Healthcare professionals' perceptions of impacts of the Covid-19-pandemic on outpatient care in rural areas: a qualitative study

Rurality, healthcare and crises: Investigating experiences, differences, and changes to medical care for people living in rural areas

Healthcare provision in rural areas is a global challenge, characterised by a dispersed patient population, difficulties in the recruitment and retention of healthcare professionals and a physical distance from hospital care. This research brings together both public and doctor perspectives to explore the experience of healthcare across rural Scotland, against the backdrop of contemporary crises, including a global pandemic and extreme weather events. We draw on two studies on rural healthcare provision to understand how healthcare services have been experienced, changed and might move on after periods of short- and longer-term change caused by such crises. We highlight the importance of communicating service changes to aid in setting healthcare expectations and advocate a mixed approach to the introduction of digital solutions to best balance access to services in rural areas with the challenges of digital connectivity and literacy.

Resources needed by critical access hospitals to address identified infection prevention and control program gaps

Objective

The study examined resources needed by Infection Preventionists (IP) to address infection prevention and control (IPC) program gaps.

Design

A 49-question survey.

Setting

Licensed Critical Access Hospitals (CAHs) in Federal Emergency Management Area (FEMA) Region VII.

Participants

IP at licensed CAHs.

Methods

The survey conducted between December 2020 and January 2021 consisted of questions focusing on four categories including IPC program infrastructure, competency-based training, audit and feedback, and identification of high-risk pathogens/serious communicable diseases (HRP/SCD). An IPC score was calculated for each facility by totaling "Yes" responses (which indicate best practices) to 49 main survey questions. Follow-up questions explored the resources needed by the CAHs to implement or further strengthen best practices and mitigate IPC practice gaps. Welch t-test was used to study differences in IPC practice scores between states.

Results

50 of 259 (19.3%) CAHs participated in the survey with 37 (14.3%) answering all 49 questions. CAHs responding to all questions had a median IPC score of 35. There was no significant difference between IPC practice scores of CAHs in NE and IA. The top three IPC gaps were absence of drug diversion program (77%), lack of audits and feedback for insertion and maintenance of central venous catheters (76%), and missing laboratory risk assessments to identify tests that can be offered safely for patients under investigation for HRP/SCD (76%). Standardized audit tools, educational resources, and staff training materials were cited as much-needed resources.

Conclusion

IPC practice gaps exist in CAHs. Various resources are needed for gap mitigation.

COVID-19 epidemiology and rural healthcare: a survey in a Spanish village

We used primary care data to retrospectively describe the entry, spread, and impact of COVID-19 in a remote rural community and the associated risk factors and challenges faced by the healthcare team. Generalized linear models were fitted to assess the relationship between age, sex, period, risk group status, symptom duration, post-COVID illness, and disease severity. Social network and cluster analyses were also used. The first six cases, including travel events and a social event in town, contributed to early infection spread. About 351 positive cases were recorded and 6% of patients experienced two COVID-19 episodes in the 2.5-year study period. Five space-time case clusters were identified. One case, linked with the social event, was particularly central in its contact network. The duration of disease symptoms was driven by gender, age, and risk factors. The probability of suffering severe disease increased with symptom duration and decreased over time. About 27% and 23% of individuals presented with residual symptoms and post-COVID illness, respectively. The probability of developing a post-COVID illness increased with age and the duration of COVID-associated symptoms. Carefully registered primary care data may help optimize infection prevention and control efforts and upscale local healthcare capacities in vulnerable rural communities.

Perspective of healthcare providers on assessing the quality and accessibility of health services for chronic diseases in Jordan during Covid-19: a mixed method study

BACKGROUND

Hospital services in all parts of the world were severely affected by the crisis caused by the Coronavirus pandemic. This was particularly concerning for patients who suffer from chronic diseases.

AIM

This study aimed to: assess the level of quality and accessibility of chronic disease services from the perspectives of healthcare providers, assess the association between healthcare providers' socio-demographic factors and their perspectives on accessibility and quality level, and explore the providers' perspectives on the barriers and facilitators of quality and accessibility to chronic disease health services during the COVID -19 pandemic.

METHOD

Design: An explanatory mixed method design was employed in this study using a questionnaire and focus group discussion approach. The questionnaire consisted of three sections including, demographic, accessibility, and quality.

SAMPLE

A convenience sampling approach was used to collect the quantitative from 412 healthcare providers working at public, private, and teaching hospitals. A purposive sample of 12 healthcare providers were interviewed to collect the qualitative data.

ANALYSIS

The quantitative data were analyzed using SPSS Statistics Version 25. The qualitative data was analyzed using the thematic analysis approach.

RESULTS

This study found that the quality and accessibility of chronic disease services in northern Jordan were affected during COVID-19. Quantitative: The majority of the participants reported moderate level of accessibility and quality. Qualitative: Four main and six subthemes were identified: 1) Accessibility barriers including transportation and fear of infection; 2) Accessibility facilitators including availability of Personal Protective Equipment (PPE) and Covid-19 vaccination; 3) Quality barriers including staff shortage; 4) Quality facilitators including safety protocol.

CONCLUSION

The quality and accessibility of chronic disease services were affected due to the healthcare system restating to address the Covid-19 pandemic. Different barriers and facilitators for chronic disease healthcare services accessibility and quality were identified. The findings of this study lay the ground for healthcare decision and policymakers to develop strategies and formulate polices to ensure these patients receive the needed healthcare services, and hence improve their health outcomes.

Medical education during the Covid-19 pandemic long-term experiences of German clinical medical students

INTRODUCTION

Due to the Covid-19 pandemic and the accompanying hygiene regulations, medical students in Germany faced multiple educational and personal challenges. The challenges included the cancellation and digitalisation of courses, the closing of university institutions such as libraries, a decrease in social contacts, and the risk of a Covid-19 infection. The aim of this study was to understand medical students' pandemic experiences as well as the consequences of these experiences for the students' future work as physicians.

MATERIALS AND METHODS

We performed 15 guided, one-on-one interviews with clinical medical students (third to fifth year) at the Otto-von-Guericke-University Magdeburg. Interviews were recorded, transcribed, and anonymised. We performed a qualitative content analysis in accordance with Mayring and thereby formed an inductive category system. The Consolidated Criteria for Reporting Qualitative Research (COREQ) were applied.

RESULTS

Five categories were inductively formed: "Changes in the teaching experience", "negative effects on the learning experience", "decrease in personal social contacts", "contact with covid-19", and "pandemic-associated stress increase". The participating students reported higher levels of stress due to isolation and uncertainty regarding their educational future. Furthermore, students welcomed the digitalisation of lectures, developed individual coping strategies, and voluntarily took part in the care of Covid-19 patients. Limitations to social interactions were perceived as the major restrictive factor to their educational structure, their perceived learning success and personal development.

CONCLUSION

This study identified social restrictions as well as didactic and academic structural challenges as relevant factors contributing to perceived stress and fear for medical students during the Covid-19 pandemic, especially as regards their learning experience. Students' acceptance of digitalised learning may enable regular interaction with university peers and may facilitate a structured educational life. However, the implementation of digital resources could not provide a sufficient substitute for in-person courses.

Mental distress of physicians in the outpatient care throughout the COVID-19 pandemic: emotional and supportive human relations matter - Cross-sectional results of the VOICE-study

BACKGROUND

The aim of this cross-sectional study was to evaluate the course of self-reported mental distress and quality of life (QoL) of physicians, working in the outpatient care (POC). Outcomes were compared with a control group of physicians working in the inpatient care (PIC), throughout the Corona Virus Disease (COVID)-19 pandemic. The impact of risk and protective factors in terms of emotional and supportive human relations on mental distress and perceived QoL of POC were of primary interest.

METHODS

Within the largest prospective, multi-center survey on mental health of health care workers (HCW), conducted during the first (T1) and second (T2) wave of the COVID-19 pandemic in Europe, we investigated the course of current burden (CB), depression (Patient Health Questionnaire-2), anxiety (Generalized Anxiety Disorder-2) and QoL, cross-sectionally, in n = 848 POC (T1: n = 536, T2: n = 312). The primary outcomes were compared with an age- and gender-matchted control group of n = 458 PIC (T1: n = 262, T2: n = 196). COVID-19-, work-related, social risk and protective factors were examined.

RESULTS

At T1, POC showed no significant differences with respect to CB, depression, anxiety, and QoL, after Bonferroni correction. Whereas at T2, POC exhibited higher scores of CB (Cohen´s d/ Cd = .934, p < .001), depression (Cd = 1.648, p < 001), anxiety (Cd = 1.745, p < .001), work-family conflict (Cd = 4.170, p < .001) and lower QoL (Cd = .891, p = .002) compared with PIC. Nearly all assessed parameters of burden increased from T1 to T2 within the cohort of POC (e.g. depression: CD = 1.580, p < .001). Risk factors for mental distress of POC throughout the pandemic were: increased work-family conflict (CB: ß = .254, p < .001, 95% CI: .23, .28; PHQ-2: ß = .139, p = .011, 95% CI: .09, .19; GAD-2: ß = .207, p < .001, 95% CI: .16, .26), worrying about the patients´ security (CB: ß = .144, p = .007, 95% CI: .07, .22; PHQ-2: ß = .150, p = .006, 95% CI: .00, .30), fear of triage situations (GAD-2: ß = .132, p = .010, 95% CI: -.04, .31) and burden through restricted social contact in spare time (CB: ß = .146, p = .003, 95% CI: .07, .22; PHQ-2: ß = .187, p < .001, 95% CI: .03, .34; GAD-2: ß = .156, p = .003, 95% CI: -.01, .32). Protective factors for mental distress and QoL were the perceived protection by local authorities (CB: ß = -.302, p < .001, 95% CI: -.39, -.22; PHQ-2: ß = -.190, p < . 001, 95% CI: -.36, -.02; GAD-2: ß = -.211, p < .001, 95% CI: -.40, -.03; QoL: ß = .273, p < .001, 95% CI: .18, .36), trust in colleagues (PHQ-2: ß = -.181, p < .001, 95% CI: -.34, -.02; GAD-2: ß = -.199, p < .001, 95% CI: -.37, -.02; QoL: ß = .124, p = .017, 95% CI: .04, .21) and social support (PHQ-2: ß = -.180, p < .001, 95% CI: -.22, -.14; GAD-2: ß = -.127, p = .014, 95% CI: -.17, -.08; QoL: ß = .211, p < .001, 95% CI: .19, .23).

CONCLUSIONS

During the pandemic, the protective role of emotional and supportive human relations on the mental distress and quality of life of POC should be taken into account more thoroughly, both in practice and future research.

Differences between Rural and Urban Practices in the Response to the COVID-19 Pandemic: Outcomes from the PRICOV-19 Study in 38 Countries

This paper explores the differences between rural and urban practices in the response to the COVID-19 pandemic, emphasizing aspects such as management of patient flow, infection prevention and control, information processing, communication and collaboration. Using a cross-sectional design, data were collected through the online PRICOV-19 questionnaire sent to general practices in 38 countries. Rural practices in our sample were smaller than urban-based practices. They reported an above-average number of old and multimorbid patients and a below-average number of patients with a migrant background or financial problems. Rural practices were less likely to provide leaflets and information, but were more likely to have ceased using the waiting room or to have made structural changes to their waiting room and to have changed their prescribing practices in terms of patients attending the practices. They were less likely to perform video consultations or use electronic prescription methods. Our findings show the existence of certain issues that could impact patient safety in rural areas more than in urban areas due to the underlying differences in population profile and supports. These could be used to plan the organization of care for similar future pandemic situations.

Challenges in Care for Non-COVID-19 Patients with Severe Chronic Illnesses during COVID-19 Pandemic: A Qualitative Study of Healthcare Providers Working around Acute Care Hospitals in South Korea

BACKGROUND

The COVID-19 epidemic has afflicted patients with severe chronic illnesses who need continuous care between home and hospitals. This qualitative study examines the experiences and challenges of healthcare providers around acute care hospitals who have cared for patients with severe chronic illness in non-COVID-19 situations during the pandemic.

METHODS

Eight healthcare providers, who work in various healthcare settings around acute care hospitals and frequently care for non-COVID-19 patients with severe chronic illnesses, were recruited using purposive sampling from September to October 2021 in South Korea. The interviews were subjected to thematic analysis.

RESULTS

Four overarching themes were identified: (1) deterioration in the quality of care at various settings; (2) new emerging systemic problems; (3) healthcare providers holding on but reaching their limit; and (4) a decline in the quality of life of patients at the end of their lives, and their caregivers.

CONCLUSION

Healthcare providers of non-COVID-19 patients with severe chronic illnesses reported that the quality of care was declining due to the structural problems of the healthcare system and policies centered solely on the prevention and control of COVID-19. Systematic solutions are needed for appropriate and seamless care for non-infected patients with severe chronic illness in the pandemic.

COVID-19 Continues to Burden General Practitioners: Impact on Workload, Provision of Care, and Intention to Leave

General practitioners (GPs), already in a profession with a high workload, have been at the frontline of providing COVID-19-related healthcare in addition to routine care. Our study examined the impact of pandemic-related consultations and changes in practice organization on GPs' current workload and provision of healthcare in summer 2021 (May 2021-July 2021) and early 2022 (January 2022-February 2022). In total, 143 German GPs participated in an online survey in the summer of 2021. Of these, 51 GPs participated in the follow-up survey in 2022. Most GPs perceived an increase in consultation frequency, consultation times, and workload since the pandemic outbreak. Increased consultation times were related to the reduced provision of medical care to other patients with chronic diseases. More SARS-CoV-2 vaccination consultations were associated with reduced home visits, acute consultation times, and cancer screenings. A quarter of GPs considered leaving their job. Pandemic-related bureaucracy, restricted access to therapy and rehabilitation services specialized on COVID-19, unreliable vaccine deliveries, mandatory telematics-infrastructure implementation, and frequent changes in official regulations were the main reasons reported for dissatisfaction. Our results provide insights into how the pandemic continues to burden GPs' work routines and how better working conditions in times of high demand could be achieved in future pandemics.

Pediatricians' experiences of managing outpatient care during the COVID-19 pandemic: A qualitative study in Germany

Background

Pediatricians are important sources of information for parents regarding their children's health. During the COVID-19 pandemic, pediatricians faced a variety of challenges regarding information uptake and transfer to patients, practice organization and consultations for families. This qualitative study aimed at shedding light on German pediatricians' experiences of providing outpatient care during the first year of the pandemic.

Methods

We conducted 19 semi-structured, in-depth interviews with pediatricians in Germany from July 2020 to February 2021. All interviews were audio recorded, transcribed, pseudonymized, coded, and subjected to content analysis.

Results

Pediatricians felt able to keep up to date regarding COVID-19 regulations. However, staying informed was time consuming and onerous. Informing the patients was perceived as strenuous, especially when political decisions had not been officially communicated to pediatricians or if the recommendations were not supported by the professional judgment of the interviewees. Some felt that they were not taken seriously or adequately involved in political decisions. Parents were reported to consider pediatric practices as sources of information also for non-medical inquiries. Answering these questions was time consuming for the practice personnel and involved non-billable hours. Practices had to adapt their set-up and organization immediately to the new circumstances of the pandemic, which proved costly and laborious as well. Some changes in the organization of routine care, such as the separation of appointments for patients with acute infection from preventive appointments, were perceived as positive and effective by some study participants. Telephone and online consultations were established at the beginning of the pandemic and considered helpful for some situations, whereas for others these methods were deemed insufficient (e.g. for examinations of sick children). All pediatricians reported reduced utilization mainly due to a decline in acute infections. However, preventive medical check-ups and immunization appointments were reported to be mostly attended.

Conclusion

Positive experiences of reorganizing pediatric practice should be disseminated as "best practices" in order to improve future pediatric health services. Further research could show how some of these positive experiences in reorganizing care during the pandemic are to be maintained by pediatricians in the future.

Experiences and management strategies of Norwegian GPs during the COVID-19 pandemic: a longitudinal interview study

OBJECTIVE

When the COVID-19 pandemic reached Norway, primary health care had to reorganize to ensure safe patient treatment and maintain infection control. General practitioners (GPs) are key health care providers in the municipalities. Our aim was to explore the experiences and management strategies of Norwegian GPs during the COVID-19 pandemic - over time, and in the context of a sudden organizational change.

DESIGN

Longitudinal qualitative interview study with two interview rounds. The first round of interviews was conducted from September-December 2020, the second round from January-April 2021. In the first interview round, we performed eight semi-structured interviews with GPs from eight municipalities in Norway. In the second round, five of the GPs were re-interviewed. Consecutive interviews were performed 2-4 months apart. To analyze the data, we used thematic analysis.

RESULTS

The COVID-19 pandemic required GPs to balance several concerns, such as continuity of care and their own professional efforts. Several GPs experienced challenges in the collaboration with the municipality and in relation to defining their own professional position. Guided by The Norwegian Association of General practitioners, The Norwegian College of General Practice and collegial support, they found viable solutions and ended up with a feeling of having adapted to a new normal.

CONCLUSIONS

Although our study demonstrates that the GPs adapted to the changing conditions, the current municipal health care models are not ideal. There is a need for clarification of responsibilities between GPs and the municipality to facilitate a more coordinated future pandemic response.Key PointsFacing the COVID-19 pandemic, the primary health care service in Norway had to reorganize to ensure safe patient treatment and maintain infection control.Several GPs experienced challenges in collaboration with the municipalities.There is a need for clarification of responsibilities between GPs and the municipality.

Frontline Health Care Workers' (HCWs) perception of barriers to managing COVID-19 in Fiji

Background

Health Care Workers (HCWs) are at higher risk of COVID-19 infection with their efforts while protecting the greater community and also exposed to hazards, such as psychological distress, fatigue, and stigma. This study aimed to explore the perception of frontline HCWs on barriers of managing COVID-19 in Fiji.

Methods

A qualitative study method was approached to conduct this study among the HCWs who worked on the frontline during the COVID-19 pandemic based at ten purposively selected health facilities in the Suva subdivision in the Central Division of Fiji. The Colonial War Memorial Hospital (CWMH), the Fiji Centre for Communicable Diseases (Fiji CDC), Twomey hospital laboratory, and CWMH laboratory did the main control and most of the operations of other divisions were monitored from these settings. A semi-structured open-ended questionnaire was used to collect data using in-depth interviews. The participants' responses were audio-recorded and were later transcribed and analyzed using thematic analysis.

Results

A total of twenty-nine HCWs took part in the in-depth interview and the responses were grouped into four themes, which include: workload, poor communication, lack of resources, and hindrance to education. It was also found through this study that some of the HCWs felt tired, frustrated, got rude to patients, and found it difficult to handle situations, which affected them mentally and physically stressed.

Conclusion

Managing the COVID-19 cases has been attributed to the presence of many barriers, such as workload, tiredness, frustration, and sometimes difficult-to-handle situations, and the HCWs were indeed affected mentally and physically. Regular training for HCWs and more awareness programs would help the general public to follow the preventive measures, which reduces the cases and would help the HCWs manage COVID-19 well.

Providing ambulatory healthcare for people aged 80 and over: Views and perspectives of physicians and dentists from a qualitative survey

Background

People aged 80 and over frequently face complex chronic conditions and health limitations, including oral health problems, which are primarily addressed by ambulatory (i.e., outpatient) healthcare. This demographic development is expected to affect the provision of care. However, few studies have investigated physicians’ and dentists’ views across the various medical disciplines in non-institutional settings. This study investigated how healthcare providers perceive caring for very old people, and how they feel healthcare should be designed for this patient group.

Methods

A qualitative online survey comprising nine open-ended items was conducted among physicians and dentists practicing in the ambulatory healthcare sector in North Rhine-Westphalia, Germany. Apart from child and adolescent healthcare, no medical specialties were excluded. The results were analysed using Kuckartz’ approach of structuring qualitative content analysis. A descriptive codebook was developed first. After coding all the material, recurring patterns between the topics were investigated and compared between two groups of participants, physicians and dentists.

Results

N = 77 cases were included in the analysis, from which n = 21 originated from the field of ambulatory general practice care and internal medicine, n = 19 from specialties (e.g., neurology, urology), and n = 37 from dentistry. Caring for patients aged 80 and over was perceived as challenging because of complex health conditions and treatments such as multimorbidity and polypharmacy, and patients’ cognitive and physical limitations. In characterizing good care in older age, both groups found individual care important, as well as empathetic interactions and good collaboration in networks of healthcare providers. Inadequate reimbursement and limited resources and time were the most important barriers to providing good care, while one of the most important facilitators was healthcare providers’ attitude and motivation.

Conclusions

Physicians’ and dentists’ conceptions of good healthcare are in line with the conceptualization of patient-centred care. However, the transfer in everyday care delivery is hampered by the current design of healthcare structures. Healthcare providers feel overstrained by the increasing demands placed on them. Adaptations for improvement should focus on building strong networks of cooperating health professions, especially including dental care, and local social support structures.

Life Satisfaction and Perceived Stress versus Health Promoting Behavior among Medical Students during the COVID-19 Pandemic

AIM

The aim of this study was to evaluate health-promoting behaviors as a factor supporting life satisfaction and a protective factor against stress in a group of Polish medical students during the third wave of the SARS-CoV-2 pandemic.

MATERIAL

The study was conducted in October-December 2021. There were 306 people, including 203 students in the 1st year of medicine, aged 20.42 ± 1.92 years, and 103 students in the 5th year of medicine, aged 24.88 ± 1.7 years.

METHODS

The following were used: the Satisfaction with Life Scale (SWLS), the Health Behavior Inventory (IZZ), and the Perceived Stress Scale (PSS-10). The survey was conducted online.

RESULTS

In the study group, the average result of 23.66 ± 5.97 was obtained in the life satisfaction questionnaire. In the overall assessment of health behaviors (IZZ), an average score of 80.06 ± 13.81 points was obtained. In the PSS-10 questionnaire, the respondents obtained an average of 21.10 ± 5.89 points. There were significant, negative correlations between the results obtained in the health behavior inventory with the results obtained in the stress scale and positive correlations with the results obtained in the life satisfaction scale. Moreover, in the assessment of the influence of prohealth behavior parameters on perceived stress and life satisfaction, a positive effect of PMA on life satisfaction was demonstrated, as well as a protective effect of Positive Mental Attitude (PMA) and Prohealth Activities (PhA) in relation to stress.

CONCLUSIONS

Life in the period of the third wave of the pandemic was assessed by medical students as moderately satisfactory. Significant intensity of stress negatively correlated with life satisfaction. Health-promoting behaviors, and especially positive mental attitudes, seem to play a protective role in stressful situations and improve life satisfaction.

Health Service Accessibility, Mental Health, and Changes in Behavior during the COVID-19 Pandemic: A Qualitative Study of Older Adults

The COVID-19 pandemic has affected the access of older adults to health services. The two objectives of this study are understanding the influence of the COVID-19 pandemic on older adults’ access to health services and exploring how health service accessibility during the pandemic influenced older adults’ mental health and self-reported changes in behavior. This study included 346 older adults. Content analysis produced five themes: (1) decreased physical accessibility to health care providers (78%); (2) increased use of online health services and other virtual health care (69%); (3) growth in the online prescription of medication (67%); (4) difficulty obtaining information and accessing non-communicable disease and mental health indicators (65%); and (5) postponement of medical specialist consultations (51%). Regarding mental health, three themes emerged: (1) increased symptoms of anxiety, distress, and depression (89%); (2) the experience of traumatic situations (61%); and (3) the augmented use of alcohol or drugs (56%). Finally, the following changes in behavior were indicated: (1) frustrated behavior (92%); (2) emotional explosions (79%); and (3) changes in sleeping and eating behaviors (43%). Access to health services may have influenced the mental health and behavior of older adults, hence interventions in a pandemic must address their interactions with health services, their needs, and their well-being.