Hasselt Corona Impact Study: Impact of COVID-19 on healthcare seeking in a small Dutch town

doi:10.21203/rs.3.rs-4876940/v1

Introduction
We explored reasons for healthcare avoidance during the first COVID-19 wave in a region with high infection rates.

Methods
We conducted a mixed-method study using primary care electronic health records (n=5,980), questionnaires (n=2,361), semi-structured interviews (n=12), and an AI model to identify COVID-19 patients in a Dutch small town.

Results
Of 2,391 respondents (39% response rate), 535 (23%) reported COVID-19-related symptoms. Of these, 180 sought help, mostly from their GP. The care-seeking rate did not differ significantly between those with or without relatives who experienced severe illness or death before their own illness (p=0.270). Interviews revealed that the primary reason for not seeking help was the perception of not being ill enough and the overstressed healthcare system, especially GP services.

Conclusion
Only a third of participants with symptoms sought help, mostly from GPs. No significant difference in seeking healthcare was related to the serious illness or death of loved ones.

Health sciences/Health care

Health sciences/Medical research

COVID-19

General practice

primary care

healthcare utilization

During the first COVID-19 wave, the municipality Hasselt was one of the regions with the highest number of infections in the Netherlands. Due to the high infection rate, the local general practitioners (GPs) started a contingency plan to prevent overwhelming of the healthcare system.(1–3) Regular care and infection care were separated, and chronic care was discontinued. Consequently, the number of consultations and diagnoses in primary care for other problems, such as cancer or mental illnesses, declined.(4–6) At the same time, most appointments were conducted remotely by telephone or video calls unless there was an urgent need for an appointment in person.(7,8)

Although many symptoms in primary care are self-limiting, urgent medical evaluation is essential in some patients to mitigate health damage. The fear for patients of becoming infected with COVID-19, made it more complex to visit a GP. Furthermore, the various restrictive measures could have also influenced mental health as well, possibly resulting in modified healthcare seeking behaviour.(5,9,10)

The actual reasons for not seeking care are underexplored. Therefore, the aim of this study was to investigate the impact of COVID-19 on seeking help at the GP during the initial wave of the COVID-19 pandemic in a region heavily affected by the virus. Subsequently, we examined healthcare-seeking behaviour, particularly emphasizing cases where individuals did not seek for help despite having COVID-19 complaints.

We conducted a mixed-method study combining, combining primary care electronic health records with a questionnaire and personal interviews, focusing on the first lockdown period between March 2020 and September 2020.

Study population

The study population comprised all patients registered at one of the three different general practices in the Dutch municipality Hasselt as of March 2020. They were identified in August 2022. In the Netherlands, all inhabitants are registered with one GP, and in the study region, no other GPs hold practice.

Data collection

Baseline characteristics (March 2020) of all patients were extracted from the electronic medical files of the participating practices. Patients with a registered email-address received an online invitation and a questionnaire. All others received the same invitational letter and questionnaire through post in September 2022 (Supplementary File 1). After two weeks, a reminder was sent to all people with an online questionnaire, but not those with a postal invitation. Additionally, the research was promoted in one of the local newspapers “De Stentor”. The questionnaire was designed to identify patients who experienced symptoms of COVID-19 during the first wave but did not seek medical care. Additionally, we used an AI model (BERT model), a natural language processing (NLP) model, to identify the patients with a COVID-19 infection or consultation of the GP possibly due to COVID-19 between March 2020 and September 2020.(11) This was based on the routine care data of the practices, As imported in the AHON-registry.(12)

Based on the survey responses, we selected a subgroup of COVID-19 cases who did not seek medical help. Participants from this subgroup were selected at random and stratified based on the three different practices. They were then invited to participate in personal semi-structured interviews. For this, an interview guide was developed allowing to explore the participants’ experiences and needs during the first lockdown period. Interviews were conducted by experienced interviewers from the regional Common Health Service, until saturation was reached.

The semi-structured interviews were audio-recorded, transcribed verbatim and analyzed using inductive thematic analysis with the program Atlas.ti to identify themes. After reading the transcripts from all interviews in detail, two interviewees coded the data that were deemed to be relevant for the current study. The transcripts were not returned to the participants for review. Related codes were grouped into potential themes. Finally, we identified and labeled the themes, and developed a narrative structure accompanied by corresponding descriptions.

Statistical analysis

Statistical analysis was performed using SPSS statistics 27.0 software. Characteristics of the study population measured on a continuous scale were represented as either mean±SD or median (interquartile range), depending on the distribution. Categorical variables were presented as the total number of observations with corresponding percentages. Data comparing participants and non-responders were analyzed by using Mann-Whitney U test or Chi Square tests, depending on the type of data. P-values <0.05 were considered statistically significant.

Ethical approval

The study has been approved by the Medical Ethics Committee of the Isala Hospital, Zwolle (registration number 20211017).

Baseline characteristics

In total, 6,123 patients aged over 16 years were extracted from three different general practices. 143 patients were excluded due to missing data, leaving 5,980 patients in the study population (Figure 1). The response rate of the questionnaire was 39% (n=2,361). Baseline characteristics of participants and non-responders are shown in Table 1. The median age of participants was higher than the non-responders (median 57 years, (range 16-93) vs 40 years (16-93)). Moreover, the proportion of females was higher in the participant group (58%) compared to the non-responder group (44%). Patients with hypertension, heart failure, and malignancies exhibited higher response rates. In contrast, those with asthma or COPD had lower response rates. Lower response rates were observed in individuals identified by the AI model as having COVID-19 symptoms.

COVID-19 symptoms

According to the AI model, out of the 5,980 patients, 4,207 have had contact with their GP at least once, for various reasons. Information about COVID-19 was discovered in 3,400 unique medical records, and out of these, 1,508 patients participated in the questionnaire. In 1,660 medical records, the AI model predicted the presence of COVID-19. From this group, 41,9% participated in the survey.

Among all participants, 23% (n=535) reported experiencing any COVID-19 related symptoms (Table 2). Of these, 139 participants (26%) actually had a positive PCR-test by testing at the common health services. The most frequently reported symptoms were cough (56%), fever (56%), dyspnoea (51%), cold (51%) and muscle pain (50%). Among them, 180 participants (33.6%) reported seeking help for COVID-19, with 176 of them contacting their GP. Of the 535 participants with complaints during the first wave, 236 (44%) reported persistent complaints. Within this group, 80 participants (15%) reported experiencing symptoms for more than 24 months.

Among participants with COVID-19 symptoms, there was no significant difference in the percentage of relatives or acquaintances who experienced severe COVID-19 symptoms or passed away before their own illness, between those who sought care and those who did not (48% vs. 43%, Chi-square p=0.270). Reasons for not seeking help, as mentioned in the free-text section of the questionnaire, included ‘due to the wave of participants’, ‘we waited at home to reduce the severity of complaints to a bearable level’ and ‘the government’s advice at the time was: only seek for help if you have severe shortness of breath’.

Thematic analysis semi-structured interviews

Data saturation was reached after interviewing twelve participants, with a median age of 57 years (range 38-80 years), who generally described their current health as reasonably good (Table 3). Five of the interviewees (42%) had relatives who showed severe COVID-19 related symptoms or passed away. The main themes arising from the analyses were mental impact, physical impact, social impact and use of care (Figure 2).

One significant reason for not seeking help was participants’ assumption that they were not seriously ill. One participant (#1) said: I do not visit the GP that often, or rather, I have barely been there. If I would go to the GP, this should have a good reason. Three weeks of flu-like symptoms was not a reason for me to visit the doctor. Another participant called the GP, but was then directly referred to a special cough clinic of the nearest hospital. However, he was admitted only a few weeks later.

One participant indicated that he was experiencing ongoing complaints but did not want to burden the GP too much due to the high workload for GPs at that time. Another participant (#5) also mentioned the difficult job that GP had at the time: The knowledge that the GPs were in such a crisis and that they were so terribly busy. You heard one ambulance after the other and later on the church bells for funerals kept on ringing. I thought that was a really bizarre situation. I don’t blame anyone for that, because it was just the way it was. While most participants were satisfied despite not receiving healthcare, they were able to manage their symptoms on their own. Some participants indicated that they would have sought help if their symptoms had persisted a little longer.

Mental and social impact

The mental impact was mainly attributed to the broader COVID-19 crisis in general. Participants frequently cited social limitations and changes in social interactions as significant factors. A participant (#6) commented on the difficult social limitations as well, but added: On the other side, a lot of people around you have died, everyone had friends and acquaintances dying, and that had much more impact than not being able to do my own thing. Moreover, many participants expressed frustration regarding the lack of clarity from the national government and the frequent changes in COVID-19 regulations. Some older participants noted that the infection and crisis had a less impact on them overall, as they were already retired and engaged in fewer activities. However, one entrepreneur participating in the study reported experiencing significant stress due to the COVID-19 crisis, as his company was permanently closed and he had to lay off employees.

Several participants described the number of deaths on Hasselt as profoundly impactful and intense. One of the participants (#9) working at a nursing home said: The nursing home is where a lot of people died. I helped in the department for people with dementia where there were four different residential groups and at the end of COVID-19, there was only one group left.

Use of care

Participants expressed varied preferences regarding their ideal assistance or care. Some participants desired more support from their GP, but cited obstacles such as limited complaints and high GP workload. Bottlenecks within the healthcare system, exacerbated by the COVID-19 crisis, were also noted, including constraints in PCR test capacity and inadequate aftercare for those experiencing long-term effects of COVID-19. Suggestions for improvement included a 24-hour helpline for inquiries and concerns, as well as increased availability of guidance on managing complaints, and medication use.

Overall, various factors contributed self-direction and self-management among participants. Acceptance of their illness and the inability to visit a GP were common themes. Moreover, the majority experienced spontaneous improvement through rest. One participant (#5) described the situation as: I am positively surprised by my own ability to handle the situation and to trust the signals of my body and to think: I am sick, but not really sick, so I do not need a doctor and I can handle it by myself.

Additionally, informal support from partners or children, including performing tasks and providing emotional support, aided self-management. Participants appreciated healthcare workers despite challenges in arranging immediate assistance. While some wished for different outcomes, many understood the constraints of the crisis and refrained from blaming GPs, given the limited understanding of COVID-19 at the time. Looking ahead, participant 5 remarked: If I would have COVID-19 right now, I would prefer to visit the GP directly to discuss my complaints and what we should do, but discussing that part was not possible at that moment.

This mixed-methods study suggests that only one-third of patients who experienced COVID-19 related symptoms during the first wave sought medical care, primarily from their GP. Contrary to our hypothesis, no difference was found between healthcare seeking and the presence of serious illness or death of loved ones. The primary reason for not seeking help was found in the participants’ belief they were not sick enough, compounded by an overstressed healthcare system, particularly regarding GPs.

The study sample was representative of the Dutch population in terms of comorbidity prevalence.(13) Participants generally expressed contentment and most of them managed the situation by themselves. Suggested improvements for future health crises included: sufficient availability of PCR-tests, improved access to health advice (possibly through telephone or digital means), and enhanced information on managing complaints, including long-term symptoms.

The COVID-19 pandemic significantly impacted global mental health, with high rates of anxiety, depression, and stress were reported in the general population.(14) Our study suggests that the mental impact of COVID-19 related symptoms, primarily stemmed from the broader COVID-19 crisis. The uncertainty in this period, the reduced availability of healthcare, as well as accessibility of health resources (such as PCR-tests and face masks) influenced overall well-being of the participants. Also, the high number of deaths in this relatively small population has had impact. The relationship between uncertainty and mental health had long been demonstrated investigated.(15)

Due to the government-imposed restrictions in the Netherlands, access to primary and secondary care was limited, leading to delayed care and missed diagnosis.(4–8) Previous studies have identified several factors that may have influenced care avoidance during the COVID-19 pandemic, including female gender, poor self-perceived health, and high levels of depression and anxiety.(1,16) In our interviews, participants cited social limitations, changes in interactions, and unclear COVID-19 related regulation as key determinants of their mental health.

The COVID-19 crisis also prompted an unprecedented restructuring and rapid adaptation of all health and social care givers.(17) For example, healthcare workers increasingly relied on remote care modalities such as telemedicine. Although participants do not want telemedicine to completely supersede face-to-face contacts, participants were satisfied with the use of telemedicine. Furthermore, a UK study between GPs which used telemedicine showed that the most commonly cited benefit was time efficiency, which is an important fact in the ever-increasing demand for care, especially for GPs.(17,18)

This study provided meaningful insights in healthcare-seeking behavior in a region heavily impacted by infections during the first wave of the COVID-19 pandemic. Several limitations of this study must be acknowledged. Apart from the interviews, we did not determine how many people would have actually wanted to seek help. Probably some participants who did not seek for help, actually had no desire to seek for help because of few complaints. Second, it is unknown how severe the complaints of the participants actually were. Furthermore, the questionnaires were sent more than a year after the first COVID-19 wave, which may have caused recall bias. Applying the AI model on the routine care data resulted in a higher number of participants with a probable COVID-19 episode than the participants themselves recalled. Therefore, the self-reported incidence of COVID-19 could have been underestimated.

The COVID-19 pandemic has greatly hastened healthcare system transformations. Our study findings can enhance care structures for future pandemics, emphasizing the need for clear communication and accessible healthcare, including telemedicine options.

Funding

Funding is received from the Hogerzeil foundation.

Ethical approval

The Hasselt Corona Impact Study has been approved by the Medical Ethics Committee of the Isala Hospital Zwolle (registration number 20211017).

Competing interests

The listed authors declare that there is no conflict of interest. This manuscript has not been published prior to submission.

Author Contribution

C.V. was the principal investigator. C.V. wrote the manuscript in consultation with E.A.G., J.W.K.B., and M.H.B. A.H.R. was responsible for conducting and processing the interviews. L.B. assisted us with obtaining the questionnaires and processing the data.

Acknowledgement

The authors thank the participating GPs in Hasselt (Robert van Kleef, Nico Tuinstra and Gabriëlle Rook) for sharing their data and for their assistance in contacting the patients. Special thanks are extended to Fokko Douma for his IT-support. Acknowledgement is also given to Marieke Jansen for conducting the interviews. Finally, we extend our appreciation to Lilian Peters, Maarten Brilman and Karina Sulim for their contributions in running the AI model.

Data Availability

Data is stored in the online portal ResearchManager. If desired, this can be displayed.

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Table 1: Baseline characteristics responders vs. non-responders.

	Total	Participants	Non-responders
No. of participants	5,980	2,361 (39.5%)	3,619 (60.5%)
Age (years, median (IQR))		57 (26%)	40 (31%)
Sex Female (%) Men (%) Unknown	2,978 3,000 2	1,374 (58%) 985 (42%) 2 (<1%)	1,604 (44%) 2,015 (56%) -
Registered episodes^* Diabetes mellitus (%) Hypertension (%) Heart failure (%) Asthma/COPD (%) Malignancy (%)	357 (5%) 1,019 (17%) 74 (1%) 575 (10%) 403 (7%)	179 (50.1%) 571 (56.0%) 40 (56.3%) 251 (43.7%) 234 (58.1%)	178 (49.9%) 448 (44.0%) 34 (47.7%) 324 (56.3%) 169 (41.9)
GP consultations^** Consultations GP Medical records with COVID-19 Patients with COVID-19	4,207 3,400 1,660	1,696 (40.3%) 1,508 (44.4%) 696 (41.9%)	2,511 (59.7%) 1,892 (55.6%) 964 (58.1%)

^*Based on ICPC-codes used in the three different GP’s.

^** Based on BERT-model (11)

Table 2: COVID-19 related survey of 39% of all the people in Hasselt, a small Dutch town.

% of participants (no.)

Total no. of participants

2,361

Type of living

Together with family or other loved ones

Alone

Nursing home

Unknown

86% (n=2,028)

12% (n=287)

1% (n=5)

2% (n=41)

Complaints due to COVID-19 (%)

No

Yes, based on:

Positive PCR-test

PCR-test was not possible

Didn’t want to do a PCR-test

Not mentioned

77% (n=1,824) 23% (n=535)

<0,1% (n=2)

26% (n=139)

71% (n=378)

3% (n=18)

Different COVID-19 related complaints*

Cough (%)

Fever (%)

Dyspnoea (%)

Cold (%)

Muscle pain (%)

Sore throat (%)

Loss of taste and smell (%)

Runny nose (%)

Sneezing (%)

Nausea (%)

Diarrhoea (%)

56% (298/535)

51% (275/535)

50% (270/535)

42% (226/535)

30% (159/535)

18% (95/535)

14% (75/535)

12% (66/535)

Participants seeking help due to complaints of COVID-19

Not seeking help

Seeking help^**

GP

GP outside office hours

Hospital

66% (355/535)

34% (180/535)

31% (166/535)

4% (19/535)

2% (11/535)

Treatment for complaints of COVID-19

Corticosteroids (%)

Antibiotics (%)

Oxygen suppletion at home (%)

Assessment at the emergency department (without admission) (%)

Admission to the hospital (%)

14% (75/535)

4% (22/535)

7% (37/535)

0%

2% (9/535)

1% (7/535)

Persistent complaints after COVID-19

<6 months

<12 months

<24 months

44% (236/535)

19% (100/535)

10% (56/535)

15% (80/535)

All numbers reflect percentages with participant count.

* Percentages are based on total no. of participants experiencing COVID-19 related symptoms

** The total number is >180: some participants have sought care at more than one place.

Table 3: Characteristics interviewees.

	Age	Sex	Type of living	Employment	PCR-test	Reached out to GP	Duration severe complaints
1.	38	Male	With partner	Working	No	No	One week
2.	42	Male	With partner and child(ren)	Working	No	No	A day, less severe three weeks
3.	70	Male	With partner and child(ren)	Retired	No	No	Ten days
4.	71	Male	With partner	Retired	Yes	Yes (but didn’t receive care from the GP, directly referred to cough clinic)	Five to six weeks
5	46	Female	With partner and child(ren)	Working	No	Not during the acute symptoms, but after a few weeks of persisting complaints	Six months
6.	59	Male	With partner	Working	No	No	Fourteen days, 9 months tired
7.	56	Male	With partner	Working	No	Yes (but didn’t receive care)	Four days, long time with less energy
8.	58	Male	With partner and child(ren)	Working	Yes	No	Two weeks
9.	38	Female	With partner and child(ren)	Working	No	No	Three days
10.	76	Female	With partner	Retired	No	No	Three days, no smell for a year
11.	80	Male	Alone	Retired	No	No	Two weeks, less severe two months
12.	40	Female	With partner and child(ren)	Working	No	No (only after second infection)	One week, less severe over a year

No competing interests reported.

SupplementaryFile.docx

Hasselt Corona Impact Study: Impact of COVID-19 on healthcare seeking in a small Dutch town

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Abstract

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Introduction

Methods

Results

Discussion

Conclusion

Declarations

Author Contribution

Acknowledgement

Data Availability

References

Tables

Additional Declarations

Supplementary Files

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