The results are structured into two sections according to the objectives of the study: 1) evolution of the documents and 2) systematic review and cluster analysis.
1) Evolution of the documents during the pandemic (longitudinal analysis of the pre-existing documents)
The previous review included 26 records, but 2 were removed because they were static documents. For that reason, 24 documents were re-evaluated in the present research.
Statistically significant differences with a negligible effect size were found in the number of symptoms and mental disorders included in the documents (IG1 & IG2; t(23) = 3, p = 0.006, d = 0.18). We found an increase in these valuesin the vaccination stage (Mean = 8.75, SD = 3.25) with respect to those in the early stage of the pandemic (Mean = 8.21, SD = 2.9). A detailed analysis showed that the symptom with the greatest increase was bereavement, present in 9 to 15 documents(25%), followed by sleeping problems (from 14 to 16) and loneliness (from 17 to 18), while the rest of the symptoms remained stable. Regarding the analysed mental disorders, the presence of schizophrenia and psychotic disorders, bipolar disorders, chronic pain and obsessive-compulsive disorder increased in the selected documents up to 14.16%.
Additionally, statistically significant differences with negligible effect size were found when the questions related to information, recommendations and strategies to cope with COVID-19 were analysed (IG3-IG7, t(23) = 2.24, p = 0.035, d = 0.19), with a higher number of questions included in the vaccination stage (Mean = 26.92, SD = 7.56) than in the early stage of the pandemic (Mean = 25.42, SD = 8.1). When each domain was studied separately, we found that every question related to “COVID-19 information” (IG3) increased its presence (100%), followed by the questions associated with “MH strategies and MH-related topics” (IG5), with an increase of up to 80% of that in the vaccination stage, highlighting the variable information for domestic violence victims with up to a 20.84% increase. Furthermore, 50% of the items included in “MH recommendations & MH topics” (IG6) increased inrelevance, withprovision of telephone or online contact with the general practitionerexhibitingthe highest growth (25%). Here, Q17 was the only itemthat exhibited a reduced relevance because the provision of an online community forum was removed from one of the documents. Finally, the variables included in both “MH strategies and MH topics” (IG4) and “MH recommendations and MH-related topics” (IG7) increased up to 33% and 20%, respectively.
In terms of the documents, most document subject matter remained constant throughout the pandemic (62.5%-95.83%, regarding the group of items) because they did not include new items, while 4.17% - 33.33%, depending on the group of items, met the new criteria (new positive answers indicatedthat new items were included in the document). The number of symptoms (IG1) and variables linked to MH strategies and MH-related topics (IG5) and MH recommendations and MH topics (IG6) increased up to 33%; globally, institutions paid more attention to these topics. Only one document exhibited a reduced IG8 relevance by removing the online community forum.
From an international point of view, Finland, Greece, Hong Kong, New Zealand, Portugal, and Switzerland did not improve their pre-existing documents. Ireland, England, Spain and Australia added small changes. Ireland included new positive answers in MH strategies and MH topics (IG4) and MH strategies and MH topics (IG6), with rates of 3.71% and 3.03%, respectively. England paid more attention to symptoms (IG1, 8.33%) and MH strategies and MH topics (IG4, 5.55%), but one variable from MH recommendations and MH topics (IG6) exhibited a reduced score (-4.54%). Spain added new symptoms (IG1, 5.55%), MH strategies and MH-related topics (IG5, 6.66%) and MH recommendations and MH topics (IG6, 3.03%). Finally, Australia added new symptoms (IG1, 5.55%), MH strategies and MH topics (IG4, 7.41%), MH strategies and MH-related topics (IG5, 13.33%) and MH recommendations and MH topics (IG6, 3.03%).
The countries with the most important innovations (new positive answers mean that new items were included) in their pre-existing documents were Canada (from 68.61% to 74.42%), the United States of America (from 80.9% to 87.42%) and Mexico, showing the highest improvement from 25.03% to 59.94% (Figure 1).
2) Systematic review and cluster analysis
Document selection
A new search strategy was performed in Google© (June 9, 2021), and 3,722 records were identified. Additionally, three records were identified through other sources. No duplicate records were found. In the eligibility phase, 22 new documents fulfilled the inclusion criteria. The new records and the updated documents from the previous review,resulting in a total of 46 documents, were included in the qualitative and quantitative analyses of the second transversal cut (Figure 2).
Document characteristics
Most of the 46 included documents had the “general population” as a target population (93.48%) and the “national level” as a territory target (93.48%) (see supplementary material, Table S1, for more details). The predominant format of the documents was a“web page” (86.96%). Documents 1, 6, 7, 27, 28, 31 and 34 were the most complete, while 11 was the most specific (see supplementary material, Table S2).
Results of the cluster analysis (all documents in the second transversal cut)
The cohesion and separation profile were excellent (greater than 0.5) for each cluster analysis, and there were no outliers (Table 1). For more information on the distribution of each specific cluster (percentages of positive answers for each question), see the supplemental material (Tables S3-S9).
Table 1. Number of documents for each cluster and indicator group (IG).
|
Number of observations
|
Indicator group (IG)
|
Cluster 1
|
Cluster 2
|
Cluster 3
|
Cluster 4
|
Cluster 5
|
Cluster 6
|
Cluster 7
|
IG1 Mental symptoms
|
22
|
9
|
8
|
7
|
|
|
|
IG2 Mental disorders
|
8
|
28
|
10
|
|
|
|
|
IG3 Covid-19 information
|
43
|
3
|
|
|
|
|
|
IG4 MH strategies and MH topics
|
9
|
8
|
8
|
8
|
7
|
6
|
|
IG5 MH strategies and MH-related topics
|
10
|
11
|
9
|
16
|
|
|
|
IG6 MH recommendations and MH topics
|
9
|
8
|
7
|
6
|
3
|
9
|
4
|
IG7 MH recommendations and MH-related topics
|
4
|
23
|
6
|
6
|
7
|
|
|
Mental symptoms (indicator Group 1, IG1)
In IG1, almost all documents included stress and anxiety, followed by depression (82.61%), loneliness (76.09%), sleeping problems (73.91%) and bereavement(63.04%).
Cluster 1 contains all broad-spectrum documents that include all symptoms, while Cluster 2 excludes depression and includes bereavement with a high proportion of negative answers, Cluster 3 includes sleeping problems and bereavement to a lesser extent and excludes loneliness, and Cluster 4 excludes bereavement (Table S3).
Mental disorders (indicator Group 2, IG2)
For IG2 (mental disorders), the most common mental disorder in the selected documents was anxiety disorder (95.65%), followed by depression (78.26%) and substance use (67.39%). Regarding disorders present in less than half of the documents,eating disorders (47.83%) were followed by schizophrenia, bipolar disorder and obsessive-compulsive disorders (43.48% each). Finally, chronic pain and dermatillomania were the least relevant disorders (13.04% and 2.17%, respectively).
Cluster 1 focuses on broad-spectrum documents, and Cluster 2 excludes chronic pain and dermatillomania, while Cluster 3 represents the most specific strategies focused on anxiety and, to a lesser extent, substance use disorder and eating disorder (Table S4).
COVID-19 information (indicator Group 3, IG3)
For IG3 (COVID-19 information), 85% of the documents (Cluster 1) included updated information onthe COVID-19 situation and the government and global response, while the rest of the documents (Cluster 2) did not include it (Table S5).
MH strategies & MH topics (indicator Group 4, IG4)
For IG4 (MH strategies & MH topics), every selected document included positive answers for tips for maintaining good MH (Q4) anddescribed some psychological skills to help people cope with their anxiety and worry about COVID-19 (Q6), and almost all promoted social connection at home (Q8, 97.83%) (global layer, Figure 3). A second group of relevant strategies included positive answers for information on how to support a loved one who is very anxious about COVID-19 (Q26) and information onhow to manage stress and anxiety (Q32), with rates of 78.26% and 69.57%, respectively. Other important questions were Q39 (32.61%, link for elderly people related to symptoms or mental disorders) and Q28 (30.43%, information on how to manage stress in case of positive test results), while Q29 (26.09%, how to reduce stigma) and Q27 (19.57%, stress management while people are waiting for COVID-19 test results) were the least relevant.
Cluster 1 highlighted all the questions from IG4, while Cluster 2 excluded stress management while people are waiting for COVID-19 test results (Q27). Cluster 3 excluded Q27, stress management strategies in the case of positive testing (Q28) and how to reduce stigma (Q29) but highlighted the rest. Cluster 4 grouped the most specific documents, dominated by Q4, Q6 and Q8 but including Q28 and information on how to manage stress and anxiety (Q32), with a low proportion of positive answers (<30%). Cluster 5 excluded Q32 and links for elderly people related to symptoms or mental disorders (Q39), emphasised information on how to support a loved one who is very anxious about COVID-19 (Q26) and included, with a low proportion of positive answers, Q27, Q28 and Q29. Finally, Cluster 6 emphasised Q26 and Q32 but included Q28 with a low proportion (Table S6).
MH strategies andMH-related topics (indicator Group 5, IG5)
IG5 showed a high representation of each of its items, including percentages greaterthan 50%. The most relevant questions were information on how to maintain a healthy lifestyle (Q5, 100%), information for caregivers (Q35, 82.61%) and contemplated work at home (Q38, 80.43%).
Clusters 1 and 2 included the most complete documents; however, Cluster 1 was focused on information for health care workers (Q30), how to support health workers (Q31) and information for domestic violence victims (Q34), while Cluster 2 highlighted all the questions in the IG. However, Cluster 3 excluded Q34, and Cluster 4 was the most specific, excluding Q31 and Q33 (identifying health care staff needs) but emphasising Q35 and Q38 (Table S7).
MH recommendations andMH topics (indicator Group 6, IG6)
For IG6, most of the questions were highlighted (from 69.57% to 100%), except for Q11 (50%, offer an online psychological assessment) and Q12 (19.57%, provide feedback on the psychological assessment results) (Figure 3).
Cluster 1 included broad-spectrum documents, while the rest of the clusters excluded Q12. Clusters 3, 4, 5 and 6 also excluded Q21 (steps for understanding the child's feelings), Q17 (an online community forum), Q16 (telephone or online contact with other mental health professionals) and Q11 (offer an online psychological assessment), respectively. In contrast, Cluster 7 most specificallyemphasisedQ7 (emotional support, such as conversations for sharing tips online), Q9 and Q10 but included, with a high proportion of “NO” answers, Q13, Q15 and Q17 (Table S8).
MH recommendations andMH-related topics (indicator Group 7, IG7)
The global profile of IG7 highlighted information for parents (Q19, 86.96%) and how to explain the coronavirus to children (Q20, 76.09%), followed by alternatives to elder people to stay connected online (Q22, 52.17%). Q23 (help in getting established online and learning digital literacy skills) and Q24 (guidelines for COVID-19 outbreaks in residential care facilities) were the least relevant for this IG (23.91% and 21.74%, respectively).
In IG7, Cluster 1 included broad-spectrum documents, while Cluster 3 excluded Q23 (help in getting established online and learning digital literacy skills) and Cluster 5 excluded Q24 (guidelines for COVID-19 outbreaks in residential care facilities). In contrast, Clusters 2 and 4 were the most specific. Cluster 2 emphasised information for parents (Q19), how to explain the coronavirus to children (Q20) and, to a lesser extent, alternatives to elder people to stay connected online (Q22), while Cluster 3 was focused on the last-mentioned question (Q22) (Table S9).