Abstract

The present study investigates the association between the self-reported diagnosis of noncommunicable disease (NCD) and the adherence to social distancing and the use of health services during the COVID-19 pandemic. This was a cross-sectional study with Brazilian adults who participated in the ConVid- Behavior Survey, conducted online between April 24 and May 24, 2020(n = 45.161). This studyconsidered the following NCDs: diabetes, hypertension, respiratory disease, heart disease, and cancer, and evaluated the use of health services and the adherence to social distancing, as well as estimated the prevalences and adjusted prevalence ratio (aPR); 33,9% (95% CI: 32,5-35,3) referred to one or more NCD. Individuals with NCDsshowed a greater adherence to intense social distancing (aPR: 1,07;95% CI: 1,03-1,11), sought out health services more often (aPR:1,24; 95% CI:1,11-1,38), and found greater difficultyin scheduling doctor’s appointments (aPR:1.52; 95% CI 1,35-1,71), receiving healthcare treatment (APR:1,50;95% CI:1,22-1,84) and medication (APR:2,17;95% CI:1,77-2,67), and performing examinations (APR:1,78;95% CI:1,50-2,10) and scheduled interventions (APR:1,65;95% CI:1,16-2,34). The presence of NCDs was associated with social distancing, seeking out health care, and difficulty in using health services.

Key words:
Quarantine; Infection by coronavirus; Noncommunicable diseases; Access to health services

Introduction

Noncommunicable Diseases (NCDs) are the main cause of death worldwide and are responsible for 71% (41 million) of the deaths around the world in 2016. NCDsare also considered a public health problem due to the increase in economic and social costs caused by morbidity, hospitalization time, and mortality¹1 World Health Organization (WHO). Noncommunicable diseases country profiles 2018. Geneva: WHO; 2018 [cited 2021 Jan 19]:223 p. Available from: https://www.who.int/nmh/publications/ncd-profiles-2018/en/.

In the scenario of the Coronavirus (COVID-19) pandemic, NCDs become even more worrisome, since these diseases and their behavioral and metabolic risk factors aggravate cases, increasing hospitalization time and mortality rates by COVID-19²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.. Moreover, individuals with NCDs are more often affected by the more severe forms of COVID-19, which require hospitalization, intensive care, and the use of ventilators²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.. A study done in Italy revealed that 96.2% of the people who died from COVID-19 had hypertension (69.2%), type 2 diabetes (31.8%), ischemic heart disease (28,2%), chronic obstructive pulmonary disease (16.9%), and cancer (16.3%)³3 Istituto Superiore di Sanità. Characteristics of SARS-CoV-2 patients dying in Italy. Report based on available data on September 7th, 2020. Roma: EpiCentro; 2020. [cited 2021 Jan 23]:1-10. Available from: https://www.epicentro.iss.it/en/coronavirus/bollettino/Report-COVID-2019_7_september_2020.pdf.

Adherence to social distancing, recommended by the World Health Organization (WHO) as one of the non-pharmacological measures which contribute to lessen the spreadand transmission of COVID-19⁴4 World Health Organization (WHO). Overview of public health and social measures in the context of COVID-19. Geneva: WHO; 2020 [cited 2021Jan 23]. Available from: https://www.who.int/publications/i/item/overview-of-public-health-and-social-measures-in-the-context-of-covid-19 may, on the other hand, cause negative health effects, mainly in people with NCDs. Social distancing may result in changes in daily routines and lifestyle, such as diminishedphysical activity, an increase in theconsumption of tobacco and alcoholic beverages⁵5 Malta DC, Szwarcwald CL, Barros MBA, Gomes CS, Machado IE, Souza Júnior PRB, Romero DL, Lima MG, Damacena GM, Pina MF, Freitas MIF, Werneck AL, Silva DRP, Azevedo LO, Gracie R. A pandemia da COVID-19 e as mudanças no estilo de vida dos brasileiros adultos: um estudo transversal, 2020. Epidemio Serv Saude 2020; 29(4): e2020407.. It may also compromise access to health services²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.^,66 World Health Organization (WHO). Noncommunicable diseases in emergencies. Geneva: WHO; 2020 [cited 2021 Jan 23]. Available from: https://www.who.int/ncds/publications/ncds-in-emergencies/en/^-77 Barone MTU, Villarroel D, Luca PV, Harnik SB, Lima BLS, Wieselberg RJP, Giampaoli V. COVID-19 impact on people with diabetes in South and Central America (SACA region). Diabetes Res Clin Pract 2020; 166:108301. and, consequently, to the continuity of the medical careprovided to individuals with NCDs, thus causing a decline in their health conditions.

One study done by the Pan-American Health Organization (PAHO) revealed that NCDprevention and treatment services have been affected by the COVID-19 pandemic throughoutthe American continent⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... . Routine health services have been reorganized or discontinued, with the interruption of assistance for diseases like cancer, cardiovascular disease, and diabetes⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... . Additionally, healthcare personnel caring for NCDs were redirected to work in contingency actions against COVID-19⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... .

In this context, reduction or even interruption of routine health care constitutes a threat to people who live with NCDs and may cause a “parallel epidemic of avoidable deaths⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... .” Therefore, there is a need to investigate the use of health services during the COVID-19 pandemic by people with NCDs.

Considering what has been proposed, the present study soughtto investigate if the self-reported NCD diagnosis is in fact associated with adherence to social distancing and the useof health services during the COVID-19 pandemic in Brazil.

Methodology

Study design and sampling process

This is a cross-sectional study conducted with adult individuals (18 years of age and older) residing in Brazil, who participated in the virtual health survey “ConVid - Behavior Survey. ConVid was conducted by the Oswaldo Cruz Foundation (Fundação Oswaldo Cruz - FIOCRUZ) in a partnership with Universidade Federal de Minas Gerais (UFMG) and UniversidadeEstadual de Campinas (UNICAMP), with the objective of evaluating changes in lifestyle and the health care of Brazilians during the COVID-19 pandemic⁹9 Fundação Oswaldo Cruz (Fiocruz). Convid Pesquisa de Comportamentos [Internet]. 2020 [acessado 2021 jan 23]. Disponível em: https://convid.fiocruz.br/index.php?pag=principal
https://convid.fiocruz.br/index.php?pag=... .

Data collection took place between April 24 and May 24, 2020, through the process of filling outan online questionnaire. Eachperson of 18 years of age and older residing in Brazil was eligible to participate in this study.

The participants were invited to participate through a chain sampling procedure¹⁰10 Costa BRL. Bola de Neve Virtual: O Uso das redes sociais virtuais no processo de coleta de dados de uma pesquisa científica. Rev Interdiscip Gestão Soc 2018;7(1):15-37.. Firstly, the responsible surveyors selected a group of survey agents (called “influencers”) from different states of Brazil to commence the network of participants. After answering the questionnaire, the influencers sent the link to the survey to at least 20 people from their social networks, following a stratification by sex, age group (18 to 39; 40 to 59; 60 and older), and level of education (incomplete High School or less, complete High School or more). Each person who received the link was asked to invite three other people from their social networks through a message at the end of the questionnaire: Be a part of the ConVid Network and share this survey with three or more guests from your social networks. You can do this by clicking on this link or copying and sending our link: https://convid.fiocruz.br.

The information was collected directly through the Internet and stored inthe server of FIOCRUZ Institute of Communication and Scientific and Technological Information on Health, without the possibility of identifying the participants.

More detail about the survey can be found in the official site of the ConVid - Behavior Survey⁹9 Fundação Oswaldo Cruz (Fiocruz). Convid Pesquisa de Comportamentos [Internet]. 2020 [acessado 2021 jan 23]. Disponível em: https://convid.fiocruz.br/index.php?pag=principal
https://convid.fiocruz.br/index.php?pag=... .

Study variables

The self-reported NCD diagnosis was defined by a positive answer about the presence of one or more NCD among the following options: Diabetes, Hypertension, Respiratory disease, Heart disease, and Cancer. The question inthe online questionnaire referred to the previous medical diagnosis of these diseases: “Has any doctor diagnosed you with one of these diseases?”

To evaluate intense social distancing, the following question was used: “During the pandemic of the new coronavirus, how seriously did you follow (or still follow) restrictions in coming in contact withother people?” The answer options were: a) I did nothing, carried on with normal life”; b) I tried to take precautions, to stay away from people, reduced contact a little, did not visit elderly people, but I kept working and leaving home”; c) “I stayed home and only left to shop for groceries and to go to the drugstore”; d) “I rigorously stayed home and only left when I needed to get health treatment”. The variable was categorized as “no” (options “a” and “b”) and “yes” (options “c” and “d”).

Useof health services was evaluated according to those seeking outhealth services and the difficulties in accessing those services. To evaluate an individual’s searchfor health services, the following question was used: “During the coronavirus pandemic, did you schedulean appointment with a doctor, dentist, or other healthcare professional?”. The answers were “yes” or “no”. Concerning difficulties to access the services, the following question was used: “In the course of the pandemic, did you have any of these difficulties related to health care?”: a)”Scheduling an appointment”; b) “Having a health appointment”; c) “Getting medication”; d) “BeingHospitalized”. The answer options were “yes” or “no”.

The following sociodemographic variables were analyzed: sex (male or female), age group (18 to 39; 40 to 59 and 60 years and older) and education (incomplete High School; complete High School; and complete College).

Data Analysis

Network sampling is not probabilistic; therefore, it is impossible to calculate the natural weights of the sampling design. Hence, to obtain a representative sample and for the same population distribution to be identified in the National Household Sample Survey Sampling (PNAD in Portuguese) from the Brazilian Institute of Geography and Statistics (IBGE) in 2019, post-stratification procedures¹¹11 Szwarcwald CL, Damacena GN. Amostras complexas em inquéritos: planejamento e implicações na análise estatística de dados. Rev Bras Epidemio 2008; 11(Supl. 1):38-45. were used, according to: State of the Brazilian Federation, capital, sex, age group (18 to 29; 30 to 39; 40 to 49; 50 to 59; 60 years and older), level of education (incomplete College; Complete College), and race/color¹²12 Instituto Brasileiro de Geografia e Estatística (IBGE). Pesquisa Nacional por Amostra de Domicílios (PNAD) 2019. Rio de Janeiro: IBGE; 2019 [acessado 2021 jan 23]. Disponível em: https://biblioteca.ibge.gov.br/visualizacao/livros/liv101651_notas_tecnicas.pdf. This technique corrects the under or over representation of population groups and has often been used in entiresurveys, such as the Continuous PNAD and the Telephone Inquiry for Risk Factor Vigilance and Protection Against Noncommunicable Diseases (Vigitel in Portuguese)¹³13 Bernal RTI, Iser BPM, Malta DC, Claro RM. Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel): changes in weighting methodology. Epidemiol Serv Saude 2017; 26(4):701-712..

A descriptive analysis of the variables through the calculation of relative frequencies and 95% confidenceintervals (95% CI) was performed. To evaluate the association between self-reported diagnosis of one or more NCDs, the useof health services and the adherence to the social restriction measures, the rough and adjusted prevalence ratio (aPR) according to sex, age group, and education were calculated, as was their respective 95% CI, with the use of Poisson regression models with robust variance.

Information was processed by Stata, version 14, employing the survey method, which considers the post-stratification weights.

Ethical Aspects

This research was basedon Resolution 466/2012 from the National Health Council and approved by the National Research Ethics Commission. The participants filled outa free and informed consent form; all answers were anonymous, with no identification of the participants.

Results

A total of 47,184 people participated in this study, and 2,023 (4.3%) of the questionnaires were excluded because the information needed to calibrate the data had not been completed. These questionnaires presentedno information regarding state, sex, age, race/color, or education. The final number of interviewees was 45,151 people throughout the country.

Most of the participants were females (53.6%; 95% CI: 52.0 - 55.0), 45.7% was between 18 and 39 years of age (95% CI: 44.2 - 47.1), 72.4% had completed High School (95% CI: 71.3 - 73.5), 45.7% were light-skinned black (95% CI: 44.2 - 47.2), and 45.2% were white-skinned (43.8 - 46.6) (Table 1).

The prevalence of one or more NCD was 33.9% (95% CI: 32.5 - 35.3), which washigher among the elderly (58.6%; 95% CI: 55.3 - 61.9) and among individuals with incomplete High School education (39.3%; 95% CI: 34.4 - 44.5). The previous self-reported diagnosis of hypertension, diabetes, respiratory disease, heart disease, and cancer was reported by 19.3%, 7.2%, 11.3%, 4.3%, and 2.4% of the participants, respectively, which washigher among the elderly, except for respiratory diseases, where theprevalence was higher among young adults (18 to 39 years). Individuals with highereducation (Complete College) showeda lower prevalence of a self-reported diagnosis of hypertension, diabetes, and heart disease. Prevalences were similar for both males and females (Table 2).

When analyzing adherence to intense social distancing, it wasobserved that individuals who had one or more NCD were those who declared greateradherence (aPR: 1.07; 95% CI: 1.03 - 1.11) as compared to those with no NCDs (Figure 1).

Table 3 shows the prevalence and the measures of association of having one or more NCD, as well as the search for and difficulty in using healthcare services during the pandemic. It was verified that self-reported diagnoses of NCDs was associated with higher rate of seeking outhealth care witha doctor, dentist or other health care professional (APR: 1.24; 95% CI:1.11 - 1.38), with a higher difficulty of accessing health services, for example, scheduling an appointment (APR: 1.52; 95% CI: 1.35 - 1.71), receiving health care service (APR: 1.50; 95% CI:1.22 - 1.84); obtaining medication (APR: 2.17; 95% CI: 1.77 - 2.67), performingprescribed examinations (APR: 1.78; 95% CI: 1.50 - 2.10), and undergoingscheduledinterventions (APR: 1.65; 95% CI: 1.16 - 2.34) (Table 3).

Discussion

This study identified that approximately 34% of the participants reportedone or more NCDs: hypertension, diabetes, cancer, cardiac disease, or respiratory disease. In general, the prevalence of these diseases increased with age and was higher in population groups with lower levels ofeducation. Individuals with NCDsreported a greater adherence to measures of intense social distancing and sought out health care more frequently, but they also reported greater difficulty in accessing health services, for instance, in receiving medicalcare, scheduling appointments, obtaining medication, doing exams, and undergoing scheduledinterventions.

The prevalence of a priorself-reported diagnosis of one or more NCDs found in the present study (34%) was below that indicated by another published study, which analyzed data from the National Health Survey (NHS) from 2013 (45%)¹⁴14 Malta DC, Stopa SR, Szwarcwald CL, Gomes NL, Silva Júnior JB, Reis AAC. A vigilância e o monitoramento das principais doenças crônicas não transmissíveis no Brasil - Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015;18 (Supl. 2):3-16.. This discrepancycan be explained by the fact that this study has evaluated only five NCDs, while the NHSinvestigated a higher number. Still, according to the NHS2013, in adults, the prevalence of hypertension, diabetes, heart disease, and cancer were, respectively, 21.4%, 6.2%, 4.8%, and 1.8%¹⁴14 Malta DC, Stopa SR, Szwarcwald CL, Gomes NL, Silva Júnior JB, Reis AAC. A vigilância e o monitoramento das principais doenças crônicas não transmissíveis no Brasil - Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015;18 (Supl. 2):3-16., close to those found in the current study.

Similar tothe present study, another publication, which analyzed data from the NHS2013 identified that the prevalence of NCDs increased with age, afflicting more often individuals above 60 years of age, not including asthma, and those who have a lowerlevel of education, not including cancer¹⁵15 Theme FMM, Souza JPRB, Damacena GN, Szwarcwald CL. Prevalência de doenças crônicas não transmissíveis e associação com autoavaliação de saúde: Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol 2015; 18(Supl. 2): 83-96.. Beyond the changes in lifestyle inherent withincontemporary society and factors intrinsic to the individuals, noncommunicable diseases also have a connection with population aging¹⁶16 Veras RP. Estratégias para o enfrentamento das doenças crônicas: um modelo em que todos ganham. Rev Bras Geriatr Gerontol 2011; 14(4):779-786.. Population aging is a global phenomenon caused by the decline in fertility rates and increase in longevity, and is happening more rapidly in underdeveloped countries, although more developed countries still have a higher contingent of elderly population¹⁷17 World Health Organization (WHO). Global Health and Aging. Geneva: WHO; 2011 [cited 2021 Jan 23]:1-32. Available from: https://www.who.int/ageing/publications/global_health.pdf?ua=1^-1818 Carvalho JAM, Garcia RA. O envelhecimento da população brasileira: um enfoque demográfico. Cad Saude Publica 2003; 19(3):725-733.. It is estimated that the NCDs represent 87% of the burden of diseases among the population aged 60 years and older, and more in low, middle and high-income countries¹⁷17 World Health Organization (WHO). Global Health and Aging. Geneva: WHO; 2011 [cited 2021 Jan 23]:1-32. Available from: https://www.who.int/ageing/publications/global_health.pdf?ua=1.

Concerning the social determinants, such as education, income, and environment, these also contribute to the increase and seriousness of the NCDs, of their risk factors, and their morbidity¹⁹19 Marmot M, Bell R. Social determinants and non-communicable diseases: time for integrated action. BMJ 2019; 364: l251.. Individuals or groups with low income and less education are more likely to be more exposed to the risk factors associated with NCDs, since they have less access to or receivea lowerquality healthcare service, and have less access to balanced nutrition and to healthy environments²⁰20 Keetile M, Navaneetham K, Letamo G, Rakgoasi SD. Socioeconomic inequalities in non-communicable disease risk factors in Botswana: a cross-sectional study. BMC Public Health 2019; 19(1):1060.^-2121 World Health Organization (WHO). Preventing Cronic Diseases - a vital investment. Geneva: WHO; 2005 [cited 2021 Jan 23]. Available from: https://www.who.int/chp/chronic_disease_report/contents/en/, whichreduces these individuals’ opportunities to leada healthier life and to prevent diseases²²22 Malta DC, Moura EC, Morais Neto OL. Desigualdades de sexo e escolaridade em fatores de risco e proteção para doenças crônicas em adultos Brasileiros, por meio de inquéritos telefônicos. Rev Bras Epidemio 2011; 14(Supl.1):125-135..

It is worthmentioning that the COVID-19 pandemic is taking place in a scenario of social and economic inequalities, which can increase morbidity caused by NCDs, aggravating inequalities in access to health services²³23 Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, Barros MBA. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(Supl. 1):4s.. The prevalence and seriousness of the COVID-19 pandemic is intensified with the unequal distribution of NCDs and their risk factors, more directly affecting the most vulnerable population groups, whichindicates a close relationship with the social determinants of health²³23 Malta DC, Bernal RTI, Lima MG, Araújo SSC, Silva MMA, Freitas MIF, Barros MBA. Noncommunicable diseases and the use of health services: analysis of the National Health Survey in Brazil. Rev Saude Publica 2017; 51(Supl. 1):4s.

24 Barros MBA, Zanchetta LM, Moura EC, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saude Publica 2009; 43(Supl. 2):27-37.^-2525 Bambra C, Riordan R, Ford J, Matthews F. The COVID-19 pandemic and health inequalities. J Epidemiol Community Health 2020; 74:964-968..

Adherence to intense social distancing was higher among individuals with NCDs. These findings can be explained by the fear of getting sick and the feeling of vulnerability of that population, which chooses to follow the orientations for social distancing more accurately, seeking to protect them selves⁷7 Barone MTU, Villarroel D, Luca PV, Harnik SB, Lima BLS, Wieselberg RJP, Giampaoli V. COVID-19 impact on people with diabetes in South and Central America (SACA region). Diabetes Res Clin Pract 2020; 166:108301.. Social distancing measures do contribute to are duction in the risk of COVID-19 transmission for the entire population, especially for those who have NCDs, who have a higher risk of having more serious cases of the disease and greater mortality²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.^,2626 Nussbaumer-Streit B, Mayr V, Dobrescu AI, Chapman A, Persad E, Klerings I, Wagner G, Siebert U, Christof C, Zachariah C, Gartlehner G. Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review. Cochrane Database Syst Rev 2020; 4(4):CD013574..

The present study indicated that individuals with NCDsreportedsearching more often and having more difficulties in using health services during the pandemic. The determinants of the use of health services are related to, among other factors, the health needs of the population, defined by morbidity and the seriousness of the disease or its urgency.²⁷27 Travassos C, Martins M. Uma revisão sobre os conceitos de acesso e utilização de serviços de saúde. Cad Saude Publica 2004; 20(Supl. 2):S190-S198.NCDs, given their high burden and level of chronicity, are among those which demand more actions, procedures, and health services²⁸28 Brasil. Ministério da Saúde (MS). A vigilância, o controle e a prevenção das doenças crônicas não-transmissíveis: DCNT no contexto do Sistema Único de Saúde brasileiro. Brasília: Organização Pan-Americana da Saúde [Internet]. 2005 [acessado 2021 jan 23]:1-80. Disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/DCNT.pdf
https://bvsms.saude.gov.br/bvs/publicaco... . In that sense, one,which used data from the NHS2014, identified that the presence of at least one chronic disease was associated witha greateruse of health services (25.6%), in comparison to the absence of NCDs (10.8%)²⁹29 Malta DC, Bernal RTI, Lima MG, Araújo Silvânia SC, Silva MMA, Freitas MIF, Barros MB. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saude Publica 2017; 51(Supl. 1):4s.. Moreover, the presence of NCDs was associated with an increase in hospitalization²⁹29 Malta DC, Bernal RTI, Lima MG, Araújo Silvânia SC, Silva MMA, Freitas MIF, Barros MB. Doenças crônicas não transmissíveis e a utilização de serviços de saúde: análise da Pesquisa Nacional de Saúde no Brasil. Rev Saude Publica 2017; 51(Supl. 1):4s.. The COVID-19 pandemic has made it evident that the NCDs represent a high burden to health services and resources, demanding from authorities a more serious implementation of actions to control the consumption of tobacco, alcohol, and sugar, as well as investments in the improvement of physical activities and ahealthy diet³⁰30 The Lancet. COVID-19: a new lens for non-communicable diseases. Lancet 2020; 396 (10252):649..

The difficulties in using healthservices mentioned by the participants of this study may be explained by a lesseravailability of services by public and private healthcare facilities during the pandemic. Efforts to deal with COVID-19 have also interrupted the regular care required for individuals with NCDs³⁰30 The Lancet. COVID-19: a new lens for non-communicable diseases. Lancet 2020; 396 (10252):649.. One survey conductedby the WHO noted that 75% of the countries thatresponded reported interruption in health services and treatment of NCDs³¹31 World Health Organization (WHO). NCD Department. Rapid assessment of service delivery for noncommunicable diseases (NCDs) during the COVID-19 pandemic: Final Results. Geneva: WHO; 2020 [cited 2021 Jan 23]. Available from: https://www.who.int/publications/m/item/rapid-assessment-of-service-delivery-for-ncds-during-the-covid-19-pandemic.

The interruption of the reduction inroutine health services and theproviding of medical supplies made it more difficult to follow and handle NCDs, thus causing an increase in morbidity, disability, and avoidable mortality²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.. Another study done by PAHO, in May 2020, among countries of the American continent, also identified that, although the ambulatory NCD services had been maintained, te access to these was limited in several countries (64%)⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... .The interruption of services, completely or partially, affected various types of medical care for people with NCDs, even dental and rehabilitation care.⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... The main reasons mentioned in the answers by the member states, regarding the interruption of NCD health care services, included: canceling elective services (58%), relocating medical teams in response to COVID-19 (50%), and the reduced embracement of individuals by health services(50%)⁸8 Organização Pan-Americana da Saúde (OPAS). Informe de la evaluación rápida de la prestación de servicios para enfermedades no transmisibles durante la pandemia de COVID-19 en las Américas; 2020 [acessado 2021 Jan 23]:1-8. Disponível em: https://iris.paho.org/bitstream/handle/10665.2/52283/OPSNMHNVCOVID-19200024_spa.pdf?sequence=5&isAllowed=y
https://iris.paho.org/bitstream/handle/1... . The reduction inpublic transportation, which occurred during the pandemic, may also have increased the difficulty in using health services and may have interrupted the continuity of medical care for NCDs patients²2 Kluge HHP, Wickramasinghe K, Rippin HL, Mendes R, Peters DH, Kontsevaya A, Breda J. Prevention and control of non-communicable diseases in the COVID-19 response. Lancet 2020; 395(10238):1678-1680.. Regarding patients/customers/users who do not seek out medical care through health services, one publication, which investigated the use of health services in the first two months of the pandemic by the population with health insurance in the United States, identified a significant reduction in the use of elective and prevention services and an increase in telemedicine³²32 Whaley CM, Pera MF, Cantor J, Chang J, Velasco J, Hagg HK, Sood N, Bravata DM. Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic. JAMA Netw Open 2020;3(11):e2024984.. A possible explanation for not seeking out medical care throughhealth services may be the fear of exposure on the part ofthe patients/cusotmers/users of being contaminated by COVID-19³³33 Carlos RC, Lowry KP, Sadigh G. The Coronavirus Disease 2019 (COVID-19) Pandemic: A Patient-Centered Model of Systemic Shock and Cancer Care Adherence. J Am Coll Radiol 2020; 17(7):927-930..

Among the limitations of this study is the data collection performed through the Internet, a strategy which may not reach all the population groups, considering that not everyone has access to this means of communication. This problem can result in an underor overestimation of the proportion of the investigated indicators. This limitation, however, was minimized by the large sample size and the calibration of the sampling with data from the PNAD 2019. It should also be mentioned that the collection of data through the Internet and the process of chain sampling is the only method thatis ethically plausible, in the context of the pandemic, to evaluate the relevant questions. It is also a survey method which has a low cost in operational terms. The online surveys are becoming a promising method to evaluate and track information, behaviors, lifestyles, and perceptions during outbreaks of infectious diseases, and it is evolving quickly.

Another issue concerns data collection during the beginning of the pandemic, (more precisely, in the third month), thus reflecting the scenario of a specific moment, which is subject to conjuncture changes duringthe temporal evolution of the COVID-19 pandemic in Brazil. Additionally, due to the fact that the information is self-reported, information bias concerning the previous diagnosis of NCDs may have occurred. We should also consider that the useof only sociodemographic variables to adjust the models may result, potentially, in residual confusion.

Conclusion

The pandemic resulted in an important adherence of individuals with NCDs to social distancing. However, this group searchesfor health servicesmore oftenand has greaterdifficulty in using them. Therefore, the importance of discussing policies for reducing NCD becomes more evident, as do the actions to provide health care, when faced with the COVID-19 pandemic scenario. NCD prevention measures should not be interrupted, and health services, especially those of primary care, must adapt to the new reality to support and manage the increase in risk and to provide a continuity of medical care to NCD patients. Health professionals must be involved in the planning of strategies to respond to COVID-19 in order to ensure that the needs of the patients are provided. Specific counselling must be made available nationally and locally for NCD patients, as well as for their families and caretakers.

References

Publication Dates

History