Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future

Introduction

The World Health Organization (WHO) declared coronavirus disease (COVID-19) a global pandemic in March 2020. Between March 1^st 2020, and January 7^th 2023, Ireland registered 1,697,775 COVID-19 cases and 8,309 deaths from COVID-19¹. Ireland implemented a range of public health measures to suppress the spread of the virus, including instructions to stay at home, travel restrictions, and physical distancing, consistent with WHO and other international guidelines². The focus of this research was on the impact of these measures on self-reported health seeking behaviour in the population. While it was anticipated that these measures would reduce presentations with non COVID-19 related illness in both primary care and hospital settings, the magnitude and distribution of these effects is not well described.

A decrease in the number of attendances to Irish public hospitals providing emergency care was reported in March 2020 compared to January and February of the same year and compared with figures from March 2019³. This trend has also been reported in other countries. A study of one million medical admissions in the U.S. revealed a decline in non COVID-19 related admissions of 20% at the beginning of the pandemic between February and April 2020, including reductions in presentations of serious life-threatening conditions such as sepsis (25% reduction in the 3 month period), acute ST-elevation myocardial infarction (22%), and pneumonia (40%)⁴. A similar trend was observed in another US study, where during the pandemic, a 23% reduction was observed in ED presentations of myocardial infarction, 20% for strokes, and a 10% reduction in hyperglycaemic crises. The authors suggested that the most plausible explanation was that patients could not access care or avoided or delayed seeking care⁵. A study in the UK revealed that 45% of the population reported having potential malignancy-related symptoms during the pandemic (n=3025) and did not seek medical attention⁶. These findings suggest that individuals’ health-seeking behaviours changed during the pandemic, even in the context of significant conditions that would normally result in an emergency presentation to the hospital.

In a further US-based study, higher COVID-19 risk perception was a strong predictor of medical avoidance⁷. Risk perception was assessed using participants’ responses to three questions in an online survey: risk of COVID-19 to their community, perceived risk of infection, and perceived severity if the respondent became infected. Significant predictors of higher risk perceptions included female sex, knowing someone with COVID-19, older age, and poorer health.

In the aftermath of the pandemic, the consequences of health care avoidance became evident. A study in the US compared the first presentations of early- and late-stage breast and colorectal cancer before and during the COVID pandemic (comparing 2019 figures to 2020). That study reported a statistically significant decrease in the number of women presenting with stage 1 breast cancer but a significant increase in those presenting with stage 4 breast cancer during the pandemic. A continuation of this trend during the early months of 2021 was also observed⁸. A further study in the UK also demonstrated that patients presented with higher stages of breast cancer and more node-positive and metastatic disease on initial presentation and diagnosis in 2020 than in the pre-pandemic period in 2019⁹.

This study aimed to examine the influence of socio-demographic factors, self-reported health status, health related behaviours and exposures, and COVID-19 risk perception on self-reported health-seeking behaviours, specifically the likelihood of avoiding primary care, i.e. general practice (G.P.) and hospital-based healthcare, in the Irish population during the initial stages of the COVID-19 pandemic.

Methods

Results

Data from 969 participants were analysed. The sociodemographic characteristics of the participants are provided in Table 1.

There were similar proportions of men (48.1%) and women (51.7%). Participants ranged in age from 18–91 years, with a mean age of 47.9 (SD = 17.2). Over half of the sample had completed third-level education and worked as employees (either full-time or part-time).

Discussion

This study of sociodemographic and health related factors associated with self-reported healthcare avoidance during the initial months of the COVID pandemic in Ireland has a number of significant findings with actionable lessons for the future. Women, those with self-reported poorer health status and those reporting the experience of an adverse life event in the previous three months, were at a higher risk of avoiding contact with their G.P. about non COVID-19 related concerns. Individuals at a higher risk of avoiding hospital-based care were those aged 70 years or older and who had poorer self-reported health status.

These findings are similar to those from a US study, in which women, older adults and those with a higher perceived risk of infection which likely reflects poorer self-assessed health status were more likely to avoid seeking healthcare⁷.

The findings are also consistent with those from a cross-sectional study embedded within the ongoing population-based Rotterdam Cohort Study. In the latter study, women and individuals with lower perceived overall health and mental health issues (depression and anxiety) avoided seeking hospital-based healthcare, even when these groups had potentially serious symptoms (limb weakness, palpitations, and chest pain)¹⁴. There is also evidence from a UK study of failure to seek medical attention during the pandemic among individuals with potential malignancy-related symptoms⁶.

Thus the findings from this study complement and extend the available international literature on the impact of stay-at-home orders and related public health measures in response to a pandemic on healthcare utilisation avoidance in the population. In particular, the findings augment the available evidence that the adverse effects of public health restrictions are more pronounced in those at greatest need for healthcare.

For individuals to feel safe and able to access healthcare in future pandemics in Ireland, it is crucial that we note and learn the lessons from our experience with COVID-19. It seems clear that a significant proportion of vulnerable individuals weigh the risk of attending hospitals or GP surgery as higher than the risk of remaining at home with potentially serious issues. Post-pandemic studies have shown that these issues include late-stage, potentially curable, cancers⁸. In Ireland, the National Cancer Registry reported a 10% shortfall in expected new diagnoses of cancer in 2020, improving to a 6% shortfall in 2021¹⁵. These issues may be especially relevant to patients with blood cancer, where the nature of the cancer, which affects the bone marrow and immune system, means that they are the most vulnerable group to opportunistic infections.

Our data provide important information specific to Ireland on behaviours during the pandemic. Because this study was carried out during periods of lockdown, recall bias was minimized and respondents answered regarding behaviours in real time. These valuable data provide the basis for targeted campaigns, specific information, and encouragement for vulnerable groups to help improve outcomes in future pandemics. The findings from this study suggest that people who may be most in need of health care are those who are least likely to access it.

This study had several limitations. The estimated response rate, although relatively high for a population-based telephone survey (43.6%), is clearly sub-optimal and the weighted sample of respondents may not be adequately representative of the underlying base population. In particular, it is likely that specific vulnerable sub-groups such as the homeless community are underrepresented in the study.

Lessons can be drawn for future pandemic preparedness in Ireland. Our data supports the use of advance planning to target vulnerable groups with appropriate public information campaigns on the appropriate response to potentially significant symptoms and concerns. Planning could also include work on the infrastructure required to pivot quickly to telephone clinics and video consultations, including work on data sharing issues, where appropriate.