Our sample consisted of 25 participants, including two township heads and seven township practitioners from two THCs, nine village practitioners, one from each of the nine VCs, together with seven patients from the two THCs. Among 18 practitioners, most (11) were general practitioners, two were TCM practitioners, two were internal medicine physicians, two were heads of THCs and one was practitioner in outpatient department of the THC. Table 1 presents participant characteristics.
Table 1
Participant characteristics
|
|
Practitioner participants
|
Patient participants
|
Total number
|
|
18
|
7
|
Gender
|
Female
|
2
|
5
|
|
Male
|
16
|
2
|
Age
|
30–39
|
4
|
3
|
|
40–49
|
6
|
1
|
|
50–60
|
8
|
3
|
Education
|
No school / Illiterate
|
0
|
1
|
|
Primary School
|
0
|
2
|
|
Secondary School
|
0
|
2
|
|
Technical high school
|
9
|
1
|
|
College
|
4
|
1
|
|
Undergraduate
|
5
|
0
|
Place of work/residence
|
Township
|
9
|
1
|
|
Village
|
9
|
6
|
Location
|
Xiuning County, Huangshan Municipality
|
9
|
2
|
|
Yingquan District*, Fuyang Municipality
|
9
|
5
|
*Participants were from the rural areas of this district |
The results representing practitioners’ and patients’ views and perspectives on COVID-19 impacts on PHC services and the use of antibiotics are organised into four broad themes, (i) switch from PHC to epidemic prevention and control, (ii) concerns and challenges faced by those delivering PHC, (iii) diminished PHC, and iv) COVID-19 as a different class of illness.
Switch from primary health care to epidemic prevention and control
Practitioners reported a major change in their work to focus on COVID-19 control and prevention and away from seeing and treating patients. Clinical services were largely suspended at the beginning of the outbreak and practitioners found the majority of their workload comprised tracing and screening people at high risk for COVID-19 who ‘returned from Wuhan or returned from Hubei’ [P14, township internal medicine physician].
‘During the epidemic prevention and control period, including pharmacies, telephone follow-up, and the tracing and follow-up of fever patients, there were more things to do and they become more complicated and fragmental. Other workload reduced, the main work is related to epidemic prevention and control.’ [P1, head of THC]
Practitioners, particularly those working in VCs, described being allocated the additional work of reporting and tracing patients with fever identified in their clinics and delivering COVID-19 prevention information to residents in their area: ‘we also need to ensure the prevention and publicity work for local population.’ [P10, village practitioner]
Before the pandemic, THCs and VCs would diagnose and treat many patients presenting with respiratory infections and fever but after the introduction of epidemic control regulation, they were only allowed to screen and refer patients with suspected symptoms of COVID-19. Practitioners reported a large decrease in patients, particularly in VCs, attributed mainly to the diversion of patients with fever to specialised COVID-19 clinics. One participant said that ‘the patient amount has reduced two-thirds’ [P7, township practitioner] in his clinic.
‘… patient numbers [have] decreased because the authority required that [we] cannot see [patients with] fever.’ [P5, village TCM practitioner]
Practitioners had little knowledge and experience of COVID-19 management and felt that information about this was not relevant to them.
‘The treatment is none of our business, the physical examination is also none of our business. We only need to know that transferring patients immediately if there is certain symptom.’ [P2, village practitioner]
‘We’ve not been trained about the treatment [of COVID-19]. We mainly focused on preventions and infection control, because [patients who may need to receive] treatment were all transferred. This is our focus; we mainly highlighted the awareness of control and prevention.’ [P13, head of THC]
Concerns and challenges faced by those delivering primary health care
Practitioners were very worried about catching the virus at the beginning of the outbreak because they were working on the frontline and initially lacked personal protective equipment (PPE). They faced uncertainty about their exposure from patients in the community: ‘you contacted too many people at that time and had no idea at all about who may carry the virus’ [P17, township TCM practitioner]. Some practitioners worried about transmitting the virus to their family and chose to live at their clinics for a time.
‘Such worry is absolutely there. When this disease first outbreak, we didn’t even have a mask, but we had to go [to the frontline] when we were told. We needed to check body temperature for people who returned from other places. Once there is a confirmed case, we will also have to be isolated. How far can you be away from them when checking the temperature? At the beginning, the winter, the supplies are scarce, and the masks are limited.’ [P9, village practitioner]
‘Well, I lived at the clinic in that half month and never went back home, since those [people he checked body temperature] are all returned from Wuhan, I definitely cannot go back home. … Yes, it is [for the sake of protecting family], even we don’t care, we should protect our family, right?’ [P4, village practitioner]
Practitioners described how COVID-19 and the related changes in regulations had made their work more difficult and stressful. Despite the decrease in patients, their workload had actually increased due to COVID-19 control and prevention work. PPE was initially lacking and then difficult to use: ‘[you] cannot walk around [in protective gown] and [it] will be very difficult even to use the toilet’ [P16, township internal medicine physician].
‘That’s true that patient numbers decreased, but this thing [the epidemic made you] feel alarmed, so the burden from mental side surely increased.’ [P9, village practitioner].
‘Workload should increase, we definitely have a high workload due to COVID-19. To what extent? We need to work day and night to, first, follow-up, and another, check body temperature, of returned people [from high risk areas], the more returning people the higher your workload would be.’ [P10, village practitioner]
One participant felt the work of reporting and transferring all patients with possible COVID-19 symptoms was ‘not achievable’ and instead he just asked patients with fever to leave his clinic: ‘No referral, which will bring a lot of troubles. Just ask him [patient with fever] to leave. … Yes, there is a complicated set of procedures for referral.’ [P5, village TCM practitioner].
VCs experienced financial pressures as patient numbers and fees reduced and they became more reliant on income from the state for provision of public health infection prevention and control services. VCs had to scrap expired medicines purchased in anticipation of the normal level of need, but no financial compensation was available. Practitioners believed that they could maintain their business under such pressure, although it was more difficult than before.
‘There must be [impacts]. Since the patient number in our clinic decreased, it definitely has impact on us.’ [P3, village practitioner].
‘These types of medicine were bought with our own money, so will they [authorities] care about the expiration? They will not care about it at all. … There is no single penny from subsidy at all, not to mention others. There is nothing, just as same as usual.’ [P5, village TCM practitioner]
‘Patients [number] did decrease, [but] we also worked for public health education and the state ensured the money for this, so our life is guaranteed.’ [P11, village practitioner]
Diminished primary health care
VCs were no longer able to treat patients with common infections after the introduction of epidemic control regulation. There was no substitution of face to face with remote consultations (by phone or communications app), which practitioners attributed to the fact that most of their patients were elderly and were not used to remote consultations and/or don’t know how to use smartphones.
‘As for fever among local people, you know, the kind of cold [that can easily cause fever] especially for children. We have more child patients here, and in fact, it is very normal for them to have a fever caused by, for example, respiratory tract infections or tonsillitis, right?’ [P8, township practitioner]
‘There is no consultation [through WeChat or phone]. Almost all patients here are old people; remote consultation is rare, most of them will directly visit our village clinic.’ [P12, village practitioner]
Practitioners also reported reductions in antibiotic intravenous drip treatment because of concerns about increased risk of catching COVID-19 when spending time and/or gathering at health institutions: ‘patients are unwilling to be delayed in township hospitals’ [P1, head of THC] and ‘intravenous drips at clinics were not allowed because it would lead patients to gather together, so intravenous drips were stopped at that time.’ [P15, township practitioner].
COVID-19 specialist clinics were established in some township hospitals at the start of the epidemic and ‘most staff were transferred to work for pre-diagnosis and fever clinic’ [P13, head of THC]. However, these regional clinics soon closed to COVID-19 patents since they lacked the qualified staff and equipment required. Patients with respiratory symptoms or fever then had travel even further for treatment.
‘It was set up at the beginning; however, when the authorities came for inspection, they found these fever clinics did not meet the standards and also not have enough staff. These fever clinics were then withdrawn with only the referral counter remaining.’ [P1, head of THC]
Patients found it more difficult to access health care as a result of the pandemic. Patients were afraid of being infected with COVID-19 and most patients said they would avoid places they viewed as having a high transmission risk, like health institutions, as a precaution. Patients said they were no longer able to access treatment at township or village level and some said that it was even difficult to get to pharmacies to purchase medicine.
‘If there’s not a necessary thing, I definitely don’t want to go to hospital. After all there are many patients. What if I was all right but then be infected just because I visited there, right?’ [P19, technical high school, village, 50 years]
‘Our township [level health institutions] did not treat [patients with fever], they even did not prescribe medicine to them. Our local [health institutions] did not take any examination on them; they were all transferred to Fuyang City.’ [P23, illiterate, village, 51 years]
‘It must be inconvenient to see a doctor, it’s even impossible to go out once I wanted to buy some medicine for my niece.’ [P22, primary school, village, 46 years]
COVID-19 as a different class of illness
Practitioners described COVID-19 as different from the RTIs that, pre-pandemic, they had often treated in village and township clinics. This difference was characterised in a range of ways by different practitioners. Many described it as much more serious: ‘fierce and fatal’ [P13, head of THC]. Some described it as having a different mode of action on the body or lungs. TCM practitioners understood COVID-19 through plague theory, the TCM theory used to explain illnesses with characteristics of high transmissibility and severity, rather than the ‘hot-natured state’ and ‘hot’ conditions that have been commonly associated with common RTIs: ‘a plague [Wenyi] that related to outside environment’ [P17, township TCM practitioner].
‘It [COVID-19] is also inflammation, but its inflammation came quite fiercely and fast.’ [P11, village practitioner]
‘This COVID-19 will quickly cause shock and exhaustion; it’s so severe. If you have general pneumonia, you can recover after admission in the hospital for ten or eight days, but COVID-19 is so severe and cannot be treated by common medicine.’ [P11, village practitioner]
‘[COVID-19 is] lung consolidation that is caused by the virus rather than inflammation’ [P12, village practitioner]
COVID-19 was associated with SARS, also a serious epidemic that was not treated in the routine work of THCs and VCs. Like SARS, COVID-19 was thought to have high transmissibility and severity characteristics that were not commonly associated with normal RTIs and were of particular concern to practitioners and patients. COVID-19 was seen as more severe than SARS, partly due to the more severe and prolonged restrictions imposed to control it.
‘Like SARS and COVID-19, they all belonged to corona virus, SARS in 2003 also came fiercely and also could lead to death. …Our respiratory tract would also locate many viruses, but generally they do not cause such serious consequences, but this virus [COVID-19] is a big issue.’ [P13, head of THC]
‘[COVID-19 and] general pneumonia still have certain differences. First of all, for general pneumonia, it is not contagious in general situation. Look at it [COVID-19], then it is quite contagious… [P15, township practitioner]
‘Yes, this disease is more serious than SARS. SARS can be controlled. See how many days have been spent to control this disease? Isn't it still there?’ [P21, college, town, 31 years]
‘For sure, people will definitely be worried and afraid. In the past, even for SARS period, you didn't close the road, right? Now the villages are closed, you are not allowed to go out, and then the roads are closed, some places the roads are even cut off so you cannot use them and go out. It feels more serious.’ [P25, secondary school, village, 35 years]
Practitioners believed that the COVID-19 epidemic had not led to any changes in their antibiotic treatment practices, except that they were seeing lower numbers of patients presenting with infections and therefore the amount of antibiotics prescribed had decreased during the epidemic period. Since practitioners treated COVID-19 as different from the common RTIs seen in their daily work, they did not see their treatment experiences as relevant to COVID-19 or information about COVID-19 treatment as relevant to them.
‘That is to say, for COVID-19 epidemic’s own impact on the daily use of antibiotics and the consultation, I don't think it is much different from previous years.’ [P8, township practitioner]
‘Once [the patients] get fever, the problem is that we cannot prescribe medicine, so antibiotic use surely is less.’ [P4, village practitioner]
‘the number of patients dropped sharply and sometimes there were no patients. … Like medicines used in intravenous infusion were likely to be scrapped quite a lot, most of them were antibiotics…’ [P8, township practitioner]
‘Village clinics would not be interested in that, doctors in village clinics are impossible to see how antibiotics could be used for COVID-19; they won’t even look at it’ [P4, village practitioner]