A total of 22 individuals, 13 HCPs working in the management of NCDs and nine people with NCD, participated in this study. None of the purposively selected people to participate in this study have refused or dropped out. We tried to mix the participants from different backgrounds based on sex, age, the professional background of HCPs and NCD type for people with NCDs (see Tables 1 and 2).
Why people with NCD discontinue their follow-up during COVID-19
Interview respondents with NCD gave varied reasons for the postponement of visits related to continuous NCD care, such as obtaining long-term treatment (NCD follow-up) during COVID-19. For example, a breast cancer patient who underwent follow-up for 3.5 years emphasised the lack of welcome at the healthcare facility: ‘……. This hospital was like my second home. I used to come here every time I need reassurance and emotional support. Now it is difficult to get into the hospital even with an appointment card, gate keepers are not allowing patients to pass in easily, plus we don’t know if the repeated temperature measurements at the gate have side effects on us. These things discourage us from coming’.
Another cancer patient said: ‘…Public transport is not accessible nowadays; plus, the transport cost is double now, each passenger has to purchase the mandatory empty seat next to them……so it is difficult to continue the follow-up as before’. However, those people with NCDs who own vehicles focused more on the fear of acquiring the virus within the facility.
Moreover, some said they were told by their healthcare providers not to come to healthcare facilities.
COVID-19 as a stressor for people with NCDs
All people with NCDs stated that they were under some form of stress in relation to COVID-19. They put forward a loss of social and economic support, fear of COVID-19 infection and the high risk of death as stressors and said that their relatives, neighbours and friends who used to visit and support them emotionally and financially before COVID-19 were not doing so after COVID-19.
‘Families and friends had been visiting me before COVID-19, and they used to give me some money when they came, but now everybody is keeping their distance’ (A typical response given by a colorectal cancer patient).
A 60-year-old diabetic patient said: ‘My neighbours were the ones who were giving me my medications, but now everybody has left me; I can’t take my medication by myself as I don’t have my full vision… But I’m trying…’
‘…We are repeatedly told that we are at higher risk of death from COVID-19. This information by itself, without clearly telling what we should do about it, is really stressful…’ (Another diabetic patient).
Decreased physical activity by people with NCD during COVID-19
People with NCD who participated in this study reported their physical activity had decreased during COVID-19. For example, a diabetic patient from private clinic said: ‘as we are told that we are at higher risk of dying from COVID-19, for fear of acquiring the virus I stayed fully at home. I even gained 7 kg within one month. I tried to do some exercise at home but I couldn’t control the weight gain.’
A breast cancer patient said that she had even quit her job and stayed at home in order to minimise her risk from the virus. ‘…after I heard that we are at higher risk of death from COVID-19, I immediately quit my job. When I stayed at home, I tried to go out walking in the late afternoon, but now everybody is doing that and the walkways are crowded. Currently I’m not going out at all.’
Challenges posed by COVID-19 to HCPs working on NCDs
Health care professionals reported multiple challenges in NCD management during COVID-19. Some typical examples are as follows. ‘Deciding on appointment dates is very stressful; we get into dilemmas in deciding on earlier appointment dates for better NCD management but higher risk of COVID-19 when they are coming to health care facilities, or a later appointment date with lower risk of COVID-19 but poor NCD management’ (an endocrinologist).
In addition, most HCPs who participated in this study emphasised the shortage of personal protective equipment (PPE). ‘We are worried that we don’t have enough PPE; most attention is given to the COVID centres…but now, there is community transition and we can acquire the virus from any one of our patients…it is stressful…’ (a nurse working at a primary healthcare facility)
From the HCPs’ opinions, giving health education or not, especially for new diabetic patients, was a main challenge posed by COVID-19 for the nurses working in a diabetic clinic. Deciding on the amount of medication to give, considering fair distribution for all in need and avoiding the person’s risk of COVID from going out of the home to look for medication is another challenge for the pharmacists working in the dispensary. ‘…even if we have a stock of NCD medications for 3 months, I don’t personally encourage that because there are a lot of problems; for example, our patients share their drugs and I doubt their storage too…’ (a pharmacist).
The absence of clear direction and guidance is the biggest challenge for most of the HCPs who have participated in this study. ‘…as the pandemic is a new phenomenon for the world, we don’t have manuals and guidelines; that makes the service delivery very challenging…but we are now developing those important documents with stakeholders…’ (a senior oncologist).
Coping strategies for healthcare professionals towards COVID-19 in the management of NCDs
All HCPs said they have started virtual clinics by telephone. Many medical doctors call their NCD patients for follow-up; patients are asked about any complaints and whether they had any check-up records or investigation results. The aim was to replace the in-person check-up and to make the required clinical decisions.
However, almost all said that they had challenges in using the coping strategy designed for the phone clinic. They said that the use of a phone clinic was a new approach for them and that they were not given any training. Moreover, as they said, the phone clinic at which they were practicing had no guidelines or manuals. As a result, they missed many pertinent points and ended up with incomplete information. They also mentioned the absence of or an inaccessible contact address of patients as a challenge for the phone clinic.
Other measures adopted as a coping strategy in the management of NCDs during COVID-19 included the prescription of medication for longer times in order to avoid NCD patients having to leave home unnecessarily to replace their medication. However, people with NCD indicated that although they were given prescriptions for a longer time, it was difficult to get all the prescribed medication at once.
A chronic disease head nurse working in a primary health care facility said that they were following a community engagement strategy to address people with NCD at home ‘…As we have started house-to-house COVID-19 screening, we used this opportunity to ask for the presence of an NCD patient with health needs in the household…’ Moreover, as said by an endocrinologist: ‘messages were posted on social media for people with NCD to call their health care facilities to continue their follow-up. Contact address of HCPs were also communicated in the post…’
Coping strategies for people with NCDs towards COVID-19 in the management of NCDs
Few people with NCDs had identified their individual level coping strategies; for example, a hypertensive patient said: ‘I started to go to my office by walking, not using public transport…’ Nevertheless, as per our study participants expression, the majority of them were expecting spiritual protection and safe guard.