there are currently more than 1.2 billion children in 186 countries affected by school closures due to the pandemic. In Denmark, children up to the age of 11 are returning to nurseries and schools after initially closing on 12 March , but in South Korea students are responding to roll calls from their teachers online .

With this sudden shift away from the classroom in many parts of the globe, some are wondering whether the adoption of online learning will continue to persist post-pandemic, and how such a shift would impact the worldwide education market.

Even before COVID-19, there was already high growth and adoption in education technology, with global edtech investments reaching US$18.66 billion in 2019 and the overall market for online education projected to reach $350 Billion by 2025 . Whether it is language apps , virtual tutoring , video conferencing tools, or online learning software , there has been a significant surge in usage since COVID-19.

How is the education sector responding to COVID-19?

In response to significant demand, many online learning platforms are offering free access to their services, including platforms like BYJU’S , a Bangalore-based educational technology and online tutoring firm founded in 2011, which is now the world’s most highly valued edtech company . Since announcing free live classes on its Think and Learn app, BYJU’s has seen a 200% increase in the number of new students using its product, according to Mrinal Mohit, the company's Chief Operating Officer.

Tencent classroom, meanwhile, has been used extensively since mid-February after the Chinese government instructed a quarter of a billion full-time students to resume their studies through online platforms. This resulted in the largest “online movement” in the history of education with approximately 730,000 , or 81% of K-12 students, attending classes via the Tencent K-12 Online School in Wuhan.

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Other companies are bolstering capabilities to provide a one-stop shop for teachers and students. For example, Lark, a Singapore-based collaboration suite initially developed by ByteDance as an internal tool to meet its own exponential growth, began offering teachers and students unlimited video conferencing time, auto-translation capabilities, real-time co-editing of project work, and smart calendar scheduling, amongst other features. To do so quickly and in a time of crisis, Lark ramped up its global server infrastructure and engineering capabilities to ensure reliable connectivity.

Alibaba’s distance learning solution, DingTalk, had to prepare for a similar influx: “To support large-scale remote work, the platform tapped Alibaba Cloud to deploy more than 100,000 new cloud servers in just two hours last month – setting a new record for rapid capacity expansion,” according to DingTalk CEO, Chen Hang.

Some school districts are forming unique partnerships, like the one between The Los Angeles Unified School District and PBS SoCal/KCET to offer local educational broadcasts, with separate channels focused on different ages, and a range of digital options. Media organizations such as the BBC are also powering virtual learning; Bitesize Daily , launched on 20 April, is offering 14 weeks of curriculum-based learning for kids across the UK with celebrities like Manchester City footballer Sergio Aguero teaching some of the content.

What does this mean for the future of learning?

While some believe that the unplanned and rapid move to online learning – with no training, insufficient bandwidth, and little preparation – will result in a poor user experience that is unconducive to sustained growth, others believe that a new hybrid model of education will emerge, with significant benefits. “I believe that the integration of information technology in education will be further accelerated and that online education will eventually become an integral component of school education,“ says Wang Tao, Vice President of Tencent Cloud and Vice President of Tencent Education.

There have already been successful transitions amongst many universities. For example, Zhejiang University managed to get more than 5,000 courses online just two weeks into the transition using “DingTalk ZJU”. The Imperial College London started offering a course on the science of coronavirus, which is now the most enrolled class launched in 2020 on Coursera .

Many are already touting the benefits: Dr Amjad, a Professor at The University of Jordan who has been using Lark to teach his students says, “It has changed the way of teaching. It enables me to reach out to my students more efficiently and effectively through chat groups, video meetings, voting and also document sharing, especially during this pandemic. My students also find it is easier to communicate on Lark. I will stick to Lark even after coronavirus, I believe traditional offline learning and e-learning can go hand by hand."

These 3 charts show the global growth in online learning

The challenges of online learning.

There are, however, challenges to overcome. Some students without reliable internet access and/or technology struggle to participate in digital learning; this gap is seen across countries and between income brackets within countries. For example, whilst 95% of students in Switzerland, Norway, and Austria have a computer to use for their schoolwork, only 34% in Indonesia do, according to OECD data .

In the US, there is a significant gap between those from privileged and disadvantaged backgrounds: whilst virtually all 15-year-olds from a privileged background said they had a computer to work on, nearly 25% of those from disadvantaged backgrounds did not. While some schools and governments have been providing digital equipment to students in need, such as in New South Wales , Australia, many are still concerned that the pandemic will widenthe digital divide .

Is learning online as effective?

For those who do have access to the right technology, there is evidence that learning online can be more effective in a number of ways. Some research shows that on average, students retain 25-60% more material when learning online compared to only 8-10% in a classroom. This is mostly due to the students being able to learn faster online; e-learning requires 40-60% less time to learn than in a traditional classroom setting because students can learn at their own pace, going back and re-reading, skipping, or accelerating through concepts as they choose.

Nevertheless, the effectiveness of online learning varies amongst age groups. The general consensus on children, especially younger ones, is that a structured environment is required , because kids are more easily distracted. To get the full benefit of online learning, there needs to be a concerted effort to provide this structure and go beyond replicating a physical class/lecture through video capabilities, instead, using a range of collaboration tools and engagement methods that promote “inclusion, personalization and intelligence”, according to Dowson Tong, Senior Executive Vice President of Tencent and President of its Cloud and Smart Industries Group.

Since studies have shown that children extensively use their senses to learn, making learning fun and effective through use of technology is crucial, according to BYJU's Mrinal Mohit. “Over a period, we have observed that clever integration of games has demonstrated higher engagement and increased motivation towards learning especially among younger students, making them truly fall in love with learning”, he says.

A changing education imperative

It is clear that this pandemic has utterly disrupted an education system that many assert was already losing its relevance . In his book, 21 Lessons for the 21st Century , scholar Yuval Noah Harari outlines how schools continue to focus on traditional academic skills and rote learning , rather than on skills such as critical thinking and adaptability, which will be more important for success in the future. Could the move to online learning be the catalyst to create a new, more effective method of educating students? While some worry that the hasty nature of the transition online may have hindered this goal, others plan to make e-learning part of their ‘new normal’ after experiencing the benefits first-hand.

The importance of disseminating knowledge is highlighted through COVID-19

Major world events are often an inflection point for rapid innovation – a clear example is the rise of e-commerce post-SARS . While we have yet to see whether this will apply to e-learning post-COVID-19, it is one of the few sectors where investment has not dried up . What has been made clear through this pandemic is the importance of disseminating knowledge across borders, companies, and all parts of society. If online learning technology can play a role here, it is incumbent upon all of us to explore its full potential.

Our education system is losing relevance. Here's how to unleash its potential

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The pandemic has had devastating impacts on learning. What will it take to help students catch up?

Subscribe to the brown center on education policy newsletter, megan kuhfeld , megan kuhfeld senior research scientist - nwea @megankuhfeld jim soland , jim soland assistant professor, school of education and human development - university of virginia, affiliated research fellow - nwea @jsoland karyn lewis , and karyn lewis director, center for school and student progress - nwea @karynlew emily morton emily morton research scientist - nwea @emily_r_morton.

March 3, 2022

As we reach the two-year mark of the initial wave of pandemic-induced school shutdowns, academic normalcy remains out of reach for many students, educators, and parents. In addition to surging COVID-19 cases at the end of 2021, schools have faced severe staff shortages , high rates of absenteeism and quarantines , and rolling school closures . Furthermore, students and educators continue to struggle with mental health challenges , higher rates of violence and misbehavior , and concerns about lost instructional time .

As we outline in our new research study released in January, the cumulative impact of the COVID-19 pandemic on students’ academic achievement has been large. We tracked changes in math and reading test scores across the first two years of the pandemic using data from 5.4 million U.S. students in grades 3-8. We focused on test scores from immediately before the pandemic (fall 2019), following the initial onset (fall 2020), and more than one year into pandemic disruptions (fall 2021).

Average fall 2021 math test scores in grades 3-8 were 0.20-0.27 standard deviations (SDs) lower relative to same-grade peers in fall 2019, while reading test scores were 0.09-0.18 SDs lower. This is a sizable drop. For context, the math drops are significantly larger than estimated impacts from other large-scale school disruptions, such as after Hurricane Katrina—math scores dropped 0.17 SDs in one year for New Orleans evacuees .

Even more concerning, test-score gaps between students in low-poverty and high-poverty elementary schools grew by approximately 20% in math (corresponding to 0.20 SDs) and 15% in reading (0.13 SDs), primarily during the 2020-21 school year. Further, achievement tended to drop more between fall 2020 and 2021 than between fall 2019 and 2020 (both overall and differentially by school poverty), indicating that disruptions to learning have continued to negatively impact students well past the initial hits following the spring 2020 school closures.

These numbers are alarming and potentially demoralizing, especially given the heroic efforts of students to learn and educators to teach in incredibly trying times. From our perspective, these test-score drops in no way indicate that these students represent a “ lost generation ” or that we should give up hope. Most of us have never lived through a pandemic, and there is so much we don’t know about students’ capacity for resiliency in these circumstances and what a timeline for recovery will look like. Nor are we suggesting that teachers are somehow at fault given the achievement drops that occurred between 2020 and 2021; rather, educators had difficult jobs before the pandemic, and now are contending with huge new challenges, many outside their control.

Clearly, however, there’s work to do. School districts and states are currently making important decisions about which interventions and strategies to implement to mitigate the learning declines during the last two years. Elementary and Secondary School Emergency Relief (ESSER) investments from the American Rescue Plan provided nearly $200 billion to public schools to spend on COVID-19-related needs. Of that sum, $22 billion is dedicated specifically to addressing learning loss using “evidence-based interventions” focused on the “ disproportionate impact of COVID-19 on underrepresented student subgroups. ” Reviews of district and state spending plans (see Future Ed , EduRecoveryHub , and RAND’s American School District Panel for more details) indicate that districts are spending their ESSER dollars designated for academic recovery on a wide variety of strategies, with summer learning, tutoring, after-school programs, and extended school-day and school-year initiatives rising to the top.

Comparing the negative impacts from learning disruptions to the positive impacts from interventions

To help contextualize the magnitude of the impacts of COVID-19, we situate test-score drops during the pandemic relative to the test-score gains associated with common interventions being employed by districts as part of pandemic recovery efforts. If we assume that such interventions will continue to be as successful in a COVID-19 school environment, can we expect that these strategies will be effective enough to help students catch up? To answer this question, we draw from recent reviews of research on high-dosage tutoring , summer learning programs , reductions in class size , and extending the school day (specifically for literacy instruction) . We report effect sizes for each intervention specific to a grade span and subject wherever possible (e.g., tutoring has been found to have larger effects in elementary math than in reading).

Figure 1 shows the standardized drops in math test scores between students testing in fall 2019 and fall 2021 (separately by elementary and middle school grades) relative to the average effect size of various educational interventions. The average effect size for math tutoring matches or exceeds the average COVID-19 score drop in math. Research on tutoring indicates that it often works best in younger grades, and when provided by a teacher rather than, say, a parent. Further, some of the tutoring programs that produce the biggest effects can be quite intensive (and likely expensive), including having full-time tutors supporting all students (not just those needing remediation) in one-on-one settings during the school day. Meanwhile, the average effect of reducing class size is negative but not significant, with high variability in the impact across different studies. Summer programs in math have been found to be effective (average effect size of .10 SDs), though these programs in isolation likely would not eliminate the COVID-19 test-score drops.

Figure 1: Math COVID-19 test-score drops compared to the effect sizes of various educational interventions

Source: COVID-19 score drops are pulled from Kuhfeld et al. (2022) Table 5; reduction-in-class-size results are from pg. 10 of Figles et al. (2018) Table 2; summer program results are pulled from Lynch et al (2021) Table 2; and tutoring estimates are pulled from Nictow et al (2020) Table 3B. Ninety-five percent confidence intervals are shown with vertical lines on each bar.

Notes: Kuhfeld et al. and Nictow et al. reported effect sizes separately by grade span; Figles et al. and Lynch et al. report an overall effect size across elementary and middle grades. We were unable to find a rigorous study that reported effect sizes for extending the school day/year on math performance. Nictow et al. and Kraft & Falken (2021) also note large variations in tutoring effects depending on the type of tutor, with larger effects for teacher and paraprofessional tutoring programs than for nonprofessional and parent tutoring. Class-size reductions included in the Figles meta-analysis ranged from a minimum of one to minimum of eight students per class.

Figure 2 displays a similar comparison using effect sizes from reading interventions. The average effect of tutoring programs on reading achievement is larger than the effects found for the other interventions, though summer reading programs and class size reduction both produced average effect sizes in the ballpark of the COVID-19 reading score drops.

Figure 2: Reading COVID-19 test-score drops compared to the effect sizes of various educational interventions

Source: COVID-19 score drops are pulled from Kuhfeld et al. (2022) Table 5; extended-school-day results are from Figlio et al. (2018) Table 2; reduction-in-class-size results are from pg. 10 of Figles et al. (2018) ; summer program results are pulled from Kim & Quinn (2013) Table 3; and tutoring estimates are pulled from Nictow et al (2020) Table 3B. Ninety-five percent confidence intervals are shown with vertical lines on each bar.

Notes: While Kuhfeld et al. and Nictow et al. reported effect sizes separately by grade span, Figlio et al. and Kim & Quinn report an overall effect size across elementary and middle grades. Class-size reductions included in the Figles meta-analysis ranged from a minimum of one to minimum of eight students per class.

There are some limitations of drawing on research conducted prior to the pandemic to understand our ability to address the COVID-19 test-score drops. First, these studies were conducted under conditions that are very different from what schools currently face, and it is an open question whether the effectiveness of these interventions during the pandemic will be as consistent as they were before the pandemic. Second, we have little evidence and guidance about the efficacy of these interventions at the unprecedented scale that they are now being considered. For example, many school districts are expanding summer learning programs, but school districts have struggled to find staff interested in teaching summer school to meet the increased demand. Finally, given the widening test-score gaps between low- and high-poverty schools, it’s uncertain whether these interventions can actually combat the range of new challenges educators are facing in order to narrow these gaps. That is, students could catch up overall, yet the pandemic might still have lasting, negative effects on educational equality in this country.

Given that the current initiatives are unlikely to be implemented consistently across (and sometimes within) districts, timely feedback on the effects of initiatives and any needed adjustments will be crucial to districts’ success. The Road to COVID Recovery project and the National Student Support Accelerator are two such large-scale evaluation studies that aim to produce this type of evidence while providing resources for districts to track and evaluate their own programming. Additionally, a growing number of resources have been produced with recommendations on how to best implement recovery programs, including scaling up tutoring , summer learning programs , and expanded learning time .

Ultimately, there is much work to be done, and the challenges for students, educators, and parents are considerable. But this may be a moment when decades of educational reform, intervention, and research pay off. Relying on what we have learned could show the way forward.

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How to Write About Coronavirus in a College Essay

Students can share how they navigated life during the coronavirus pandemic in a full-length essay or an optional supplement.

Writing About COVID-19 in College Essays

Getty Images

Experts say students should be honest and not limit themselves to merely their experiences with the pandemic.

The global impact of COVID-19, the disease caused by the novel coronavirus, means colleges and prospective students alike are in for an admissions cycle like no other. Both face unprecedented challenges and questions as they grapple with their respective futures amid the ongoing fallout of the pandemic.

Colleges must examine applicants without the aid of standardized test scores for many – a factor that prompted many schools to go test-optional for now . Even grades, a significant component of a college application, may be hard to interpret with some high schools adopting pass-fail classes last spring due to the pandemic. Major college admissions factors are suddenly skewed.

"I can't help but think other (admissions) factors are going to matter more," says Ethan Sawyer, founder of the College Essay Guy, a website that offers free and paid essay-writing resources.

College essays and letters of recommendation , Sawyer says, are likely to carry more weight than ever in this admissions cycle. And many essays will likely focus on how the pandemic shaped students' lives throughout an often tumultuous 2020.

But before writing a college essay focused on the coronavirus, students should explore whether it's the best topic for them.

Writing About COVID-19 for a College Application

Much of daily life has been colored by the coronavirus. Virtual learning is the norm at many colleges and high schools, many extracurriculars have vanished and social lives have stalled for students complying with measures to stop the spread of COVID-19.

"For some young people, the pandemic took away what they envisioned as their senior year," says Robert Alexander, dean of admissions, financial aid and enrollment management at the University of Rochester in New York. "Maybe that's a spot on a varsity athletic team or the lead role in the fall play. And it's OK for them to mourn what should have been and what they feel like they lost, but more important is how are they making the most of the opportunities they do have?"

That question, Alexander says, is what colleges want answered if students choose to address COVID-19 in their college essay.

But the question of whether a student should write about the coronavirus is tricky. The answer depends largely on the student.

"In general, I don't think students should write about COVID-19 in their main personal statement for their application," Robin Miller, master college admissions counselor at IvyWise, a college counseling company, wrote in an email.

"Certainly, there may be exceptions to this based on a student's individual experience, but since the personal essay is the main place in the application where the student can really allow their voice to be heard and share insight into who they are as an individual, there are likely many other topics they can choose to write about that are more distinctive and unique than COVID-19," Miller says.

Opinions among admissions experts vary on whether to write about the likely popular topic of the pandemic.

"If your essay communicates something positive, unique, and compelling about you in an interesting and eloquent way, go for it," Carolyn Pippen, principal college admissions counselor at IvyWise, wrote in an email. She adds that students shouldn't be dissuaded from writing about a topic merely because it's common, noting that "topics are bound to repeat, no matter how hard we try to avoid it."

Above all, she urges honesty.

"If your experience within the context of the pandemic has been truly unique, then write about that experience, and the standing out will take care of itself," Pippen says. "If your experience has been generally the same as most other students in your context, then trying to find a unique angle can easily cross the line into exploiting a tragedy, or at least appearing as though you have."

But focusing entirely on the pandemic can limit a student to a single story and narrow who they are in an application, Sawyer says. "There are so many wonderful possibilities for what you can say about yourself outside of your experience within the pandemic."

He notes that passions, strengths, career interests and personal identity are among the multitude of essay topic options available to applicants and encourages them to probe their values to help determine the topic that matters most to them – and write about it.

That doesn't mean the pandemic experience has to be ignored if applicants feel the need to write about it.

Writing About Coronavirus in Main and Supplemental Essays

Students can choose to write a full-length college essay on the coronavirus or summarize their experience in a shorter form.

To help students explain how the pandemic affected them, The Common App has added an optional section to address this topic. Applicants have 250 words to describe their pandemic experience and the personal and academic impact of COVID-19.

"That's not a trick question, and there's no right or wrong answer," Alexander says. Colleges want to know, he adds, how students navigated the pandemic, how they prioritized their time, what responsibilities they took on and what they learned along the way.

If students can distill all of the above information into 250 words, there's likely no need to write about it in a full-length college essay, experts say. And applicants whose lives were not heavily altered by the pandemic may even choose to skip the optional COVID-19 question.

"This space is best used to discuss hardship and/or significant challenges that the student and/or the student's family experienced as a result of COVID-19 and how they have responded to those difficulties," Miller notes. Using the section to acknowledge a lack of impact, she adds, "could be perceived as trite and lacking insight, despite the good intentions of the applicant."

To guard against this lack of awareness, Sawyer encourages students to tap someone they trust to review their writing , whether it's the 250-word Common App response or the full-length essay.

Experts tend to agree that the short-form approach to this as an essay topic works better, but there are exceptions. And if a student does have a coronavirus story that he or she feels must be told, Alexander encourages the writer to be authentic in the essay.

"My advice for an essay about COVID-19 is the same as my advice about an essay for any topic – and that is, don't write what you think we want to read or hear," Alexander says. "Write what really changed you and that story that now is yours and yours alone to tell."

Sawyer urges students to ask themselves, "What's the sentence that only I can write?" He also encourages students to remember that the pandemic is only a chapter of their lives and not the whole book.

Miller, who cautions against writing a full-length essay on the coronavirus, says that if students choose to do so they should have a conversation with their high school counselor about whether that's the right move. And if students choose to proceed with COVID-19 as a topic, she says they need to be clear, detailed and insightful about what they learned and how they adapted along the way.

"Approaching the essay in this manner will provide important balance while demonstrating personal growth and vulnerability," Miller says.

Pippen encourages students to remember that they are in an unprecedented time for college admissions.

"It is important to keep in mind with all of these (admission) factors that no colleges have ever had to consider them this way in the selection process, if at all," Pippen says. "They have had very little time to calibrate their evaluations of different application components within their offices, let alone across institutions. This means that colleges will all be handling the admissions process a little bit differently, and their approaches may even evolve over the course of the admissions cycle."

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• 1 Faculty of Public Administration, University of Ljubljana, Ljubljana, Slovenia
• 2 Department of Primary Level Education, University of the Aegean, Rhodes, Greece

The outbreak of the COVID-19 pandemic significantly disrupted higher education by forcing the transition to online learning, which became a mandatory teaching process during the lockdowns. Although the epidemiological situation has gradually improved since then, online learning is becoming ever more popular as it provides new learning opportunities. Therefore, the paper aims to present recent research trends concerning online learning in higher education during the COVID-19 pandemic by using selected bibliometric approaches. The bibliometric analysis is based on 8,303 documents from the Scopus database published between January 2020 and March 2022, when repeated lockdowns meant most countries were experiencing constant disruptions to the educational process. The results show that the COVID-19 pandemic increased interest in online learning research, notably in English-speaking and Asian countries, with most research being published in open-access scientific journals. Moreover, the topics most frequently discussed in the online learning research during the COVID-19 pandemic were ICT and pedagogy, technology-enhanced education, mental health and well-being, student experience and curriculum and professional development. Finally, the COVID-19 pandemic encouraged explorations of emergency remote learning approaches like e-learning, distance learning and virtual learning, which are intended to limit physical contact between teachers and students, where the specific requirements of a given field of study often guide which online learning approach is the most suitable. The findings add to the existing body of scientific knowledge and support the evidence-based policymaking needed to ensure sustainable higher education in the future.

1. Introduction

The outbreak of the COVID-19 pandemic significantly disrupted higher education by forcing the transition to online learning, which became a mandatory teaching process during the lockdowns ( Aristovnik et al., 2020a ). Despite the educational process saw disruptions on all levels of education, i.e., primary, secondary and tertiary ( Tang, 2023 ), as well as in adult education ( James and Thériault, 2020 ), worker education ( Dedeilia et al., 2023 ) and lifelong education ( Waller et al., 2020 ), higher education students proved to be one of the worst affected groups because the social distancing measures, on top of their education, challenged their financial and housing situation ( Aristovnik et al., 2020a ). Challenges arising from the density of students in educational facilities (e.g., campuses, faculties, dormitories etc.) meant higher education institutions were forced to offer education relying on various information and communication technologies (ICTs) and tried to ensure education comparable in quality to traditional learning, noting that the quality of online learning delivery holds important implications for student satisfaction and student performance ( Keržič et al., 2021 ). Nevertheless, the lockdown periods were devastating for many students also in terms of their emotional functioning ( Raccanello et al., 2022 ). The COVID-19 pandemic eventually grew more predictable and manageable, allowing higher education institutions to gradually shift back to traditional learning approaches. Although the epidemiological situation has improved over time, online learning is becoming increasingly popular as it provides new learning opportunities, especially when combined with traditional learning.

The rapid, yet from the health protection point of view necessary ( Aristovnik et al., 2020b ), shift from traditional learning to online learning considerably affected teaching and learning. The transition to online learning was made without adequate consideration of whether the study materials and teaching methods were suitable for this mode of higher education delivery. This was an ad hoc shift in a situation of great uncertainty for both teachers and students. The transition to online learning has also brought to the surface gaps in higher education providers’ preparedness and their lack of ICT infrastructure, resulting in unequal access to quality education for all, particularly students from rural areas and regions with lower socio-economic development. It is important to note here that the rapid shift to an online learning environment in emergency circumstances should not be confused with properly planned online education equipped with appropriate infrastructure that enables and supports pedagogical work and study in an online environment ( Hodges et al., 2020 ; Fuchs, 2022 ; Misiejuk et al., 2023 ). Apart from the changes in teaching and learning, the social aspect of students’ lives has been affected as well. The most worrying consequence has been social isolation leading to a lack of crucial social interaction for students ( Elmer et al., 2020 ; Bonsaksen et al., 2021 ; Fried et al., 2021 ; Van der Graaf et al., 2021 ) and in some cases also in coronavirus-related post-traumatic stress syndrome (PTSD) ( Ochnik et al., 2021 ). According to Gavriluţă et al. (2022) , three dimensions affected students during the COVID-19 pandemic: educational, social, and emotional. The transition from traditional to online learning entailed a significant transformation in education, requiring changes in teaching practices and new learning approaches. Further, the social aspect of the COVID-19 pandemic and associated lockdowns is evident in the absence of relational, economic and professional problems (in)directly affecting the transition to adulthood. The new reality changed attitudes to various aspects of life and, in turn, also affected emotional responsiveness. Briefly, substantial changes to everyday student lives were made during the COVID-19 pandemic that may hold far-reaching effects of currently unknown scope in the near and distant future ( Campos et al., 2022 ; Gao et al., 2022 ; Keržič et al., 2022 ; Rasli et al., 2022 ).

Therefore, the educational community requires greater insights into different aspects of the COVID-19 pandemic’s impact on online learning, e.g., students, teachers, pedagogy, ICT technology, online learning approaches and implications for various fields of study. In the context of higher education, some bibliometric studies (e.g., Gurcan et al., 2022 ; Saqr et al., 2023 ) have already sought to address issues involving online learning during the pandemic. Yet, they relied on a limited and narrow bibliographic dataset of peer-reviewed literature or lacked a qualitative synthesis of the results beyond the metrics, thereby neglecting some general comprehensive outlines of the global research into the topic ( Saqr et al., 2023 ). Moreover, despite some bibliometric studies focusing on technical aspects (e.g., Navarro-Espinosa et al., 2021 ; Bozkurt, 2022 ; Tlili et al., 2022 ), the identification of the most effective ICT tools for specific online learning approaches remains unclear. Finally, there are also some bibliometric studies that attempt to determine the effectiveness of online learning in providing higher education ( Brika et al., 2021 ; Baber et al., 2022 ; Bilal et al., 2022 ; Bozkurt, 2022 ; Fauzi, 2022 ; Küçük-Avci et al., 2022 ; Yan et al., 2022 ), however, they often overlook the specific requirements of individual fields of study, thereby neglecting the crucial aspect of tailoring online learning provision to different disciplines.

The bibliometric study presented in the paper accordingly aims to fill the presented gaps in the literature. Specifically, it aims to present a global overview of the recent research trends in online learning in higher education using a comprehensive dataset of literature encompassing different varieties of online learning approaches that can facilitate online learning during the COVID-19 pandemic, provide some relevant qualitative synthesis of the results beyond the metrics and examine the relationships between ICT tools, online learning approaches and fields of study. Thus, the present bibliometric study, focusing on higher education, tries to answer the following three research questions:

• RQ1: What is the current state of the online learning research by conducting a descriptive overview and identifying top-cited documents?

• RQ2: What is the scientific production of online learning research across countries and sources?

• RQ3: Which are the main research hotspots and concepts in online learning research?

The remainder of the paper is structured as follows. The next section provides a literature review of recent bibliometric studies. The following section outlines the materials and methods applied in the study before the results of the present bibliometric analysis are described in the next section. At the end, the final section provides a discussion and conclusion while summarizing the main findings and implications.

2. Literature review

The outbreak of the COVID-19 pandemic led many governments to expand the use of online learning approaches as a solution to the global health challenge. Researchers thus showed rising interest in investigating the field of online learning, its dimensions, and its trends on all levels of education, particularly higher education. Such research relied heavily on bibliometric approaches to analyzing scientific research in the higher education context. Pham et al. (2022) concluded based on the 414 articles that although in the decades prior, there was an increase in the number of articles touching on the components of e-learning, such as the learning management system, this rise was accelerated during the pandemic in both developed and developing countries. This may be attributed to the attention of governmental policies that considered the topic of e-learning to be critical and worthy of priority. Similarly, Fauzi (2022) investigated 1,496 articles and concluded that the research focused on a few specific topics. The first is the delivery factor, which refers to selecting the appropriate learning practices. The second is the health and safety factor that relates to minimizing any risk that e-learning could bring to the mental and physical health of learners or teachers, such as stress, anxiety or even depression. The third topic refers to the field of study and the impact of e-learning. In areas like medical education, where clinical activities and labs have to be attended in person, some online learning approaches might be less appropriate than when used in other areas, such as social studies, where the requirements are less complex or different. Zhang et al. (2022) confirmed this finding after performing bibliometric research on 1,061 articles published between January 2020 and August 2021. They explained that theorists and researchers showed a growing interest in ways to respond to crises, such as the pandemic, and how to develop the best practices to ensure the quality and efficiency of e-learning. Examples of such practices might be inquiry-oriented learning and hands-on activities. This could derive from the already existing tendency of education researchers to respond to unprecedented global challenges or changes. The authors explain that this conclusion addresses interest in e-learning practices holistically.

In the same context, Yan et al. (2022) employed a bibliometric approach and identified that various digital tools are used in e-learning in the field of health studies. After investigating 132 studies, they concluded that selecting appropriate tools depends on many factors, including the field of a given course, the aims, and their effectiveness. They add that these findings can be significant for groups of people such as experts or trainee teachers. Okoro et al. (2022) researched 1,722 articles published between 2012 and 2021 and detected a surge in interest in the mental health of postgraduate students, as revealed by the research trends discussed in these articles. Still, they describe this surge as having been greater between 2020 and 2021, which may be attributed to the COVID-19 restrictions and their implications. Moreover, they believe that this research focus will likely continue soon.

After looking at 2,307 articles published between 2017 and 2021, Baber et al. (2022) detected an increasing trend in researching digital literacy. While this was underway before the pandemic, the latter caused a statistically significant further surge. Digital literacy is approached in the studied articles through parameters like instruction, teachers, learners, ICT and its applications, content knowledge, competencies, skills, perceptions, and higher education. It is also associated with acquiring the qualities required to deal with topics such as misinformation, fake news, technological content knowledge, health literacy, COVID-19, and distance education. The authors state that their study identified dynamics hidden in these research trends, which will likely continue in the next few years.

In higher education specifically, based on 602 articles, Brika et al. (2021) corroborated the growing trend of publishing articles on e-learning during the pandemic and outlined certain sub-topics of it, namely: motivation and students’ attitudes; blended and virtual learning comparison; types of online assessment; stress, anxiety and mental health; strategies to improve learners’ skills; quality; performance of the education delivered; challenges; and the potential of technology to lead to change and reform of higher education syllabi or curricula. The scope of those articles was to paint a bigger picture of how higher education communities and institutions use and treat online learning. This is expected to help with efficient decision-making in the future in order to have better results and functions in higher education and appropriate response to crises.

The bibliometric studies carried out during the pandemic identified a trend among researchers in higher education institutions to investigate more the technology factor and how the progress of the Internet, along with information and communication technologies generally, can further assist new modes of learning, such as online learning and distance learning. This might be attributed to a vision for a better means for new types of learning, as Küçük-Avci et al. (2022) claimed after carrying out a bibliometric analysis of 1,547 articles published between 2020 and 2021. The authors detected certain trends regarding distance learning in higher education. A main finding of their study, along with the increase in studies on distance education and e-learning in higher education, is that before the pandemic, the fact that these approaches were not so mandatory meant there was greater efficiency, probably due to the learners’ motivation. The authors further claim that researchers show a stronger interest in the technological means that can assist these types of learning. In addition, while researching 1,986 articles, Bozkurt (2022) established an increase in the implementation of blended learning by researchers who also aim to investigate the relationship between technological applications and learning institutions. Within these tendencies, researchers consider four thematic fields: a comparison of online and onsite learning with regard to effectiveness and efficiency; the experience, impressions and attitudes of stakeholders and learning community members with respect to blended learning; teacher training and curriculum development that will assure the appropriate and challenge-free implementation of blended learning; and the use of mostly a quantitative approach to research of blended learning.

Bilal et al. (2022) also examined research trends concerned with e-learning in higher education during the COVID-19 period by researching 1,595 studies published between 2020 and 2021. The four main trends they identified were supplementary to those mentioned by other authors: the first is about the challenges regarding online learning or blended learning along with the appropriate strategies in response; the second is student-centered collaborative learning and appropriate curriculum design; the third concerns home-based learning through a type of laboratory and the general conditions surrounding it; and the fourth addresses teachers’ background, training, professional competencies and interdisciplinary learning.

Tlili et al. (2022) focused on mapping COVID-19’s impact on Massive Open Online Courses (MOOCs). The overall finding from the 108 articles they considered is that there has been growing interest in these courses generally, and more specifically in research around their function and quality. This interest encompasses the main features of such courses, which provide easy accessibility and flexibility. However, they noted that this interest followed another trend among researchers in the context. In other words, the countries that published on MOOCs before the pandemic are the same countries that published during the period under study. Moreover, they stated that there is interest in the technical characteristics and requirements of such courses. Finally, the authors concluded that although most MOOCs were ICT courses, research has escalated into courses that refer to business, personal development or the humanities.

Several conclusions can be drawn from the above bibliometric studies. First, the series of bibliometric studies conducted during the pandemic demonstrates the rise of interest in online learning in higher education during the pandemic. Of course, there was a tendency toward e-learning before the pandemic, but between 2020 and 2022, this seems to have accelerated. The phenomenon is more intense in countries such as the USA, Canada, Australia, the UK, India and China. Concerning the area of study, the focus of researchers appears to be greater in fields such as Engineering, Sciences, and Health Sciences, albeit all fields seem to be investigated ( Djeki et al., 2022 ; Pham et al., 2022 ; Vaicondam et al., 2022 ; Zhang et al., 2022 ). Various studies have focused on determining the effectiveness of e-learning classes and courses or pointing out parameters that influence their effectiveness. These could be the appropriate conditions or subtopics like motivation, blended learning, learning tools, teacher training, cooperation between different institutions or efficient practices ( Brika et al., 2021 ; Baber et al., 2022 ; Bilal et al., 2022 ; Bozkurt, 2022 ; Fauzi, 2022 ; Küçük-Avci et al., 2022 ; Yan et al., 2022 ). A specific trend of authors is to examine virtual classes and laboratories ( Kartimi et al., 2022 ; Rojas-Sánchez et al., 2022 ; Zhang et al., 2022 ). Finally, there is a focus on the technology factor. Namely, researchers have concentrated on technical issues and conditions related to e-learning courses and their proper functioning ( Navarro-Espinosa et al., 2021 ; Bozkurt, 2022 ; Tlili et al., 2022 ).

3. Materials and methods

Comprehensive bibliometric data on online learning research during the COVID-19 pandemic were retrieved on 1 March 2022 from Scopus, a world-leading bibliographic database of peer-reviewed literature. The Scopus database was preferred because it has a broader coverage of scientific research than other databases such as Web of Science ( Falagas et al., 2008 ). This was confirmed by an initial search using the same search query in each database, revealing that Scopus provided more relevant documents than Web of Science. Moreover, compared to the Scopus database, the Web of Science has been found to be a database that significantly underrepresents the scientific disciplines of the Social Sciences and the Arts and Humanities ( Mongeon and Paul-Hus, 2016 ). Although English dominates in both Scopus and Web of Science, Scopus generally offers wider coverage of non-English documents, given that the titles, abstracts, and keywords are in English ( Vera-Baceta et al., 2019 ). According to the basic statistical theory, which can also be applied in the context of bibliometric analysis, larger samples lead to analytical outcomes that are likely to be more accurate ( Rogers et al., 2020 ). Therefore, Scopus appears to be a more relevant bibliographic database meeting the specifics of online learning research during the COVID-19 pandemic.

The search strategy was based on title, abstract, and keywords search using the advanced search engine and the search query covered keywords related to different online learning types (using the Boolean operator ‘OR’) and the COVID-19 pandemic (using the Boolean operator ‘AND’). The search was further limited to the period 2020–2022 (using the Boolean operator ‘AND’) to capture documents published between January 2020 and March 2022, when most countries were experiencing constant disruptions in the educational process imposed by repeated lockdowns. As the search query had no language restrictions, the full text of the obtained documents can be in any language, provided that the titles, abstracts, and keywords are in English. Therefore, the language has no impact on the results, as the bibliometric analysis is conducted solely based on the titles, abstracts, and keywords of the documents. According to the presented search query, 9,921 documents were obtained. After further revising the obtained documents, it was identified that some of them are not explicitly related to the context of higher education. By machine screening of documents by title, abstract, and keywords, those related to lower levels of education (i.e., primary and secondary education), as well as adult and worker education (i.e., lifelong education), were excluded from the database. There were 1,618 or 16% of such documents. The remaining 8,303 documents were identified as eligible for further bibliometric examination of online learning research during the COVID-19 pandemic. The bibliometric analysis utilized several bibliometric approaches ( Figure 1 ).

Figure 1 . Bibliometric approaches used in the bibliometric analysis. Own elaboration.

First, a descriptive overview was conducted to examine particular general bibliometric items, including timespan, number of (all, cited, single-authored) documents, authors, sources and author keywords and authors, references, and citations per document as well as to identify the most relevant documents. Scientific production was also examined to determine the most relevant countries and sources. Finally, network analysis was performed to identify the research hotspots according to the keyword co-occurrence network and examine the relationship between the main concepts based on a three-field plot analysis. The presented bibliometric approaches required the use of several different software tools. The descriptive overview was conducted using the Python Data Analysis Library Pandas ( McKinney, 2012 ), scientific production was visualized by the Python Visualization Library Matplotlib ( Hunter, 2007 ), while network analysis was performed using VOSviewer (keyword co-occurrence) ( Van Eck and Waltman, 2010 ) and the Python Visualization Library Plotly (a three-field plot) ( Pandey and Panchal, 2020 ). Specifically, the calculation for the three-field plot analysis included the following steps. Suppose that C 1 , C 2 , … , C m are analysed concepts where each concept C i is defined by a set of keywords and represented by binary indicators W i 1 , W i 2 , … , W i k i , expressed as C i = max j = 1 , … , k i W i j for i = 1 , … , m (matrix column). Using this notation, the relationship between C i and C j can be defined as C 1 T ∗ C j (matrix multiplication) where i and j are from three different sets (ICT tools, online learning approaches, fields of study).

The descriptive overview presented in Table 1 shows the main characteristics of online learning and COVID-19 research in the higher education context. This research area covers a total of 8,303 documents (of which 7,922 (95%) have the full text in English) published in 2,447 sources between January 2020 and March 2022. Slightly less than half (46%) of these documents have at least one citation, while a relatively small number (15%) were written by a single author. The average number of references per document in this research area is 31.39, which is below the general scientific area of Educational Research (44.00) ( Patience et al., 2017 ), suggesting that online learning research during the COVID-19 pandemic is grounded on fewer existing studies than general research. Finally, 3.50 citations per document can be observed for this research area. Due to the potential benefits of online learning, especially when combined with the traditional learning approaches and hence the development of the blended learning environment, this research is expected to further develop and be extended in the ensuing years ( Fauzi, 2022 ). Further, upon analyzing the documents, it is evident that the average year of references is 2014.03, with an h-index of 60 (indicating at least 60 papers with 60 or more citations each) and a g-index of 94 (denoting that the top 94 publications have accumulated citations equal to or greater than the square of 94). Finally, it was found that within the examined dataset, a total of 1,334 documents (16%) have achieved a minimum of 5 citations (C5), while 691 documents (8%) have attained at least 10 citations (C10), 302 documents (4%) have obtained a minimum of 20 citations (C20), 79 documents (1%) have acquired at least 50 citations (C50), and 31 documents (0.4%) have obtained more than 100 citations (C100).

Table 1 . Descriptive overview of online learning and COVID-19 research (2020–2022).

The most relevant (top-10) highly cited documents in online learning and COVID-19 research in the context of higher education are shown in Table 2 . The overview of the most relevant documents reveals several important topics that were intensively discussed. The first most relevant topic concerns ICT. The COVID-19 pandemic has created significant challenges for higher education, especially for medical and surgical education, which requires personal attendance in clinical activities and labs. Accordingly, several innovative ICT tools (i.e., videoconferencing, social media, and telemedicine) and online learning approaches (i.e., flipped classroom or blended learning and virtual learning) were proposed to address this challenge. It is also stressed that by using appropriately established ICT solutions, online learning can lead to more sustainable education ( Adedoyin and Soykan, 2020 ; Chick et al., 2020 ; Dedeilia et al., 2020 ).

Table 2 . Most relevant documents in online learning and COVID-19 research (2020–2022).

The next top-cited topic relates to pedagogy. The disruption of education around the world due to the COVID-19 pandemic required teachers to possess specific pedagogical content knowledge related to designing and organizing better learning experiences with digital technologies. At the same time, challenges for online assessment and post-pandemic pedagogy are also highlighted ( García Peñalvo et al., 2020 ; Iyer et al., 2020 ; Murphy, 2020 ; Rapanta et al., 2020 ). Finally, life and work is another of the most cited topics. Namely, the COVID-19 pandemic has considerably reshaped education and other aspects of life and work, often also through the perspective of mental health or emotional well-being ( Dwivedi et al., 2020 ; Kapasia et al., 2020 ; Aristovnik et al., 2020a ).

Furthermore, it is noteworthy that all of the highly cited documents were published in 2020. However, it is also evident that there are notable and highly relevant publications that emerged in the second year of the COVID-19 pandemic. Accordingly, there are two documents with a minimum of 100 citations published in 2021. In the COVID-19 pandemic context, Watermeyer et al. (2021) , with 148 citations, examined the implications of digital disruption in universities within the United Kingdom, highlighting the challenges and opportunities arising from the emergency shift to online learning. Meanwhile, Pokhrel and Chhetri (2021) conducted a literature review to assess the impact of the COVID-19 pandemic on teaching and learning.

The scientific production across countries and sources is presented in terms of the number of documents and citations, whereby additional information is provided by a circle’s size, revealing the h-index as a measure of the scientific impact ( Harzing and Van Der Wal, 2009 ) and by its color, presenting the time dimension in scientific production. The most relevant (top-10) highly cited countries in online learning and COVID-19 research are shown in Figure 2 . While the United States of America stands out among all countries, the United Kingdom, China and India have a relatively large number of documents and citations. The findings are similar to those of other bibliometric studies on this topic ( Saqr et al., 2023 ).

Figure 2 . Most relevant countries in online learning and COVID-19 research (2020–2022). Own elaboration based on the Scopus database.

The most relevant (top-10) highly cited sources in online learning and COVID-19 research in the context of higher education are presented in Figure 3 . Despite conference proceedings being prominent in terms of the relatively high number of documents, the most prominent journals, considering the number of citations, are Journal of Chemical Education, with the highest number of citations as well as documents, followed by Sustainability, International Journal of Environmental Research and Public Health, and Education Sciences. More specifically, the most relevant journals address different topics. First, Journal of Chemical Education covers the attempts, successes and failures of distance learning during the COVID-19 pandemic in chemistry education. It covers various topics, including the development of at-home practical activities ( Schultz et al., 2020 ), student engagement and learning ( Perets et al., 2020 ), online assessments ( Nguyen et al., 2020 ) and virtual reality labs ( Williams et al., 2021 ). Further, Sustainability is focused on student and teacher perceptions of e-learning and related challenges ( Khan et al., 2020 ; Aristovnik et al., 2020a ) and sustainability in education during the COVID-19 pandemic ( Sobaih et al., 2020 ) to improve online learning and sustain higher education during uncertain times. Further, the International Journal of Environmental Research and Public Health covers various topics like the health and psychological implications of the COVID-19 pandemic ( Sundarasen et al., 2020 ), including well-being and changes in behavior and habits. Finally, Education Sciences publishes some general research on the challenges and opportunities for online learning ( Almazova et al., 2020 ), including student and teacher experiences ( García-Alberti et al., 2021 ; Müller et al., 2021 ).

Figure 3 . Most relevant sources in online learning and COVID-19 research (2020–2022). Own elaboration based on the Scopus database.

The keyword co-occurrence network is presented in Figure 4 . Note that the nodes indicate keywords and the links the relations of co-occurrence between them. The node size is proportional to the number of keyword occurrences, showing the research intensity (node degree), while the link width is proportional to the co-occurrences between keywords (edge weight). In addition, the node color indicates the cluster to which a particular keyword belongs ( Wang et al., 2020 ; Ravšelj et al., 2022 ). The keyword co-occurrence analysis reveals five research hotspots in online learning in higher education research during the COVID-19 pandemic. These are ICT and pedagogy (red cluster), technology-enhanced education (green cluster), mental health and well-being (blue cluster), student experience (yellow cluster) and curriculum and professional development (purple cluster).

Figure 4 . Keyword co-occurrence network in online learning and COVID-19 research (2020–2022). Own elaboration based on the Scopus database.

A detailed synopsis of the research hotspots, including representative (the most frequent) keywords and documents (with several representative keywords), is presented in Table 3 . The first research hotspot highlights the relevance of ICT and pedagogy in higher education during the COVID-19 pandemic. The most representative documents looked at the quality of online learning mechanisms ( Gritsova and Tissen, 2021 ), active learning activities ( Yan et al., 2021 ) and the role of e-learning departments in controlling the quality of academic processes ( Hamdan et al., 2021 ). The second research hotspot refers to technology-enhanced education from different perspectives, such as opportunities to incorporate technological and curricular innovations ( Shapiro and Reza, 2021 ), the adoption of different virtual experiences such as telehealth and virtual learning ( Kahwash et al., 2021 ), and the utilization of social media to reach higher education students ( Leighton et al., 2021 ). The third research hotspot emphasizes the problem of mental health and well-being issues that became a prevalent topic of discussion during the COVID-19 pandemic. Namely, several studies showed an increase in depression, anxiety and stress levels among higher education students in response to the COVID-19 pandemic ( Abu Kwaik et al., 2021 ; Keskin, 2021 ; Yaghi, 2022 ). The fourth cluster is about student experience during the COVID-19 pandemic with specific focus on the between interaction and online learning satisfaction ( Bawa'aneh, 2021 ; Bismala and Manurung, 2021 ; She et al., 2021 ). The fifth research hotspot underscores the relevance of curriculum and professional development. Several studies described the ways in which courses were adapted to online learning during the COVID-19 pandemic as well as the related challenges and strategies ( Chen et al., 2020 ; Gonzalez and Knecht, 2020 ; Rhile, 2020 ).

Table 3 . Research hotspots based on the author keyword co-occurrence network in online learning and COVID-19 research (2020–2022).

Finally, the three-field plot analysis of the relationship between the main concepts (i.e., ICT tools, online learning approaches, fields of study) is presented in a Sankey diagram shown in Figure 5 . The size of a rectangle corresponds to the number of documents for each theme, while the edge width reflects the inclusion index for connected themes ( Wang et al., 2020 ; Ravšelj et al., 2022 ). These three concepts have been proven to be relevant in the context of online learning. Namely, ICT tools are a precondition for delivering course content through different online learning approaches, while the choice of online learning approaches may depend on the field of study ( Ferri et al., 2020 ). During the COVID-19 pandemic, most attention was devoted to exploring e-learning (a combination of asynchronous and synchronous learning), distance learning (pre-recorded online lectures), followed by virtual learning (real-time online lectures). Since all these online learning approaches limit physical contact between teachers and students, they have been referred to as emergency remote learning approaches ( Hodges et al., 2020 ; Fauzi, 2022 ; Fuchs, 2022 ), while other online learning approaches (computer-based learning, blended learning, m-learning) do not necessarily take place in an online learning environment. The emergency remote learning approaches were primarily supported by several ICT tools, particularly by social media (e.g., Facebook), gamification/simulation and virtual reality (integration of game-like elements into online learning platforms, mobile applications, or virtual reality simulations), Zoom and other videoconferencing platforms, as well as telehealth (for educating health professionals). Regarding the fields of study, e-learning, distance learning and virtual learning were mostly addressed in the context of medical/health education, while computer-based learning (i.e., specific engineering software programs etc.) was examined in the context of engineering education. This implies that the specific requirements of a given field of study often guide the selection of the most suitable online learning approaches ( Fauzi, 2022 ).

Figure 5 . Three-field plot showing the network between ICT tools (left), online approaches (middle), and fields of study (right) (2020–2022). Own elaboration based on the Scopus database.

5. Conclusion

The presented bibliometric study provides several important insights arising from research into online learning during the COVID-19 pandemic. In this period, a large volume of scientific knowledge was produced in the context of education that considered a range of aspects ( Saqr et al., 2023 ). Therefore, a combination of selected bibliometric approaches was utilized to extract some general comprehensive outlines of the global research. The bibliometric analysis revealed the following.

As suggested by the descriptive overview of the state of Educational Research ( Patience et al., 2017 ), the research into online learning during the COVID-19 pandemic is characterized by greater cooperation between authors, which coincides with the general observation that (international) scientific collaboration grew significantly during the pandemic ( Duan and Xia, 2021 ). Further, online learning research during the COVID-19 pandemic is grounded on fewer studies than Educational Research ( Patience et al., 2017 ), which may be explained by the absence of COVID-19-related literature at the time these documents were published. Nevertheless, noting the potential benefits of online learning approaches also when the epidemiological conditions are favorable, this line of research is expected to further develop and be extended in the ensuing years ( Fauzi, 2022 ). The potential benefits refer especially to the development of a blended learning environment, which combines online and traditional learning approaches ( Rasheed et al., 2020 ). The overview of the most relevant documents revealed three topics that were intensively discussed in the academic community, i.e., ICT, pedagogy, and life and work. The COVID-19 pandemic highlighted the importance and role of reliable ICT infrastructure for ensuring effective pedagogy in the online environment, as was needed to prevent the spread of the virus and to protect public health. Apart from the devastating health consequences for those directly affected by the virus and the disrupted educational process, the COVID-19 pandemic also dramatically affected students’ social life and work ( Aristovnik et al., 2020a ). The educational community is increasingly interested in finding ways to respond to crises like the COVID-19 pandemic and develop effective pedagogical practices that assure high-quality and efficient education in the online learning environment ( Zhang et al., 2022 ).

The scientific production of online learning during the COVID-19 pandemic was geographically uneven. The greatest scientific production in terms of citations and number of documents can be observed in the United States, followed by the United Kingdom, China and India. Besides developed English-speaking countries, emerging Asian economies also seem to have played a crucial role in online learning research. Similar findings also emerged from other bibliometric studies on this topic ( Saqr et al., 2023 ). Moreover, despite conference proceedings being prominent in terms of the relatively high number of documents, the most prominent journals, considering the number of citations, are Journal of Chemical Education, Sustainability, International Journal of Environmental Research and Public Health and Education Sciences, indicating that online learning research at the time of the COVID-19 pandemic was primarily published in open-access journals, as already observed in other research ( Zhang et al., 2022 ).

The network analysis revealed five research hotspots in online learning research during the COVID-19 pandemic in the context of higher education: (1) ICT and pedagogy, focused on the quality of online learning mechanisms ( Gritsova and Tissen, 2021 ), active learning activities ( Yan et al., 2021 ) and the role of e-learning departments in controlling the quality of academic processes ( Hamdan et al., 2021 ); technology-enhanced education concentrated on opportunities to incorporate technological and curricular innovations ( Shapiro and Reza, 2021 ), the adoption of different virtual experiences such as telehealth and virtual learning ( Kahwash et al., 2021 ), and the utilization of social media to reach higher education students ( Leighton et al., 2021 ); (2) mental health and well-being issues facing higher education students, including depression, anxiety, and stress levels ( Abu Kwaik et al., 2021 ; Keskin, 2021 ; Yaghi, 2022 ); student experience with specific focus on the between interaction and online learning satisfaction ( Bawa'aneh, 2021 ; Bismala and Manurung, 2021 ; She et al., 2021 ) and (3) curriculum and professional development, focused on the ways in which courses were adapted to online learning during the COVID-19 pandemic as well as the related challenges and strategies ( Chen et al., 2020 ; Gonzalez and Knecht, 2020 ; Rhile, 2020 ).

Further, the COVID-19 pandemic led to the exploration of emergency remote learning approaches such as e-learning, distance learning and virtual learning, which are intended to limit physical contact between teachers and students. These approaches were chiefly supported by several ICT tools, including social media, gamification/simulation, virtual reality, videoconferencing platforms, and telehealth. While computer-based learning, blended learning and m-learning do not necessarily occur in an online learning environment, they may still be suitable for certain fields of study, especially in the post-COVID-19 pandemic period. This implies that the determination of which online learning approach is the most suitable is often guided by the specific requirements of a given field of study ( Fauzi, 2022 ).

Before generalizing these conclusions, it is important to note the limitations of the paper. First, the bibliometric analysis relied on documents indexed in the Scopus database, which might not cover the entire collection of research. Namely, documents that are published in journals indexed in other databases such as Web of Science, Education Research Index, Educational Resources Information Centre, etc. are not included in the analysis. However, to achieve the comparability of bibliometric metrics across documents, the bibliometric metrics are obtained from the single and, in general, broader Scopus database. Given the substantial overlap of documents across different databases of peer-reviewed literature, this limitation might not significantly affect the general observations on global research trends. Nevertheless, to check the robustness of the findings, it is still valuable to consider other bibliometric databases for future research. Second, the bibliometric analysis is conducted the bibliometric is based on a short time period (January 2020 – March 2022), which may also impact the metrics of documents published in closed-access (subscription-based) journals, placing them at a disadvantage compared to documents published in open-access journals. While it is not possible to overcome this limitation at present, conducting a bibliometric study with a longer time span would provide further time-dimensional insights. This would also be beneficial in terms of achieving better comparability between documents published in closed-access and open-access journals. Finally, despite the detailed search queries, some other relevant keywords may have been overlooked in the document search. Finally, the bibliometric method, as a method based on big data analysis, may miss certain highlights from the scientific literature that a systematic literature review would otherwise capture. Therefore it would be beneficial for future bibliometric studies also to incorporate a systematic literature review methodology, as the combined approach can provide a more comprehensive and nuanced understanding of the implications of the COVID-19 pandemic on online learning in higher education.

The bibliometric study provides some possible avenues for future research. First, in future bibliometric studies, it would be beneficial to conduct in-depth analyses of the relevant contexts that have emerged as highly significant in online learning during the pandemic. These include ICT and innovation, mental health and well-being, online learning and engagement, and curriculum and professional development. Examining these contexts more comprehensively can provide valuable insights into the specific dynamics and trends within each area, contributing to a deeper understanding of the implications of online learning during the pandemic. Second, it would be beneficial to conduct separate bibliometric analyses and comparisons to examine the differences between developed and developing countries. This approach can shed light on the unique research trends, contributions, and challenges faced by each group of countries in the context of online learning during the pandemic. This can provide a more nuanced understanding of the global landscape and identify potential areas for collaboration and knowledge sharing between developed and developing countries. Finally, it would be valuable to investigate the long-term impact of rapid publishing in open-access journals on the recognition and dissemination of scholarly findings in the field of online learning in higher education during the pandemic.

From the practical perspective, the COVID-19 pandemic has significantly disrupted higher education, but at the same time, it also accelerated the use of online learning tools in the educational process. Although the COVID-19 pandemic has gradually subsided over time, online learning approaches developed during this period continue to hold relevance and value for future education. Therefore, higher education institutions should prioritize leveraging ICT tools and innovative solutions in their educational delivery, which proved effective during the pandemic. Moreover, higher education institutions should also prioritize adapting appropriate online learning approaches and curricula to align with modern realities and the corresponding fields of study. This adaptation is crucial for enhancing student engagement and ensuring that educational programs remain relevant and responsive to the evolving needs of students in various disciplines.

The findings may help not only the scientific community in detecting research gaps in online learning research during the COVID-19 pandemic but also evidence-based policymaking by assisting in identifying appropriate educational practices in emergency circumstances. Specifically, the findings may help higher education policymakers to address the underlying shortcomings of the existing educational framework exposed by the COVID-19 pandemic and to design proactive mechanisms to deal effectively with such disruptions, thereby enabling them to create a more resilient and adaptable education system that can successfully navigate unforeseen challenges and ensure the continuity of quality higher education in the future.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

Author contributions

AA contributed to the design of the study. DR and LU assisted with the data identification, cleaning, and analysis. DR and KK wrote the manuscript in consultation with AA. All authors contributed to the manuscript’s revision and read and approved the submitted version.

This research and the APC were funded by the Slovenian Research Agency under grant numbers P5-0093 and Z5-4569.

Acknowledgments

The authors acknowledge the financial support from the Slovenian Research Agency (research core funding no. P5-0093 and project no. Z5-4569). A preliminary version of the paper was presented at the International Conference on Information, Communication Technologies in Education (ICICTE) in July 2022. The authors are grateful to colleagues who attended the presentation and provided interesting comments and suggestions. Further, they wish to thank the reviewers for their valuable suggestions and comments.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: online learning, e-learning, higher education, bibliometrics, mapping, visualization, VOSviewer, COVID-19

Citation: Aristovnik A, Karampelas K, Umek L and Ravšelj D (2023) Impact of the COVID-19 pandemic on online learning in higher education: a bibliometric analysis. Front. Educ . 8:1225834. doi: 10.3389/feduc.2023.1225834

Received: 19 May 2023; Accepted: 14 July 2023; Published: 03 August 2023.

Reviewed by:

Copyright © 2023 Aristovnik, Karampelas, Umek and Ravšelj. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Aleksander Aristovnik, [email protected] ; Dejan Ravšelj, [email protected]

This article is part of the Research Topic

Increased Quality Education Through Cross-Campus Learning Environments

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Peer-reviewed

Research Article

Online education and its effect on teachers during COVID-19—A case study from India

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Area of Humanities and Social Sciences, Indian Institute of Management Indore, Indore, Madhya Pradesh, India

• Surbhi Dayal

• Published: March 2, 2023
• https://doi.org/10.1371/journal.pone.0282287
• Reader Comments

COVID pandemic resulted in an initially temporary and then long term closure of educational institutions, creating a need for adapting to online and remote learning. The transition to online education platforms presented unprecedented challenges for the teachers. The aim of this research was to investigate the effects of the transition to online education on teachers’ wellbeing in India.

The research was conducted on 1812 teachers working in schools, colleges, and coaching institutions from six different Indian states. Quantitative and qualitative data was collected via online survey and telephone interviews.

The results show that COVID pandemic exacerbated the existing widespread inequality in access to internet connectivity, smart devices, and teacher training required for an effective transition to an online mode of education. Teachers nonetheless adapted quickly to online teaching with the help of institutional training as well as self-learning tools. However, respondents expressed dissatisfaction with the effectiveness of online teaching and assessment methods, and exhibited a strong desire to return to traditional modes of learning. 82% respondents reported physical issues like neck pain, back pain, headache, and eyestrain. Additionally, 92% respondents faced mental issues like stress, anxiety, and loneliness due to online teaching.

As the effectiveness of online learning perforce taps on the existing infrastructure, not only has it widened the learning gap between the rich and the poor, it has also compromised the quality of education being imparted in general. Teachers faced increased physical and mental health issues due to long working hours and uncertainty associated with COVID lockdowns. There is a need to develop a sound strategy to address the gaps in access to digital learning and teachers’ training to improve both the quality of education and the mental health of teachers.

Citation: Dayal S (2023) Online education and its effect on teachers during COVID-19—A case study from India. PLoS ONE 18(3): e0282287. https://doi.org/10.1371/journal.pone.0282287

Editor: Lütfullah Türkmen, Usak University College of Education, TURKEY

Received: November 13, 2021; Accepted: January 27, 2023; Published: March 2, 2023

Copyright: © 2023 Surbhi Dayal. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data apart from manuscript has been submitted as supporting information .

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

As of November 4, 2021, the spread of novel coronavirus had reached 219 countries and territories of the world, infecting a total of 248 million people and resulting in five million deaths [ 1 ]. In March 2020, several countries including India declared a mandatory lockdown, resulting in the temporary closure of many institutions, not least educational ones. Since then, various restrictions and strategies have been implemented to counter the spread of the virus. These include wearing masks, washing hands frequently, maintaining social and physical distance, and avoiding public gatherings. The pandemic has greatly disrupted all aspects of human life and forced new ways of functioning, notably in work and education, much of which has been restricted to the household environment. The closure for over a year of many schools and colleges across the world has shaken the foundations of the traditional structures of education. Due to widespread restrictions, employees have been forced to carve out working spaces in the family home; likewise, students and teachers have been compelled to bring classes into homes [ 2 ]. Nearly 1.6 billion learners in more than 190 countries have been physically out of school due to the pandemic. In total, 94 percent of the world’s student population has been affected by school closures, and up to 99 percent of this student population come from low-to middle-income countries [ 3 ].

According to the World Economic Forum, the pandemic has changed how people receive and impart education [ 4 ]. Physical interaction between students and teachers in traditional classrooms has been replaced by exchanges on digital learning platforms, such as online teaching and virtual education systems, characterized by an absence of face-to-face connection [ 5 ]. Online education has thus emerged as a viable option for education from preschool to university level, and governments have used tools such as radio, television, and social media to support online teaching and training [ 6 ]. Various stakeholders, including government and private institutions, have collaborated to provide teachers with resources and training to teach effectively on digital platforms. New digital learning platforms like Zoom, Google Classroom, Canvas, and Blackboard have been used extensively to create learning material and deliver online classes; they have also allowed teachers to devise training and skill development programs [ 7 ]. Many teachers and students were initially hesitant to adopt online education. However indefinite closure of institutions required educational facilities to find new methods to impart education and forced teachers to learn new digital skills. Individuals have experienced different levels of difficulty in doing this; for some, “it has resulted in tears, and for some, it is a cup of tea” [ 8 ].

Teachers have reported finding it difficult to use online teaching as a daily mode of communication, and enabling students’ cognitive activation has presented a significant challenge in the use of distance modes of teaching and learning. Teachers have also expressed concerns about administering tests with minimal student interaction [ 9 ]. Lack of availability of smart devices, combined with unreliable internet access, has led to dissatisfaction with teacher-student interaction. Under pressure to select the appropriate tools and media to reach their students, some teachers have relied on pre-recorded videos, which further discouraged interaction. In locations where most teaching is done online, teachers in tier 2 and tier 3 cities (i.e., semi-urban areas) have had to pay extra to secure access to high-speed internet, digital devices, and reliable power sources [ 10 ]. Teachers in India, in particular, have a huge gap in digital literacy caused by a lack of training and access to reliable electricity supply, and internet services. In rural or remote areas, access to smart devices, the internet, and technology is limited and inconsistent [ 6 ]. In cities, including the Indian capital Delhi, even teachers who are familiar with the required technology do not necessarily have the pedagogical skills to meet the demands of online education. The absence of training, along with local factors (for example, stakeholders’ infrastructure and socio-economic standing), contributes to difficulties in imparting digital education successfully [ 10 ]. The gap in digital education across Indian schools is striking. For example, only 32.5% of school children are in a position to pursue online classes. Only 11% of children can take online classes in private and public schools, and more than half can only view videos or other recorded content. Only 8.1% of children in government schools have access to online classes in the event of a pandemic-related restrictions [ 11 ].

The adverse effects of COVID-19 on education must therefore be investigated and understood, particularly the struggles of students and teachers to adapt to new technologies. Significant societal effects of the pandemic include not only serious disruption of education but also isolation caused by social distancing. Various studies [ 7 , 12 , 13 ] have suggested that online education has caused significant stress and health problems for students and teachers alike; health issues have also been exacerbated by the extensive use of digital devices. Several studies [ 6 , 11 , 14 ] have been conducted to understand the effects of the COVID lockdown on digital access to education, students’ physical and emotional well-being, and the effectiveness of online education. However, only a few studies [ 13 , 15 – 17 ] have touched the issues that teachers faced due to COVID lockdown.

In this context, this study is trying to fill existing gaps and focuses on the upheavals that teachers went through to accommodate COVID restrictions and still impart education. It also provides an in-depth analysis of consequences for the quality of education imparted from the teachers’ perspective. It discusses geographical inequalities in access to the infrastructure required for successful implementation of online education. In particular, it addresses the following important questions: (1) how effectively have teachers adapted to the new virtual system? (2) How has online education affected the quality of teaching? (3) How has online education affected teachers’ overall health?

Because of lockdown restrictions, data collection for this study involved a combination of qualitative and quantitative methods in the form of online surveys and telephonic interviews. A questionnaire for teachers was developed consisting of 41 items covering a variety of subjects: teaching styles, life-work balance, and how working online influences the mental and physical well-being of teachers. In the interviews, participants were asked about their experiences of online teaching during the pandemic, particularly in relation to physical and mental health issues. A pilot study was conducted with thirty respondents, and necessary changes to the items were made before the data collection. The survey tool was created using google forms and disseminated via email, Facebook, and WhatsApp. A total of 145 telephonic interviews were also conducted to obtain in-depth information from the respondents.

The data were collected between December 2020 and June 2021. The Research Advisory Committee on Codes of Ethics for Research of Aggrawal College, Ballabhgarh, Haryana, reviewed and approved this study. A statement included in the google survey form as a means of acquiring written consent from the participants. Information was gathered from 1,812 Indian teachers in six Indian states (Assam, Haryana, Karnataka, Madhya Pradesh, New Delhi, and Rajasthan) working in universities, schools, and coaching institutions. Nearly three-quarters of the total sample population was women. All participants were between the ages of 18 and 60, with an average age of 34 and a clear majority being 35 or younger. Nearly three-quarters of participants work in private institutions (25% in semi-government entities and the remainder in government entities). In terms of education, 52% of participants have a graduate degree, 34% a postgraduate degree, and 14% a doctorate. Table 1 summarizes the demographic characteristics of the participants.

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Results & discussion

Upon analyzing the survey responses, three crucial areas were identified for a better understanding of the effect of COVID-19 on the Indian education system and its teachers: how effectively teachers have adapted, how effective teaching has been, and how teachers’ health has been affected.

1. How effectively have teachers adapted to the new virtual system?

The first research question concerns how willing teachers were to embrace the changes brought about by the online teaching system and how quickly they were able to adapt to online modes of instruction. This information was gathered from December 2020 to June 2021, at which point teachers had been dealing with school lockdowns for months and therefore had some time to become conversant with online teaching.

While 93.82% of respondents were involved in online teaching during the pandemic, only 16% had previously taught online. These results were typically different from the results of a similar study conducted in Jordon where most of the faculty (60%) had previous experience with online teaching and 68% of faculty had also received formal training [ 16 ]. Since the spread of COVID-19 was rapid and the implementation of the lockdown was sudden, government and educational institutions were not prepared for alternative modes of learning, and teachers needed some time for adjustment. Several other factors also affected the effectiveness of the transition to online education, namely access to different types of resources and training [ 18 ].

a. Access to smart devices.

Online teaching requires access to smart devices. A surprising number of teachers stated that they had internet access at home via laptops, smartphones, or tablets. A more pertinent question, however, was whether they had sole access to the smart device, or it was shared with family members. Only 37.25% of those surveyed had a device for their exclusive use while others shared a device with family members, due to lack of access to additional devices and affordability of new devices. During the lockdown, an increase in demand led to a scarcity of smart devices, so that even people who could afford to buy a device could not necessarily find one available for purchase. With children attending online classes, and family members working from home, households found it difficult to manage with only a few devices, and access to a personal digital device became an urgent matter for many. Respondents admitted to relying on their smartphones to teach courses since they lacked access to other devices. Teachers on independent-school rosters were significantly better equipped to access smart devices than those employed at other types of schools. The data also indicates that teachers in higher education and at coaching centers had relatively better access to laptops and desktop computers through their institutions, whereas teachers in elementary and secondary schools had to scramble for securing devices for their own use.

b. Internet access.

Internet access is crucial for effective delivery of online education. However, our survey shows that teachers often struggled to stay connected because of substantial differences between states in the availability of internet. Of the respondents, 52% reported that their internet was stable and reliable, 32% reported it to be satisfactory and the rest reported it to be poor. Internet connectivity was better in the states of Karnataka, New Delhi, and Rajasthan than in Assam, Haryana, and Madhya Pradesh. Internet connectivity in Assam was particularly poor. Consequently, many teachers with access to advanced devices were unable to use them due to inadequate internet connection.

The following comments from a teacher in Assam capture relevant situational challenges: “I do not have an internet modem at home, and teaching over the phone is difficult. My internet connection is exhausted, and I am unable to see or hear the students.” Another teacher from Haryana reported similar difficulties: “During the lockdown, I moved to my hometown, and I do not have internet access here, so I go to a nearby village and send videos to students every three days.” Another teacher from Madhya Pradesh working at a premier institution reported experiencing somewhat different concerns: “I am teaching in one of the institute’s semi-smart classrooms, and while I have access to the internet, my students do not, making it difficult to hear what they are saying.”

These responses indicates clearly that it is not only teachers living in states where connectivity was poor who experienced difficulties in imparting education to students; even those who had good internet connectivity experiences problems caused by the poor internet connections of their students.

c. Tools for remote learning.

Teachers made use of a variety of remote learning tools, but access to these tools varied depending on the educator’s affiliation. Teachers at premier institutions and coaching centers routinely used the Zoom and Google Meet apps to conduct synchronous lessons. Teachers at state colleges used pre-recorded videos that were freely available on YouTube. Teachers in government schools used various platforms, including WhatsApp for prepared material and YouTube for pre-recorded videos. To deliver the content, private school teachers used pre-recorded lectures and Google Meet. In addition to curriculum classes, school teachers offered life skill classes (for example, cooking, gardening, and organizing) to help students become more independent and responsible in these difficult circumstances. In addition to online instruction, 16% of teachers visited their students’ homes to distribute books and other materials. Furthermore, of this 36% visited students’ homes once a week, 29% visited twice a week, 18% once every two weeks, and the rest once a month. Additionally, a survey done on 6435 respondents across six states in India reported that 21% teachers in schools conducted home visits for teaching children [ 19 ].

d. Knowledge and training for the use of information and communication technologies.

With the onset of the pandemic, information and communication technology (ICT) became a pivotal point for the viability of online education. The use of ICT can facilitate curriculum coverage, application of pedagogical practices and assessment, teacher’s professional development, and streamlining school organization [ 20 ]. However, the effective adoption and implementation of ICT necessitated delivery of appropriate training and prolonged practice. Also the manner in which teachers use ICT is crucial to successful implementation of online education [ 21 ]. While countries such as Germany, Japan, Turkey, the United Kingdom, and the United States recognized the importance of ICT by integrating it into their respective teacher training programmes [ 22 ], this has not been case in India. However, there are some training programmes available to teachers once they commence working. In accordance with our survey results, the vast majority of respondents (94%) lacked any ICT training or experience. In the absence of appropriate tools and support, these teachers self-experimented with online platforms, with equal chances of success and failure.

The transition from offline to online or remote learning was abrupt, and teachers had to adapt quickly to the new systems. Our data indicate that teachers in professional colleges and coaching centers received some training to help them adapt to the new online system, whereas teachers in urban areas primarily learned on their own from YouTube videos, and school teachers in rural areas received no support at all. Overall, teachers had insufficient training and support to adjust to this completely new situation. Policy research conducted on online and remote learning systems following COVID-19 has found similar results, namely that teachers implemented distance learning modalities from the start of the pandemic, often without adequate guidance, training, or resources [ 23 ]. Similar trends have been found in the Caribbean, where the unavailability of smart learning devices, lack of or poor internet access, and lack of prior training for teachers and students hampered online learning greatly. Furthermore, in many cases the curriculum was not designed for online teaching, which was a key concern for teachers [ 24 ]. Preparing online lectures as well as monitoring, supervising and providing remote support to students also led to stress and anxiety. Self-imposed perfectionism further exacerbated these issues while delivering online education [ 15 ]. A study conducted on 288 teachers from private and government schools in Delhi and National Capital Region area, also found that transition to online education has further widened the gap between pupils from government and private schools. It was more difficult to reach students from economically weaker sections of the society due to the digital divide in terms of access, usage, and skills gap. The study also found that even when teachers were digitally savvy, it did not mean that they know how to prepare for and take online classes [ 10 ].

2. How has online education affected the quality of teaching?

Once teachers had acquired some familiarity with the online system, new questions arose concerning how online education affected the quality of teaching in terms of learning and assessment, and how satisfied teachers were with this new mode of imparting education. To address these questions, specific questionnaire items about assessment and effectiveness of teaching has been included.

a. Effectiveness of online education.

Respondents agreed unanimously that online education impeded student-teacher bonding. They reported several concerns, including the inattentiveness of the majority of the students in the class, the physical absence of students (who at times logged in but then went elsewhere), the inability to engage students online, and the difficulty of carrying out any productive discussion given that only a few students were participating. Another significant concern was the difficulty in administrating online tests in light of widespread cheating. In the words of one teacher: “I was teaching a new class of students with whom I had never interacted in person. It was not easy because I could not remember the names of the students or relate to them. Students were irritated when I called out their names. It had a significant impact on my feedback. I would like us to return to class so I do not have to manage four screens and can focus on my students and on solving their problems.”

For these reasons, 85.65% of respondents stated that the quality of education had been significantly compromised in the online mode. As a result, only 33% reported being interested in continuing with online teaching after COVID-19. The results show slightly higher dissatisfaction in comparison to another study conducted in India that reported 67% of teachers feeling dissatisfied with online teaching [ 25 ]. Findings of this study were similar to the findings of a survey of lecturers in Ukraine assessing the effectiveness of online education. Lower quality student work was cited as the third most mentioned problem among the problems cited by instructors in their experience with online teaching, right behind unreliable internet connectivity and the issues related with software and hardware. Primary reasons for lower quality student work were drop in the number of assignments and work quality as well as cheating. Almost half (48.7%) of the participants expressed their disapproval of online work and would not like to teach online [ 26 ].

Due to the nature of the online mode, teachers were also unable to use creative methods to teach students. Some were accustomed to using physical objects and role-playing to engage students in the classroom, but they found it extremely difficult to make learning exciting and to engage their students in virtual space. Similar trends have been reported in Australia, where schoolteachers in outback areas did not find online education helpful or practical for children, a majority of whom came from low-income families. The teachers were used to employing innovative methods to keep the students engaged in the classroom. However, in online teaching, they could not connect with their students using those methods, which significantly hampered their students’ progress. Some teachers mentioned difficulties with online teaching caused by not being able to use physical and concrete objects to improve their instructions [ 27 ].

b. Online evaluation.

Of our respondents, 81% said that they had conducted online assessments of their students. Teachers used various online assessment methods, including proctored closed/open book exams and quizzes, assignment submissions, class exercises, and presentations. Teachers who chose not to administer online assessments graded their students’ performance based on participation in class and previous results.

Almost two-thirds of teachers who had administered online assessments were dissatisfied with the effectiveness and transparency of those assessments, given the high rates of cheating and internet connectivity issues. They also reported that family members had been helping students to cheat in exams because they wanted their children to get higher grades by any means necessary. In response, the teachers had tried to devise methods to discourage students and their families from cheating, but they still felt powerless to prevent widespread cheating.

As one respondent stated: “We are taking many precautions to stop cheating, such as asking to install a mirror behind the student and doing online proctoring, but students have their ways out for every matter. They disconnect the internet cable or turn it off and reconnect it later. When we question them, they have a connectivity reason ready”.

Teachers are also concerned about the effects of the digital skills gap on their creation of worksheets, assessments, and other teaching materials. As a result, some private companies have been putting together teacher training programs. The main challenge pertains to be implementation of a type of specialized education that many teachers are unfamiliar with and unwilling to adopt [ 28 ]. Because of the lack of effective and transparent online assessments, school teachers have reported that students were promoted to the next level regardless of their performance. Thus, only time will tell how successful online education has been in terms of its effects on the lives of learners.

3. How has online education affected teacher’s overall health?

The onset of the COVID-19 pandemic brought about a situation that few people had experienced or even imagined living through. Governments and individuals tried their best to adjust to the new circumstances, but sudden lockdown, confinement to the household periphery, and working from home had adverse effects on the mental and physical health of many people, including educators and students. To clarify the effects of online education on teachers’ overall health, a number of questionnaire items were focused on respondents’ feelings during the lockdown, the physical and mental health issues they experienced, and their concerns about the future given the uncertainty of the present situation.

a. Physical health issues.

COVID-19 brought a multitude of changes to the lives of educators. Confinement to the household, working from home, and an increased burden of household and caregiving tasks due to the absence of paid domestic assistants increased physical workload and had corresponding adverse effects on the physical health of educators.

Of the study participants, 82% reported an increase in physical health issues since the lockdown ( Fig 1 ). Notably, 47% of those who were involved in digital mode of learning for less than 3 hours per day reported experiencing some physical discomfort daily, rising to 51% of teachers who worked online for 4–6 hours per day and 55% of teachers who worked more than 6 hours per day. Respondents reported a variety of physical health issues, including headaches, eye strain, back pain, and neck pain.

https://doi.org/10.1371/journal.pone.0282287.g001

The number of hours worked showed a positive correlation with the physical discomfort or health issues experienced. A chi-square test was applied to determine the relationship between the number of online working hours and the frequency of physical issues experienced by the participants and found it to be significant at the 0.05 level ( Table 2 ).

https://doi.org/10.1371/journal.pone.0282287.t002

As Fig 2 shows, 28% respondents’ complaint about experiencing giddiness, headaches; 59% complain of having neck and back pain. The majority of the participants had eye-strain problems most of the time; 32% faced eye problems sometimes, and 18% reported never having any eye issue. In addition, 49% had experienced two issues at the same time and 20% reported experiencing more than 2 physical issues at the same time.

https://doi.org/10.1371/journal.pone.0282287.g002

The data in this study indicates a link between bodily distresses and hours worked. As working hours increased, so did reports of back and neck pain. 47% respondents reported back and neck pain after working for 3 hours or less, 60% after working for 3–6 hours, and nearly 70% after working for 6 hours or more.

The analysis also indicates link between physical issues experienced and the educator’s gender. Women experienced more physical discomfort than men, with 51% reporting frequent discomfort, compared to only 46% of men. Only 14% of female educators reported never experiencing physical discomfort, against 30% of male educators.

In terms of types of discomfort, 76% of female teachers and 51% of male teachers reported eye strain; 62% of female teacher and 43% of male teachers reported back and neck pain; 30% of female teachers and 18% of male teachers said they had experienced dizziness and headaches. The gender differences may be caused by the increase in household and childcare responsibilities falling disproportionately on female educators compared to their male counterparts. Several studies [ 17 , 29 – 31 ] have reported similar results, indicating that the gender gap widened during the pandemic period. The social expectations of women to take care of children increased the gender gap during the pandemic by putting greater responsibilities on women in comparison to men [ 29 ]. Women in academics were affected more in comparison to the men. Working from home burdened female educators with additional household duties and childcare responsibilities. A study done [ 32 ] in France, Germany, Italy, Norway, Sweden, the United States and the United Kingdom discovered that women were immensely affected by lockdown in comparison to men. On top of this, women with children are affected more than women without children.

No effect of age on physical discomfort was observed in this study but increasing use of online tools (such as class websites) for content creation and delivery and extended working periods were major contributors to health problems.

b. Mental health issues.

The psychological effects of the COVID-19 pandemics have also proved difficult to manage. Being at home all day with limited social interaction, not to mention other pandemic-related sources of stress, affected the mental health of many people. The majority of the participants in this study admitted experiencing mental health issues including anxious feelings, low mood, restlessness, hopelessness, and loneliness. According to UNESCO [ 33 ], due to the sudden closure of schools and adaptability to new systems, teachers across the world are suffering from stress. Studies conducted in various parts of the world confirmed similar trends [ 34 , 35 ]. In Israel, teachers reported psychological stress due to online teaching. 30.4% teachers reported being stressed in comparison to 6.1% teachers in traditional classroom settings [ 34 ]. In Spain, teachers experienced various kinds of mental health issues like anxiety, stress, and depression [ 36 ]. An Arabian study found an increased number of cases related to anxiety, depression, and violence during the pandemic [ 37 ]. In New Zealand teachers in Higher education reported being overwhelmed due to the online teaching [ 15 ].

Online teaching appears to have negatively affected the mental health of all the study participants. Women (94%) reported more mental health issues than men (91%), as shown in Fig 3 . Nearly two-thirds of participants said they had been dealing with mental health issues regularly and a third occasionally; only 7% said they never dealt with them. Findings of this study are in line with other studies which found that female teachers had higher levels of stress and anxiety in comparison to men [ 36 ]. Studies conducted in China reported that teachers developed mental health issues due to online classes [ 37 , 38 ].

https://doi.org/10.1371/journal.pone.0282287.g003

Our analysis indicated a positive relationship between the number of working hours and the frequency of mental health issues. Of the respondents who worked online for less than 3 hours, 55% experienced some kind of mental health issue; this rose to 60% of participants who worked online for 3–6 hours, and 66% of those who worked more than 6 hours every day. A chi-square test was applied to determine the relationship between the number of online working hours and the frequency of mental issues experienced by the participants and found it to be significant at the 0.05 level ( Table 3 ).

https://doi.org/10.1371/journal.pone.0282287.t003

In terms of types of mental health issues, respondents reported restlessness, anxious feelings, and a sense of powerlessness, along with feelings of hopelessness, low mood, and loneliness as shown in Fig 4 . The stress of adapting to a new online working environment, the extended hours of work required to prepare content in new formats, the trial-and-error nature of learning and adopting new practices, uncertainty caused by lockdown, and an overall feeling of having no control were some of the contributing factors.

https://doi.org/10.1371/journal.pone.0282287.g004

Mental health issues were more common among those under the age of 35, with 64% reporting a problem most of the time compared to 53% of those over 35. It has been found that job uncertainty is one of the primary causes of a higher prevalence of mental health concerns among younger respondents than among older respondents. These findings are in line with other studies which found higher levels of stress among the young people in comparison to older one [ 36 , 39 ]. Feelings of loneliness and a sense of no control were reported by 30% of respondents under the age of 35, with these feelings occurring constantly or most of the time; only 12% of respondent over the age of 35 reported experiencing these feelings always or most of the time. Of respondents under 35 years of age 61% felt lonely at some point during the COVID-19 pandemic, compared to only 40% of those age 35 or older.

This study also found gender-based differences in the frequency of mental health issues experienced, with 62% of male respondents and 52% of female respondents reporting that they had always experienced mental health issues. The types of issues also differed by gender, with men more likely to report restlessness and loneliness and women more likely to report feeling anxious or helpless. More female respondents reported feelings of hopelessness than male respondents (76% compared to 69%), and they were also more anxious (66%).

The uncertainty of the pandemic seems to have caused helplessness and anxious feelings for female teachers in particular, perhaps because a lack of paid domestic help increased the burden of household and caregiving tasks disproportionately for women at a time when the pressure to adapt to new online platforms was particularly acute. In some cases, respondents left their jobs to accommodate new family dynamics, since private employers offered no assistance or flexibility. Deterioration of mental health also led to the increased number of suicides in Japan during COVID-19 [ 39 ].

However, female teachers fared better than their male counterparts on some measures of mental health. Although half of the respondents (men and women equally) reported low mood during the pandemic, the men reported more restlessness (53%) and loneliness (59%) than the women (50% and 49%, respectively). Restrictions on eating and drinking outside the household may have had a disproportionate effect on male respondents, making them more likely to feel restless or lonely than their female counterparts, who may have handled COVID-related isolation better by being more involved in household work and caregiving.

Number of hours worked online was also a factor contributing to mental health issues. Just as respondents had more physical complaints (including eye strain, back and neck pain, and headaches) the more hours they worked online, respondents who worked longer hours online reported more mental health issues.

One of the major drawbacks of online education is the widespread occurrence of physical and mental health issues, and the results of this study corroborate concerns on this point. This study found that online teaching causes more mental and physical problems for teachers than another study, which only found that 52.7% of respondents had these problems [ 12 ].

A report by the University of Melbourne has also indicated that online teaching and learning have a negative effect on the physical and mental well-being of individuals. Teachers working from home, in particular, have reported isolation, excessive screen time, inability to cope with additional stress, and exhaustion due to increased workload; despite being wary of the risks of exposure to COVID-19, they were eager to return to the campus [ 27 ].

c. Support mechanisms.

In general, teachers experienced good support from family and colleagues during the pandemic, with 45.64% of teachers reported receiving strong support, 29.64 percent moderate support (although the remainder claimed to have received no or only occasional support from family and colleagues). 9.39% of male respondents reported that they have never received any support in comparison to 4.36% females. Female respondents reported receiving more support than male respondents perhaps because they have access to a more extensive network of family members and coworkers. Children, parents, and siblings were cited as the provider of a robust support system by most female respondents. For example, maternal relatives called or texted children to keep them engaged and helped them with homework, and female participants said their peers helped them to prepare lectures and materials. A link was also found between age and support; the older the respondent, the stronger the support system. A possible explanation for this difference is that older people have had time to develop stronger and longer-lasting professional and personal ties than younger people.

This study explored the effects of the COVID-19 pandemic on the Indian education system and teachers working across six Indian states. The effectiveness of online education methods varied significantly by geographical location and demographics based on internet connectivity, access to smart devices, and teachers’ training. While premier higher education institutions and some private institutions had provided teachers with the necessary infrastructure and training to implement effective successful online learning with relatively few challenges, teachers at schools and community colleges have more often been left to adopt a trial-and-error approach to the transition to an online system. Further, it indicates that online education has had a significant effect on the quality of education imparted and the lives and wellbeing of teachers. While online learning has enabled teachers to reach out to students and maintain some normalcy during a time of uncertainty, it has also had negative consequences. Owing to the lack of in-person interaction with and among students in digital classes, the absence of creative learning tools in the online environment, glitches and interruptions in internet services, widespread cheating in exams, and lack of access to digital devices, online learning adversely affected the quality of education. Teachers experienced mounting physical and mental health issues due to stress of adjusting to online platforms without any or minimal ICT training and longer working hours to meet the demands of shifting responsibilities. A positive correlation was found between working hours and mental and physical health problems.

The long-term impact of COVID-19 pandemic on both the education system and the teachers would become clear only with time. Meanwhile, this study sheds light on some of the issues that teachers are facing and needs to be addressed without further ado. These findings will provide direction to the policy makers to develop sound strategies to address existing gaps for the successful implementation of digital learning. However, researchers should continue to investigate the longer-term effects of COVID pandemic on online education.

Supporting information

S1 file. supplementary material..

https://doi.org/10.1371/journal.pone.0282287.s001

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• Open access
• Published: 08 May 2024

The digital transformation in pharmacy: embracing online platforms and the cosmeceutical paradigm shift

• Ahmad Almeman   ORCID: orcid.org/0000-0002-6521-9463 1  

Journal of Health, Population and Nutrition volume  43 , Article number:  60 ( 2024 ) Cite this article

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In the face of rapid technological advancement, the pharmacy sector is undergoing a significant digital transformation. This review explores the transformative impact of digitalization in the global pharmacy sector. We illustrated how advancements in technologies like artificial intelligence, blockchain, and online platforms are reshaping pharmacy services and education. The paper provides a comprehensive overview of the growth of online pharmacy platforms and the pivotal role of telepharmacy and telehealth during the COVID-19 pandemic. Additionally, it discusses the burgeoning cosmeceutical market within online pharmacies, the regulatory challenges faced globally, and the private sector’s influence on healthcare technology. Conclusively, the paper highlights future trends and technological innovations, underscoring the dynamic evolution of the pharmacy landscape in response to digital transformation.

Introduction

Digital technology is driving a massive shift in the worldwide pharmacy industry with the goal of improving productivity, efficiency, and flexibility in healthcare delivery. In the pharmacy industry, implementing digital technologies like automation, computerization, and robotics is essential to cutting expenses and enhancing service delivery​​ [ 1 ]. With a predicted 14.42% annual growth rate, the digital pharmacy market is expanding significantly and is expected to reach a market volume of about $35.33 billion by 2026. This expansion reflects the pharmacy industry’s growing reliance on and promise for digital technologies​ [ 2 ].

Pharmacy services have always been focused on face-to-face communication and paper-based procedures. However, the drive for more effective, transparent, and patient-centered healthcare is clear evidence of the growing need for digital transformation. Breakthroughs like mobile communications, cloud computing, advanced analytics, and the Internet of Things (IoT) are reshaping the healthcare sector. These breakthroughs have the potential to greatly improve patient care and service delivery, as demonstrated in other industries including banking, retail, and media [ 3 ].

In the pharmacy industry, a number of significant factors are hastening this digital transition. Important concerns include the desire for cost-effectiveness, enhanced patient care, and more transparency and efficiency in medication development and manufacture. This change has been made even more rapid by the COVID-19 pandemic, which has highlighted the necessity for digital solutions to address the difficulties associated with providing healthcare in emergency situations [ 4 ].

In terms of specific technologies being adopted, artificial intelligence (AI) and machine learning are playing a pivotal role. The McKinsey Global Institute estimates that AI in the pharmaceutical industry could generate nearly $100 billion annually across the U.S. healthcare system. The use of AI and machine learning enhances decision-making, optimizes innovation, and improves the efficiency of research and clinical trials. This results in more effective patient care and a more streamlined drug development process​ [ 5 ].

The digital transformation in the pharmacy sector represents a pivotal shift in the delivery and experience of healthcare services. This evolution is more than a transient trend; it’s a fundamental alteration in the healthcare landscape [ 6 ]. The adoption of digital technologies is reshaping aspects of healthcare, including patient engagement and medication adherence, leading to enhanced healthcare outcomes. Research indicates that digital tools in pharmacy practices have resulted in more individualized and efficient patient care. Telehealth platforms, exemplified by companies like HealthTap, are being increasingly incorporated by pharmacies to augment patient care via technological solutions. The contribution of digital health technology to medication adherence is notable, employing a variety of tools such as SMS, mobile applications, and innovative devices like virtual pillboxes and intelligent pill bottles. These advancements are pivotal in addressing the critical issue of medication nonadherence in healthcare. Furthermore, digital health tools are empowering pharmacists with expanded clinical responsibilities, particularly in the management of chronic diseases like diabetes, where apps and smart devices provide essential features such as blood glucose tracking and medication reminders. This comprehensive integration of digital health into pharmacy practice signifies a transformative era in healthcare delivery and patient management [ 7 ].

Online platforms are being used increasingly by the pharmaceutical sector and educational institutions to improve efficiency, flexibility, and accessibility. The telepharmacy program at CVS Pharmacy is an example of how telepharmacy services, which provide remote counseling and prescription verification, bring pharmaceutical care to underprivileged communities [ 8 ]. Prescription accuracy and drug management are enhanced by e-prescribing software like Epic’s MyChart and digital health apps like Medisafe [ 9 ; 10 ]. Blockchain technology is also being investigated for transparent and safe supply chain management. Continuous learning and professional networking are made possible in education by Virtual Learning Environments (VLEs) like Moodle [ 11 ], simulation software like SimMan 3G Plus [ 12 ], Continuing Professional Development (CPD) platforms like the American Pharmacists Association [ 13 ], and online conference platforms, as shown in Fig.  1 . While these platforms offer significant benefits like enhanced access and cost-effectiveness, they also present challenges, including addressing the digital divide and ensuring the quality and credibility of online services to maintain professional standards and patient safety.

In this review, we summarized the digital transformation in the pharmacy sector, emphasizing the integration of online platforms and the emerging significance of cosmeceuticals. We discussed the global shift towards digital healthcare, including telehealth and online pharmacy services, and how these changes have been accelerated by the COVID-19 pandemic. The paper also examined the impact of digital technologies on pharmacy practice and education, with a focus on telepharmacy services, e-prescribing software, and digital health apps. Additionally, it addresses the challenges and opportunities presented by this transformation, including regulatory and safety concerns, and the need for continuous professional development in the digital era.

Comprehensive overview of different platforms in the pharmaceutical industry and education illustrating purposes and exemplary cases

The global impact of online pharmacy platforms

In recent years, the landscape of pharmacy practice and education has undergone a significant transformation, driven by technological advancements and catalyzed by the global COVID-19 pandemic. A study highlighting the increasing consumer trust in online medication purchases pre, during, and post-pandemic reveals a shift in consumer behavior towards online pharmacies [ 14 ]. This trend underscores a greater reliance on these platforms, where the perceived benefits significantly outweigh the perceived risks, indicating a positive reception and growing trust in digital healthcare solutions.

The adoption of telehealth, including telepharmacy, exemplifies this shift. In the United States, patient adoption of telehealth services surged from 11% in 2019 to 46%, with healthcare providers expanding their telehealth visits [ 15 ]. This shift is a reflection of how adaptable the healthcare sector is to digital platforms and how customer acceptance is increasing. The epidemic has also served as a catalyst, hastening the creation and uptake of online telepharmacy services throughout the world. The “new normal” has forced the addition of new platforms to support established sources of health information. The creation and evaluation of an online telepharmacy service in the Philippines during the pandemic serves as an example of this, demonstrating how quickly the global pharmacy industry adopted digital solutions. These services are essential for providing and elucidating pharmaceutical information within the context of primary healthcare delivery; they are not merely supplementary [ 16 ].

Simultaneously, pharmacist-led companies such as MedEssist and MedMehave, innovated digital platforms to facilitate services like flu shots or COVID-19 tests, reflecting a move towards customer-centric, digital-first services [ 17 ]. This transition enhances convenience and access to care but also introduces significant regulatory challenges. As the growth of online medicine sales disrupts traditional pharmacy markets, navigating these challenges becomes crucial for maintaining patient safety, quality standards, and fostering a trustworthy online healthcare environment [ 18 ].

Parallel to the practice changes, educational platforms for pharmacy have also evolved, especially under the impetus of the pandemic. These platforms have integrated a mix of traditional and student-centered teaching methodologies, including remote didactic lectures and on-site experiential training. The implementation of blended learning approaches, which combine remote lectures with on-site laboratory classes, reflects a broader educational trend towards hybrid models. This approach aims to leverage the advantages of both online and traditional methods, offering a more flexible and potentially more effective educational experience [ 19 ].

It takes more than just implementing new tools to integrate educational technology into pharmacy education, it also requires understanding how these technologies affect instruction and student learning. To effectively improve the educational experience, their utilization must have a purpose. There is an increasing amount of scholarly interest in this field, as evidenced by systematic reviews of the effects of new technologies on undergraduate pharmacy teaching and learning [ 20 ]. These digital platforms will probably become more significant in the future of pharmacy education, helping to mold the profession and guaranteeing that pharmacists are equipped to fulfill the ever-changing demands of the healthcare system. This development is indicative of a larger trend in the healthcare industry toward a more flexible, patient-focused, and technologically advanced environment [ 21 ].

Digital transformation in global healthcare

The recent advancements in digital transformation within global healthcare are significantly reshaping the landscape of healthcare and pharmacy services. These transformations are largely driven by the integration of digital technologies, which are redefining the tools and methods used in health, medicine, and biomedical science, ultimately aiming to create a healthier future for people worldwide [ 22 ]. In a 2018 report [ 23 ], Amazon’s potential entry into the $500 billion U.S. pharmacy market, the second-largest retail category, through mail-order and online pharmacies was highlighted as a significant industry disruptor. With licenses in at least 12 states in the US and a strategy focused on bypassing middlemen, Amazon’s historical success positions it to transform the pharmacy landscape, promising enhanced efficiency and cost savings for consumers.

One of the critical areas identified in recent research is the establishment of five priorities of e-health policy making: strategy, consensus-building, decision-making, implementation, and evaluation. These priorities emerged from stakeholders’ perceptions and are crucial for the effective integration and adoption of digital health technologies​ [ 24 ]. This holistic approach is increasingly relevant for scholars and practitioners, suggesting a focus on how multiple stakeholders implement digital technologies for management and business purposes in the healthcare sector [ 25 ]​​. The deployment of technological modalities, encompassed within five distinct clusters, can facilitate the development of a digital transformation model. This model ensures operational efficiency through several dimensions: enhanced operational efficacy by healthcare providers, the adoption of patient-centered methodologies, the integration of organizational factors and managerial implications, the refinement of workforce practices, and the consideration of socio-economic factors [ 25 ].

Studies focusing on value creation through digital means suggest healthcare as a consumer-centric realm ripe for center-edge transformations, characterized by self-service and feedback cycles. These transformations are vital in addressing inherent tensions between patients and physicians, steering the focus towards value co-creation and service-dominant logic [ 26 ]. Participatory design and decision-making approaches are emphasized for enhancing health information technology’s performance and institutional healthcare innovation. Such approaches are particularly crucial in developing national electronic medical record systems and improving chronic disease treatment through electronic health records. Additionally, telehealth research integrates patients’ perceptions, contributing to the understanding of technology, bureaucracy, and professionalism within healthcare [ 27 ].

The impact of health information technology (HIT) on operational efficiencies is profound. Empirical studies, such as those by Hong and Lee [ 28 ], Laurenza et al. [ 29 ], and Mazor et al. [ 30 ], demonstrate positive correlations between HIT and patient satisfaction, quality of care, and operational efficiency. However, challenges remain, as Rubbio et al. [ 31 ] highlight deficiencies in resilience-oriented practices for patient safety. Organizational and managerial factors in digital healthcare transformation also receive significant attention. Hikmet et al. [ 32 ] and Agarwal et al. [ 33 ] investigate the role of organizational variables and barriers in HIT adoption, whereas Cucciniello et al. [ 34 ] delve into the interdependence between implementing electronic medical records (EMR) systems and organizational conditions. Further, Eden et al. [ 35 ] and Huber and Gärtner [ 36 ] explore workforce adaptations and the implications of health information systems in hospitals that can increases transparency of work processes and accountability. Lastly, examining healthcare financialization and digital division provides an international perspective, contrasting the regulated environment in the EU with the US’s use of online medical crowdfunding as a potential solution to reduce bankruptcy [ 37 ; 38 ]. Collectively, these studies suggest a comprehensive model where stakeholders leverage digital transformation for management, enhancing operational efficiency in healthcare service providers.

Marques and Ferreira [ 39 ] performed a systematic literature review of digital transformation in healthcare, spanning the period from 1973 to 2018. Utilizing the SMARTER (Simple Multi-attribute Rating Technique Exploiting Ranks) method, 749 potential articles were analyzed, culminating in the prioritization and selection of 53 articles for detailed examination. The literature was organized into seven thematic areas: (1) Integrated management of IT in healthcare, (2) Medical images, (3) Electronic medical records, (4) IT and portable devices in healthcare, (5) Access to e-health, (6) Telemedicine, and (7) Privacy of medical data. It was observed that the predominant focus of research resides in the domains of integrated management, electronic medical records, and medical images. Concurrently, emerging trends were identified, notably the utilization of portable devices, the proliferation of virtual services, and the escalating concerns surrounding privacy. See Fig.  2 for visual representation of multifaceted digital transformation in healthcare.

Visual representation of multifaceted digital transformation in healthcare: a synthesis of provider-patient dynamics, HIT impact, and strategic management. HIT; health information technology, HC; healthcare, EMR; electronic medical records. IT; information technology, Pt.; patient

Telehealth and online pharmacy advancements in pandemic management

In the realm of online pharmacies and telehealth, digital health technologies have been instrumental in managing the COVID-19 pandemic through surveillance, contact tracing, diagnosis, treatment, and prevention. These technologies ensure that healthcare, including pharmacy services, is delivered more effectively, addressing the challenges of accessibility and timely care. The role of telemedicine and e-pharmacies, in particular, has been emphasized in improving access to care worldwide. By enabling remote consultations and drug delivery, these platforms are making healthcare more accessible, especially in regions where traditional healthcare infrastructure is limited or overstretched [ 40 ].

The Canadian Virtual Care Policy Framework advocates for the swift adoption and integration of virtual care, propelled by the COVID-19 pandemic. It emphasizes enhancing access and quality, ensuring equity and privacy, and devising appropriate remuneration models, employing a collaborative, patient-centered approach while addressing digital disparities. During the COVID-19 pandemic, Canadian provinces and territories rapidly adopted virtual health care, leading to 60% of visits being virtual by April 2020, up from 10 to 20% in 2019. However, these implementations were often temporary and not fully integrated into healthcare systems. By August 2020, virtual visits decreased to 40%, with variations across regions, while provinces and territories used temporary billing codes for these services. The framework’s “Diagnostique” provides a thorough analysis of policy enablers and strategies for virtual care, underscoring the need for comprehensive policy and partnership engagement [ 41 ]. In the context of digital transformation in pharmacy, the Hospital News article outlines the application and infrastructure of telepharmacy services in Canada, highlighting the geographical challenges and the early adoption of telepharmacy in certain regions since 2003. It notes the use of various technologies like Medication Order Management, Videoconferencing, and Remote Camera Verification. Although lacking specific quantitative data, the article underscores the necessity for expanded telepharmacy services to ensure uniform care quality across diverse locations [ 42 ].

Similarly, Telehealth offers extensive resources for patients and providers in the United States, emphasizing programs like the Affordable Connectivity Program and Lifeline to facilitate access. The Health Resources and Services Administration enhances telehealth through support services, research, and technical assistance, reflecting a significant outreach impact [ 43 ]. The Office for the Advancement of Telehealth (OAT) under Health Resources and Services Administration (HRSA) works to improve access to quality health care through integrated telehealth services in the US. It supports direct services, research, and technical assistance, with over 6,000 telehealth technical assistance requests sent to Telehealth Resource Centers and approximately 22,000 patients served [ 44 ].

Internationally, In the UK, the National Health Service (NHS) spearheads digital health and care, providing significant innovation opportunities through vast data management. Support for digital health spans various stages, from discovery with organizations like Biotechnology and Biological Sciences Research Council (BBSRC) and Intelligent Data Analysis (IDA) research group, to development with networks such as Catapults and CPRD, and delivery with entities like the Academic Health Science Networks (AHSNs) and DigitalHealth.London. Regulatory bodies like the Medicines and Healthcare products Regulatory Agency (MHRA) and NICE ensure safety and efficacy. The collaborative ecosystem involves academic, healthcare, and industry stakeholders, aiming to enhance health and care services through technology and innovation [ 45 ].

In Australia, the government’s investment of over $4 billion into COVID-19 telehealth measures has facilitated universal access to quality healthcare. This initiative has provided over 85 million telehealth services to more than 16 million patients, with approximately 89,000 healthcare providers engaging in this service delivery. From 1 January 2022, telehealth services, initially introduced in response to COVID-19, will become an ongoing part of Medicare. This will allow eligible patients across Australia continued access to general practice (GP), nursing, midwifery, and allied health services via telehealth, deemed clinically appropriate by the health professional [ 46 ].

European nations such as the Netherlands, Austria, and Italy are at the forefront of implementing cross-organizational patient records, significantly enhancing telehealth communication and facilitating cross-border healthcare. The role of strong government support in advancing telehealth is pivotal. Ursula von der Leyen, the President of the European Commission, has been a prominent advocate for eHealth. She proposed the establishment of a European Health Data Space to streamline health data exchange across member states. France, a leader in telehealth legislation for nearly a decade, has pioneered a public funding scheme for tele-expertise at a national scale. Despite these advancements, challenges like legislative barriers and the lack of consistent political direction continue to impede progress in the telehealth domain​ [ 47 ].

The Asia-Pacific region anticipates a surge in telehealth adoption driven by digital demand and pandemic-induced behavioral changes, while South East Asia exhibits widespread telehealth growth across healthcare aspects [ 48 ]. The telehealth adoption across the Asia-Pacific region has shown remarkable growth between 2019 and 2021 and is projected to continue rising by 2024. China’s adoption nearly doubled to 47% and is expected to reach 76%. Indonesia’s usage more than doubled to 51%, with a forecast of 72%. Malaysia and the Philippines both anticipate reaching a 70% adoption rate, increasing from 30% to 29%, respectively. India’s adoption is projected to more than double to 68%, while Singapore, which had a significant increase from 5 to 45%, is expected to achieve a 60% adoption rate. This trend indicates a robust uptake of telehealth services in the region [ 48 ].

Global telemedicine and E-pharmacy policy dynamics

In the context of telemedicine and e-pharmacy regulations within South East Asia, a notable distinction emerges with Singapore, Malaysia, and Indonesia being the only countries to have formalized legal frameworks governing both telemedicine practices and the dissemination of electronic information. In these countries, tele-consultation is restricted to patients already under the care of healthcare practitioners or as part of ongoing treatment, specifically in Singapore and Malaysia. Additionally, for scenarios requiring more intensive medical intervention, such as new referrals, emergency cases, or invasive procedures, both Malaysia and Indonesia mandate physical presence and face-to-face consultations, emphasizing a cautious and regulated approach to remote healthcare. In Malaysia, the regulations further stipulate that online prescriptions, excluding narcotics and psychotropic substances, are permissible solely under the continuation of care model, reflecting a judicious use of digital prescription services [ 49 ].

In Central and Eastern Europe (CEE), telemedicine has experienced substantial growth, primarily catalyzed by the COVID-19 pandemic, which necessitated rapid advancements in technology and alterations in healthcare practices. The region’s robust digital infrastructure, coupled with the innovative drive of local companies and the challenges posed by an aging demographic, has significantly contributed to this expansion. According to the European Commission’s Market Study on Telemedicine, the global telemedicine market was projected to grow annually by 14% by 2021, a rate that was likely surpassed due to the pandemic’s impact. More specifically, the Europe Telehealth Market, valued at US $6,185.4 million in 2019, is anticipated to witness an annual growth rate of 18.9% from 2020 to 2030. This trend underscores the increasing reliance on and potential of telemedicine in addressing healthcare needs in the CEE region [ 50 ].

In the Middle East, telehealth and telepharmacy, have seen varied degrees of adoption and progress. Despite attempts to reform healthcare delivery in the region, the progress of telemedicine has been somewhat slow, with certain expectations yet to be fully realized. However, there has been notable development in the use and adoption of these technologies [ 51 ]​. In a survey comparing the utilization of digital-health applications in Saudi Arabia and the United Arab Emirates (UAE), it was observed that a higher percentage of Saudi participants have utilized online pharmacy services (48%) compared to the UAE (36%). Conversely, awareness of teleconsultation services without prior use was higher in the UAE (43%) than in Saudi Arabia (35%). Retention data indicates that a significant proportion of users in both countries continue to engage with these services, with 80% of Saudi participants and 71% of UAE participants using teleconsultations at varying frequencies. Notably, a substantial majority of users in Saudi Arabia reported regular use of online pharmacies (90%), slightly higher than the UAE (78%), reflecting robust ongoing engagement with these digital health modalities. Notably, consumer adoption of telehealth products is primarily driven by time savings (48%) and convenience (47%), with 24-hour accessibility and efficacy both influencing 34% of users. Affordability and personal recommendations are also notable factors, while a wide range of options and quality are lesser but relevant considerations [ 52 ].

In response to the COVID-19 pandemic, a cross-sectional study was conducted among 391 licensed community pharmacists in the United Arab Emirates to assess the adoption and impact of telepharmacy services. The study revealed a predominant use of telepharmacy services, particularly via phone (95.6%) and messaging applications (80.0%). The findings highlighted that pharmacies with more pharmacists and those operating as part of a group or chain were more likely to implement a diverse range of telepharmacy services. The study identified significant barriers to telepharmacy adoption in individual pharmacies, including limited time, inadequate training, and financial constraints. There was a noticeable shift in service provision during the lockdown, with an increased reliance on telepharmacy, especially among pharmacies serving 50–100 patients per day. However, a reduction in services such as managing mild diseases and selling health products was observed during the lockdown period. The study concluded that telepharmacy played a pivotal role in supporting community pharmacies during the pandemic, with its expansion facilitated by the UAE’s advanced internet infrastructure, supportive health policies, and widespread digital connectivity [ 53 ]. Collectively, these insights reflect a global shift towards integrating and enhancing telehealth services as a response to emerging healthcare needs and technological advancements.

Unni et al. [ 54 ] provided an extensive review of telepharmacy initiatives adopted globally during the COVID-19 pandemic. Predominantly, virtual consultations were utilized to enable at-risk patients and others to remotely access pharmacists, thereby monitoring chronic illnesses, optimizing medication usage, and providing educational support [ 55 ]. Home delivery of medicines was widely implemented to decrease the necessity for in-person visits and mitigate exposure risks [ 56 ]. Additionally, patient education was prioritized to ensure effective management of health conditions from a distance [ 57 ]. Notably, a network of hospitals in China developed cloud-pharmacy care, allowing patients to consult pharmacists via text and the internet, while Spain utilized information and communication technologies for remote pharmaceutical care [ 58 ; 59 ]. Zero-contact pharmaceutical care, introduced in China, facilitated online medication consultations, eliminating direct contact [ 60 ]. The Kingdom of Saudi Arabia and other regions adapted new e-tools and teleprescriptions to enhance service accessibility [ 61 ]. The U.S. focused on credentialing pharmacists for telehealth to ensure competent service provision, and New Zealand implemented hotline numbers for phone consultations to further reduce physical visits [ 62 ; 63 ]. These initiatives reflect a significant shift towards innovative, technology-driven solutions in pharmaceutical care during a global health crisis. Refer to Fig.  3 for a graphical depiction of the worldwide distribution and applications of telepharmacy initiatives.

The global distribution of telepharmacy programs with an analysis of geographical distribution, technological applications, and associated benefits

Tracing the Private Sector’s Impact on Healthcare’s Technological Transformation

The role of the private sector in the fourth industrial revolution.

The World Economic Forum underscores the private sector’s leading role in digital inclusion and the acceleration of actions pertinent to the Fourth Industrial Revolution. This revolution affects economies, industries, and global issues profoundly, indicating the private sector’s critical role in driving technological advancements and digital platforms that deliver impactful healthcare solutions [ 64 ].

Mapping digital transformation in healthcare

A comprehensive analysis performed by Dal Mas et al. [ 65 ] meticulously maps the intricate terrain of digital transformation in healthcare, spotlighting the private sector’s instrumental role. Initially, the investigation encompassed an extensive array of diverse studies, leading to the identification of five main areas of digital technologies: smart health technologies, data-enabled and data collection technologies, Industry 4.0 tools and technologies, cognitive technologies, and drug & disease technologies. These domains frame the future research pathways, primarily steered by the private sector’s innovative drive. A significant proportion of the literature addresses healthcare broadly, suitable for both private and public sectors, yet a notable segment specifically focuses on the private sector’s endeavors, with a pronounced emphasis on the pharmaceutical domain [ 66 ; 67 ].

Public-private partnerships in healthcare delivery

The highlighted technologies, including digital platforms and telemedicine, exemplify the private sector’s trailblazing contributions to digital healthcare advancements. For instance, public-private partnerships (PPP) in India have emerged as a pivotal model for realizing universal healthcare (UHC), especially against the backdrop of acute healthcare shortages and urban-rural divides. Notably, mega PPP projects have successfully deployed technology-enabled remote healthcare (TeRHC), demonstrating its feasibility and impact in reaching isolated communities. These initiatives, overcoming various challenges, serve as a compelling example for global adoption, underscoring the transformative role of PPP in healthcare delivery [ 68 ].. Furthermore, a considerable majority of the literature in telemedicine underscores the necessity for profound research implications, yet a significant minority suggests policy implications [ 69 ; 70 ], reflecting a complex synergy between the private and public sectors in sculpting the digital healthcare framework [ 71 ]. This synthesis underscores the private sector’s critical influence in propelling the digital transformation in healthcare, charting a course that progressively fuses technological innovation with healthcare provision.

A study highlights Indonesia’s strategic initiatives to capitalize on telehealth business opportunities, driven by the Ministry of Research and Technology’s robust support for Technology-Based Start-up Company schemes [ 72 ]. With a demographic boon of 298 million from 2020 to 2024, escalating non-communicable diseases (71%), and a growing base of 222.4 million JKN participants, the stage is set for transformative growth. Despite a critical shortage of health workers (0.4 doctors per 1000 population), the enthusiasm for telemedicine is evident, with 71% satisfaction in hospital telemedicine and 32 million active telehealth users. The Ministry’s foresight in fostering technology start-ups, exemplified by the TEMENIN platform with its 11 health platforms, is steering Indonesia towards a future where high-quality healthcare is accessible and sustainable.

Lab@AOR: a model for PPPs in healthcare sector

The “Lab@AOR” initiative stands as a paradigmatic example of PPPs effectuating digital transformation within the healthcare sector. This strategic collaboration, between the University Hospital of Marche and Loccioni [ 73 ], a private entity, underscores the capacity of PPPs to navigate intricate challenges, stimulate international cooperation, and contribute to the development of sustainable, patient-centric healthcare solutions. Specifically, Lab@AOR was instituted to confront the nuanced challenges associated with the robotization of healthcare service delivery, highlighting the initiative’s role in fostering technological advancement through public and private sector synergy [ 74 ]. The project illustrates the evolution of Lab@AOR through three main phases: the pioneering stage, where groundwork for collaboration was laid; the nurturing stage, where collaborative exchanges were fostered; and the harvesting stage, wherein the potential of the PPP was fully unleashed. In the pioneering stage, Lab@AOR focused on a critical healthcare service component: the in-hospital preparation of medications for oncological patients. The University Hospital of Marche identified a need for innovation to improve service quality, efficiency, and safety, while Loccioni sought a real-life setting to test and refine its robotized system, APOTECAchemo [ 75 ]. This convergence of needs led to a symbiotic partnership aiming to enhance healthcare delivery through technological advancement.

During the nurturing stage, the partnership expanded the scope of APOTECAchemo to include non-oncological medications and developed additional tools like APOTECAps for manual preparation support. This phase was characterized by intensive collaboration, knowledge sharing, and continuous innovation, demonstrating the dynamic capability of the PPP to adapt and evolve in response to emerging healthcare challenges. The harvesting stage marked the international expansion of Lab@AOR, transforming it from a local initiative to an international community focused on leveraging digitalization and robotization to improve care quality and patient-centeredness. The PPP’s growth was catalyzed by its open perspective and inclusive approach, engaging entities from various cultural and institutional contexts, and fostering a network of 31 nodes across 19 countries and 3 continents.

Advancements in telehealth business models and frameworks

In their investigative study, Velayati et al. [ 76 ] delved into the articulation of emergent business models in telehealth and scrutinized the deployment of established frameworks across a variety of telehealth segments. The research spanned an extensive range of sectors, notably telemonitoring, telemedicine, mobile health, and telerehabilitation, alongside telehealth more broadly. The scope further extended to encompass niche areas such as assisted living technologies, sensor-based systems, and specific fields like mobile teledermoscopy, teleradiology, telecardiology, and teletreatment, presenting a thorough analysis of the telehealth landscape. Within the telemedicine and telehealth services sector, Barker et al. [ 77 ] introduced the Arizona Telemedicine Program (ATP) Model, a quintet-layer approach aimed at efficiently distributing telemedicine services throughout Arizona. Complementing this, Lee and Chang [ 78 ] proposed a four-component model specifically tailored for mobile health (mHealth) services pertaining to chronic kidney disease, focusing on offering a cost-effective platform for disease support and management. In the realm of telemonitoring, Dijkstra et al. [ 79 ] utilized the Freeband Business Blueprint Method (FBBM), which includes service, technological, organizational, and financial domains, to facilitate multiple telemonitoring services. Furthermore, the systemic and economic differences were explored in care coordination through Business to customer (B2C) and business (B2B) models for telemonitoring patients with chronic diseases, with the B2C model’s economic advantages were highlighted [ 80 ].

General telemedicine frameworks also received attention. Lin et al. [ 81 ] constructed a six-component framework analyzing major telemedicine projects in Taiwan, while Peters et al. [ 82 ] developed the CompBizMod Framework in Germany, encompassing value proposition, co-creation, communication and transfer, and value capture, designed to evaluate and enhance competitive advantages in telemedicine. In the specialized field of telecardiology, a comprehensive nine-component sustainable business model was crafted to facilitate mutual benefits for service providers and patients. This model emphasizes the importance of a holistic approach in ensuring the longevity and effectiveness of healthcare delivery within this domain [ 83 ]. Meanwhile, Mun et al. [ 84 ] presented a suite of five teleradiology business models aimed at providing effective, high-quality, and cost-efficient diagnoses.

The teletreatment sector saw innovative models from Kijl et al. [ 85 ], who designed a model for treating patients with chronic pain, focusing on the interrelation of components in the value network and the role of information technology. Complementarily, Fusco and Turchetti [ 86 ] introduced four models for telerehabilitation post-total knee replacement, emphasizing partnerships between care units and equipment suppliers to reduce costs and waiting lists. The mHealth and assisted living technology sector witnessed the introduction of a wearable biofeedback system model by Hidefjäll and Titkova [ 87 ], which employed Alexander Osterwalder’s Business Model Canvas and focused on a comprehensive commercialization process. Additionally, Oderanti and Li [ 88 ] presented a seven-component sustainable business model for assisted living technologies, aimed at encouraging older individuals to invest in eHealth services while reducing the pressure on health systems. These diverse clusters and models reflect the multifaceted nature of telehealth, each tailoring its approach to meet the unique demands of its domain. They collectively aim to optimize service delivery, stakeholder involvement, cost efficiency, and patient care quality, marking significant strides in the ongoing evolution of digital healthcare.

Challenges and biases in healthcare technology

One key aspect is the emergence of novel medical technologies and their potential biases. These biases are often a result of insufficient consideration of patient diversity in the development and testing phases. For example, disparities in the performance of medical devices like pulse oximeters among different racial groups have been observed, potentially due to a lack of diverse representation in clinical trials. This indicates a tendency for the development of healthcare technologies that may not adequately serve all patient populations [ 89 ]. A study on the profitability and risk-return comparison across health care industries highlights the use of return on equity (ROE) as a measure of profitability from a shareholder’s perspective. This measure combines profit margin, asset utilization, and financial leverage. The study analyzed financial data of publicly traded healthcare companies, providing insights into the financial dynamics of the healthcare sector. It revealed that while companies like Pfizer Inc. and UnitedHealth Group reported similar profitability, they had substantial differences in profit margin and asset utilization, indicating diverse financial strategies within the healthcare sector. This study underscores the complexity of financial performance in healthcare, where profitability measures need to be balanced with risk assessment and the broader impact on healthcare provision​ [ 90 ].

Additionally, an article discusses the benefits, pitfalls, and potential biases in healthcare AI. It emphasizes that as the healthcare industry adopts AI, machine learning, and other modeling techniques, it is seeing benefits for both patient outcomes and cost reduction. However, the industry must be mindful of managing the risks, including biases that may arise during the implementation of AI. Lessons from other industries can provide a framework for acknowledging and managing data, machine, and human biases in AI. This perspective is crucial in understanding how the integration of advanced technologies in healthcare can be influenced by the drive for profitability and efficiency, possibly at the expense of equitable and patient-centered care [ 91 ; 92 ].

Cosmeceuticals in the online pharmacy market

Cosmeceuticals, a term derived from the combination of cosmetics and pharmaceuticals, refer to a category of products that are formulated to provide both aesthetic improvements and therapeutic benefits. These products, typically applied topically, are designed to enhance the health and beauty of the skin, going beyond the mere cosmetic appearance. The exploration of cosmeceuticals in the online pharmacy market reveals a multifaceted and rapidly expanding industry. Bridging the gap between cosmetics and pharmaceuticals, they form a significant portion of the skincare industry. Cosmeceuticals are formulated from various ingredients, with their main categories being constantly discussed and analyzed in the scientific community [ 93 ]. They have taken a considerable share of the personal care industry globally, constituting a significant part of dermatologists’ prescriptions worldwide [ 94 ]. This surge is further fueled by increasing consumer demand for effective and safe products, including anti-aging skincare cosmeceuticals, a need which has been intensified by concerns over pollution, climate change, and the COVID-19 pandemic [ 95 ].

The global cosmeceuticals market is experiencing robust growth. Valued at USD 56.78 billion in 2022, it’s projected to expand to USD 95.75 billion by 2030, with a compound annual growth rate (CAGR) of 7.45%. This growth trajectory is propelled by the innovative integration of bioactive ingredients known for their medical benefits​ [ 96 ]. Another report confirms this upward trend, indicating the market was worth $45.56 billion in 2021 and is on a path of significant growth to USD 114 billion by 2030. The global disease burden is significantly impacted by various skin diseases, with dermatitis, psoriasis, and acne vulgaris among the most prevalent, contributing 0.38%, 0.19%, and 0.29% respectively. The pervasive nature of these conditions drives a substantial demand for effective treatments, propelling the integration of cosmeceuticals into the online pharmacy market. This integration not only offers convenient access to a range of therapeutic skincare products but also caters to the rising consumer inclination towards self-care and preventive healthcare. As a result, the online availability of cosmeceuticals is not just addressing the immediate needs of individuals suffering from skin conditions but is also reshaping the landscape of personal healthcare by making specialized treatments more accessible and customizable [ 97 ]. See Fig.  4 .

The left panel presents the market share distribution for key segments in the cosmeceuticals industry in 2021, including Skin Care Segment, and Supermarket & Specialty Stores, for Asia Pacific Revenue, with percentages for each category. The right panel displays the market value progression over time from 2021 to the projected value in 2030, with bold numbers indicating the value in billion USD for each year. The lower horizontal bar chart depicts the percentage contribution of various skin diseases to the global disease burden

Several factors are contributing to this expansion of the cosmeceuticals market. The market is driven by innovation in natural ingredients and a significant penetration of internet, smartphone, and social media applications, which attract potential consumer populations and reflect constantly changing consumer behavior [ 98 ]​​. The cosmeceuticals market’s robust CAGR and revenue share, especially in regions like Asia Pacific, further signify its burgeoning presence and potential within the global market [ 99 ]​. Integration into online pharmacies is a key aspect of this market’s evolution, offering easier access to these products for a wider customer base. As the market continues to grow, it’s anticipated that the blend of cosmeceuticals with online pharmaceutical platforms will become increasingly seamless, offering consumers a diverse range of accessible, effective, and beneficial skincare and health products. This integration is likely to be driven by the growing trend of e-commerce and digitalization in healthcare and personal care sectors.

The landscape of online pharmacies, particularly concerning cosmeceuticals, is evolving. While the overall penetration for non-specialty drugs in mail-order and online pharmacies is low, they represent a significant portion of specialty prescription revenues at 37%. Despite this, only 13% of consumers consider these as their primary pharmacy choice, indicating a growing but still emerging market​​​​. Strategies are in place to enhance the market appeal of these pharmacies, focusing on speed, convenience, and personalized experiences, such as video telehealth visits, to attract a broader consumer base [ 100 ].

The dissertation “L’Oréal Portugal: A Digital Challenge for the Active Cosmetics Division” authored by Ascenso [ 101 ] provides an in-depth examination of the impact of digital evolution on the Portuguese cosmeceutical sector and its implications for L’Oréal, a significant cosmetics company. It posits that while L’Oréal has foundational digital competencies, the rapidly evolving digital landscape presents a broad spectrum of potential risks and opportunities. The study details the operations of L’Oréal’s Active Cosmetics Division, which manages brands predominantly sold in pharmacies and parapharmacies, and explores the potential repercussions of digitalization on L’Oréal Portugal’s strategic and operational frameworks. Furthermore, the thesis highlights the expanding role of e-pharmacies and the need for legal reforms to facilitate their operation. It discusses the prevalent trends in the cosmetic industry, such as the increasing demand for natural, male-focused, and environmentally friendly products. The dissertation scrutinizes L’Oréal’s strategic pillars, including innovation, acquisition, and regional growth, emphasizing the need for the company to integrate advanced technologies and recalibrate its business methodologies in light of digital progression [ 101 ]. Although L’Oréal has initiated some digital strategies targeting consumers and pharmacies, there’s a recognized need for an intensified focus on digital marketing aimed at clients. An exploratory attempt by L’Oréal to implement an online ordering platform for pharmacies did not meet success, indicating possible industry unreadiness for such advancements. This case study serves as a critical examination of how traditional companies in the pharmaceutical and cosmetics sectors must adapt to the digital age’s challenges and opportunities [ 101 ].

In a collaborative endeavor with L’Oréal, an associated digital agency provided a comprehensive suite of services that encompasses the full management of social media pages, the development of e-commerce websites, the establishment of Customer Relationship Management (CRM) platforms tailored for pharmacies, and the execution of digital campaigns leveraging QR codes, SMS marketing, and newsletters. These digital tools confer a competitive edge, facilitating a deeper comprehension of consumer behavior and the potential to augment value extraction from customer interactions. For the laboratories, particularly those associated with cosmetics, the advantages are twofold: an increase in sell-out figures, thereby enhancing direct sales to end consumers, and a boost in sell-in metrics, reflecting a rise in transactions to pharmacies or wholesalers. The online ordering feature, as noted by João Roma, a manager at La Roche-Posay, could result in a cacophony of processes if laboratories were to individually develop distinct methods. He advocates for the utilization of pre-existing platforms, such as the established e-learning infrastructure, to spearhead ventures into the online marketplace [ 101 ].

A survey conducted specifically for L’Oréal’s e-learning platform, cosmeticaactiva.pt [ 102 ], across the Portuguese landscape garnered responses from 324 participants, comprising 71% general pharmacists, 13% technical assistants, 8% directors, 7% individuals responsible for procurement from laboratories, and 2% beauty/cosmetic advisors. The findings from this survey underscore the pervasive adoption of digital tools within the pharmacy sector: 82% of respondents affirmed the presence of their pharmacies on social media platforms, 80% reported the use of basic management software, 64% indicated the deployment of advanced management systems, 61% were conversant with online ordering systems directed at laboratories, 38% utilized a store locator, 28% had an established website presence, and a smaller segment of 12% offered online shopping facilities.

Another survey conducted within this study to evaluate the significance of dermocosmetic products in pharmacies yielded a mean importance rating of 4.38 out of 5, indicating that a majority of pharmacists consider these products to be highly important to their business operations. Factors critical to the differentiation of a proficient laboratory/supplier were innovation and cost-effectiveness, with mean scores of 1.9 and 2.7 respectively, on a scale from 1 (most important) to 5 (least important). A substantial majority of pharmacists, amounting to 81.8%, perceive their pharmacies as beacons of innovation and modernity. Detailed interviews elucidated that digital tools are indispensable in augmenting sales for cosmeceutical products by catalyzing demand—a dynamic not feasible with medicinal products. These tools are paramount in managing customer loyalty, facilitating enhanced communication with existing clients via online and mobile channels. Despite the challenges posed by digitalization, particularly in the realms of logistics and human resources, the management at L’Oréal is well-equipped to swiftly adapt to the evolving business landscape, as evidenced by the proactive adoption and integration of these digital strategies [ 101 ] as illustrated in Fig.  5 .

Results from Ascenso [ 101 ] survey assessing digital challenges for L’Oréal in the Portuguese cosmeceutical sector. Digital Tools Usage in Pharmacies (upper left) : the bar chart showing the percentage of respondents using various digital tools in pharmacies. Suppliers’ Choosing Factors (upper right) : the bar chart displaying the mean scores of factors that distinguish a good laboratory/supplier. General Pharmacists Opinion (lower left) : A line chart illustrating the mean ratings of pharmacists’ opinions on whether the pharmaceutical sector is modern, changing, conducive to innovations, adapted to consumer needs, and more developed than other sectors. Importance of Digital Development Tools for Pharmacies (lower right) : A vertical bar chart demonstrating the mean scores for the importance of different digital development tools for pharmacies

The digital transformation strategies, exemplified by companies like L’Oréal, extend beyond the mere targeting of end consumers, encompassing the perspectives of various stakeholders, including retailers. This broadened focus reflects a holistic and integrated approach to digital marketing and customer engagement, indicative of a larger trend within the market. The significance of digital channels in facilitating comprehensive customer interaction and brand development is increasingly recognized. The distinction of organizations such as L’Oréal in their digital initiatives highlights the competitive advantage that can be garnered through innovative digital strategies.

The receptiveness of industry professionals, such as pharmacists, to emerging digital trends, along with the readiness of companies to engage in non-face-to-face sales models, marks a paradigm shift in traditional sales and distribution methods. This shift is reflective of a broader market trend where digital platforms are becoming integral to the customer journey. Furthermore, the potential for online sales in specialized sectors, such as dermocosmetics, and the benefits that organizations derive from the technological advancement of their client base, underscore an escalating acknowledgment of e-commerce and digital tools as crucial elements of a business strategy. This trend, with L’Oréal as a prime example, emphasizes the broader market movement towards digital transformation, not merely as an option but as a necessity for maintaining relevance and competitiveness in an ever-evolving market landscape.

The global regulatory landscape for cosmeceuticals

Sophisticated regulatory legislation and enforcement mechanisms characterize many developed countries such as the USA, EU Member States, Canada, and Japan. These nations, along with influential organizations like the World Health Organization (WHO), significantly shape international market rules and regulations due to their market size and regulatory capacity [ 103 ]. The WHO is particularly noted for its crucial role in setting global standards, with a focus on developing and promoting international standards related to food, biological, pharmaceutical, and similar products [ 104 ]. In contrast to pharmaceuticals, the cosmetic industry necessitates a more advanced international regulatory framework due to consumers’ extensive exposure to these products. The distinction between cosmetics and pharmaceuticals varies significantly across different countries, with the USA employing a voluntary registration system for cosmetics and the EU and Japan requiring mandatory product filings prior to marketing [ 105 ]. Concerns over the safety of pharmaceutical and cosmetic products are highlighted, with an increasing consumer focus on “natural, ecological, and clean” products [ 106 ]. However, the lack of a regulatory framework for these categories underscores the need for more advanced regulations to mitigate health risks.

Intergovernmental cooperation is emphasized, with the US and EU portrayed as dominant players in the pharmaceutical and cosmetic industries, respectively. Regulatory capacity, which is essential for defining, implementing, and monitoring market rules, varies among countries and markets. This capacity depends on several factors, including staff expertise, statutory sanctioning authority, and the degree of centralization of regulatory authority [ 103 ]. The regulatory systems of the EU and US are explored, focusing on their unique approaches to medicine authorization and regulation. The European Medicines Agency (EMA) in the EU and the Food and Drug Administration (FDA) in the US serve as pivotal regulatory bodies [ 107 ; 108 ]. The EMA’s centralized procedure and the FDA’s premarket approval process are detailed, along with subsequent postmarket regulatory procedures. For instance, EU and US cosmetic regulations are compared, revealing differences in their approaches and the evolution of the EU’s regulatory landscape through various amendments and directives. In particular, directive 76/768/EC has been superseded by Regulation (EC) N° 1223/2009, serving as the principal regulatory framework for finished cosmetic products in the EU market. This regulation enhances product safety, optimizes the sector’s framework, and eases procedures to promote the internal cosmetic market. Incorporating recent technological advancements, including nanomaterials, it maintains an internationally acknowledged regime focused on product safety without altering existing animal testing prohibitions [ 109 ].

The Eurasian Economic Union’s (EAEU) regulatory framework for medicines and medical devices is detailed, including the legal framework established for regulating the circulation of these products. The conformity assessment methods, such as the EAC Declaration and the State Registration process, are required for manufacturers to demonstrate their products’ compliance with the standards [ 110 ]. Armenia is also part of the EAEU’s legal framework, which aims to unify regulations for the production and registration of pharmaceuticals and medical products by 2025. This unification is expected to reduce administrative costs for manufacturers and improve medicinal products for patients. Despite significant developments in the cosmetics industry, Armenia does not have an extensive regulatory framework for it. Prior to joining the EAEU, the only regulation concerning cosmetic products was the Order of the Minister of Health of the Republic of Armenia on “Hygiene Requirements of the Production and Safety of Perfume-Cosmetic Products.” Since joining the EAEU, Armenia has unified its national legislation with EAEU regulations, but there are challenges and gaps in the direct applicability of the EAEU’s technical regulations in the country [ 111 ].

In the context of the necessity for clear regulatory framework stems from two reasons. Firstly, cosmeceuticals - products straddling cosmetics and drugs - demand intensified regulatory attention. Examples include the 2007 FDA seizure of Jan Marini’s Age Intervention Eyelash, which contained the drug ingredient bimatoprost, and products boasting human stem cell cultured media, which claim rejuvenating effects but may pose safety risks due to minimal oversight [ 112 ]. A noted 1450% increase in FDA warnings (from 4 to 62 letters) between 2007 and 2011 and 2012–2017, with 8 targeting stem cell ingredient promotions, underscores the growing concern [ 113 ]. The FDA’s limited capacity to identify and assess potential drug-adulterated cosmetics raises concerns.

The second aspect focuses on the necessity for a more comprehensive and unbiased scientific and medical perspective in the FDA’s ingredient review process. The Personal Care Products Safety Act proposes a balanced committee formation including industry, consumer, and medical representatives, yet advocates for the inclusion of specialized professionals like chemists, dermatologists, toxicologists, and endocrinologists. Specific ingredients like diazolidinyl urea and quarternium-15, although effective antimicrobials, are flagged for potential skin allergy risks and formaldehyde release. The preservative 4-methylisothiazolinone, banned in Europe for rinse-off products, is noted for increasing allergic contact dermatitis cases in the US [ 114 ]. The lag in US cosmetic regulation compared to the EU is acknowledged, with the Personal Care Products Safety Act considered a significant advancement, albeit in need of further refinement [ 115 ].

The importance of consumer safety in the global regulatory landscape for cosmeceuticals, particularly for products that blur the line between cosmetics and pharmaceuticals, is a critical issue due to several key factors. Firstly, the cosmeceutical market is expanding rapidly, driven by new ingredients promising various skincare benefits like anti-aging and photoprotection. This growth necessitates clear regulatory guidelines to ensure that these products are safe and their claims are clinically proven. The FDA, for instance, differentiates between cosmetics and cosmeceuticals based on their intended use, particularly if a product is marketed as a cosmetic but functions in a way that affects the structure of the human body, classifying it as a cosmeceutical [ 116 ].

Secondly, the legal and regulatory distinctions between drugs and cosmetics are significant. Drugs are subject to FDA approval based on their intended use in treating diseases or affecting the body’s structure or function, whereas cosmetics are not. This difference becomes crucial when products are marketed with drug-like claims but are not regulated as drugs, potentially leading to consumer safety issues. For example, botanical cosmeceuticals, which contain natural ingredients like herbal extracts, need thorough evaluation to ensure consistency in therapeutic effects [ 117 ]. Additionally, cosmeceutical manufacturers must be careful with marketing and advertising claims to avoid legal implications. Misleading claims can lead to lawsuits and regulatory actions, as seen in past cases where companies faced consequences for unfounded product claims. Moreover, the FDA advises cosmeceutical manufacturers to follow Good Manufacturing Practices (GMP) to reduce the risk of misbranding or mislabeling. These guidelines include production practices and specific warning statement guidelines, emphasizing the importance of substantiating the safety of these products [ 118 ].

The global regulatory landscape for online pharmacy

Online pharmacies pose various risks to consumers, including the potential health hazards from counterfeit or substandard medications and the inappropriate use of prescription drugs. The regulatory landscape for these pharmacies varies significantly across nations, with some countries like the United States implementing specific laws, while others, such as France, have instituted outright bans [ 119 ]. The European Union, for instance, has implemented a mandate effective from 1 July 2015, which requires member states to adhere to legal provisions for a common logo specific to online pharmacies. This is coupled with an obligation for national regulatory authorities to maintain a registry of all registered online medicine retailers, as detailed by the European Medicines Agency [ 120 ]. Furthermore, the sale of certain medications online within the EU is permissible, contingent upon the registration of the pharmacy or retailer with respective national authorities​ [ 121 ]. Additionally, the Council of Europe’s MEDICRIME Convention introduces an international treaty that criminalizes the online sale of counterfeit medicinal products, enforcing prosecution irrespective of the country in which the crime is perpetrated [ 122 ].

Switzerland presents a unique stance, where Swissmedic strongly advises against the online purchase of medicines due to the high risk of illegal sourcing and poor quality. However, Swiss mail-order pharmacies with a valid cantonal license to operate a mail-order business are exempted from this advisory​ [ 123 ]. The Swiss Mail-Order Pharmacists Association and its affiliates, such as Zur Rose AG and MediService AG, actively advocate for a modern and equitable regulation of mail-order medicine sales​ [ 124 ]. The legislative framework is further bolstered by the Federal Act on Medicinal Products and Medical Devices, which regulates therapeutic products to guarantee their quality, safety, and efficacy​ [ 125 ]. In the Middle East, community pharmacy practice is predominantly governed by national Ministries of Public Health or equivalent governmental entities, with most community pharmacies being privately owned​ [ 126 ]. The region’s involvement in the Global Cooperation Group, which encompasses various international regulatory bodies like the EMA and USFDA, signifies a collaborative approach towards drug regulatory affairs in the MENA region [ 127 ]. Despite these advances in regulatory collaboration, it is notable that currently no specific regulations have been detected for online purchases from online pharmacies in the Middle East, highlighting a significant area for potential regulatory development. Furthermore, a notable transition is observed in pharmacy education across several Middle Eastern nations, with an inclination towards introducing Pharm.D degrees to replace traditional pharmacy degrees, reflective of evolving educational standards in the pharmaceutical field [ 128 ]. This shift in education parallels the need for updated regulatory frameworks, especially in the context of the burgeoning online pharmacy sector.

Furthermore, Australia permits the sale of both Prescription-Only Medicines (POMs) and Over-the-Counter (OTC) medications online, provided that brick-and-mortar pharmacies comply with all relevant laws and practice standards [ 129 ]. In contrast, South Korea maintains a stringent stance, prohibiting the online sale of both POMs and OTC medicines, with sales confined exclusively to physical stores registered with the Regulatory Authority (RA) [ 130 ]. China, Japan, Russia, Singapore, and Malaysia exhibit a more selective regulatory framework. China and Russia allow the online sale of OTC medicines only, with China imposing additional restrictions on third-party e-commerce platforms and Russia having introduced a draft law in December 2017 to formalize this practice [ 131 ; 132 ]. Japan permits the online sale of certain OTC medicines, explicitly excluding specific substances such as fexofenadine and loratadine [ 133 ]. Similarly, Singapore and Malaysia endorse the online sale of specific OTC medicines only, adopting a “buyers beware” approach to caution consumers about the associated risks [ 134 ; 135 ]. Lastly, the legal landscapes in India and Indonesia remain ambiguous. India’s RA has effectively banned the online sale of medicinal products, yet this prohibition lacks legislative backing. Indonesia, too, grapples with unclear regulations, leaving the legal status of online pharmacies indeterminate [ 136 ].

In response to these risks, several initiatives have been developed to guide and certify online pharmacies. In the United States, LegitScript offers certification to online pharmacies that comply with criteria such as appropriate licensing and registration [ 137 ]. Similarly, the Verified Internet Pharmacy Practice Sites (VIPPS) program, accredited by the National Association of Boards of Pharmacy, ensures pharmacies adhere to licensing requirements in the states where they dispense medications [ 138 ]. Internationally, the Health On the Net Foundation has introduced the HONcode, an ethical standard for health websites globally. This code certifies sites that provide transparent and qualified information. However, due to the absence of international harmonization, the HONcode’s certification is limited to US and Canadian pharmacies verified by VIPPS [ 139 ]. The lack of a harmonized international approach presents significant challenges. Consumers do not have access to a comprehensive, global repository of all certified pharmacies. The diverse certification schemes are not well articulated or interconnected, leading to consumer unawareness about their significance or existence. Moreover, enforcing standards across different legal jurisdictions is complex without a unified agreement. To enhance consumer protection, it is imperative to develop and promote a standardized, minimal international code of conduct for online pharmacies. Such a code would unify requirements and allow all initiatives to clarify their roles under a common framework. Adequate oversight in the borderless online pharmacy market can only be achieved through collaborative efforts. To visualize the infographic of the global regularity landscape for the online pharmacy see Fig.  6 .

Comprehensive representation of the regulatory landscape for global online pharmacies, detailing international and national initiatives, certification programs, and conventions aimed at minimizing risks associated with the purchase of medications via online platforms

Technological innovations and Future trends in global pharmacy

The global pharmacy sector is undergoing a transformative shift, driven by the rapid advancement of technological innovations. As the world becomes increasingly digital, the integration of cutting-edge technologies like Artificial Intelligence (AI) and blockchain is setting the stage for a new era in pharmaceutical care and management. These advancements promise to revolutionize the industry by enhancing efficiency, accuracy, and security, ultimately leading to improved patient outcomes and a more streamlined healthcare experience [ 140 ].

Walgreens, in partnership with Medline, a telehealth firm, has developed a platform for patient interaction with healthcare professionals via video chat. AI’s role extends to inventory management in retail pharmacies, allowing pharmacists to predict patient needs, stock appropriately, and use personalized software for patient reminders. Although not all inventory management software in retail pharmacies utilizes AI, some, like Blue Yonder’s software developed for Otto group, demonstrate the potential of AI in predicting product sales with high accuracy, thus enhancing supply chain efficiency [ 141 ; 142 ]. At the University of California San Francisco (UCSF) Medical Center, robotic technology is employed to improve patient safety in medication preparation and tracking. This technology has prepared medication doses with a notable error-free record and surpasses human capabilities in accuracy and efficiency. It prepares both oral and injectable medicines, including chemotherapy drugs, freeing pharmacists and nurses to focus on direct patient care. The automated system at UCSF receives electronic medication orders, with robotics handling the picking, packaging, and dispensing of individual doses. This system also assembles medications on bar-coded rings for 12-hour patient intervals and prepares sterile preparations for chemotherapy and intravascular syringes [ 143 ].

In the realm of global pharmacy, blockchain technology emerges as a pivotal force, driving advancements across various facets of healthcare and pharmaceuticals. At the forefront of its application is the enhancement of supply chain transparency [ 144 ]. Blockchain’s immutable ledger ensures the provenance and legitimacy of medical commodities, offering an unprecedented level of visibility from manufacturing to distribution. This is particularly vital in areas plagued by counterfeit drugs, where systems like MediLedger are instrumental in verifying the legality and essential details of medicines [ 145 ].

The utility of blockchain extends to the implementation of smart contracts — scripts processed on the blockchain that bolster transparency in medical studies and secure patient data management [ 146 ]. These contracts find extensive use in advanced medical settings, as evidenced by a blockchain-based telemonitoring system for remote patients and Dermonet, an online platform for dermatological consultation [ 147 ].

Furthermore, blockchain is revolutionizing patient care through patient-centric Electronic Health Records (EHRs). By decentralizing EHR maintenance, blockchain empowers patients with secure access to their historical and current health records [ 148 ]. Prototypes like MedRec and systems such as MeD Share exemplify how blockchain can provide complete, permanent access to clinical documents and facilitate the sharing of medical data between untrusted parties, respectively, ensuring high information authenticity and minimal privacy risks [ 149 ; 150 ]. In verifying medical staff credentials, blockchain again proves invaluable. Systems like ProCredEx, based on the R3 Corda blockchain protocol, streamline the credentialing process, offering rapid verification while allowing healthcare entities to leverage their existing data for enhanced transparency and assurance about medical staff experience [ 151 ].

The integration of blockchain with Internet of Things devices for remote monitoring marks another leap forward, significantly bolstering data security. By safeguarding the integrity and privacy of patient data collected by these devices, blockchain mitigates the risk of tampering and ensures that only authorized parties can access sensitive information [ 152 ]. Besides, a blockchain-based drug supply chain initiative, PharmaChain, utilizes AI for approaches against drug counterfeit and ensures the drug supply chain is more traceable, visible, and secure. For online pharmacies, this means a more reliable supply chain and assurance of drug authenticity, crucial for maintaining trust and safety [ 153 ].

In response to the COVID-19 pandemic, the PharmaGo platform has emerged as an innovative solution in Sri Lanka, revolutionizing the delivery of pharmacy services. As traditional pharmacies grapple with the challenges of meeting all customer needs in one location, PharmaGo addresses this by providing a comprehensive online pharmaceutical service. It allows customers to access a wide range of medications through a single platform, reducing the need to visit multiple pharmacies. Utilizing image processing technology, pharmacy owners can accurately identify prescribed medicines, while the system’s predictive analytics forecasts future drug demands, enhancing stock management. Additionally, PharmaGo’s AI-powered medical chatbot offers real-time guidance, ensuring a seamless and efficient customer experience. This platform represents a significant advancement in healthcare accessibility and pharmacy service delivery in the pandemic era [ 154 ]. In the same context, ontology-based medicine information system, enhancing search relevance through a chatbot interface was presented by Amalia et al. [ 155 ]. Addressing conventional search engines’ limitations in interpreting data relationships, it employs semantic technology to represent metadata informatively. The ontology as a knowledge base effectively delineates disease-medicine relationships, with evaluations indicating a 90% response validity from the chatbot, offering a robust reference for medical information retrieval and its semantic associations.

Future trends for the digital transformation of in the pharmaceutical sector

Future trends for the digital transformation of pharmacies globally are heavily influenced by the transformative impact of digital technologies on healthcare delivery. The integration of telemedicine, electronic health records, and mobile health applications is pivotal in enhancing patient care. These technologies are instrumental in improving data sharing and collaboration among healthcare professionals, increasing the efficiency of healthcare services. Additionally, they offer significant potential for personalized medicine through data analytics and play a crucial role in patient engagement and self-management of health. The importance of these technologies in creating a more connected and efficient healthcare system is underscored, marking a significant shift in the global healthcare landscape [ 156 ].

In the pharmaceutical sector, the COVID-19 pandemic has catalyzed a significant shift towards Pharmaceutical Digital Marketing (PDM), particularly for over-the-counter drugs. This shift focuses on utilizing online pharmacies and digital platforms for targeted advertising, directly reaching consumers. The trend towards purchasing OTC drugs online has grown, driven by the convenience and efficiency of digital channels. While PDM faces challenges like regulatory constraints and the need for digital proficiency, it offers substantial opportunities in enhancing customer engagement and precise marketing. The future of PDM is poised to be more consumer-centric, integrating advanced technologies like AI, and emphasizing personalized marketing strategies to strengthen brand engagement and customer interaction [ 157 ].

Artificial intelligence holds immense potential to revolutionize the field of pharmacy, offering numerous benefits that can significantly enhance efficiency and patient care. One of the primary applications of AI in this sector is the automation of routine tasks. By utilizing AI, pharmacies can automate critical processes such as prescription processing, checking for drug interactions, and managing inventory. This automation not only streamlines operations but also minimizes the likelihood of human error, thereby increasing the overall efficiency of pharmacies [ 158 ].

Furthermore, AI can play a pivotal role in personalized medication management. This is particularly beneficial for patients with chronic conditions such as diabetes who require careful management of their insulin dosages, as fluctuations in blood sugar levels can lead to serious complications. AI systems can monitor patients continuously, provide timely reminders for medication intake, and dynamically adjust treatment plans based on individual health data. Such personalized management ensures that patients receive optimal care tailored to their specific needs, potentially improving treatment outcomes. Incorporation of AI into electronic health records presents another significant advancement. By integrating AI with EHRs, healthcare providers can access real-time patient data. This integration empowers healthcare professionals to make more informed care decisions, enhancing the quality of patient care. Moreover, it significantly reduces the likelihood of medication errors, a critical concern in healthcare.

Likewise, AI’s capability to analyze extensive patient data is invaluable. It can identify patterns and trends in medication adherence, detect potential drug interactions, and pinpoint adverse drug reactions. These insights are crucial for healthcare professionals and researchers. By understanding these patterns, they can develop more effective medication adherence strategies and support systems, contributing to better patient outcomes and advancing the overall field of pharmaceutical care.

In the expansive realm of chemical space, the pharmaceutical industry faces the continual challenge of identifying new active pharmaceutical ingredients (APIs) for diverse diseases [ 159 ]. High throughput screening (HTS), despite its advancements in recent decades, remains resource-intensive and often yields unsuitable hits for drug development. The failure rate of investigational compounds remains high, with a study citing only a 6.2% success rate for orphan drugs progressing from phase I to market approval [ 160 , 161 ].

Machine learning presents a transformative approach to this challenge. It offers an alternative to manual HTS through in silico methodologies. ML-driven drug discovery boasts several advantages: it operates continuously, surpasses the capacity of manual methods, reduces costs by decreasing the number of physical compounds tested, and early identifies negative characteristics of compounds, such as off-target effects and sex-dependent variability [ 162 ].

A substantial advancement in the realm of machine learning has emerged from major pharmaceutical entities, notably AstraZeneca, in conjunction with research institutions. This progress is evidenced by the development of an innovative algorithm that demonstrates both time efficiency and effectiveness in the sphere of drug discovery. The recent introduction of this algorithm significantly enhances the process of determining binding affinities between investigational compounds and therapeutic targets. It surpasses traditional in silico methods in terms of performance. The application of this algorithm underscores the remarkable potential of machine learning in accelerating the identification and development of novel therapeutic agents [ 163 ].

Moreover, the proficiency of machine learning in managing vast and intricate datasets has rendered it indispensable in research focused on cancer targets, utilizing diverse and extensive datasets. This approach is fundamental in numerous drug discovery initiatives, especially those targeting various forms of cancer. A wide array of ML techniques, ranging from supervised to unsupervised learning, are employed to discern chemical attributes that are indicative of potential therapeutic efficacy against a spectrum of cancer targets. This methodology is crucial in identifying novel compounds that could be effective in cancer treatment, leveraging the rich and complex data available in oncological research [ 164 ].

The digital transformation in the pharmacy sector is significantly reshaping healthcare delivery, driven by the integration of cutting-edge technologies like Artificial Intelligence and blockchain. This transformation is marked by a substantial growth in the digital pharmacy market, with a projected annual growth rate of 14.42%, leading to a market volume of approximately $35.33 billion by 2026​​.

One major aspect of this transformation is the growing reliance on online pharmacy platforms, largely influenced by the COVID-19 pandemic. Consumer trust in online medication purchases has significantly increased, indicating a shift towards digital healthcare solutions. The adoption of telehealth services, including telepharmacy, has surged, with patient adoption in the United States increasing from 11% in 2019 to 46%. This shift towards digital-first services enhances convenience and access to care but also introduces regulatory challenges, particularly in maintaining patient safety and quality standards in the rapidly evolving online healthcare environment​​.

The cosmeceuticals market, a segment within online pharmacies, is experiencing robust growth. Cosmeceuticals, which bridge the gap between cosmetics and pharmaceuticals, have become a significant part of the skincare industry. The market, valued at USD 56.78 billion in 2022, is projected to expand to USD 95.75 billion by 2030. This expansion is driven by factors like innovation in natural ingredients and significant penetration of internet, smartphone, and social media applications. Despite the growth, the overall penetration for non-specialty drugs in mail-order and online pharmacies remains low, representing a significant portion of specialty prescription revenues. The evolving landscape of online pharmacies in the cosmeceuticals sector reflects a trend towards more accessible and customizable personal healthcare solutions​​.

Technological innovations are setting the stage for a new era in pharmaceutical care and management. AI’s role extends to areas like inventory management in retail pharmacies, where it predicts patient needs and enhances supply chain efficiency. Blockchain technology enhances supply chain transparency and legitimizes medical commodities, especially crucial in areas affected by counterfeit drugs. Blockchain also plays a vital role in patient-centric Electronic Health Records and telemonitoring systems. For instance, PharmaGo, an innovative platform developed in response to the pandemic, provides a comprehensive online pharmaceutical service, demonstrating the significant advancements in healthcare accessibility and pharmacy service delivery​​.

These technological advancements are instrumental in improving data sharing and collaboration among healthcare professionals. They offer significant potential for personalized medicine through data analytics, playing a crucial role in patient engagement and self-management of health. The future trends in the pharmaceutical sector, particularly influenced by the COVID-19 pandemic, indicate a shift towards Pharmaceutical Digital Marketing (PDM) and a more consumer-centric approach. AI’s potential in revolutionizing pharmacy includes automation of routine tasks, personalized medication management, real-time patient data access, and the identification of patterns in medication adherence and potential drug interactions​​.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The researcher would like to thank the Deanship of Scientific Research, Qassim University for funding the publication of this project.

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Department of Pharmacology, College of Medicine, Qassim University, Buraydah, Saudi Arabia

Ahmad Almeman

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Conceived the conceptual framework, Wrote the paper, Designed search strategies, Critically reviewed the manuscript for important intellectual content: A.A.

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Almeman, A. The digital transformation in pharmacy: embracing online platforms and the cosmeceutical paradigm shift. J Health Popul Nutr 43 , 60 (2024). https://doi.org/10.1186/s41043-024-00550-2

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Received : 14 February 2024

Accepted : 09 April 2024

Published : 08 May 2024

DOI : https://doi.org/10.1186/s41043-024-00550-2

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