Factors influencing the likelihood of accessing healthcare 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 since the start of the pandemic¹. In line with WHO guidelines to suppress the spread of the virus, public health measures, including instructions to stay at home, travel restrictions, and physical distancing, were implemented in Ireland². We asked whether these measures, introduced to protect the public, may have impacted non COVID-19 related medical care and population well-being.

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, substantiating the hypothesis that the pandemic and associated restrictions had an impact on the health behaviours of the population. This trend has also been reported in previous studies. 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. Similar results were 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 44.8% 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.

One US-based study demonstrated that higher risk perception was a strong predictor of medical avoidance⁷. Risk perception was measured using participants’ responses to three questions in an online survey completed by Massachusetts Institute of Technology (MIT) researchers: risk of COVID-19 to their community, perceived risk of infection, and infection severity. Significant predictors of higher risk perceptions included female sex, knowing someone with COVID-19, older age, and poorer health. A higher risk perception was associated with avoiding medical care⁷.

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 demographic and self-reported health factors on health-seeking behaviours, specifically the likelihood of avoiding 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 analysed¹². The sociodemographic characteristics of the participants are provided in Table 1.

There were similar numbers of men 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

Our study of the factors influencing the likelihood of accessing healthcare during the initial months of the COVID pandemic in Ireland has identified several significant findings with actionable lessons for the future. This study identified subgroups of individuals who were at a greater risk of healthcare avoidant behaviours during the initial period of easing COVID-19 restrictions in Ireland. Women, and those identified as being at an increased risk of infection, as well as individuals who reported experiencing 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 50–59 years, adults over 70 years, individuals at an increased risk of infection, smokers, and those who agreed that they were likely to become infected with COVID-19.

Our findings replicate those of a US study, in which women and older adults were also more likely to avoid seeking healthcare. The study also showed that a higher perceived risk of infection is associated with a higher probability of avoiding medical care⁷. There is evidence from a UK study of failure to seek medical attention during the pandemic among individuals with potential malignancy-related symptoms¹³.

A Dutch study also identified that 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. Taken as a whole, including our findings in the Irish population, studies clearly demonstrate an avoidance in healthcare-seeking behaviour from the beginning of the pandemic in several vulnerable groups.

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 the COVID emergency, here in this country and elsewhere. The shift in the behaviour of some vulnerable groups in our population during the pandemic suggests that individuals appear to be weighing 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, in 2020, the National Cancer Registry reported a 10% shortfall in expected new diagnoses of cancer, improving to a 6% shortfall in 2021¹⁵.

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.

These findings are especially relevant to patients with blood cancer, where the nature of the cancer, which affects the marrow and immune system, means that they are the most vulnerable group to opportunistic infections. Anecdotally, immunocompromised haematology patients frequently required telephone discussion and reassurance prior to hospital attendance during the pandemic and management of a structurally separate non -COVID pathway within the hospital setting while receiving emergency care for infection/ possible sepsis during the pandemic.

This study had several limitations. The estimated response rate was relatively high for a population-based telephone survey (43.6%). However, individuals who did not respond to the survey, for whatever reason, may have responded differently to participants who responded to the survey, creating a response bias. Our study population may underrepresent the elderly population or the homeless community, who may be less likely to have access to a phone or respond to a telephone survey.

Responders’ reports of being at risk of infection are based on self-perception and may or may not be based on their medical diagnoses. However, this has the advantage of representing the respondents’ understanding of their own situation, which is a likely determinant of decisions, regardless of any objective underlying diagnoses.

Lessons can be drawn for future pandemic preparedness in Ireland. Our data supports the use of advance planning to target vulnerable groups with appropriate information and reassurance regarding safety measures for care. Planning could include infrastructure for pivoting quickly to more telephone clinics, preparing for video consultations, and laying the necessary groundwork for any data sharing issues, including utilizing artificial intelligence where appropriate. Addressing the technical requirements in advance would be helpful. All of these measures could assist in managing emergent pathogens in the groups shown to avoid hospital and healthcare settings. Planning for effective communication between these groups and general practitioners is also prudent. In Ireland, the coexistence of the cyber attack on the HSE during the pandemic also hampered efforts to provide appropriate on-site or remote care. Contingency planning for multiple simultaneous threats is required in the current global climate.