essay about communication during pandemic

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• Published: 09 August 2021

Has the pandemic changed the way we communicate?

• David Westgarth 1  

BDJ In Practice volume  34 ,  pages 14–18 ( 2021 ) Cite this article

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Has COVID-19 changed the what and the how of communication?

What are the implications?

Could the changes be a good thing?

Introduction

There's a very funny picture doing the rounds on social media that says you can drive for four hours in America and you're on the same road in the same State, but in the same distance in UK the accent and name for a bread roll has changed 18 times. Besides the geographical challenges and differences posed by the countries, it is fascinating how language, accent and dialect change so much. Despite spending precisely zero minutes growing up in the North East, it's still the accent people tell me I have. And yet, after a weekend at home in Cumbria, upon my return to the city my Cumbrian accent is stronger than ever. Few people will forget how hilarious former England football manager Steve McLaren adopted a Dutch accent during his time coaching one of the country's clubs, only for it to disappear on his return to England.

The environment around us has a significant impact on what we say and how we say it. Throughout the pandemic, many of the normal social conventions have been put on hold, altered and changed. Dentistry felt those alterations and changes hard, but just how has communication within the profession been impacted?

The what and the how

There has been plenty said about the 'how' changes, most notably the increased use of teledentistry for patient-facing processes. Less has been said about the vast quantity of digital learning that has taken place, for dental students and those fully qualified. The disruption, as with most things since March 2020, provided challenges and opportunities. Research has previously highlighted four key areas that have been adversely impacted: 1

Online communication skills teaching

While not necessarily the optimum way to strengthen communication skills, many teachers are learning and seeking to identify best practices for virtual communication skills teaching during the pandemic. Teachers need information on how best to employ videoconferencing platforms such as Zoom and WebX for experiential communication skills learning, which includes peer role play and practice with simulated patients.

Clinical learners not seeing patients

In many health professional schools around the world, many clinical rotations have been suspended. Sharing resources for continuing case-based and other forms of learning in the absence of direct patient encounters is another pressing need and opportunity.

' The environment around us has a significant impact on what we say and how we say it. Throughout the pandemic, many of the normal social conventions have been put on hold, altered and changed.'

Workplace-based learning

Not all learners have been removed from clinical settings during the pandemic and many, such as residents, are experiencing increased clinical obligations. It will be helpful to identify opportunities for continued emphasis on communication skills learning and development in the clinical setting. Innovations that adhere to the need for physical distancing and still emphasise communication content could include virtual rounding, video recording with asynchronous feedback of learner-patient encounters, and communication-focused debriefing of patient/family encounters.

Virtual communication assessments

In addition to in-person teaching, the pandemic has made in- person assessments such as OSCEs untenable. Many schools are developing successful and innovative ways to continue to conduct communication-focused performance-based assessments, including involvement of simulated patients using videoconferencing platforms.

While I found it interesting that the authors highlighted that there are some successes and innovations to aid students, trainers and qualified alike, the impact caused by a lack of face-to-face training was not discussed. Dentistry by its very nature is hands-on, so who knows what impact that has had on dental student and course attendees? Only time will tell.

In addition to the setting, the qualifications and the virtual nature of conversations, what we say has also changed over the pandemic. Almost every conversation I've had with friends and loved ones has included a discussion on positivity rates, or R value, the vaccine or the desire for things to go back to the way they were. There are few situations where every person on the planet can sympathise and empathise with what you're going through; this is one of those. Pre-pandemic, what did a mask mean? Did it mean ski mask and thoughts of a happier nature? Did it mean a masquerade ball and again, happy, party vibes? In dentistry it was a staple of treating a patient. Its role hasn't changed. The difference was to talk to a patient, you could pop it off as soon as you were done treating them. To this end, it's another example of how practitioners talk to patients has changed. Practitioners need to enhance non-verbal communication to compensate for the loss of visible facial expression, as Jane Merivale has previously written:

'Facial expressions signal our thoughts and emotions and most of us become fairly adept at reading the faces of others to understand what they are thinking and feeling. We have evolved 42 muscles of facial expression for this purpose!

' Many schools are developing successful and innovative ways to continue to conduct communication-focused performance-based assessments, including involvement of simulated patients using videoconferencing platforms.'

'Being able to observe the mouth can impact on the patient's perception of a dentist's emotional intelligence, and their likeability, which directly affects patient satisfaction, regardless of the actual treatment outcome.' 2

Masks, necessary as they are, can create problems. Research shows high-frequency sounds are reduced by 3-4 decibels (dB) when wearing a surgical mask, and by 12 dB when wearing an N95 mask.3 A 10-decibel reduction will be twice as quiet as the original decibel reading. As people age, their hearing loss generally affects these higher frequencies, resulting in greater difficulty hearing. 4 Add some background noise (such as air purifiers for the room), and this decrease in decibels is enough of a reduction to affect the quality of speech for people with some level of hearing loss. 3

Masks also make it impossible to read lips. They muffle sounds, and with more than half of the face covered, it is more difficult to decipher facial expressions. Wearing two masks and a face shield likely affects the quality of speech even more. For patients to be able to make a decision on their treatment based on informed consent and understand all of their treatment options, the ability to hear and understand what we are attempting to communicate is of utmost importance.

Muffled sound through 15 months (and counting) of masked communication may also impact on how we pronounce our words. At Michigan State University Sociolinguistics Lab, a team of researchers have been collecting recorded speech from Michigan residents since the beginning of April 2020 to track changes to language during the pandemic. According to them, the most recent time a major event had such an impact on language was the Second World War, because it brought people together who ordinarily wouldn't have had contact with one another. They would have had to speak louder and clearer during bombing campaigns, for example.

With the pandemic, it's just the opposite. We've been pried apart, and 'you're on mute', 'you broke up a bit there' and 'I can't quite hear you' have become norms for meetings. Research isn't available to date, but anecdotally I would think I've probably changed how I speak - I'm louder, slower and clearer, for masks and for virtual discussions. For someone softly and quietly spoken, they would perhaps have had to adapt more than a public speaker, for example. And yet, as one of the points in Box 1 shows, it can be difficult to speak louder for clarity and retain patient confidentiality. This may well have been improved upon since the beginning of the pandemic, but as restrictions persist and foundation dentists take up posts from next month, it is something many will be encountering for the first time.

The implications

In the last ten years, the biggest change we have seen to communication is that it has become a lot more immediate. Instead of sending emails back and forth from the computer, and waiting for the recipient to be at their desk before they can send a reply, most people now have got access to instant messaging software, which is now becoming integrated into working offices too. When the very first iPhone came out back in 2007, no-one could foresee how smartphones would come to dominate our lives. Our phones are an essential lifeline - they're on the same checklist as keys, wallet and masks when you leave the house. Chances are you're probably reading this on your phone, too, as the number of mobile web users has now outstripped their desktop counterparts. Email does still have its place, but instant messaging apps will soon make them obsolete and a thing of the past at current rates of progress.

' Masks also make it impossible to read lips. They muffle sounds, and with more than half of the face covered, it is more difficult to decipher facial expressions.'

This immediacy means patients have come to expect it too, which is why you wonder if - for a large segment of patients - it should stay. It's one less barrier to getting patients into the practice. Toothbrushes use smart technology to send data back to a patient's dentist. It would perhaps be more cost-effective and enable dental practitioners with targets to achieve them easier. Would it even be a cost-effective bridge for patients to access private dentistry more often and take the pressure off the health service, clearly under pressure? These parameters would apply to a small section of the population, but the implications for a return to 'how things used to be' simply places pressure on a system still essentially operating with peak-pandemic restrictions; it shouldn't happen.

This has also led to another change in precisely how we communicate, namely the length of how we communicate. It wasn't all that long ago that you could expect lengthy emails about even the simplest of topics, Now, though, there's no need to do that when you're communicating with someone in 'real-time'. Conciseness is the order of the day, particularly because that ease of communication means that we often have a lot to keep on top of at once.

And that rings true of most scenarios, except for consent.

Conciseness is not the order of the day. As with consent, and the changes adopted as a result of the Montgomery case, records and consent need to be tailored to the individual patient and therefore being concise will never work in your favour. There is no substitute for good communication, and it is important that what is written in the records actually took place; the patient may argue that there was no such dialogue and no such agreement to proceed on those terms. BDA Indemnity has previously reaffirmed:

'In order to be valid, the consent process needs to be tailored to each patient and their particular circumstances, taking into account what matters most to them. Essentially, this summarises the legal precedent created by the Montgomery case in 2015. Hence your records are the only sure method of demonstrating the consent process which will inevitably evolve over the period you are treating the patient; remembering also that the patient can withdraw their consent at any point.' 5

When providing dental treatment, it is important that every patient fully understands any dental treatment that is proposed in order to make an informed decision about how they would like to proceed. Fully and concise in this scenario do not mix, and it is important to consider the implications of discussing treatment plans with a patient via traditional means and the problems associated with masks, and digital means, particularly if the patient seems like they'd rather be elsewhere.

Conversely, some of the problems that may arise from muffled communication - those with hearing difficulties, those who do not have English as their first language, those living with a disability or other impairment - may reverse the 'instant' nature of communication. Could practitioners be extra cautious about giving patients too much information if there are concerns about misinterpretations or misunderstandings? It's not beyond the realms of possibility, and yet there is still a balance to ensure the patient gets information they can understand and will digest.

True progress, or progress for the sake of it

Sometimes it can feel like technology is being used for the sake of it, and as a result there's no communication, other than with a responsive piece of software. Dentistry must not find itself implementing changes purely for the sake of it - any of the pandemic learnings integrated into everyday practising should be done so for the benefit of the patient and practitioner.

Take receptionists, for example. An integral part of the dental team, yet for some there will be a temptation to make the check-in process digital through touchpads and/or voice-activated programs. Their numbers could potentially dwindle. Besides the fact they're one skillset most at risk from COVID-19 given how many different people they see in a static environment, they're an invaluable asset in any practice. Could a touchpad resolve a query? Yes, most likely. Could a receptionist be able to iron out the beginnings of a complaint? Yes, absolutely. It's those intangible aspects that savings - which many practice owners will naturally seek to find post-pandemic - cannot replace.

' When providing dental treatment, it is important that every patient fully understands any dental treatment that is proposed in order to make an informed decision about how they would like to proceed.'

For dental students, would a hybrid model of learning be something they wish to incorporate? Do they need to be present in lectures as well as clinics? There's an argument for one, but a weaker one for the other.

Do practice meetings need to be in-person when everyone has adopted and integrated technology replacements so ably?

It's easy to say technology - in these scenarios - replaces the need for in-person communication. Truth is they do. The question is should they replace them, to which the answer is anything but straight forward. The 'soft skill' is something many are concerned is lacking in many students and young dentists, given their focus on clinical skills. Researchers have previously concluded that: ' An increase in service industry and competitive private practices emphasises the need for soft skills. Soft skills are used in personal and professional life.

'These soft skills help to organise, plan and manage, and track changes during the course of the growing dental practices. However, understanding of the soft skills in practice management, its simplicity and complex contexts of practice is essential. It is really helpful to all practitioners to grow their practices using soft skills.' 6

Given the shift to instant communication, and in a post-pandemic world where we're actively discouraged from being face-to-face with someone, being able to read the conversation, the flow and the body language, it will be fascinating to see the long-term impact this has on the profession - and wider society - moving forward.

COVID-19 has changed clinical communication practices, of that there is no doubt. The transition from and the balance of face-to-face communication with remote encounters has shifted, even for a profession as reliant upon in-person as dentistry. Which of those changes becomes the norm will only be seen once COVID-19 is in the rear view mirror - for how much longer will masks be mandatory for the entirety of the appointment? For how much longer will practitioners have to speak above air filtration units on top of that? How will this affect those of partial hearing too? How those changes affect the way we communicate will take even longer to gestate - will we all end up speaking slowly and loudly, like Brits abroad do when they want to order something off the menu from behind the counter but have no idea of how to do so in the local language? ◆

Box 1 Tips for masked communication

Dr Jane Merivale, senior dento-legal advisor for BDA Indemnity, has previously suggested the following for communicating wearing a mask2

The environment - Minimise the noise and distractions in the surgery; patients need to understand what is being said and if not hearing fully, especially in the absence of lip-reading cues, they will 'make a guess' at what's been said, particularly patients with a cognitive or hearing impediment

Make eye contact - This conveys 'I see you' activating empathy and connection. Too much and the patient feels uncomfortable, but enough strengthens the greeting and promotes trust

Introductions are key - Wear a name badge so everyone knows 'who's who' and their job title

Explain why you are wearing a mask - This can enhance trust in the dental setting signalling adherence to cross infection control measures given dentistry is carried out at such close quarters

Listen well - Let patients tell their story, uninterrupted

Give reassurance that the patient is safe and acknowledge the extra difficulties imposed by wearing a mask

Check your tone of voice - The tone conveys over 38% of the non-verbal emotional content of what we say. The pace, rhythm and pitch of spoken language is called prosody. Prosody infuses a layer of emotion that goes above and beyond the singular meaning of each word and we are all highly sensitive to variations in tone of voice. In a famous study by Nalini Ambady, audiotapes of surgeons talking with patients were filtered so only the volume, pace and rhythm of their communications were audible. When the tapes were played to a group of volunteers, listeners could determine the surgeons who had a history of complaints and claims

Name your emotion - If the PPE makes it difficult to express it: for example, 'You make me smile' or 'I empathise with you'

Convey openness, warmth and respect with body language - Sit down with patients, turn towards them, and sit at eye level whilst maintaining social distance.

Encourage questions to gauge understanding - In the face of any lack of comprehension that is critical to obtaining valid consent. Information gathered by the dentist may otherwise be incomplete leading to clinical and consent inaccuracies.

Use gestures - Thumbs up or down to clarify what has or hasn't been understood

Give more supplementary written information than usual

Safeguard confidentiality - It can be difficult to speak louder for clarity. You may have to move somewhere more confidential if the situation demands it

Use technology creatively to supplement information given - some dentists are experimenting with live transcript applications compatible with mobile phone technology as a means of communication solving, so the patient can listen again when they've left the surgery.

Rubinelli S, Myers K, Rosenbaum M and Davis D. Implications of the current COVID-19 pandemic for communication in healthcare. Patient Educ Couns 2020; 103: 1067-1069.

Merivale J. 'Masked' communication. BDJ In Pract 2021; 34: 28.

Goldin A, Weinstein B, Shiman N. How do medical masks degrade speech reception? Hearing Review 2020; 27: 8-9.

Centers for Disease Control and Prevention. What noises cause hearing loss? National Center for Environmental Health. Updated October 7, 2019. Available online at: www.cdc.gov/nceh/hearing_loss/what_noises_cause_hearing_loss.html (Accessed August 2021).

Merivale J. Adapting patient consent in response to COVID-19. BDJ In Pract 2021; 33: 26-27.

Dalaya M, Ishaquddin S, Ghadage M, Hatte G. An interesting review on soft skills and dental practice. J Clin Diagn Res 2015; 9: ZE19-ZE21.

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Westgarth, D. Has the pandemic changed the way we communicate?. BDJ In Pract 34 , 14–18 (2021). https://doi.org/10.1038/s41404-021-0845-x

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Published : 09 August 2021

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DOI : https://doi.org/10.1038/s41404-021-0845-x

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• Volume 76, Issue 2
• COVID-19 pandemic and its impact on social relationships and health
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• http://orcid.org/0000-0003-1512-4471 Emily Long 1 ,
• Susan Patterson 1 ,
• Karen Maxwell 1 ,
• Carolyn Blake 1 ,
• http://orcid.org/0000-0001-7342-4566 Raquel Bosó Pérez 1 ,
• Ruth Lewis 1 ,
• Mark McCann 1 ,
• Julie Riddell 1 ,
• Kathryn Skivington 1 ,
• Rachel Wilson-Lowe 1 ,
• http://orcid.org/0000-0002-4409-6601 Kirstin R Mitchell 2
• 1 MRC/CSO Social and Public Health Sciences Unit , University of Glasgow , Glasgow , UK
• 2 MRC/CSO Social and Public Health Sciences Unit, Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• Correspondence to Dr Emily Long, MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow G3 7HR, UK; emily.long{at}glasgow.ac.uk

This essay examines key aspects of social relationships that were disrupted by the COVID-19 pandemic. It focuses explicitly on relational mechanisms of health and brings together theory and emerging evidence on the effects of the COVID-19 pandemic to make recommendations for future public health policy and recovery. We first provide an overview of the pandemic in the UK context, outlining the nature of the public health response. We then introduce four distinct domains of social relationships: social networks, social support, social interaction and intimacy, highlighting the mechanisms through which the pandemic and associated public health response drastically altered social interactions in each domain. Throughout the essay, the lens of health inequalities, and perspective of relationships as interconnecting elements in a broader system, is used to explore the varying impact of these disruptions. The essay concludes by providing recommendations for longer term recovery ensuring that the social relational cost of COVID-19 is adequately considered in efforts to rebuild.

• inequalities

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study. Data sharing not applicable as no data sets generated or analysed for this essay.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ .

https://doi.org/10.1136/jech-2021-216690

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Introduction

Infectious disease pandemics, including SARS and COVID-19, demand intrapersonal behaviour change and present highly complex challenges for public health. 1 A pandemic of an airborne infection, spread easily through social contact, assails human relationships by drastically altering the ways through which humans interact. In this essay, we draw on theories of social relationships to examine specific ways in which relational mechanisms key to health and well-being were disrupted by the COVID-19 pandemic. Relational mechanisms refer to the processes between people that lead to change in health outcomes.

At the time of writing, the future surrounding COVID-19 was uncertain. Vaccine programmes were being rolled out in countries that could afford them, but new and more contagious variants of the virus were also being discovered. The recovery journey looked long, with continued disruption to social relationships. The social cost of COVID-19 was only just beginning to emerge, but the mental health impact was already considerable, 2 3 and the inequality of the health burden stark. 4 Knowledge of the epidemiology of COVID-19 accrued rapidly, but evidence of the most effective policy responses remained uncertain.

The initial response to COVID-19 in the UK was reactive and aimed at reducing mortality, with little time to consider the social implications, including for interpersonal and community relationships. The terminology of ‘social distancing’ quickly became entrenched both in public and policy discourse. This equation of physical distance with social distance was regrettable, since only physical proximity causes viral transmission, whereas many forms of social proximity (eg, conversations while walking outdoors) are minimal risk, and are crucial to maintaining relationships supportive of health and well-being.

The aim of this essay is to explore four key relational mechanisms that were impacted by the pandemic and associated restrictions: social networks, social support, social interaction and intimacy. We use relational theories and emerging research on the effects of the COVID-19 pandemic response to make three key recommendations: one regarding public health responses; and two regarding social recovery. Our understanding of these mechanisms stems from a ‘systems’ perspective which casts social relationships as interdependent elements within a connected whole. 5

Social networks

Social networks characterise the individuals and social connections that compose a system (such as a workplace, community or society). Social relationships range from spouses and partners, to coworkers, friends and acquaintances. They vary across many dimensions, including, for example, frequency of contact and emotional closeness. Social networks can be understood both in terms of the individuals and relationships that compose the network, as well as the overall network structure (eg, how many of your friends know each other).

Social networks show a tendency towards homophily, or a phenomenon of associating with individuals who are similar to self. 6 This is particularly true for ‘core’ network ties (eg, close friends), while more distant, sometimes called ‘weak’ ties tend to show more diversity. During the height of COVID-19 restrictions, face-to-face interactions were often reduced to core network members, such as partners, family members or, potentially, live-in roommates; some ‘weak’ ties were lost, and interactions became more limited to those closest. Given that peripheral, weaker social ties provide a diversity of resources, opinions and support, 7 COVID-19 likely resulted in networks that were smaller and more homogenous.

Such changes were not inevitable nor necessarily enduring, since social networks are also adaptive and responsive to change, in that a disruption to usual ways of interacting can be replaced by new ways of engaging (eg, Zoom). Yet, important inequalities exist, wherein networks and individual relationships within networks are not equally able to adapt to such changes. For example, individuals with a large number of newly established relationships (eg, university students) may have struggled to transfer these relationships online, resulting in lost contacts and a heightened risk of social isolation. This is consistent with research suggesting that young adults were the most likely to report a worsening of relationships during COVID-19, whereas older adults were the least likely to report a change. 8

Lastly, social connections give rise to emergent properties of social systems, 9 where a community-level phenomenon develops that cannot be attributed to any one member or portion of the network. For example, local area-based networks emerged due to geographic restrictions (eg, stay-at-home orders), resulting in increases in neighbourly support and local volunteering. 10 In fact, research suggests that relationships with neighbours displayed the largest net gain in ratings of relationship quality compared with a range of relationship types (eg, partner, colleague, friend). 8 Much of this was built from spontaneous individual interactions within local communities, which together contributed to the ‘community spirit’ that many experienced. 11 COVID-19 restrictions thus impacted the personal social networks and the structure of the larger networks within the society.

Social support

Social support, referring to the psychological and material resources provided through social interaction, is a critical mechanism through which social relationships benefit health. In fact, social support has been shown to be one of the most important resilience factors in the aftermath of stressful events. 12 In the context of COVID-19, the usual ways in which individuals interact and obtain social support have been severely disrupted.

One such disruption has been to opportunities for spontaneous social interactions. For example, conversations with colleagues in a break room offer an opportunity for socialising beyond one’s core social network, and these peripheral conversations can provide a form of social support. 13 14 A chance conversation may lead to advice helpful to coping with situations or seeking formal help. Thus, the absence of these spontaneous interactions may mean the reduction of indirect support-seeking opportunities. While direct support-seeking behaviour is more effective at eliciting support, it also requires significantly more effort and may be perceived as forceful and burdensome. 15 The shift to homeworking and closure of community venues reduced the number of opportunities for these spontaneous interactions to occur, and has, second, focused them locally. Consequently, individuals whose core networks are located elsewhere, or who live in communities where spontaneous interaction is less likely, have less opportunity to benefit from spontaneous in-person supportive interactions.

However, alongside this disruption, new opportunities to interact and obtain social support have arisen. The surge in community social support during the initial lockdown mirrored that often seen in response to adverse events (eg, natural disasters 16 ). COVID-19 restrictions that confined individuals to their local area also compelled them to focus their in-person efforts locally. Commentators on the initial lockdown in the UK remarked on extraordinary acts of generosity between individuals who belonged to the same community but were unknown to each other. However, research on adverse events also tells us that such community support is not necessarily maintained in the longer term. 16

Meanwhile, online forms of social support are not bound by geography, thus enabling interactions and social support to be received from a wider network of people. Formal online social support spaces (eg, support groups) existed well before COVID-19, but have vastly increased since. While online interactions can increase perceived social support, it is unclear whether remote communication technologies provide an effective substitute from in-person interaction during periods of social distancing. 17 18 It makes intuitive sense that the usefulness of online social support will vary by the type of support offered, degree of social interaction and ‘online communication skills’ of those taking part. Youth workers, for instance, have struggled to keep vulnerable youth engaged in online youth clubs, 19 despite others finding a positive association between amount of digital technology used by individuals during lockdown and perceived social support. 20 Other research has found that more frequent face-to-face contact and phone/video contact both related to lower levels of depression during the time period of March to August 2020, but the negative effect of a lack of contact was greater for those with higher levels of usual sociability. 21 Relatedly, important inequalities in social support exist, such that individuals who occupy more socially disadvantaged positions in society (eg, low socioeconomic status, older people) tend to have less access to social support, 22 potentially exacerbated by COVID-19.

Social and interactional norms

Interactional norms are key relational mechanisms which build trust, belonging and identity within and across groups in a system. Individuals in groups and societies apply meaning by ‘approving, arranging and redefining’ symbols of interaction. 23 A handshake, for instance, is a powerful symbol of trust and equality. Depending on context, not shaking hands may symbolise a failure to extend friendship, or a failure to reach agreement. The norms governing these symbols represent shared values and identity; and mutual understanding of these symbols enables individuals to achieve orderly interactions, establish supportive relationship accountability and connect socially. 24 25

Physical distancing measures to contain the spread of COVID-19 radically altered these norms of interaction, particularly those used to convey trust, affinity, empathy and respect (eg, hugging, physical comforting). 26 As epidemic waves rose and fell, the work to negotiate these norms required intense cognitive effort; previously taken-for-granted interactions were re-examined, factoring in current restriction levels, own and (assumed) others’ vulnerability and tolerance of risk. This created awkwardness, and uncertainty, for example, around how to bring closure to an in-person interaction or convey warmth. The instability in scripted ways of interacting created particular strain for individuals who already struggled to encode and decode interactions with others (eg, those who are deaf or have autism spectrum disorder); difficulties often intensified by mask wearing. 27

Large social gatherings—for example, weddings, school assemblies, sporting events—also present key opportunities for affirming and assimilating interactional norms, building cohesion and shared identity and facilitating cooperation across social groups. 28 Online ‘equivalents’ do not easily support ‘social-bonding’ activities such as singing and dancing, and rarely enable chance/spontaneous one-on-one conversations with peripheral/weaker network ties (see the Social networks section) which can help strengthen bonds across a larger network. The loss of large gatherings to celebrate rites of passage (eg, bar mitzvah, weddings) has additional relational costs since these events are performed by and for communities to reinforce belonging, and to assist in transitioning to new phases of life. 29 The loss of interaction with diverse others via community and large group gatherings also reduces intergroup contact, which may then tend towards more prejudiced outgroup attitudes. While online interaction can go some way to mimicking these interaction norms, there are key differences. A sense of anonymity, and lack of in-person emotional cues, tends to support norms of polarisation and aggression in expressing differences of opinion online. And while online platforms have potential to provide intergroup contact, the tendency of much social media to form homogeneous ‘echo chambers’ can serve to further reduce intergroup contact. 30 31

Intimacy relates to the feeling of emotional connection and closeness with other human beings. Emotional connection, through romantic, friendship or familial relationships, fulfils a basic human need 32 and strongly benefits health, including reduced stress levels, improved mental health, lowered blood pressure and reduced risk of heart disease. 32 33 Intimacy can be fostered through familiarity, feeling understood and feeling accepted by close others. 34

Intimacy via companionship and closeness is fundamental to mental well-being. Positively, the COVID-19 pandemic has offered opportunities for individuals to (re)connect and (re)strengthen close relationships within their household via quality time together, following closure of many usual external social activities. Research suggests that the first full UK lockdown period led to a net gain in the quality of steady relationships at a population level, 35 but amplified existing inequalities in relationship quality. 35 36 For some in single-person households, the absence of a companion became more conspicuous, leading to feelings of loneliness and lower mental well-being. 37 38 Additional pandemic-related relational strain 39 40 resulted, for some, in the initiation or intensification of domestic abuse. 41 42

Physical touch is another key aspect of intimacy, a fundamental human need crucial in maintaining and developing intimacy within close relationships. 34 Restrictions on social interactions severely restricted the number and range of people with whom physical affection was possible. The reduction in opportunity to give and receive affectionate physical touch was not experienced equally. Many of those living alone found themselves completely without physical contact for extended periods. The deprivation of physical touch is evidenced to take a heavy emotional toll. 43 Even in future, once physical expressions of affection can resume, new levels of anxiety over germs may introduce hesitancy into previously fluent blending of physical and verbal intimate social connections. 44

The pandemic also led to shifts in practices and norms around sexual relationship building and maintenance, as individuals adapted and sought alternative ways of enacting sexual intimacy. This too is important, given that intimate sexual activity has known benefits for health. 45 46 Given that social restrictions hinged on reducing household mixing, possibilities for partnered sexual activity were primarily guided by living arrangements. While those in cohabiting relationships could potentially continue as before, those who were single or in non-cohabiting relationships generally had restricted opportunities to maintain their sexual relationships. Pornography consumption and digital partners were reported to increase since lockdown. 47 However, online interactions are qualitatively different from in-person interactions and do not provide the same opportunities for physical intimacy.

Recommendations and conclusions

In the sections above we have outlined the ways in which COVID-19 has impacted social relationships, showing how relational mechanisms key to health have been undermined. While some of the damage might well self-repair after the pandemic, there are opportunities inherent in deliberative efforts to build back in ways that facilitate greater resilience in social and community relationships. We conclude by making three recommendations: one regarding public health responses to the pandemic; and two regarding social recovery.

Recommendation 1: explicitly count the relational cost of public health policies to control the pandemic

Effective handling of a pandemic recognises that social, economic and health concerns are intricately interwoven. It is clear that future research and policy attention must focus on the social consequences. As described above, policies which restrict physical mixing across households carry heavy and unequal relational costs. These include for individuals (eg, loss of intimate touch), dyads (eg, loss of warmth, comfort), networks (eg, restricted access to support) and communities (eg, loss of cohesion and identity). Such costs—and their unequal impact—should not be ignored in short-term efforts to control an epidemic. Some public health responses—restrictions on international holiday travel and highly efficient test and trace systems—have relatively small relational costs and should be prioritised. At a national level, an earlier move to proportionate restrictions, and investment in effective test and trace systems, may help prevent escalation of spread to the point where a national lockdown or tight restrictions became an inevitability. Where policies with relational costs are unavoidable, close attention should be paid to the unequal relational impact for those whose personal circumstances differ from normative assumptions of two adult families. This includes consideration of whether expectations are fair (eg, for those who live alone), whether restrictions on social events are equitable across age group, religious/ethnic groupings and social class, and also to ensure that the language promoted by such policies (eg, households; families) is not exclusionary. 48 49 Forethought to unequal impacts on social relationships should thus be integral to the work of epidemic preparedness teams.

Recommendation 2: intelligently balance online and offline ways of relating

A key ingredient for well-being is ‘getting together’ in a physical sense. This is fundamental to a human need for intimate touch, physical comfort, reinforcing interactional norms and providing practical support. Emerging evidence suggests that online ways of relating cannot simply replace physical interactions. But online interaction has many benefits and for some it offers connections that did not exist previously. In particular, online platforms provide new forms of support for those unable to access offline services because of mobility issues (eg, older people) or because they are geographically isolated from their support community (eg, lesbian, gay, bisexual, transgender and queer (LGBTQ) youth). Ultimately, multiple forms of online and offline social interactions are required to meet the needs of varying groups of people (eg, LGBTQ, older people). Future research and practice should aim to establish ways of using offline and online support in complementary and even synergistic ways, rather than veering between them as social restrictions expand and contract. Intelligent balancing of online and offline ways of relating also pertains to future policies on home and flexible working. A decision to switch to wholesale or obligatory homeworking should consider the risk to relational ‘group properties’ of the workplace community and their impact on employees’ well-being, focusing in particular on unequal impacts (eg, new vs established employees). Intelligent blending of online and in-person working is required to achieve flexibility while also nurturing supportive networks at work. Intelligent balance also implies strategies to build digital literacy and minimise digital exclusion, as well as coproducing solutions with intended beneficiaries.

Recommendation 3: build stronger and sustainable localised communities

In balancing offline and online ways of interacting, there is opportunity to capitalise on the potential for more localised, coherent communities due to scaled-down travel, homeworking and local focus that will ideally continue after restrictions end. There are potential economic benefits after the pandemic, such as increased trade as home workers use local resources (eg, coffee shops), but also relational benefits from stronger relationships around the orbit of the home and neighbourhood. Experience from previous crises shows that community volunteer efforts generated early on will wane over time in the absence of deliberate work to maintain them. Adequately funded partnerships between local government, third sector and community groups are required to sustain community assets that began as a direct response to the pandemic. Such partnerships could work to secure green spaces and indoor (non-commercial) meeting spaces that promote community interaction. Green spaces in particular provide a triple benefit in encouraging physical activity and mental health, as well as facilitating social bonding. 50 In building local communities, small community networks—that allow for diversity and break down ingroup/outgroup views—may be more helpful than the concept of ‘support bubbles’, which are exclusionary and less sustainable in the longer term. Rigorously designed intervention and evaluation—taking a systems approach—will be crucial in ensuring scale-up and sustainability.

The dramatic change to social interaction necessitated by efforts to control the spread of COVID-19 created stark challenges but also opportunities. Our essay highlights opportunities for learning, both to ensure the equity and humanity of physical restrictions, and to sustain the salutogenic effects of social relationships going forward. The starting point for capitalising on this learning is recognition of the disruption to relational mechanisms as a key part of the socioeconomic and health impact of the pandemic. In recovery planning, a general rule is that what is good for decreasing health inequalities (such as expanding social protection and public services and pursuing green inclusive growth strategies) 4 will also benefit relationships and safeguard relational mechanisms for future generations. Putting this into action will require political will.

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Twitter @karenmaxSPHSU, @Mark_McCann, @Rwilsonlowe, @KMitchinGlasgow

Contributors EL and KM led on the manuscript conceptualisation, review and editing. SP, KM, CB, RBP, RL, MM, JR, KS and RW-L contributed to drafting and revising the article. All authors assisted in revising the final draft.

Funding The research reported in this publication was supported by the Medical Research Council (MC_UU_00022/1, MC_UU_00022/3) and the Chief Scientist Office (SPHSU11, SPHSU14). EL is also supported by MRC Skills Development Fellowship Award (MR/S015078/1). KS and MM are also supported by a Medical Research Council Strategic Award (MC_PC_13027).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

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