Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India: a mixed methods study

As the global burden of novel coronavirus disease 2019 (COVID-19) continues to increase, particularly in low- and middle- income countries such as India, it imposes huge costs on individuals, communities, health systems, and economies [1]. Although some countries and regions are seeing improvements in hospitalization and death rates, COVID-19 remains a major concern for vulnerable and underserved populations globally [2, 3]. People with chronic conditions are disproportionately prone to COVID-19–related hospitalizations, intensive care admissions, and mortality, compared to those without chronic conditions [4‐7]. Moreover, they may be particularly susceptible to adverse health impacts from delayed or foregone care during the pandemic. The 2020 World Health Organization (WHO) report on the impact of COVID-19 on noncommunicable diseases (NCDs) in 163 countries highlighted that nearly half of the countries report that patients experienced partial or complete disruption of services for hypertension, diabetes, and related complications during the pandemic. One-third reported disrupted services for cardiovascular emergencies. Further, most countries reassigned the health staff towards COVID-19 support, which affected routine care for NCDs [8]. Several reports indicated change in routine care to virtual consultations and worsened mental health problems during the pandemic. Diabetes, chronic obstructive pulmonary disease, and hypertension were the most impacted conditions due to significant reduction in access to care [9‐14]. Given the syndemic interaction ─interrelationship between COVID-19 and various socio-ecological and biological factors contributing to preexisting NCD epidemics─ people with chronic conditions are more vulnerable to COVID-19 infection [15, 16].

As of March 11, 2021 more than 11 million people in India had been infected with COVID-19, and about 158,000 had died [6]. The spread of COVID-19 in India is of great concern due to the country’s large and densely populated areas with widespread poverty and high migration rates, coupled with a high prevalence of chronic conditions [17‐19] that are generally poorly controlled [20‐22]. Further, the progression of COVID-19 from urban to rural areas, the strict lockdown measures, and the associated economic shocks are likely to impede efforts to address other health scourges in India such as diabetes, hypertension, and cardiovascular diseases. On March 24, 2020, the Indian government ordered a nationwide lockdown, which was extended until June in four phases, and later further extended to specific containment zones. During the lockdowns, many health facilities were functioning sub-optimally or were converted to COVID facilities and provided only essential and emergency services.

Measures to address coronavirus spread including lockdowns may have serious economic consequences and unintended effect of exacerbating rather than mitigating health disparities [8, 9, 23, 24]. However, to date, few data document the impact of the COVID-19 pandemic on disparities in chronic disease management in India. Given the unprecedented and rapidly evolving COVID-19 situation in India, we aimed to assess the health, psychosocial and economic impacts of COVID-19 pandemic on people with chronic conditions in India.

COVID-19 pandemic related restrictions implemented to control it had unforeseen adverse impacts on the health status, access to treatment, and achievement of care goals among people with chronic conditions in India. We found rural participants disproportionately experienced acute medical illnesses; difficulties in accessing healthcare; relatively less availability of functioning health facilities; poor treatment satisfaction; and reduced fruit and vegetable consumption.

Infectious disease epidemics have tended to have spillover effects onto the wider economy [14, 33‐37]. This study showed that impacts of the pandemic extend beyond health to encompass adverse effects on household incomes, individual livelihoods, interpersonal relationships, coping skills, nutritional intake, and other factors. Our quantitative and qualitative data underscore significant economic impacts from loss of employment and household income in the study population, due at least in part to restrictions preventing workers from returning to work. Those repercussions may in turn lead to further stress and additional impacts on health. People with diabetes and hypertension were worst affected due to their difficulty in accessing health care and experienced worsening symptoms or uncontrolled BP or FBS during the lockdowns, which might lead to poor health outcomes and avoidable micro- and macrovascular complications. People with chronic conditions are known to be most vulnerable to the complications of COVID-19 as highlighted in the WHO global survey and several published reports [8, 9, 23, 38‐40]. It is unclear how the dual impact of COVID-19 and the health care disruptions affect these individuals in the long-term.

Our study results are consistent with other online surveys conducted among people with chronic conditions and healthcare providers that showed the coronavirus pandemic and its related lockdowns significantly reduced access to healthcare, adversely impacted self-care behaviors, and increased mental health problems [11, 15, 16, 24, 38]. A recent study from India reported the effects of COVID-19–related lockdowns on the adoption of newer technologies and changes in glycemic control in patients with diabetes and found that the pandemic did not poorly affect glycemic control (HbA1c levels before vs. during lockdown: 8.2% vs. 7.7%). However, that study was conducted at a single private clinic, and the higher socio-economic status of the surveyed participants could influence the study results [41]. Another cross-sectional study from India evaluating the impact of COVID-19 related lockdowns on changes in health behaviors and metabolic parameters in people with diabetes found that adherence to therapy, glycemic control, and monitoring did not differ significantly pre- and post-lockdowns [42]. However, in a sub-analysis of our study, we noted significant increase in the mean FBS reported during lockdown (198 mg/dl) vs. before lockdown (165 mg/dl) in the cohort participants. This indicates that people with diabetes appear to be at greater risk of experiencing uncontrolled blood sugar during the pandemic, which is consistent with the results of another study from India that found diabetes to be the most common comorbidity among COVID-19 decedents [43]. COVID-19 has also been a major concern in higher-income countries, with many European countries and the United States experiencing significant excess mortality in 2020 and a greater proportion of deaths from NCDs at home [44‐49].

The COVID-19 pandemic is unprecedented and serious, and several of the policy measures taken to mitigate and contain it were necessary and understandable. At the same time, we believe that the data from our study provide insights for policy makers as they consider the asymmetrical psycho-social and economic impacts of the pandemic on people with chronic conditions, especially underprivileged urban residents and underserved rural communities. In our study, rural residents and those of lower educational attainment experienced more difficulties in accessing medicines, controlling for other demographics and self-reported income. Difficulty in access to medicines, in turn was associated with worsening of diabetes or hypertension symptoms. Global supply chain disruptions during the pandemic contributed to reported shortages of essential medicines for chronic conditions [50]. Furthermore, the pandemic caused people with chronic conditions to face many lifestyle disruptions (unhealthy diet and physical inactivity, sleep disturbances, stress, and anxiety) needing remedial measures [16, 51]. Government aid was associated with fewer difficulties in access to medicines, but varied significantly across locations, demonstrating the importance of appropriate policies at the state and local levels. To mitigate the disparities in chronic disease management and reduce the potential longer-run health impacts of the current crisis, a promising approach is to focus on enabling access to medicines for vulnerable populations (i.e., those in rural areas, with lower educational attainment, and those experiencing poverty exacerbated by loss of jobs and household income). New models of healthcare delivery combined with new skills (e.g., patient-centered orientation and leveraging consumer-facing technologies) for the health workforce can promote patient engagement and health literacy, ultimately improving health outcomes.

Our data may assist health authorities to redesign care delivery models to address the urgent needs of people with chronic conditions. We recommend a three-pronged approach to design resilient healthcare systems during and after the COVID-19 pandemic: a) develop and implement digital campaigns to disseminate information on how to adopt healthy behaviors, better self-manage NCDs, and control COVID-19; b) decentralize healthcare delivery for people with chronic conditions by involving trained community health workers and using technology-assisted medical interventions along with home monitoring devices to improve health care services; c) provide effective social and economic support for people with chronic conditions, particularly rural communities, elderly, and those with severe mental health problems. Many have experienced loss of livelihoods, isolation, stress, and anxiety during the pandemic; however, those with preexisting chronic conditions have often experienced compounding effects that exacerbate their illness [52]. Therefore, social networks and family members have an important role to play within the community and at home in monitoring and enhancing self-care behaviors among patients with chronic conditions. Although regulatory authorities in many countries have approved one or more COVID-19 vaccines for emergency use, important challenges remain in mass producing and distributing vaccines in developing countries. In addition, the lasting and complex syndemic effects of the pandemic may linger; therefore, social health measures remain important. Greater investment in prevention efforts and strengthening primary care can help save future healthcare costs, reduce the burden of NCDs, and enhance resilience against future pandemics [53].

The strength of this study lies in its empirical mixed methods study design and focus on people with chronic conditions from both urban and rural populations. It is the first such study from a populous country like India. However, future research is needed to evaluate the longer-run impact of the COVID-19 pandemic on healthcare access and health outcomes for those both with and without NCDs.

In response to the rapid spread of the COVID-19 pandemic and associated health system disruptions experienced in under-resourced and low-income settings, there needs to be renewed focus on building resilient health systems that can deliver routine care using innovative telehealth approaches during the pandemic and respond to the shocks induced by infectious disease pandemics or other health crises effectively. People living in rural areas and underserved communities in urban areas faced greater challenges in access to healthcare and experienced worsening of diabetes or hypertension symptoms, as well as significant losses of income and employment. The pandemic exposed disparities in chronic disease management, but also provides opportunities to close gaps with innovations in the new post-COVID India.