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*Corresponding Author: Charlene L.M. Lam, Laboratory of Clinical Psychology and Affective Neuroscience, The University of Hong Kong, Hong Kong, China.
Citation: Min-rui Zhu., Cheuk-Hang Lam., Charlene L.M. Lam., (2023), Perceived Loneliness and Anxiety During Covid-19: A Moderated Mediation Model of Hope and Age, Psychology and Mental Health Care, 7(4): DOI:10.31579/2637-8892/221
Copyright: © 2023, Charlene L.M. Lam. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 29 March 2023 | Accepted: 12 June 2023 | Published: 18 June 2023
Keywords: perceived loneliness; hope, anxiety, age; covid-19 peritraumatic distress
Background: Hope has been identified as a psychological factor protecting against the negative impacts of anxiety and perceived loneliness. However, little is known about how the two factors of hope, namely agency thinking and pathway thinking, mitigate the negative psychological impacts of COVID-19 and how age might impact the relationship between perceived loneliness and anxiety. The current study aimed to examine the mediating effect of agency and pathway thinking between perceived loneliness and anxiety among young and older adults.
Methods: 154 participants (77 young adults; 77 old adults) were recruited during the fourth wave of COVID-19 in Hong Kong. They completed questionnaires on hope, perceived loneliness, anxiety and COVID-peritraumatic stress.
Results: Hope agency modulated the negative influence of perceived loneliness in younger adults compared to the older adults (b = -0.14, SE = 0.06, 95% CI [-0.28, -0.03]). Moreover, hope pathways modulated the COVID-19 peritraumatic distress in the younger adults compared with the older adults (b = -0.09, SE = 0.04, 95% CI [-0.19, -0.02]).
Conclusions: Different mental health strategies might be employed to reduce the negative impacts of perceived loneliness and anxiety related to COVID-19 in the younger and older populations.
The World Health Organization (WHO) declared the novel coronavirus outbreak (COVID-19) a global pandemic in March 2020 (WHO, 2020). Since its outbreak, numerous regions and countries have adopted strict social distancing policies in order to mitigate the spread and the negative impacts of the disease. Such policies and regulations, however, often undermined social interactions and led to social isolation to various degrees. Previous studies showed that levels of perceived loneliness have considerably increased among the general public during the outbreak (Cohn-Schwartz et al., 2022; Rogers et al., 2021).
Previous studies suggest that perceived loneliness has a bimodal distribution: younger and older adults reported higher levels of perceived loneliness (e.g., Hawkley & Cacioppo, 2010). Social distancing might have impacted the young and the old to various degrees. On the one hand, older adults might place more significance on the quality, rather than quantity, of their relationships and social engagements (Luong et al., 2011). On the other hand, social distancing made it harder for older adults to access family, friends, and social services on which they are often functionally dependent, specifically for those living in nursing homes (Hwang et al., 2020). Older adults may not be proficient in using virtual technology (e.g., video calls) for social connection (Armitage & Nellums, 2020; Hwang et al., 2020), making them more vulnerable to higher levels of perceived loneliness and mental distress during the pandemic. For younger adults, previous studies report that they are vulnerable to perceived loneliness and anxiety/depression during the pandemic (Loades et al., 2020). Younger adults might evaluate their social enjoyment and success based on the size of their social network and the number of social contacts (Wicken et al., 2021), both of which are directly impacted by social distancing.
Hope as a psychological buffer
Hope has been considered a psychological buffer against loneliness and anxiety (Muyan et al., 2016; Chang et al., 2019). Hope refers to an individual’s goal-oriented belief induced by agency thinking (i.e., the motivation to initiate and pursue goals) and pathway thinking (i.e., the perceived capacity to reach goals) (Snyder, 1994). Agency thinking, or hope agency, represents the willpower to achieve the expected outcome and reward, while pathway thinking, or hope pathways, involves concrete approaches and plans for the achievement of outcomes (Snyder, 2002). Previous research indicates that hope acts as a protective factor against anxiety and other mental outcomes (Carretta et al., 2014; Chang et al., 2016). Individuals with higher levels of hope demonstrated more adaptive emotional control and reported fewer anxious and depressive symptoms (Gallagher et al.,2021). Several studies have reported a negative association between perceived loneliness and hope during the pandemic (Bareket-Bojmel et al., 2021; Chang et al., 2019). For instance, perceived loneliness correlated negatively with hopeful thinking and acted as a mediator between social support and hope in a large sample of healthy adults from the U.K., the U.S., and Israel (Bareket-Bojmel et al., 2021). Lonely individuals reported higher scores in social inhibition and lower scores on hope and social network size compared to their non-lonely counterparts (Ypsilanti & Lazuras, 2022). However, findings of specific hope components (i.e., agency and pathways) on perceived loneliness and anxiety were limited and mixed. Most studies did not distinguish the two components when investigating hope as a construct and its relationship with other factors. Few studies reported that both hope agency and hope pathways were negatively associated with perceived loneliness (Chang et al., 2019; Ekas et al., 2016). Likewise, several studies suggested that hope agency, but not hope pathways, was a significant predictor of anxiety symptoms (Germann et al., 2018; May et al., 2015). On the contrary, only hope pathways effectively protected against anxiety in a group of high school students (Wang et al., 2017). As suggested by Chang et al. (2019), clarifying the contribution of each component of hope is important because it could avoid theoretical and empirical confusion compared to a single composite score. Such clarification not only refines the hope theory but also points to appropriate interventions that bolster hope through strategically facilitating agency thinking, pathway thinking, or both, when designing mental health programs for combatting the negative impacts of public health outbreaks such as COVID-19 in the future.To our knowledge, the findings about the effect of age on the relationship between hope, perceived loneliness and anxiety have not been fully investigated. Previous studies reported that hope is associated with emotion regulation and resilience that tend to increase with age (Losada-Baltar et al., 2021; Wickens et al., 2021). The current study aimed to elucidate the impact of hope and age on the relationship between perceived loneliness and anxiety during COVID-19 with the following objectives: 1) to examine the three relationships among hope (agency thinking and pathway thinking), perceived loneliness and anxiety; 2) to test whether hope mediated the relationship between perceived loneliness and anxiety, 3) to test the moderating effect of age, in which relationships vary across young adults and old adults (Figure 1). Based on the existing literature, we hypothesized that agency thinking and pathway thinking were negatively associated with anxiety and perceived loneliness; both agency thinking and pathway thinking mediated the relationship between perceived loneliness and anxiety; and 3) young adults with low hope were more likely to report high levels of anxiety compared to older adults.
Note. *Hope will be analyzed by agency and pathways subscales separately.
Figure 1: The proposed moderated mediation model.
One hundred and fifty-four healthy Chinese were recruited from local universities, communities, and elderly centers from March 2021 to May 2021. The inclusion criteria were: [1] either aged 18 to 25 or aged 65 to 85; [2] able to read Chinese. The exclusion criteria were: [1] with a present or history of Covid-19 diagnosis; [2] with a present or history of psychiatric or neurological illnesses. Studies have found that the infection and long COVID-19 symptoms are highly associated with an increase in
mental health problems (Magnúsdóttir et al., 2022; Robinson et al., 2022). The infection rate in Hong Kong was low during the data collection. Therefore, people with the infection were excluded to avoid the confounding effect. The sample comprised 77 young adults (Mage = 45.18, SD = 25.83, 50.6
The information on demographic variables is shown in Table 1.
| Demographic characteristics | Young adults (n = 77) | Old adults (n = 77) | Full sample (N = 154) |
| n (%) | n (%) | n (%) | |
| Gender | |||
| Male | 38 (49.4) | 42 (54.5) | 80 (51.9) |
| Female | 39 (50.6) | 35 (45.5) | 74 (48.1) |
| Education | |||
| No formal education | 0 (0) | 11 (14.3) | 11 (7.1) |
| Primary school | 0 (0) | 35 (45.5) | 35 (22.7) |
| Secondary school | 5 (6.5) | 31 (40.3) | 36 (23.4) |
| Bachelor degree or above | 72 (93.5) | 0 (0) | 72 (46.8) |
| Marital status | |||
| Unmarried | 77 (100) | 2 (2.6) | 79 (51.3) |
| Married | 0 (0) | 49 (63.6) | 49 (31.8) |
| Divorced/widowed | 0 (0) | 26 (33.8) | 26 (16.9) |
| Living arrangement | |||
| Alone | 5 (6.5) | 16 (20.8) | 21 (13.6) |
| Otherwise | 72 (93.5) | 61 (79.2) | 133 (86.4) |
| Presence of children | |||
| Yes | 0 (0) | 71 (92.2) | 71 (46.1) |
| No | 77 (100) | 6 (7.8) | 83 (53.9) |
| Employment | |||
| Studying | 66 (85.7) | 0 (0) | 66 (42.9) |
| Working | 7 (9.1) | 5 (6.5) | 12 (7.8) |
| Unemployed | 4 (5.2) | 0 (0) | 4 (2.6) |
| Retired | 0 (0) | 72 (93.5) | 72 (46.8) |
Table 1: Descriptive statistics.
The means, standard deviations and Pearson’s correlation matrix of each variable are shown in Table 2.
| Variable | M | SD | 1 | 2 | 3 | 4 |
| 1. Perceived loneliness | 42.20 | 9.57 | ||||
| 2. Hope (Agency) | 21.51 | 4.35 | -0.26** [-0.40, -0.11] | |||
| 3. Hope (Pathway) | 22.02 | 5.16 | -0.27*** [-0.41, -0.12] | 0.76*** [0.68, 0.82] | ||
| 4. Anxiety | 4.90 | 4.56 | 0.54*** [0.41, 0.54] | -0.07 [-0.23, 0.09] | -0.13 [-0.28, 0.03] | |
| 5. CPD | 11.66 | 8.17 | 0.58*** [0.47, 0.68] | -0.14 [-0.30, 0.01] | -0.18* [-0.33, -0.02] | 0.69*** [0.60, 0.77] |
Note. M = mean, SD = standard deviation. CPD: covid peritraumatic distress. Values in brackets indicate the 95% confidence interval. * p < .05, ** p < .01, *** p < .00
Perceived loneliness was positively associated with anxiety and covid peritraumatic distress, and negatively correlated with hope agency and pathways. Hope pathways were negatively correlated with covid peritraumatic distress (r = -0.18, p = .025). However, hope agency and hope pathways were not significantly associated with levels of anxiety and covid peritraumatic distress in the overall sample. In addition, young adults reported significantly higher levels of loneliness, anxiety and peritraumatic distress compared to the older adults (perceived loneliness: t(152) = 6.40, p < .001, d = 1.03, 95% CI [0.67, 1.38]; anxiety: t[146] = 8.24, p < .001, d = 1.33, 95% CI [-0.21, 0.42]; CPD: t[136] = 8.31, p < .001, d = 1.34, 95% CI [0.96, 1.72]), while they reported similar levels of agency and pathway thinkings (hope agency: t(146) = 1.51, p = .134, d = 0.24, 95% CI [-0.08, 0.56]; hope pathways: t[145] = 0.64, p > .05, d = 0.10, 95% CI [-0.21, 0.42]).
The mediating effect of hope on the relationship between perceived loneliness and anxiety is shown in Figure 2
Note. *** p < .001.
Figure 2: The mediation effect of hope agency on perceived loneliness and anxiety.
(hope agency) and Figure 3
Note. *** p < .001.
Figure 3: The mediation effect of hope pathways on perceived loneliness and anxiety.
(hope pathways). Concerning the model involving hope agency, perceived loneliness was positively associated with anxiety (β = 0.56, t = 7.95, p < .001), and had a significant negative effect on hope agency (β = -0.26, t = -3.35, p < .001). However, agency thinking was not significantly associated with the levels of anxiety (β = 0.09, t = 1.21, p > .05). There was no evidence for a mediating effect of hope agency on the relationship between perceived loneliness and anxiety (indirect effect = -0.02, SE = 0.02, 95% CI [-0.07, 0.02]). Similarly, there was no evidence for a mediating effect of hope pathways on the relationship between perceived loneliness and anxiety (indirect effect = -0.01, SE = 0.02, 95% CI [-0.06, 0.03]) in the whole sample.
Our results showed that the indirect effect of perceived loneliness on anxiety via hope agency was moderated by age (b = -0.14, SE = 0.06, 95% CI [-0.28, -0.03]). Specifically, the hope agency acted as a mediator in the young adults (b = 0.10, SE = 0.05, 95% CI [0.01, 0.22]), but not in the older adults (b = -0.04, SE = 0.04, 95% CI [-0.12, 0.01]). For young adults, higher levels of hope agency were associated with lower levels of anxiety (b = -0.41, p < .001), whereas for old adults, such a relationship was not significant (b = 0.06, p > .05) (Figure 4).
Figure 4: Anxiety at low vs. high hope agency for young and old adults.
Regarding the model involving hope pathways, both perceived loneliness × age and hope pathways × age was not significantly associated with anxiety. In other words, age did not buffer the mediating effect of hope pathways on the relationship between perceived loneliness and anxiety in the two age groups (young adults: b = 0.08, SE = 0.06, 95% CI [-0.04, 0.19]); old adults (b = -0.01, SE = 0.03, 95% CI [-0.08, 0.03]).
Hope agency did not mediate the relationship between perceived loneliness and CPD (young adults: b = 0.05, SE = 0.04, 95% CI [-0.01, 0.15]; old adults: b = 0.00, SE = 0.02, 95% CI [-0.03, 0.04]) in the whole sample. Interestingly, we found that hope pathways × age were significantly associated with covid peritraumatic distress, (b = -0.09, SE = 0.04, 95% CI [-0.19, -0.02]). Moreover, such mediation was only detected in young adults (b = 0.08, SE = 0.04, 95% CI [0.02, 0.17]), but not in the older adults (b = -0.01, SE = 0.02, 95% CI [-0.05, 0.02]). Further, the simple slope diagram (Figure 5)
Figure 5: CPD at low vs. high hope pathways for young and old adults.
illustrated that higher levels of hope pathways were associated with lower levels of CPD for young adults (b = -0.45, p < .001), whereas such a relationship was not significant for old adults (b = 0.04, p > .05).
The current study aimed to examine the mediating effect of agency thinking and pathway thinking between perceived loneliness and anxiety among young and older adults. Our results revealed that hope agency modulated the negative influence of perceived loneliness in younger adults compared to the older adults. Moreover, hope pathways modulated the reported covid-19 peritraumatic distress in the younger adults compared with the older adults.First of all, we found positive associations between loneliness and anxiety, and a negative association between loneliness and hope, which were in line with previous findings (e.g., Beutel et al., 2017; Okruszek et al., 2020). Consistent with other studies reporting young people were more negatively affected by the COVID-19 (e.g, Varma et al., 2021), young adults in our study reported higher levels of perceived loneliness and anxiety than older adults. Despite the reports of higher general distress, younger adults reported similar levels of hope agency and pathways as the older adults. To our knowledge, no previous studies examined the age difference in hope during COVID-19; our study suggested that hope might be a stable construct in young and old adult groups.
Despite the fact that neither pathway thinking nor agency thinking mediated the relationships between perceived loneliness and anxiety in the overall sample, our findings revealed specific roles of agency and pathway thinking in mitigating the negative impacts of COVID-19. Specifically, hope agency mediated the relationship between perceived loneliness and anxiety in young adults, and hope pathways mediated the relationship between perceived loneliness and peritraumatic distress in the young adults. In the original theory of Hope, Synder et al. (1991) proposed that both components of hope facilitate psychological adjustment. Our results showed that hope agency and pathways may have unequal contributions to anxiety and distress during COVID-19. Only
hope agency mediated the effect of perceived loneliness on anxiety in our young adult samples. It might imply that despite feeling lonely, younger adults with higher motivation to initiate or achieve a goal would result in lower anxiety. In fact, lacking motivation might be an important source of anxiety symptoms in young adults. Consistently, several studies have suggested the stronger involvement of hope agency on anxiety over hope pathways (Chang et al., 2016; Muyan & Chang, 2019). In contrast, the effect of perceived loneliness on COVID-19 peritraumatic distress, an index aimed to quantify pandemic-related acute stress reactions involving additional mental health factors, was mediated only by hope pathways. We conjecture that high pathway thinking, the perceived ability that a specific and concrete goal can be attained, might enable young adults to cope with stress more effectively. The null findings in old adults might be understood by their low requirements for social connections. In other words, the quarantine policies did not significantly undermine the fulfillment of their needs for social network nor changed their daily routine (Luong et al., 2011). Another possible explanation is the widespread adoption of digital technology for Hong Kong elderly. Although being inexperienced in using virtual technology could increase the vulnerability of feeling loneliness, such situation may not have applied to Hong Kong old adults. Yang et al. (2022) reported that around 70 percent of old adults have taken advantage of smartphones for social connections in 2021 (e.g., video calls with family members), which countered the negative impact caused by quarantine policies. Moreover, Philip et al. (2020) proposed a potential explanation that older adults generally have greater resilience, emotion regulation and coping strategies which provided better psychological responses during the pandemic.
Our study provides insight that hope could buffer the relationship between perceived loneliness and anxiety in young adults during COVID-19. The findings underscored the importance of hope, both agency and pathways thinking, in young adults to enhance their resilience in combatting COVID-related distress. Several hope-focused interventions suggested by previous studies could improve the hopeful thinking for young adults. Berg et al. (2020) developed an 8-week app-based program, focused on psychoeducation on hope-related skills (e.g., how to maintain motivations towards life goals) and addressed the enhanced mental well-being. Another brief single-session hope intervention conducted by Feldman and Dreher (2012) showed the greater hope of college students and facilitated their goal progress.In addition to specific hope intervention, problem-focused coping, aiming to resolve stressful situations with strategies such as reason identification, new skills learning, and implementation of alternative plans and approaches could also ameliorate the hope pathways (Folkman & Lazarus, 1985). What is worth mentioning, due to the interactive nature of the relationship between agency and pathways, the enhancement of either agency or pathways thinking should be another effective method to boost each other. For instance, distressed young adults who engage in such coping training should have more pathways to achieve goals and, as a result, gain more confidence and self-esteem (i.e., agency promotion). Lindsay et al. (2019) conducted a study about a 2-week smartphone-based mindfulness training, which reduced loneliness significantly and improved the feeling of social connectedness. Such training should be appropriate under the pandemic circumstance.Hope is also a crucial determinant of mental health for older adults although our study did not discover its mediation effect of hope among this group. Maintenance of a healthy hope level could prevent or lower the risk of other mental health problems. Two psychological interventions based on cognitive behavioral therapy (CBT) and life review are recommended to improve hope in older adults after a systematic review (Hernandez & Overholse, 2021). CBT facilitates goal-setting (e.g., breaking goals down into several manageable steps) and life review therapy enables one to recollect previously fulfilled particularized hopes to strengthen generalized hope.
The findings should be considered in light of several important limitations upon which future research can build. First, we conducted a cross-sectional study so inferences of any causality should be cautioned. Second, it is unclear if the present model is useful across other age groups (e.g., middle age group). We emphasized on young adults and older adults in our study because they are the two group psychologically more susceptible to the impact of the pandemic (Birditt et al., 2021). Future studies could consider including more age groups, so as to paint a more complete picture of the moderating effect of age. Third, the participants were recruited by the convenience sampling procedure, therefore the generalizability of our findings to other groups (e.g., old adults who live at home) might be limited. Given the null findings in the older adults group, further studies should attempt to use random sampling, particularly in the older population to unveil the relationships among hope, perceived loneliness and mental distress.
The COVID-19 pandemic will not be the last in our lifetime. Despite the current pandemic is nearly over, it is important to learn from the past such that we can be better prepared for the next pandemic. The present study highlights the importance of hope as an important psychological resource that we can enhance to help us manage through challenging situations. This internal psychological resource seems to play a more important role in younger adults compared to their older counterparts. Future work should focus on strategies to enhance hope in younger adults while further exploring other psychological resources that might help older adults to combat the next pandemic.
No potential conflict of interest was reported by the author(s).
Acknowledgement
The authors thank Ms. Tiffany Li for contributing her time and effort in the data collection of this project.
This project is supported by the State Key Laboratory of Brain and Cognitive Sciences Research Fund.
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Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
