Introduction

During the outbreak of COVID-19 pandemic healthcare services have been substantially disrupted leading to negative health consequences and excessive deaths. As of 9 August 2023, there have been 769.4 million confirmed cases of COVID-19, including 6.9 million death, globally [1]. Besides the devastating numbers of death from COVID-19 infection, the pandemic also contributed to the massive reduction in health service utilization, especially among patients with less severe conditions [2]. Notably, the reduction of essential treatment services may lead to complications and significant deaths.

Acute Coronary Syndrome (ACS) is a life-threatening heart condition that requires immediate treatments to prevent adverse cardiac events and mortality risk [3–5]. Prior to the pandemic, pre-hospital treatment delays, which is a major cause of mortality among patients with ACS, have been reported in many low-and middle-income countries [6]. Lack of awareness of signs and symptoms of ACS, lack of adequate Emergency Medical Services (EMS), limited access to transportation, and delay decision to seek treatment are among important factors contributing to such delays [6]. During the pandemic, significant reduction in the number of ACS admissions and the increase in delayed presentation of ACS patients were consistently observed. These suggested that treatment seeking behaviors of patients with ACS during the pandemic might differ from the prior period [7–9].

Indonesia is the fourth most populous country in the world, located in Southeast Asia. ACS is considered a major cause of mortality and disability in Indonesia [10]. In 2019, Indonesia was ranked as the 6th country in the world with the highest number of cardiovascular deaths [11]. Prior to the COVID-19 pandemic, unmet timely care among ACS patients has been a major concern in Indonesia [12–14]. Starting from 3 January 2020 to 16 August 2023 [1], approximately 6,813,000 confirmed cases of COVID-19 and 161,916 deaths were reported in Indonesia.

It should be noted that several additional factors could profoundly affect treatment seeking behaviour/decision during the pandemic. These might include the fear of contracting COVID-19 [15], lock down policies [16], and stay-home advices [17]. In addition, several additional strategies such as COVID-19 screening procedure, isolation process of infected patients, visitor restriction, the use of personal protective equipment, and surface and equipment cleaning/decontamination process were implemented in the hospitals to mitigate the transmission [18]. Overcrowding and scarce medical resources have been widely reported during the pandemic [19]. These aforementioned factors could affect treatment seeking behaviour as well as treatment experiences of the patients during the pandemic. There is an urgent need to comprehend the treatment seeking behaviour of patients, the barriers that may cause delayed presentation of acute coronary syndrome (ACS) patients at healthcare facilities, and the treatment experiences of ACS patients during the pandemic. However, the available evidence on these matters is extremely limited [20, 21]. This qualitative study, therefore, aimed to explore patients’ treatment seeking behaviour, barriers in seeking medical treatment, and treatment experiences of patients with ACS during the COVID-19 pandemic. Findings from this study could serve as an important lesson for healthcare staffs and policy makers to develop suitable and practical strategies to promote timely decision to seek treatment among patients with ACS and to improve the quality of ACS care process during the future crisis.

Methods

Results

In-depth interviews were conducted among 30 patients. Of these, 22 were males while 8 were females. The age of the patients ranged from 40 to 63 years old. All were married. Participants’ characteristics were shown in Table 1. The following three themes were identified: 1) treatment seeking decision, 2) barriers in seeking medical treatment during COVID-19, and 3) experiencing both good and bad impression from entering and staying in the hospital. These main themes and eleven sub‐themes within them were discussed below along with the relevant quotations.

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Table 1. Participant’s characteristics.

https://doi.org/10.1371/journal.pone.0302320.t001

Discussions

This study provided insight into treatment seeking behaviour, barriers and enabling factors for seeking medical treatment, and experiences after entering hospitals, communicating with healthcare staffs, and receiving medical treatment for ACS patients during the COVID-19 pandemic. We found that treatment seeking decision was aligned with the evidences prior to the pandemic in that mild ACS symptoms led to the delay in seeking medical treatment [25–28]. When symptoms were mild, such as fatigue and tiredness, patients might misinterpret and believed that these symptoms were caused by hard work and could be fully recovered in a few days without specific medical treatment. Therefore, many participants with mild symptoms preferred treating themselves with traditional/herbal medicine to seeking immediate medical treatment. Like previous study in Indonesia [29], our study found that many participants with ACS relieved their symptoms by only massaging and rubbing their arms or chest with oil as applied in the medical pluralism concept [30].

Similarly, tendency to choose self-treatment by using home remedies to solve their symptoms was also found by previous study among women in Middle East country [25]. A previous review found that low intensity symptoms were considered as not serious disease then leading patients to delay for seeking medical helps [26] or just wait and believe that the symptoms will be away in the near future [28]. However, when symptoms emerged again and again, or when symptoms were severely aggravated, patients were triggered to seek effective medical care.

Fear of being afflicted with COVID became the main obstacle for patients to seek medical help in the healthcare facilities. In our study, fear of approaching and staying in the hospital was driven by media and numbers of dead patients in the hospitals announced every day. These have been reported in other studies [20, 31, 32]. However, for some patients, fear of severe ACS condition overcame that of COVID-19 infection. Thus, leading them to urge for medical treatment.

Our study also found that confidence in safety measures proposed and recommended by the Indonesian government were frequently and strongly expressed by most participants. A prior investigation concerning the relationship between trust in the government and behavioural reactions amidst the COVID-19 pandemic revealed that patients have faith in power of their government in managing or controlling health care system and spaces to achieve the safe and hygienic zone of all patients. Hence, they were willing to enter the hospital with confidence. [33]. Thus, our findings indicate that a segment of Indonesian society has a high level of faith in the government and health system while dealing with the pandemic.

In our study, some participants mentioned that their concern and fear were considerably alleviated and resolved by the power of God. This is consistent with the Muslim’s belief that health is one of the greatest blessings from God while illness is seen as part of the human condition by God’s wills [34]. Therefore, they tended to put all their faith in God and feel less fear. In summary, the health seeking behaviours identified from our study findings were in line with the concept of health belief model [35] in that health seeking behaviour was influenced by the following factors; 1) Perceived susceptibility to the disease, 2) Perceived severity of the disease, 3) Perceived benefits of the intervention, 4) Perceived barriers,, and 5) cues for action. According to our findings, patients who perceived that he/she might be susceptibility to ACS and those who experienced severe symptoms were likely to seek immediate treatment. On the other hands, fear of COVID-19, and perceived of overcrowding environment in the hospitals were identified as barriers for treatment seeking behaviour. However, when the symptoms were more severe so that the perceived threat of the ACS outweigh the fears of COVID-19 together with the perception on the benefit of medical treatment, the decision to seek medical treatment was, then, made. Moreover, the advices from others such as family members and neighbours, and advices from government especially about health care hygiene for preventing COVID-19 were served as the cue to action identified in our study.

Based on these findings, media campaign should focus on the value of the immediate treatment for ACS patients by emphasizing these specified symptoms as “severe” and “must go to the hospital”, as well as benefits of timely treatment to encourage patient’s decision to seek ACS treatment in the midst of pandemic. Fear of COVID-19 contracting, which was the main barrier for seeking medical treatment should also be minimized by disseminating the information that the effective prevention strategies were implemented at the hospitals to limit the transmission during the pandemic.

While other studies found that living alone [36] or reluctant to bother other [6] were cited as barriers for treatment seeking for ACS it is not the cases in our study. Similar to the pre-COVID period, we found that the treatment-seeking decision involved discussion with family members and neighbours. Involvement of family members in treatment decision-making is rooted in family and culture of Indonesia. Culturally, for both in rural and urban area, family plays an important role to help the patients in treatment decision-making process [37, 38]. In addition, the involvement of neighbours is also common in Indonesia [38]. According to Javanese culture, members of the community have a strong need to be in close proximity with one another and seem to have a harmonious and tight relationship with others in the society [39, 40].

In terms of treatment experiences, despite the fear of contracting COVID-19 prior to the hospital visits, patients were satisfied with medical services they received during the pandemic. In addition, they felt confident and safe while staying in the hospital and waiting for their surgery. This might be due to the fact that their safe health conditions were reassured by the very clean medical facilities and the very hygienic medical procedures, as it similarly reported by the previous study [21]. Moreover, all medical staff wore protective equipment and strict routine process to separate normal patients from those with COVID-19 were enforced continuously. Nevertheless, in order to maintain safe and secured health conditions for everyone, especially all vulnerable patients, duration to visit and talk with patient must be limited, numbers of family members allowed to meet each patient had to be restricted, and close contact between patients and guests was not permitted. As a result, most participants revealed that all restrictions during the pandemic made both patients and their lack of emotional support and cause much psychological distress. These negative impacts were vividly observed and experienced in various settings [20] and might have more severe effects on paediatric patients and patients with terminal illnesses, whose family support is extremely needed [41]. In fact, medical pluralism concerns of visiting restriction might affect patients’ decision to urge for medical treatment during the pandemic. Fortunately, with the advancement in technologies, several strategies including online applications, that could provide communication support between patients and their families were available and easily used. These technologies should be adopted for healthcare situation to improve emotional support and alleviate patient’s sufferings during the future crisis, especially when inpatient visit restriction has been seriously implemented.

Furthermore, negative consequences from protective medical devices such as surgical-mask and PPE clothes were identified as the barriers in communication. Specifically, masks and PPE clothes made it difficult to communicate with the health care providers. To improve the communication during the pandemic while still maintaining all standard protocols to ensure both patient’s safety and satisfaction, several strategies could be implemented and evaluated. These included increasing volume, articulating speech, emphasized on importance of non-verbal communication [42].

It is important to acknowledge that this study has certain limitations. Since half of the participants came from the moderate-to-low socioeconomic status, when perceiving symptoms like fatigue and tiredness, all were inclined to interpret these symptoms as “results from hard work” that was very common and normal in their everyday lives, not abnormal symptoms signifying the serious health conditions. Thus, they tended to neglect or tolerate to these trivial symptoms and still went for their work as usual instead of going for a medical check-up in the hospital. Hence, the result from our study cannot totally apply for those who were in the different socio-economic status. In addition, our study was conducted in Yogyakarta, a city rich in conservative culture, where relationship between family members and neighbours were still closed and tight. When one was in abnormal health condition, families, relatives, or neighbours were prompt and willing to help and accompany him/her to the hospital. If they considered that participant’s symptoms were serious, these relatives and neighbours encouraged or took participants to go to the hospital abruptly. Therefore, these findings could not be applied to the big and commercialized city, where relationships among people, including family and neighbours, were very loose and distanced. Furthermore, all hospitals selected in this study were very ready and effective in dealing with critical cases and also had strict and standardized procedures to control the pandemic situation very well. These cannot be generalized to all hospitals in Indonesia since ranges of standardized and hygienic protocol in dealing with both COVID-19 and other critical health conditions were various. Experiences of patients with ACS after entering the emergency room and staying in the hospital were different.

There are a number of potential biases that could influence the in-depth interview study. The initial source of bias pertained to the interviewer. The interviewer in this study (PEN) completed a one-semester course on qualitative research in order to prevent interviewer bias and was appropriately trained in interviewing techniques such active listening, open questioning and probing, and rapport-building to foster a rich information. The transcriptions were also examined by the team members in order to determine any situations in which the interviewer might have introduced bias into the interviewee’s response.

Secondly, we may be concerned about participant bias, which occurs when participants present themselves or their experiences in a manner that they perceive to be consistent with the expectations of the researchers. As the interviews were conducted in the hospital, some participants might feel reluctant to express some concerns on their treatment experiences. To mitigate the participant bias, our interviewer was trained to establish trust, and create a non-judgmental environment that encouraged open and honest sharing. Also, the interviews took place in a private room, during which the interviewer duly informed each participant that she was not affiliated with the hospital personnel and that any information provided would be treated as strictly confidential.

Thirdly, we recognized the potential for selection bias to manifest in our research. It should be noted that we relied on the nurses and cardiologists, whose comparatively greater familiarity with patient characteristics, to select our respondents. As a result, there might be the cases that we might missed some patients who had negative experiences on the ACS treatment. Furthermore, non-response bias could also be occurred. Unfortunately, we were unable to compare the characteristics of non-respondents and respondents. Lastly, recall biases could possibly occurred as participants were required to recall their behaviours and experiences during the hospitalization with ACS.

While many studies were conducted to examine the impact of COVID-19 pandemic on the delay in treatment seeking, clinical management, and outcome of patients with ACS [7, 8], very limited qualitative studies were conducted to gain more in-depth details in terms of treatment seeking behaviour and treatment experiences of patients with ACS during the pandemic [20]. Thus, our study provided useful information which reflected how patients seek treatment for this acute and life-threatening condition as well as their experiences during the crisis. Nevertheless, further studies examining experiences, barriers as well as strategies adopted to overcome ACS treatment provision among health care providers during the pandemic are also warranted.

Conclusions

In terms of treatment seeking behavior, the lack of ACS symptoms recognition, especially the mild one, was considered a key non-COVID related factor contributing to delayed in seeking medical treatment. Fear of being infected is a significant barrier that hindered patients to seek medical treatment in the midst of pandemic. Family members and neighbours were the significant ones to persuade and carried the participants with critical symptoms of ACS to go for immediate treatment at the hospitals. The patient’s faith in God bolstered their motivation to seek medical assistance and undergo procedures to alleviate the symptoms of ACS.

With respect to treatment experience, most participants reflected their very positive impression from the fast and effective medical management as soon as entering the emergency room. In addition, they all experienced the hygienic and standardized procedures while staying in the hospitals and receiving surgery care and felt safe and relaxed. Nevertheless, under the very strict regime of serious disease control, opportunities for participants to communicate with medical staffs, their families and friends were inconvenient and difficult. Moreover, they mentioned positively that although all medical professionals were fully covered with surgical mask and tight costumes, they tried so hard to explain about details of participant’s conditions and medical treatment. Thus, they felt very satisfied and impressive with the attempt and kindness of all medical staffs.

Our study highlights the need of educational media and campaigns to promote the awareness of symptoms of ACS and the risk of delayed ACS treatment pervasively. During the future pandemic event, safety measures adopted by the hospitals and government to minimize risk of patients should be outline clearly to alleviate the fear of visiting hospitals and reassure that hospital is the safe place to seek immediate care for ACS. Innovative strategies, especially those involves technological advancement should be considered to mitigate the psychological distress from visit restriction policy.

Supporting information

Acknowledgments

The authors would like to thank all participants for their contribution and time to this study. Authors’ gratitude also addressed to all cardiologist and nurses from all participated hospitals (RSUD Wates, PKU Muhammadiyah Gamping, and RSUP. DR. Sardjito) for their valuable support during the data collection process.