Background

The healthcare system must be ready to respond to a wide range of emergencies and disasters that may threaten public health [1]. In fact, strong healthcare preparedness is essential for effective disaster response [2]. Natural hazards, including hurricanes, earthquakes, tornadoes, fires, and floods, may pose significant and varied risks across the countries. In addition, human and animal infectious diseases, including those previously undiscovered, may present considerable risks to the communities. Technological and accidental hazards, such as dam failures or chemical substance spills or releases, may also have the potentials to cause extensive fatalities. These issues show the importance of a flexible healthcare system, and federal, state, and local governmental agencies are responsible for planning, training, and exercising for emergencies and disasters [3].

During an emergency, especially those that are primarily health-focused, the public will often and inevitably ask the public health communities for guidance and assistance [4]. One of the main solutions to respond to the public health queries is implementing hotline services [5]. These services have been used for more than 60 years and have helped people to receive accurate and timely health information to make informed decisions about their conditions [6]. Health call centers or hotlines have the potential to be particularly impactful in strengthening health systems in low- and middle-income countries, as they allow users to call and receive health advice over the phone. Offering access to health information over the phone mitigates some challenges, such as transportation costs, cost of in-person visits, and healthcare professional shortages. Additionally, the anonymous nature of a hotline may alleviate stigma and nervousness that could prevent a client from discussing a sensitive health topic with a local healthcare provider [7]. Health hotlines/helplines/call centers differ on a variety of characteristics, including operating hours, purposes, or the health topics that they cover, operators’ characteristics, and target groups. While call centers in high- income countries tend to host more all-purpose hotlines, the hotlines in low-income countries are typically designed to cover specific health topics. In sub-Saharan Africa, for instance, individual hotlines have traditionally focused on one specific content area such as maternal health education, antiretroviral adherence, management of non-communicable diseases, or triaging post-operative adverse events [8].

Apart from many public health crises which have been experienced by different countries, in the 21st century, three respiratory pandemic diseases, namely Severe Acute Respiratory Syndrome (SARS), Middle East Respiratory Syndrome (MERS), and Covid-19, have impacted human life [9]. The last one was first reported in Wuhan, China in late December 2019, and on 11th March 2020, the World Health Organization (WHO) declared Covid-19 as a global pandemic [10]. Statistics indicate that more than 769 million people have been infected with Covid-19 across the globe, and more than six million deaths have been reported to the WHO throughout the world [11].

During the outbreak of the disease, different countries implemented various strategies including patient quarantine, controlling individuals’ movement, closure of schools and restaurants, restrictions on international travel, use of masks, social distancing, as well as providing online self-assessment tools and helplines to control the spread of the disease [12, 13]. The implementation of hotlines/helplines was in line with one of the most important WHO strategies; namely providing accurate information to the public, because information plays a crucial role in disease control and protection of individuals against the disease. Although social networks and messaging apps play a crucial role in disseminating information, sometimes they can be effective in spreading false information that may endanger public health [14]. Studies have shown that during the outbreak of a new disease, phone lines are an important and accessible resource for providing information to reduce public panic [5, 15,16,17].

During the Covid-19 pandemic, the World Health Organization’s Regional Office for Europe developed guidelines for the establishment and management of Covid-19 hotlines and call centers [18]. Examples of the launched phone lines and call centers in different countries include the 1339 hotline in South Korea [19], a special hotline in China [5], Covid-19 call centers in the United States [20], Germany [21], Bolivia [22], the 937 call center in Saudi Arabia [23], and the 4030 call center in Iran [24]. The use of phone lines could reduce public anxiety during the pandemic and provided accurate information while answering people’s questions. In addition to incoming calls, some hotlines operators were calling patients for the screening process and identifying positive Covid-19 cases [24,25,26]. in addition, data obtained from people’s calls could help others. Daily collection and weekly sharing of information from callers could reveal emerging trends in worries and attitudes and help policymakers to take effective actions to be more responsive [5]. It should be noted that many of health strategies, in addition to their advantages, may have unintended consequences, which makes it necessary to conduct periodic and comprehensive evaluations [27, 28].

Previously, a number of studies have been conducted to describe the use of call centers and phone lines, especially during the Covid-19 pandemic [21, 22, 29, 30]. For instance, Nina-Mollinedo et al. reported beneficial findings regarding the tracking of suspected Covid-19 cases at the national level through early diagnosis by the Covid-19 call center of the Ministry of Health and Sports in Bolivia [22]. In another study, Vonderlin et al. evaluated the psychological hotline during the first wave of the Covid-19 pandemic. The results indicated that delivering psychological services via phone was feasible in pandemic conditions and played an important role in overcoming individuals’ psychological stress [21]. In Cheng et al.’s study, the results showed that the assessment of a phone line for Covid-19 primary care in Oregon state met the public’s need for information and access to primary care. The findings demonstrated that further investigations on the factors influencing the success or failure of this strategy are necessary [31].

According to the best of our knowledge, no systematic review study has been conducted or officially published on the implementation of hotlines/helplines/call centers during the Covid-19 pandemic. Therefore, the aim of the present study was to systematically review the characteristics, challenges, and lessons learned from implementing these services during the Covid-19 pandemic. In this study, hotlines/helplines/call centers that were set up specifically for Covid-19 and related issues during the pandemic were investigated. The results of this study can contribute to improve the theoretical knowledge on the implementation of these services during the pandemics.

Methods

This systematic review was completed in 2024. Prior to conducting the research, the ethics approval was obtained from the National Ethics Committee of Biomedical Research (IR.IUMS.REC.1401.332). This review study was conducted in accordance with the PRISMA 2020 statement: an updated guideline for reporting systematic reviews [32].

Protocol registration

The study protocol was registered in INPLASY, an international platform for registration of systematic review and meta-analysis protocols (Registration number: INPLASY202420052, DOI number: https://doi.org/10.37766/inplasy2024.2.0052).

Identifying the research question

In a review study, the starting point is to identify the research question to be able to develop the search strategies. The initial literature search suggested that the information about the implementation of Covid-19 hotlines, helplines and call centers were fragmented; therefore, we generated a research question as follows:

What were the characteristics of Covid-19 hotlines/helplines/call centers?

What were the challenges of implementing Covid-19 hotlines/helplines/call centers?

What were the lessons learned of implementing Covid-19 hotlines/helplines/call centers?

Eligibility criteria

The timeframe of the study was between 1st January 2020 and 31st December 2023. To select the most relevant studies, some inclusion and exclusion criteria were set. Then, all research papers, reviews, conference papers, theses, and dissertations which were related to the Covid-19 hotlines, helplines and call centers, and their full-texts were available were included in the study. In addition, we decided to include only articles which were published in English. In fact, choosing English language articles is common in conducting reviews and may have minimal effect on overall conclusions [33]. Moreover, a limited number of papers were in non-English languages, and we had limited resources to be able to translate these papers. Furthermore, protocols, reports, letters to the editor, and studies in which hotlines, helplines or call centers were used in fields other than Covid-19 were excluded from the study.

Information sources

Six databases, namely, PubMed, Web of Science, Scopus, the Cochrane Library, IEEE Xplore, and ProQuest databases, as well as Google Scholar were systematically searched from 1st January 2020 until 31st December 2023. In addition, the Open Grey database was searched to find the grey literature. The search process was also carried out by reference and citation checking. If the full text of an article was not available, the corresponding author was contacted.

Search strategy

To develop a search strategy, MeSH (Medical Subjects Headings) Terms such as Covid-19, coronavirus, severe acute respiratory syndrome, SARS-CoV-2, hotline, and call center, as well as key terms such as Corona, 2019-nCoV, Covid, helpline, crisis line, and emergency line were identified, and combined using “AND” and “OR” operators. The list of databases and used search strategies are presented in Appendix I.

The selection process was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 flow diagram [32]. After retrieving relevant articles, the EndNote software (Version X8) was used, and duplicates were removed. The initial search was conducted by (MEJ) and the screening processes were completed by both authors (MEJ and HA). The authors independently screened the title, abstract, and full text of all eligible articles, and any disagreements were resolved through discussion between the two researchers and reaching a consensus or discussing the issue with the third author (AE). Both authors had a related background to the topic of the study.

Data collection process

Data were extracted using a data extraction form which consisted of the name(s) of the author(s), year of publication, country, research objective, research methods, name of the hotline, target users, activation period, hotline access time, purpose of implementing the hotline, reasons for call, key findings, challenges, and lessons learned. Other data, such as the methods for service promotion, number of calls, call agents’ (operators’) profession, service provider, and quality of services were also extracted. The first author (MEJ) initially collected the data, and the reports were reviewed independently by authors (HA) and (AE). In case of disagreement, the researchers discussed the issue and resolved it by reaching a consensus.

Data items

In this study, the characteristics of Covid-19 hotlines and call centers, challenges and lessons learned were the main data items that were examined and compared in different studies.

Study quality and risk of bias assessment

Quality assessment was performed by two researchers (MEJ and HA) independently and any disagreement between the researchers was resolved by discussion. As different research methodologies were used in the reviewed articles, the Appraisal tool for Cross-Sectional Studies (AXIS) was used to assess the risk of bias, quality of design, and quality of reporting in quantitative studies [34]. The tool had 20 questions, and each question had three responses (yes (1), no and don’t know (0)). Each individual study received a score between zero and 20. Based on these scores, the individual studies were categorized into three groups: Good (> 15), fair (10–15) & poor (< 10). As mixed-methods methodology was used in one study, its quality was assessed using the Mixed Methods Appraisal Tool (MMAT) [35]. It consists of five questions with “yes”, “no” and “can’t tell” as the response options. Using this tool, the quality of an article can be assessed as zero, 25%, 50%, 75% and 100% (zero (no criterion met), 25%, 50%, 75% and 100% (all criteria met)). Indeed, a higher score indicates higher quality. As some of the included studies used qualitative designs, the Critical Appraisal Skills Programme (CASP) Checklist were used to assess the quality and risk of bias for these papers [34]. It consists of 10 questions, with “yes,” “no,” or “can’t tell” as the answer options. The calculated scores showed the quality of each study as high (7–10), medium (4–6), or low (1–3).

Synthesis methods

As different qualitative, quantitative, and mixed methods studies were included in the current research, we were not able to conduct a meta-analysis. Therefore, to report the results, the characteristics of Covid-19 hotlines, helplines, and call centers challenges, and learned lessons were described. To summarize data, tables were developed based on the data extraction form, and finally, the results were synthesized narratively.

Results

Study selection

In this study, 1440 articles were retrieved through searching six databases and Google Scholar. Initially, all articles were entered into the EndNote software (Version X8), and duplicates (n = 487) were removed. Then, the relevancy of the remaining articles to the study objective was examined based on their titles and abstracts, and 867 articles were excluded. The full texts of the remaining articles (n = 251) were searched, and 165 articles were not retrieved. The full texts of the remaining articles (n = 86) were reviewed, and 43 articles were removed as their full text did not meet the inclusion criteria. Finally, 43 articles were selected to be included in the current study (Fig. 1).

Fig. 1
figure 1

Article selection process based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

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Study characteristics

As Table 1 shows 18 Studies were undertaken in the Asia (India [36,37,38,39,40,41,42,43], China [30, 44,45,46,47], Qatar [48, 49], Bangladesh [50], Indonesia [51], Nepal [52]), 11 in the North America (United States [17, 20, 29, 31, 53,54,55,56,57,58], Dominican Republic [59]), 10 in the Europe (Austria [60], France [61], United Kingdom (UK) [62, 63], Slovenia [64], German [65], Ireland [66], Poland [16], Serbia [67], Spain [68]), 3 in Africa (Tunisia [69], Egypt [70], Uganda [71]), and 1 in South America (Bolivia [22]). Among them, 11 studies were published in 2020, 11 in 2021, 9 in 2022, and 12 in 2023, and a summary of them is presented in Table 1.

Table 1 Summary of the selected articles
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Risk of bias in the studies

The quality and risk of bias in the selected studies were assessed using AXIS [34], MMAT [35], and CASP Checklists [34]. The results are presented in Appendix II. Based on the information provided in each study, most of the studies had a low risk of bias.

Results of individual studies

According to the finding, most of the studies aimed to describe a Covid-19 hotline/helpline/call center [17, 20, 29, 31, 40, 44, 49, 52, 56, 58,59,60,61,62,63,64,65, 69], analyze the calls [16, 20, 22, 29, 30, 37,38,39,40,41,42,43, 45,46,47, 49,50,51,52, 54, 55, 57,58,59,60,61,62,63,64,65,66,67,68, 71] and the demographic characteristics of the callers [16, 22, 29, 30, 37, 38, 40, 41, 43, 45, 46, 48,49,50, 54, 58,59,60, 65, 68, 70], examine the callers’ feedback on the hotline/helpline/call center [30, 31, 36,37,38, 52, 59, 60, 62, 69, 70], and assess hotline/helpline/call center volunteers’ experiences [53, 66, 71].

In terms of the research methodology, about half of the articles used quantitative methods (n = 23), and the rest of them used qualitative (n = 3) and mixed methods approaches (n = 17). Most hotlines/helplines/call centers were launched in March (n = 19) and April (n = 14) 2020, and the others were set up in January 2020 (n = 3), February 2020 (n = 3), June 2020 (n = 1), May 2021 (n = 2), and the activation period was not reported in 1 article. (Fig. 2).

Fig. 2
figure 2

Hotlines/helplines/call centers launch times

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Access time

About half of the hotlines/helplines/call centers (n = 22) [29,30,31, 37, 41,42,43,44,45, 47, 49, 51, 54,55,56, 60,61,62, 64, 65, 70, 71] were active seven days a week. The access time for other hotlines/helplines/call centers were different and included six days a week [48], five days a week [16, 58, 63, 66, 68], working days and Saturday [67], Monday to Wednesday [59], (seven days a week, then Monday to Saturday, then Monday to Friday) [20] and the access time was not reported in 12 articles [17, 22, 36, 38,39,40, 46, 50, 52, 53, 57, 69].

About one third of the hotlines/helplines/call centers were active 24 h a day [29, 30, 37, 41,42,43,44,45, 47, 51, 54,55,56, 61, 70]. The rest of them were available 16 h a day from Monday to Friday, and 9 h a day on Saturday and Sunday [71],15.5 h a day [52], 14 h on working days and 7 h on Saturdays [67], 12 h a day [16, 20, 31, 38, 40, 49, 50, 64, 68], 9 h a day [62, 63, 65], 8 h a day [58, 63], 6 h a day [55, 60], 4 h a day [39, 59], 3 h a day [66], and the number of hours were not reported in 8 studies [17, 22, 36, 46, 48, 53, 57, 69].

Hotlines/helplines/call center callers

Callers were the public [16, 17, 22, 29,30,31, 36,37,38,39,40,41,42, 44,45,46,47,48,49,50,51,52, 54, 56, 58,59,60, 64, 66,67,68,69], health workers [43, 69, 71], rural populations [53], hospital workers [61], health care providers, GPs, nurses and pharmacists [20, 62], nursing home staff [57], NHS trust staff [63], patients [20, 55, 58, 69], patients’ families [69], and older adults [65]. (Fig. 3)

Fig. 3
figure 3

Hotlines/helplines/call center callers

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Purpose of implementing hotlines/helplines/call centers

The purposes of using hotlines/helplines/call centers could be categorized in providing psychological support [16, 29, 30, 36,37,38, 40, 42, 43, 45,46,47,48, 50, 58,59,60,61, 63, 65, 66, 68, 69], reliable information about Covid-19 [17, 20, 40, 41, 51, 53, 56, 57, 64, 67], consultation [22, 39, 40, 44, 48, 49, 52, 62], and triage services [31, 48, 49, 54, 55, 70, 71].

Hotlines/helplines/call centeres promotion

As Table 2 shows, in most studies, the Covid-19 hotlines/helplines/call centers were advertised through the media (n = 16) including social networks [59, 60], social media [40, 49, 52, 62, 69, 70], media outlets [49, 64], online official social accounts [30], social networking websites [38], Twitter [61], Facebook [16, 61], WeChat public account [44], WhatsApp groups [59], national media [59], TV Channel [39, 49, 70], TV interview [60], news media [44, 52], and media [30, 51]. In some studies, local print media [38], posters [61, 69, 71], newsletters [61], local newspapers [40, 49, 52, 65], news bulletins [16], journalistic notes reporting [59], and flyers [40, 71] were the common ways to introduce the service. In some studies, the service was advertised via the internet pages [30, 63,64,65] and websites [16, 38, 44, 60, 69], radio stations [30, 49, 52, 65], national radio [66], text message alerts [17, 30], recorded messages [63], emails [61, 63], press conferences [17], broadcasting [30], government announcements [41, 68], organization and administrations [52, 68], nationally known celebrities [66] and health care provider [70].

Table 2 Characteristics of Covid-19 hotlines/helplines/call centers in the selected studies
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Call agents’ (operators’) professions

The profession of the hotlines/helplines/call centers agents (operators) in selected studies were mental health professionals (n = 20), such as psychologists, psychiatrists, psychotherapists, psychological practitioners, psychiatry residents, psychological consultants, psychotherapy professionals, clinical psychologists and neurologists; clinicians (n = 18) such as physicians, consultant physicians, physician assistants, triage physicians, general practitioners (GPs), medical assistants, medical consultants, medical officers, clinical officers, respiratory clinicians, triage clinicians; nurses and psychiatric nurses (n = 12); radiology technologists, assistant chief radiology technologists, and senior radiology residents (n = 1); students (n = 9) in medical, medicine, pharmacy, nursing, dentistry, public health, and social work; social worker and psychiatric social workers (n = 2); pharmacists (n = 1); volunteers graduates in postgraduate bereavement courses (n = 1); epidemiologist (n = 1); chaplains (n = 1); nonmedical staff, central scheduling staff, and patient service representatives (n = 3). In 20 studies, the profession of call agents were not reported.

Hotlines/helplines/call centeres providers

As Table 2 shows, Covid-19 hotlines/helplines/call centers were implemented by healthcare organizations (n = 25), government (n = 5), cooperation between government and healthcare organizations (n = 11), a non-profit organization (n = 1), and other organizations (n = 1).

Evaluation of the service quality

In 15 studies, service quality was evaluated by receiving feedback from the callers and operators. Overall, the callers and operators were satisfied with Covid-19 hotlines/helplines/call centers services in most studies. (Table 2).

Challenges of the Covid-19 hotlines/helplines/call centers

The most common challenges mentioned in the articles included unavailability of hotlines/helplines/call centers [44, 52, 60, 62, 70], lack of specific protocols to support different situations of callers [47, 59, 60], delay in updating information about Covid-19 [36, 51, 53, 58, 62], different backgrounds and experiences of hotlines/helplines/call centers volunteers [37, 45, 47, 53], and lack of experience or the previous models for developing and implementing hotlines/helplines [53, 60]. Moreover, the physical examination of patients was not possible [17, 29, 37, 52, 55, 57, 61, 70, 71], and there were challenges related to human resources and sufficient equipment [51, 52], delay in receiving a prompt response due to the operators’ workload [51, 69], receiving calls via personal phones and being exposed to threats such as hacking their accounts [59, 69, 70], inadequacy of training [53, 58, 66], limited funds [69], and a large number of calls [56, 70]. A summary of challenges is presented in Table 3.

Table 3 Summary of the challenges and lessons learned in the selected articles
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Lessons learned

Hotlines/helplines/call centers can be used to reduce the burden placed on the strained medical systems, especially in lower and middle-income countries (LAMIC) [38, 55]. Essential factors for successful hotline/helpline/call center development included clear instructions for implementation [40, 61], adequate and appropriate human resources [31, 49, 61], receiving support by competent advisers [45, 49, 59, 61], adequate technological resources [31, 49, 61], getting the feedback from users of the hotline [40, 42, 60, 63, 66], forming a transparent management system [45], staff training [40, 53, 56, 70], adequate funding [31], availability of interpreters [48, 56, 57], maintaining anonymity [61]. a clear communication plan [61], accessibility [52, 64, 71], toll-free [52, 64, 71], updating information [41], promoting the helpline [40, 41, 57, 64, 70], and integrating the call center/hotline with different parts of a health center or hospital [51]. Another issue is related to the 24 h accessibility of this services which needs more contribution from the healthcare professionals and additional financial assistance [52]. A summary of challenges and the lessons learned is presented in Table 3.

Syntheses

The results showed that, in terms of the geographical distribution, most studies were undertaken in Europe & Central Asia (n = 10), South Asia (n = 10), and North America (n = 10). In terms of the income, about half of the studies were conducted in high income countries (n = 21), 14 in lower middle-income countries, 7 in upper middle-income countries, and 1 in a low-income country. Half of the hotlines/helplines/call centers were active seven days a week, and about one third of them were active 24 h a day. About half of the hotlines/helplines/call centers provided psychological services and the rest of them provided Covid-19 information services as well as answering questions, consultation, and triage services. In the selected studies, the challenges such as the unavailability of services, lack of up-to-date information, limitations in the physical examination of the callers, lack of budget allocation, and lack of a standard protocol were identified. To achieve success, hotlines/helplines/call centers need to be easy to use with free access. They also need to be supported by proper advertising of the hotlines/helplines/call centers, adequate human resources, training, funding, equipment, and receiving feedback.

Discussion

This systematic review aimed to investigate the characteristics of telephone lines and call centers implemented in various countries during the Covid-19 pandemic, along with their associated challenges and lessons learned. The research findings revealed that most studies initiated the deployment of hotlines/helplines/call centers in March and April 2020. These channels were established to deliver psychological services, Covid-19-related information, consultation, and triage services. The primary challenges highlighted in the examined studies encompassed restrictions on physical examination of patients, unavailability of hotlines/helplines/call centers, exposure to rapidly evolving Covid-19 information, inability to promptly respond to incoming calls, various clinical backgrounds and experiences of volunteers who worked as a call agent (operator), as well as the lack of established protocols and previous successful models for telephone line implementation. The lessons derived from these studies demonstrated that several key factors need careful consideration before implementing hotlines/helplines/call centers. These factors encompass ensuring ease of use and free access, ensuring an adequate number of competent human resources, providing proper staff training, allocating sufficient financial resources, procuring additional equipment, utilizing video tools and platforms to enable visual assessment of callers, ensuring access to interpreters, and establishing mechanisms for receiving feedback from relevant stakeholders.

Utilizing remote health services experienced a substantial increase in the year 2020 when the global Covid-19 pandemic started [72]. In the early stages of the lockdown measures, health authorities recommended the replacement of in-person counseling sessions with remote consultations in order to minimize the risk of viral transmission within the traditional clinic settings [73]. Koonin et al.‘s study demonstrated that the provision of healthcare services underwent a transformation during the Covid-19 pandemic, as evidenced by a 154% surge in the utilization of remote health services during the last week of March 2020 compared to a similar timeframe in 2019 [74]. It appears that the World Health Organization’s global declaration on March 11, 2020 has exerted a significant influence on public behavior regarding the adoption of remote health options [75]. Similarly, Wong et al. discovered that the United States exhibited the highest demand and interest in offering remote health services compared to other countries [75].

The results of a systematic review on the telemedicine platforms in lockdown periods during the Covid-19 pandemic indicated that the real-time interaction modalities, for example, online chatting, telephone communication, and video conference technologies offered immediate and easy-to-use services, and provided care remotely during the current pandemic. This method of communication was more effective than other methods, such as E-mail, fax, forums, file transfer technologies, and prerecorded multimedia [76]. Similarly, the short message service (SMS) can timely provide abundant anti-epidemic alerts to mobile users. SMS tracking platforms could be useful as an early warning system to refer patients with worsening clinical status to hospital-based care or additional clinician advice [77]. Yu et al.’s study showed a positive attitude towards content and the necessity of public-interest in SMS during the pandemic [77].

Overall, developing free interactive chat services can help the general public learn about important issues related to Covid-19. Users can ask questions and get connected to appropriate healthcare services for Covid-19 [78]. Different researchers reported positive experiences delivering care remotely using both telephone and video during the Covid-19 pandemic and believe both modalities are critical for enabling access to care [79]. Video-specific advantages included enhanced ability to engage patients and use of visual cues to get a comprehensive look into the patient’s condition. Similarly, telephone presented unique benefits, including greater privacy, feasibility, and ease of use [79]. The telephone is a familiar and dependable technology, which is adequate for many Covid-19 related conversations. Patients who just want general information about Covid-19 should be directed to a telephone message or other online resources [80].

Research investigating the impact of Covid-19 has revealed that apart from its mortality consequences, this novel disease has triggered various psychological effects, including heightened levels of anxiety. Fardin’s study showed that as the prevalence of Covid-19 and the subsequent imposition of restrictive measures mounted, anxiety levels were also escalated. Consequently, enhancing public awareness about this disease and broadcasting psychological programs focused on stress management through media outlets and contributed to anxiety reduction within communities [81]. Furthermore, quarantine measures have been found to inflict significant adverse psychological effects on individuals, including post-traumatic stress symptoms, confusion, and anger [82].

In a comprehensive review study conducted by Pedrosa et al. the impact of Covid-19 on global mental health was examined and the results revealed that not only are vulnerable groups affected by the transmission of the virus and resulting fatalities, but they also encounter emotional, behavioral, and psychological consequences such as fear, anxiety, depression, and suicidal thoughts [83]. Similarly, in the present study the results showed that, seeking remote psychological services was one of the main purposes of contacting hotlones/ helplines/call centers.

The results of the present study showed that one of the objectives of implementing phone lines and call centers was providing information related to Covid-19 and answering questions. As it was a new disease, providing the callers with sufficient information about the virus was necessary, while preventing the dissemination of incorrect information [84]. In this regard, Alvarez-Risco et al. found that the Covid-19 pandemic led to an increase in the sharing of fake news and misinformation from unofficial resources. This, in turn, can be detrimental to the control of the pandemic and hinder the provision of appropriate responses by public health authorities [85].

One way to prevent the spread of misinformation is to provide reliable information resources. Central and local governments play a role similar to that of policy-makers in providing Covid-19-related information. This need might be met via using information and communication technologies, as well as establishing call centers and hotlines/helplines [51]. The Covid-19 helpline is an interactive information service that allows individuals to directly contact and obtain information about Covid-19 through the phone. The use of the Covid-19 helpline can be an option for the general public to receive information more quickly, as operators answer promptly [51].

One of the additional goals of implementing hotlines and call centers was to provide counseling services related to Covid-19. During the first wave of the pandemic, most countries experienced a rapid decrease in in-person medical consultations and an increase in remote consultations for primary and secondary care, with the majority of counseling sessions being conducted over the phone [13]. Neshnash et al. found that during the Covid-19 pandemic, the use of telephone counseling in primary healthcare has been timely and effective, with more than half of primary care physicians being satisfied or very satisfied with the telephone consultations [86]. In fact, remote counseling improves access to primary care and enables general practitioners to see patients who require an in-person appointment more quickly [86]. Similarly, Green et al.‘s study revealed that telephone counseling in the UK has nearly tripled from February 2020 to August 2021 [87].

One of the other services provided by hotlines and call centers was the Covid-19 triage. Ray et al. acknowledged that this type of triage can help to reduce unnecessary hospital visits and, as a result, minimize unnecessary face-to-face interactions. More importantly, this method guaranteed optimal utilization of test kits due to the shortage of testing kits during the initial months of the pandemic [88]. The main challenges mentioned in the studies were limitations in physical examination of patients, unavailability of hotlines/helplines/call centers, diverse clinical backgrounds of operators and counselors, and the absence of a previous protocol and a successful model for implementing hotlines. Similarly, other studies have highlighted the difficulty of diagnosing patients without physical examination and visual data [89,90,91].

The lessons learned indicated that in order to implement successful hotlines/helplines, certain factors such as ease of use and free access, sufficient human resources, staff training, adequate financial and physical resources, video tools and platforms for objective clinical assessment of the callers, having a translator, and receiving feedback from the stakeholders should be considered. Hasani et al. demonstrated that staff training is essential for high-quality and sustainable telephone counseling services in primary health care (PHC). Additionally, availability of translators for some patients is necessary [92]. Similarly, the lessons learned in Neshnash’s study showed that in order to achieve safe and effective remote consultation, healthcare systems must provide primary healthcare providers with adequate training and implement a national digital health framework for ensuring continuity of care [86]. Other researchers showed that a lack of sufficient training or a lack qualification for helpline operators may adversely impact the mental health of callers. Therefore, in order to improve the quality and performance of helplines, the development of short-term training courses for volunteers along with assessing their knowledge and skills through the output of exams, is necessary. Additionally, customer satisfaction feedback should be collected and reported periodically [93]. Overall, it seems that hotlines/helplines/call centers have been identified as an essential part of strategic response to crises. Findings demonstrated that many countries have used hotlines to support, and provide reliable information to the public.

Research limitations

In this systematic review, only studies published in English were included. Therefore, research articles published in languages other than English were excluded due to the time and resource constraints. In addition, despite making efforts to get access to the full texts of articles and contacting the authors, the full texts of a number of studies were not available and we had to exclude them from the current study.

Conclusion

The aim of this study was to investigate the characteristics, challenges and lessons learned of implementing Covid-19 hotlines/helplines/call centers during the pandemic. The results indicated that most hot lines/helplines/call centers were launched simultaneously with the official announcement of the coronavirus pandemic in March 2020 and were mostly accessible to the public seven days a week. The majority of callers included the public, hospital staff, healthcare providers, patients, families of patients, and elderly individuals. The services provided by call centers and phone lines primarily focused on providing psychological support, providing information to the individuals, answering their questions, offering counseling services, and triage. However, the implementation of these services faced challenges such as service unavailability, outdated information, limitations in physical examination of the callers, budget constraints, and the lack of standardized protocols. Factors such as providing ease of use and free access, allocating sufficient human resources, staff training, adequate financial and physical resource allocation, using video tools and platforms for objective examination of the callers, having a translator, and receiving feedback from stakeholders were reported as lessons learned in the relevant studies. It appears that healthcare managers and policy makers can utilize the findings of this study for successful implementation of hotlines/helplines/call centers in future crises. Therefore, developing strategies for future demands and conducting further research on the performance of current hotlines/helplines/call centers and experiences of the callers/operators are recommended.