The COVID-19 Pandemic substantially disrupted individuals' routine healthcare utilization; since March 2020, the World Health Organization declared COVID-19 a global pandemic, and governments around the world have generally imposed restrictions on the use of hospitals and outpatient services, eliminated all elective, routine and non-emergency patient procedures, implemented stricter physical distancing measures and transitioned to remote care to reallocate resources to the urgent care of patients with COVID-19[]. Globally, the Chinese government's endeavours to contain the spread of the COVID-19 pandemic have been widely praised, which may have contributed to a more severe influence on individuals' routine healthcare utilization during the early stages of the outbreak compared to other countries[9]. To the best of our knowledge, this is the first study to explore the impact of health service utilization on self-care behaviors among Chinese adult populations during the early COVID-19 pandemic based on a large sample covering 31 provinces in China. Understanding how self-care behavior and expectations may have been affected by RHSU due to the pandemic, can assist in better planning for inevitable future crises.
In our study, we observed that the situation of RHSU was significantly associated with positive self-care behavior, which includes prevention behavior, weight control, physical activity, and online medical consultation; the association remained significant even after adjusting for individual, environmental, and risk-perceptive control variables. Similar to the results of studies before (like medical services supply decline)and after the outbreak of the COVID-19 pandemic, these researchers also observed the association between social inequalities,pandemic-related changes, and individual health behavior[35–38]. For instance, when individuals have potential health risks (including reduced accessibility to healthcare or deterioration of health status), this may stimulate the self-care activities and behaviors that were aimed at preventing or reducing health risks and optimizing health and quality of life[][]. Evidence from Anderson's health behavior model likewise supports a relationship between the use of preventive health services and self-care ability in daily life[]. Another study from England claimed that pandemic-related changes facilitated increased self-care for self-limiting infections such as respiratory tract infections[]. Except for inequities in health service utilization, the risk perception[36] and actual infection risk related to the pandemic[38] are critical indicators of health behavior choices. From psychological responses, the higher the risk an individual perceives, the more motivated they might be to engage in protective behaviors[]. Despite this, previous research highlighted that not everyone responds to health risks similarly and that risk perception alone does not explain health behavior[]. For example, the literature suggests that the self-care behavior of chronic disease patients is associated with a high perceived susceptibility to disorders; they may tend to avoid in-person visits to hospitals, clinics, and emergency departments for fear of exposure to potential COVID-19[]. Likewise, older adults are more vulnerable to COVID-19 infection, have a worse prognosis after infection, and are also at greater risk of developing one or more non-communicable diseases. Therefore, they may experience heightened levels of instilled fear of COVID-19 exposure during in-person medical services[34]. In general, caution must be exercised when comparing these findings.
Online medical consultation
Regression analyses also indicated the significant correlations in online medical consultation across age, gender, income, married status, health status and infection risk perception, those findings align with previous studies[28,]. Specifically, with the outbreak of COVID-19, social distance, isolation, and hospital restrictions forced chronic patients to re-organize their routine care through temporary in-person visits; this led to a widespread and significant increase in telemedicine utilization[34]. However, the middle-aged and older populations and low-income groups in our study showed relatively weak performance in medical consultation; these findings align with previously published studies indicating that people aged above 65 years are less likely than the younger generation to have had the chance to familiarize themselves with ICT either at school or at work, combined with the cognitive, motor, digital gap and sensory decline associated with ageing, older adults face more barriers to and challenges in using online technology for health than their younger counterparts[]. Some studies claim that the digital divide created by digital technologies might widen social inequalities by alienating disadvantaged groups that do not have access to digital resources[][]. Furthermore, other concerns surrounding the promotion of online medical consultations include quality of care[], communication and language barriers[], and patient satisfaction[]. Chronic disease was also related to the higher online medical consultation score; previous research showed that patients with chronic disease may avoid in-person visits to hospitals, clinics, and emergency departments for fear of exposure to potential COVID-19[34,41]. This may be one of the main reasons that chronic patients tend to implement telemedicine or seek online medical consultation during a pandemic. Despite this, the difference in RHSU related to online medical consultation scores between the age and chronic disease subgroups was insignificant in the adjusted model; more empirical studies are needed to illustrate those associations.
However, our study noted that residents with high infection risk levels were more likely to report above-average online medical consultation scores when they had experienced RHSU compared to those with lower risk levels. Here, we observe the potential risks arising from high infection-risk living environments, which contribute to additional barriers to the health status of populations exposed to restricted or inequitable health service utilization; those barriers, as claimed by the concept of efficacy beliefs introduced in the Health Behaviour Model, are vital contributors to an individual’s willingness to make behavioral changes[].
Physical activity and Weight control
Research with adults during the COVID-19 pandemic suggests that self-isolation at home due to lockdown is associated with a lower level of physical activity and modifications in eating behavior.[][]It is difficult to change and maintain a lifestyle held for a long time. Nevertheless, self-care behavior such as physical activity, diet, weight control, smoking cessation and abstinence from alcohol could help those with restricted health services to reduce systolic and diastolic blood pressure and decrease the occurrence of complications such as hyperglycemia and diabetes and keep disease stable[28][]. Previous studies claim that there is an association between decreased healthcare utilization and increased leisure-time physical activity. Also, this association remains after adjustment for socio-economic confounders[], which is consistent with our findings. Furthermore,the strength of this association varies with different infection risk levels in living areas by subgroup analysis; the residential environments with high infection risk levels might indirectly affect participants with restricted healthcare services to be more inclined to engage in physical activity. Likewise, a literature review suggested that individual age, health literacy, and self-rated health could indirectly influence the association between healthcare utilization and physical activity through mediation analyses[].
In contrast, no significant associations were found in the model of weight control among subgroups analysis; this means that the strength of the association between RHSU and weight control was not affected by age, chronic diseases and actual infection risk level of the respondent's residence. According to the relevant literature, we found a few reasons that could become confounding to our findings; for instance, it was widespread for people to experience barriers to diet and healthy eating during the COVID-19 pandemic lockdown[50,55–56](e.g., food shortage, lacking motivation and control around food ), research has suggested that social closure measures may have a wide-ranging effect, making it more difficult for many people to adopt weight gain protective behaviors[]. Also, some mental health issues due to the pandemic, such as anxiety, stress, and poor mood, were found to be risk factors for obesity during the pandemic[]. Collectively, the factors mentioned above may make it more difficult to distinguish differences in weight control behaviors among populations.
Prevention behavior
Our study results indicated that RHSU was associated with prevention behavior in the adjusted model, not only for the whole sample but also in some of the subgroups. In particular, we found that prevention behavior scores were lower among males, unmarried, those with chronic disease, and those who perceived low risks of infection, consistent with results exploring population characteristics of prevention behaviors during the pandemic[30]. The previous studies also indicated that 30-49-year-old adults, those with a higher level of education, and those who were employed and had a high income were more knowledgeable and better able to take appropriate measures to prevent the spread of COVID-19[25][]. On the other hand, participants in the survey had generally high scores on prevention behaviors related to COVID-19, and the majority perceived a high infection risk level, which is attributed to the Chinese government's extensive publicity and appropriate supervision of interrupting the spread of the disease in the early stages of the COVID-19 pandemic[].
In subgroup analysis, compared to those without chronic disease, chronic patient populations were more likely to report higher preventive behavior scores in response to the COVID-19 pandemic after experiencing RHSU, which implied that RHSU might be more harmful to chronic patients' health. They would be more eager to improve their health behaviors because of perceived more significant potential health hazards. The self-care behavior of some chronic patients is associated with the high perceived susceptibility of disorders, which indirectly supports this speculation[].
Implications for research and practice
Our study results described the disparities in the implementation of self-care behavior among different adult populations during the early stages of the COVID-19 pandemic in China; however, those vulnerable population groups, such as the middle-aged and elderly, low self-rated health and low-income populations, were exposed to increased risks and susceptible to adverse health outcome[], still less likely to adopt self-care behaviors to enhance their health status during COVID-19 pandemics. Therefore, identifying vulnerable populations of self-care would broaden our knowledge of the prevalence of self-care behavior and inequities in promoting individual well-being during the pandemic, and those findings may provide insight into future policies in the event of a future lockdown.
Given that individuals who experienced restricted health service utilization were more actively engaged in self-care behavior, particularly those living in high infection-risk level areas, our study highlights the impact of health service inequalities and potential risk hazards on health behavior choices during the pandemic and the necessity of promoting self-care behavior when implementing pandemic prevention strategies, especially for people with vulnerable health conditions. Moreover, appropriate self-care behavior can bring convenience for individuals and help save medical expenditures. However, it will also benefit the health system by relieving the burden during a public health crisis[]. Compared to developed countries, developing countries such as China still need to improve in promoting self-care behavior, which may require policymakers to provide more strategic support for self-care behavior regarding personal health literacy development, public healthcare services, online healthcare services, continuing medical education, etc. In all, it is critical for policymakers to understand the reasons for self-care behavior changes in each population group that were significantly impacted to reform current health policies for better and fairer healthcare systems and to prepare and respond to a future pandemic adequately.
Limitations and innovations
Our study includes several fundamental limitations that must be acknowledged and addressed in future studies. Given the cross-sectional nature of this study, one of the main limitations was that there was no baseline response rate before the pandemic and no available data on participants' previous self-care behavior; neither can make definitive statements about causality in regression analyses. Second, this study assessed outcome variables by employing few single-item scales; also, only three dimensions were collected to describe the performance of self-care behavior. Therefore, future research should determine variables more comprehensively by using multiple scales to provide more conclusive evidence on the predictive validity of self-care behavior. Third, participants were recruited using a snowball sampling method through social media; the advantage of this method is that a large number of samples can be collected quickly. However, many participants were well-educated and below 40 years old, leading to a particular bias in the results, which made it difficult to identify more subgroups with significant differences.
However, This study has some innovative findings. First, our findings extend the existing literature by exploring the impact of restricted health service utilization on self-care behavior in a large sample covering all provinces in mainland China. Before this study, there was substantial evidence of the negative impact of COVID-19 and its reallocation of medical resource strategies on individuals' health status; however, little attention has been paid to the interaction of restricted health service utilization and self-care behavioral choices associated with COVID-19. Second, In contrast to previous studies mainly focusing on the impact of inequalities in health service accessibility or quality on self-care behavior in the context of regional economic disparities, our study contributes to the existing knowledge base by investigating the relationship between restricted health service utilization and self-care behavior during global infectious disease crisis. Third, we also take into account differences in risk perception when exploring the impact of inequalities in health service utilization on the outcome variables, so we tried to describe and compare the association between the RHSU and self-care behavior among the age, chronic disease and high, middle or low risk of infections living area subgroups, it is effective in terms of filling the gap in the relevant literature.