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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 1  |  Page : 18-25

Impact of COVID-19 Pandemic on the Care of Non-COVID Pediatric Patients: A Healthcare Workers’ Survey from India


1 Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
2 Department of Pediatrics, Sitaram Bhartia Institute of Science and Research, New Delhi, India

Date of Submission07-Sep-2021
Date of Decision29-Jan-2022
Date of Acceptance07-Feb-2022
Date of Web Publication18-Feb-2022

Correspondence Address:
Dr. Puneet Kaur Sahi
Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_103_21

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  Abstract 


<**b**>Background: Coronavirus disease 2019 (COVID-19) pandemic-related refocusing of healthcare along with needs for social distancing, complete or partial lockdowns, and burgeoning economic crisis has created immense barriers to the access of healthcare services by the non-COVID patients. <**b**>Aim: We aimed to assess the perspectives of Indian healthcare workers taking care of pediatric patients on the barriers to healthcare delivery to pediatric non-COVID illnesses. <**b**>Methods: Indian healthcare workers, working in both public and private sectors, taking care of pediatric patients were surveyed using a predesigned pretested online questionnaire over a period of 1 month (May 2020). The impact on healthcare delivery was graded using a Likert scale. <**b**>Results: Of the total of 356 responses obtained, 75.3% reported a significant negative impact of the COVID-19 pandemic on delivery of healthcare to non-COVID pediatric patients. Respondents of government and COVID hospitals reported a significantly worse impact than private (<**i**>P = 0.0002) and non-COVID hospitals (<**i**>P = 0.01), respectively. Significant decline in number of non-COVID patients attending outpatient department (86.2%), admitted in wards (71.6%), number of routine (81.7%) and emergency surgeries (60.5%), number of diagnostic procedures (61.2%), and scheduled therapies (50.2%) was reported by the surveyed healthcare workers. Most important factors for disrupted healthcare delivery were restricted travel (78.3%) and fear of contracting COVID-19 (68.8%). Telemedicine (67.4%) was the commonest alternate strategy deployed for continuing care of patients. <**b**>Conclusion: Several challenges exist to maintain the continuity of healthcare services to pediatric non-COVID patients especially in those with chronic diseases, poor financial background, and follow-up in COVID government hospitals. Use of telemedicine, strategic preplanning, strengthening peripheral healthcare, and optimal resource reallocation may help reduce the broader health impact of the COVID-19 pandemic.

Keywords: Chronic disease, healthcare barriers, SARS-CoV-2


How to cite this article:
Kaur Sahi P, Meena P, Pallavi, Mandal A, Dabas A. Impact of COVID-19 Pandemic on the Care of Non-COVID Pediatric Patients: A Healthcare Workers’ Survey from India. MAMC J Med Sci 2022;8:18-25

How to cite this URL:
Kaur Sahi P, Meena P, Pallavi, Mandal A, Dabas A. Impact of COVID-19 Pandemic on the Care of Non-COVID Pediatric Patients: A Healthcare Workers’ Survey from India. MAMC J Med Sci [serial online] 2022 [cited 2022 Aug 19];8:18-25. Available from: https://www.mamcjms.in/text.asp?2022/8/1/18/337891




  Introduction Top


The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented refocusing of healthcare resources to contain the COVID-19-related damage. Additionally, needs for social distancing, complete or partial lockdowns, and burgeoning economic crisis have created immense barriers to the access of healthcare services by the general masses. Healthcare services for diseases other than COVID-19 are likely to have been severely disrupted.[1],[2],[3] Child immunization, maternal healthcare visits, outpatient access, inpatient admissions, surgical procedures, among other healthcare services have been adversely affected highlighted by the several published opinions and reviews.[2],[3],[4] However, only few studies till date have actually assessed the impact of the COVID-19 pandemic on the delivery of healthcare services to non-COVID patients.[1],[5] Child healthcare has been no exception. A significant drop in child healthcare visits and vaccination counts in first few weeks after the pandemic-related lockdown has been reported.[5],[6],[7],[8] Modeling studies have suggested that even modest reductions in child healthcare access could result in lakhs of additional deaths in low- and middle-income countries.[9] Thus, the need for understanding the impact of the COVID-19 pandemic on the delivery of healthcare services to the non-COVID patients is imperative. Healthcare workers (HCWs) are directly involved in delivery of these services. Hence, in this study, we aimed to assess the HCWs’ perspective on the barriers to healthcare delivery to pediatric patients of non-COVID illnesses amid the COVID-19 pandemic. Secondarily, we also aimed to assess their perspectives on the patient populations most affected, the possible reasons for the same and solutions thereof.


  Materials and Methods Top


Study design and population

A cross-sectional survey of the HCWs taking care of pediatric patients regarding barriers faced by them when delivering healthcare for non-COVID illnesses amid the COVID-19 pandemic was performed. The study was conducted over a period of 1 month (May 2020) after approval from the Institutional Ethics Committee (IEC number: F.1/IEC/MAMC/(76/04/2020/no 117). All HCWs, that is, practicing physicians/consultants, residents (postgraduate/senior resident/DM resident), interns, and nursing staff, from both public and private sectors in India, who took care of pediatric patients and gave implied informed consent, were included. There were no exclusion criteria.

Study tool

The tool used for the survey was an English language predesigned online questionnaire (Google forms) with 16 questions in total. Of these, 12 were close-ended questions, whereas 4 were open-ended questions (age in years, address of workplace, branch of super-specialization, if pursued, and any possible positive impact of the pandemic). The following information was recorded:
  1. Demographic details of the respondents (including sector of work, i.e., government or private) and whether working in COVID hospital (hospitals partially or completely dedicated to care of COVID patients).
  2. The degree of impact on the healthcare delivery to patients with non-COVID illnesses (Likert scale of 1–5 was used for these questions, with 1 = least impact, 5 = most impact in the data). This included questions regarding decline in outpatient department (OPD) attendance, IPD admissions, surgical, radiologic, and diagnostic procedures.
  3. The kind of healthcare services (medical/surgical/diagnostic/vaccination) hampered. This included questions regarding routine surgeries, emergency surgeries, “scheduled imaging or diagnostic procedures” (such as endoscopy, colonoscopy, bone marrow evaluation, liver biopsy, kidney biopsy), and “scheduled therapies” (such as chemotherapy, radiotherapy, steroids, adrenocorticotropic hormone course, enzyme replacement, iron chelators, blood transfusions, dialysis).
  4. The patient populations most affected according to subspecialty of their illness.
  5. The perceived reasons for disrupted healthcare delivery to non-COVID patients.
  6. Alternative strategies of healthcare delivery adopted by HCWs.


Validation and pilot study

Before wide dissemination of the questionnaire, a preliminary phase was conducted to assess its validity and reliability. Three pediatric experts evaluated the degree to which items in the questionnaires were relevant and could correctly measure the impact of healthcare delivery to non-COVID pediatric patients amid the COVID-19 pandemic. Suitable modifications to the questionnaire were performed. Thereafter, the questionnaire was pretested on 20 participants (excluded from the final analysis) who filled the questionnaire twice 1 week apart. Acceptable internal consistency reliability (Cronbach alpha = 0.76) and test–retest reliability (intraclass correlation coefficient = 0.92) were obtained.

Data collection

After validation and pretesting, the invitation to participate in the survey was circulated by e-mail and disseminated via the WhatsApp messenger. The number of responses were restricted to one per respondent. Data anonymity during collection and analysis was maintained.

Sample size

Taking the prevalence of perceived disruption of healthcare delivery amid the COVID-19 pandemic as 65%[7] with precision of 5% and confidence interval of 95%, the required sample size was calculated to be 350.

Statistical analysis

Descriptive statistical methods were used to summarize data on demographic characteristics and responses to questions regarding impact on healthcare delivery, perceived reasons, and possible solutions. The data were expressed as frequencies (n) and percentages for categorical variables. The significance level of differences between the proportions was tested by Chi-square test. The data obtained from the questionnaire was entered in a MS excel sheet and analyzed using MS Excel and Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM United States Software Announcement 213-309). A P-value of <0.05 was considered statistically significant.


  Results Top


A total of 356 responses were obtained with average age of respondents being 31.9 ± 7 years and 52.5% being males. Baseline characters of respondents are described in [Table 1].
Table 1 Baseline characteristics of the respondents

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The care of pediatric patients with non-COVID illness was reported to be negatively impacted by 268 (75.3%) respondents, whereas another 51 (14.3%) felt that care of such patients may be affected. HCWs employed in the government sector and in COVID hospitals reported a significantly higher negative impact on the delivery of healthcare to pediatric non-COVID patients compared to those employed in the private sector (P = 0.0002) and non-COVID hospitals (P = 0.01) [Table 2] and [Table 3]. Among subset of pediatric non-COVID illnesses, the delivery of healthcare to oncology patients was most affected (score 4 or 5 on Likert scale given by 54% of surveyed HCWs) followed by cardiology (49.7%) patients [Figure 1].
Figure 1 Healthcare workers’ responses regarding the subset of non-COVID pediatric patients severely impacted amid the COVID-19 pandemic. The percentages highlighted on top of every bar reflect the percentage of respondents who reported the respective non-COVID illness as being severely (very high impact = Likert scale 5 and high impact = Likert scale 4) impacted. COVID-19, coronavirus disease 2019.

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Table 2 Impact of government versus private workplace on the delivery of healthcare to non-COVID pediatric patients amid the COVID-19 pandemic

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Table 3 Impact of COVID versus non-COVID hospital on the delivery of healthcare to non-COVID pediatric patients amid the COVID-19 pandemic

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The number of pediatric patients accessing healthcare and delivery of healthcare services has sharply declined amid the pandemic as shown in [Figure 2]. Among the delivered services, delay in scheduled routine surgeries, diagnostic procedures, and therapies for chronic patients were reported by 94%, 93.5%, and 89% of the respondents, respectively, with degree of delay depicted in [Figure 3]. Reported delay in scheduled diagnostic procedures for non-COVID patients was significantly higher in COVID hospitals than in non-COVID hospitals (P < 0.006). Likewise, the reported delay (1 week to 1 month) in scheduled surgeries was significantly higher in respondents of COVID hospitals (P < 0.007)
Figure 2 Impact of COVID-19 pandemic on the number of pediatric patients accessing healthcare and delivery of healthcare services. The y-axis indicates the number of respondents. COVID-19, coronavirus disease 2019.

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Figure 3 Degree of delay in the delivery of healthcare services amid the COVID-19 pandemic. COVID-19, coronavirus disease 2019.

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Among the factors disrupting care of pediatric non-COVID patients [Figure 4], most common was restricted travel due to lockdown (as per 78% respondents) followed by fear of contracting COVID-19 infection during the hospital visit (68.8%); nonaffordability of treatment at private hospitals was also a hindering factor (50%). Teleconsultation was the most common alternate strategy adopted by HCWs in managing pediatric non-COVID patients (as per 67.4% respondents) [Figure 5].
Figure 4 Reasons for disrupted healthcare delivery to non-COVID patients. The percentages highlighted on top of every bar reflect the percentage of respondents who reported the particular cause as contributory to disrupted healthcare of the non-COVID patients. Very high impact = Likert scale 5 and high impact = Likert scale 4. COVID-19, coronavirus disease 2019.

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Figure 5 Alternate strategies used by healthcare workers for managing patients with non-COVID illnesses. COVID-19, coronavirus disease 2019.

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Overall, 85.3% of respondents believed that the current pandemic will lead to increased mortality of non-COVID patients, whereas 89% believed that they will have increased morbidity. Another, 79.2% and 63.7%, respectively, felt that there may a sudden surge of vaccine preventable illnesses and non-COVID patients in the postpandemic times.

Lastly, an open-ended question regarding any potential positive impact of the COVID-19 pandemic attracted certain common responses including improved hygiene practices (18.4% respondents), decreased infection rates (12.8%), decreased exacerbations of chronic respiratory illnesses (10.7%), and improved care and family time for children (8.1%).


  Discussion Top


Our survey highlights the significant decline in the delivery of healthcare services to pediatric patients of non-COVID illnesses amid the COVID-19 pandemic. The sharp drops in OPD attendance, inpatient admissions, routine as well as emergency surgeries for non-COVID patients observed in our survey are in concurrence with the few other published studies.[6],[7],[10] In a survey of medical oncologists in Canada, 59% expressed moderate-to-extreme concern regarding adequate healthcare of their cancer patients if they became seriously ill from a non-COVID illness.[7] In another survey of the practicing hepatobiliary surgeons of Europe and Africa, 63% reported running less than half of their usual numbers of operating theatres.[6] In a prospective cohort study done in a rural area of South Africa, child health visits decreased by over 50% from before to immediately after the lockdown.[5] Similar concerns have been echoed widely by family pediatricians in Italy.[10] Official hospital statistics in Italy during the lockdown period show substantial decreases (73–88%) in pediatric emergency department visits compared with the same time period in 2019 and 2018.[10] Vaccination rates in children have declined to the tune of 20% in certain regions compared to the prepandemic times.[8],[11],[12] A large proportion (79.2 %) of our surveyed HCWs believed there may be a rise in vaccine-preventable diseases. In the past, twice as many children had died of measles than of the primary Ebola outbreak itself in Africa.[13] Majority of our respondents feared increased morbidity and mortality of children with non-COVID illnesses.

These findings imply five things. Firstly, routine as well as emergency childcare visits have significantly reduced. This may create a humongous backlog of patients over a period of time due to delayed diagnosis and treatment. Secondly, sick children are likely to present late and in more severe conditions to the healthcare centers. Thirdly, children with stable disease requiring interventions may become sick awaiting treatment. There have been multiple reports of late and severe presentations of patients with non-COVID-19 conditions to healthcare facilities during this pandemic.[14],[15] Fourthly, measures are needed to minimize vaccination gaps currently and ensure catch-up vaccination camps in the postpandemic times.[16] Lastly, continuity of “critical” healthcare services should be a high priority to reduce the broader health impact of the COVID-19 pandemic.

This also brings to fore the vulnerability of children with chronic diseases who are affected disproportionately more due to any diagnostic lags and treatment delays or interruptions. In our survey, the respondents believed that oncologic patients were most severely impacted followed by cardiac and nephrology patients. Nearly 90% of our respondents also reported a delay in diagnostic procedures and scheduled therapies for chronic patients with a quarter to third believing this delay to be of more than a month. Concurrent with our findings, cancellation or deferral of patient follow-up visits has been reported by 78% of respondents in one survey,[7] whereas chemotherapy and tumor surgery/radiotherapy delays have been reported by 29% and 44% centers, respectively, in another study.[7],[17]

Importantly, per our survey, care of pediatric non-COVID patients was significantly more impacted in government and COVID hospitals in comparison with the private and non-COVID ones, respectively. This may be due to large-scale resource reallocation to treat COVID patients (medical and paramedical staff, beds, ventilators, oxygen, and medications) along with government policies that primarily focused COVID care in government hospitals.

In our survey, restricted travel was the predominant factor responsible for delayed hospital visits. This survey was conducted during the period of complete lockdown in India, whence the entire public transport system was shut making healthcare access difficult. The poor financial status of a large proportion of our patients precluded treatment at a private hospital or arrangement of private travel to their treating hospital. This has been the case in other nations implementing similar travel restrictions.[4] Fear of contracting COVID-19 was the second most important factor preventing several patients from seeking timely healthcare per our respondents with similar cases being reported world-over.[10] Lastly, cancellation or postponement of surgeries/scheduled therapies was reported as important causes for healthcare disruption in our survey. This is likely to have happened due to healthcare reallocation in existing facilities and shutting of several small clinics. One of India’s largest cancer centers in Mumbai had to scale back operations by about one-third, whereas all major tertiary hospitals in Delhi suffered significant decline in non-COVID services.[18],[19] Majority of the HCWs in our survey relied on one or more alternate methods of continuing patient care, the predominant mode being telemedicine (telephone and WhatsApp). Similar telemedicine systems have been incorporated into healthcare globally.[20] In fact, the Telemedicine Practice Guidelines have been published by the Medical Council of India to streamline patient care amid the pandemic.[21] Nevertheless, nearly half of our respondents still reported transfer of non-COVID patients to other non-COVID hospitals, whereas many outstation patients were advised to continue treatment from centers in proximity to their residence. A large proportion of our respondents reported modifications of existing treatments similar to other published surveys.[7]

The prime limitation of our survey is that it reflects the perspectives of HCWs primarily based in Delhi. The situation may be similar or worse in other parts of the country, where the number of COVID cases are as many or more and the underlying health infrastructure is poorer that the Indian capital. We also acknowledge that this is only a cross-sectional viewpoint of HCWs during the period of complete lockdown. This may have had an exaggerated influence on the disruption of healthcare services. Moreover, the pandemic is a dynamic situation; rising cases may further deteriorate the situation or vice versa.

To conclude, several challenges exist to maintain the continuity of healthcare services to children with non-COVID illnesses, especially among those with chronic diseases, poor financial background, and follow-up in COVID government hospitals. Use of telemedicine, strategic preplanning, strengthening peripheral healthcare, and optimal resource reallocation may help reduce the broader health impact of the COVID-19 pandemic.

Authors’ contributions

  1. Dr Puneet Kaur Sahi: Collected and analyzed data, conceptualized and drafted the manuscript
  2. Dr Priyanka Meena: Collected and analyzed data
  3. Dr Pallavi: Collected data and critically appraised the manuscript
  4. Dr Anirban Mandal: Collected data, drafted, and critically appraised the manuscript
  5. Dr Aashima Dabas: Conceptualized, drafted, and critically appraised the manuscript


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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