Delay or avoidance of routine, urgent and emergency medical care due to concerns about COVID‐19 in a region with low COVID‐19 prevalence: Victoria, Australia

Abstract

To the Editors: In August 2020, the World Health Organization reported that 89% of 105 surveyed countries reported disruption to essential health services during the coronavirus disease 2019 (COVID-19) pandemic. In late June 2020, when there were 2.5 million cumulative confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections in the United States, 40.9% of 4977 surveyed US adults reported having delayed or avoided medical care due to COVID-19 concerns. Given the potential shortand long-term consequences of medical care delay or avoidance, we sought to determine whether similar care avoidance was observed in a region with low SARS-CoV-2 prevalence. As of mid-September 2020, the Australian state of Victoria reported fewer than 20,000 cumulative SARS-CoV-2 cases with a low positivity rate in a population of approximately 6.7 million people. Cross-sectional Internet-based surveys were therefore administered to respondent panellists aged ≥18 years residing in Victoria by Qualtrics using quota sampling in the third Australian wave of The COVID-19 Outbreak Public Evaluation (COPE) Initiative (www.thecopeinitiative.org). To assess medical care avoidance cross-sectionally while minimizing potential confounders of varying mitigation measures or SARS-CoV-2 prevalence, surveys were administered during 15–24 September 2020, when peak COVID-19 prevention measures were in place. Participants were asked, ‘In the past month, have you delayed or avoided medical care due to concerns related to COVID-19?’ Delay or avoidance was evaluated for emergency (e.g., immediate life-threatening conditions), urgent (e.g., immediate non-life-threatening conditions) and routine (e.g., annual check-ups) medical care. Urgent and emergency care avoidance were combined for analysis (urgent or emergency care) due to potential variance in perception of level of care needed, and a variable representing any care avoidance was created. Demographic and health information were collected as covariates, including sex, age, ancestry, regional versus metropolitan postcode, education attainment, employment status, unpaid caregiver status (providing unpaid care for children only, for adults only, for both age groups [multigenerational] or not an unpaid caregiver), disability status and support through the National Disabilities Insurance Scheme (NDIS) and presence of underlying conditions known to increase the risk of severe COVID-19, including: obesity (BMI > 30 kg/m), diabetes, hypertension, cardiovascular disease, chronic kidney disease, liver disease, chronic obstructive pulmonary disease and cancer. Surveys underwent Qualtrics data-quality screening procedures, including algorithmic and keystroke analysis for click-through behaviour, duplicate responses, machine responses and inattentiveness. The investigators conducted secondary cleaning for missing sex and age, invalid postcodes and BMI below 14 or above 100 kg/m. Iterative proportional fitting (raking) and weight trimming ([1/3] ≤ weight ≤ [3]) were employed to improve sample representativeness by age and sex according to Victorian population estimates from the Australian Bureau of Statistics 2016 Census of Population and Housing. Rao–Scott adjusted Pearson chi-square tests with a Bonferroni adjustment (10 comparisons) were used to test for differences in delay or avoidance of routine, urgent or emergency, and any medical care by demographic subgroups. Adjusted prevalence ratios (aPRs) and 95% CIs for delay or avoidance of any medical care were estimated using Poisson regressions with robust SEs among respondents who had complete data for the following variables: sex, age, ancestry, regional or metropolitan residence, education attainment, employment status and unpaid caregiver status. Additional models including these variables plus either disability status or presence of underlying medical conditions were used to estimate aPRs for these collinear variables. Statistical analyses were conducted with Python (version 3.7.8; Python Software Foundation) and R version 4.0.2 (The R Project for Statistical Computing) using the R survey package version 3.29; p < 0.05 were deemed statistically significant. During 15–24 September 2020, 1260 of 4900 (25.7%) eligible invited Victorian adults completed surveys, including 1168 (92.7%) first-time respondents and 92 (7.3%) re-contacted respondents. Overall, 414 (32.9%) adults reported having delayed or avoided any medical care due to concerns about COVID-19, including routine medical care (333 [26.4%]) and urgent or emergency care (128 [10.1%]) (Table 1). Populations that most commonly reported delay or avoidance of any medical care were those with disabilities with NDIS support (40 of 48 [83.9%]), multigenerational unpaid caregivers (128 of 189 [67.8%]), adults with higher education degrees (83 of 156 [53.4%]), adults with multiple Received: 1 April 2021 Accepted: 18 May 2021