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Discussion
This study conducted a comprehensive and robust analysis to investigate the influence of the pandemic of COVID-19 on the medical services utilisation of middle-aged and older adults in multiple countries. The results indicated that the pandemic shock has significantly increased the risk of unmet medical needs of middle-aged and older adults, regardless of age or sex. These findings not only support the results of previous studies but also provide further clarification regarding the role of the pandemic in this particular context. As suggested by WHO in implications of the COVID-19 pandemic for patient safety, severe disruptions in all major health areas have led to delays in the diagnosis and treatment of diseases, especially in countries experiencing fragility, social and economic instability, conflict and violence.32
The potential mechanisms underlying the negative effect of the pandemic on the medical utilisation of middle-aged and older adults may be wide-ranging. On the one hand, the outbreak and rapid spread of COVID-19 inevitably crowded out the limited resources of medical services, resulting in a diversion of substantial health resources including human and material resources towards COVID-19 prevention, virus detection and patient care. As a consequence, there was a significant reduction in resources available for the management and care of other diseases.33–35 At the same time, general medical resources have been further reduced by the suspension of hospitals to deal with the potential risk of nosocomial infections, the inability of medical services workers to work due to infections and the emergence of strikes by medical services workers in some countries or regions.36–38 These have objectively reduced the supply of geriatric care in some regions where healthcare systems have reached the point of exhaustion,39 especially in the severe early days of COVID-19.
On the other hand, in response to a sudden outbreak of a new infectious disease, countries and regions have been experimenting and changing their coping strategies, such as some emergency measures such as community closure, traffic control and social distancing to prioritise the response to the spread of the pandemic. Some of the countries analysed in our study also adopted such strategies such as the stay-at-home orders in Singapore,40 which may not only lead to active or passive changes in daily life behaviour and social interaction but also undoubtedly reduces the accessibility of medical services resources, especially in cross-regional medical treatment.41 This is particularly evident among middle-aged and older adults, who may put on hold non-acute or urgent medical needs. In contrast, the impact of the pandemic and social distance can have a significant negative impact on the physical and psychological well-being of older adults.42 For example, studies have shown that the pandemic may increase anxiety, depression, poor sleep quality, nutritional deficiencies and physical inactivity among older adults,43–45 which in turn further amplifies the demand for medical services among the older population, leading to a greater gap between demand and utilisation.
After SARS, the last major pandemic with a significant impact on the population,46 COVID-19 is a wake-up call for humanity at the beginning of entering the 20s of the 21st century, when governments, industries and families are once again aware of the challenges of the emerging disease in this new era, in addition to the traditional disease threats. However, just as we should not overlook emerging infectious diseases due to the increasing prevalence of chronic diseases during epidemiological transitions, we should also not neglect the healthcare needs for chronic and other conventional diseases during a pandemic. With the WHO declaring that the COVID-19 pandemic is no longer a PHEIC, governments worldwide are reflecting on lessons learnt and developing preparedness plans for future pandemics. The increased medical utilisation gaps, particularly among middle-aged and older individuals resulting from the COVID-19 pandemic as discovered in this study, should undoubtedly be given full consideration by policymakers and clinical healthcare professionals. Declines in essential health service utilisation could even result in more deaths than the disease outbreak itself.47 Measures should be taken to reduce the neglect of healthcare needs for other diseases during a pandemic and formulate effective strategies to balance the allocation of healthcare resources.
It is clear that, our research is based on countries with varying levels of socioeconomic development and healthcare resources, and overall, consistent with previous studies,48 49 higher levels of socioeconomic status and healthcare resources at the country level were found to be associated with a lower risk of unmet medical needs in the sample included in this study (see online supplemental table S6). However, even after controlling for these country-level covariates, the impact of the pandemic shock on unmet medical needs remains significant. While this is an ‘averaged’ outcome, such estimates provide support and basis for advocating international attention to ensuring basic healthcare service provision from a more macroscopic global perspective during public health emergencies. Indeed, the WHO has released a position paper calling on countries and the international community to build resilient health systems by integrating universal health cover and health security efforts during COVID-19 pandemic and beyond in 2021.50 In the postpandemic era, the WHO also needs to assume greater international responsibilities in this field and rebuild trust among the people to prepare for the next pandemic.51 The results of our study once again highlights the need for countries all over the world to take every opportunity to build resilient health systems and all-hazards emergency risk management based on a strong primary healthcare foundation and rebuild the health systems sustainably, more equitably and closer to communities.52
There are also some shortcomings in this study. First, several potential confounders, such as the objective medical conditions of participants that were not controlled because of data accessibility, may have had some impact on the results. Second, although the cumulative confirmed infected cases were obtained from the WHO, they were based on the integration of official reports from various countries or regions and the different criteria in each region may produce some bias. Third, the results should be interpreted with caution given that the exposure period groupings in our analysis are in years and the results reflect the average long-term effect over that period. Furthermore, as our data were aggregated at the country level, all individuals within a country were grouped together. This might introduce bias stemming from regional variations within each country. The limited number of countries also poses a potential threat to the external validity when making global generalisations of our research findings and presents challenges in deriving policy implications and recommendations for specific nations. In addition, self-rated health might have a bidirectional relationship with our outcome variable. However, we opted to retain it as a covariate due to the lack of a more appropriate exogenous health condition variable. Additionally, it is unfortunate that we lack further relevant variables pertaining to healthcare access for migrant populations in each country. Consequently, we have solely considered migrant status as a regression factor. Moreover, we did not distinguish between the specific types of medical needs of the participants because there was no such information in the database. Nevertheless, to the best of our knowledge, this study contributes to the literature pool by providing trustworthy evidence about the impact of COVID-19 on medical services utilisation among middle-aged and older adults at the global level based on reliable data and methods for the first time.
The findings of this study on the global pandemic on the medical services utilisation of middle-aged and older adults in multiple countries emphasise the importance of balancing medical resources in the response to outbreaks. In addition to the investment of resources for prevention and control directly related to pandemic prevention and control, other medical services for people, especially middle-aged and older adults with high needs and vulnerabilities for disease treatment and rehabilitation, should be further strengthened in strategies to address the emerging infectious diseases transmission for a better health promotion and high-quality population development in an ageing world.
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