The current mode of operations of the healthcare systems, which is largely based on an assumption that humans are rational beings and seek care when necessary, has been facing challenges amidst the pandemic. As the number of confirmed cases have surpassed the 8 million mark, hospitals continue to be overburdened with the increasing number of patients and have become hotspots for Covid-19 transmission. Similar to the Ebola and SARS outbreak in 2003, where the disease had transmitted among the healthcare workers, patients and visitors, Covid-19 is rapidly spreading in healthcare setups. The clinical and non-clinical staff along with the visitors and other patients in the hospitals are at high risk of exposure and becoming potential vectors for onward community transmission.
The pandemic has further caused havoc outside the hospital walls as well. While struggling to keep up with the new normal, communities are scared of the disease consequences. With the increased number of positive cases, deaths and the situation of lockdown, the world has come to a standstill. The uncertain nature of the situation, with limited knowledge about the virus behaviour, absence of vaccine and possible treatment and limited awareness amongst people is fuelling the existing fear in the communities. If fear stems from an accurate perceived risk, it may translate into favourable behaviours including wearing masks, washing hands and maintaining hygiene. However, if fear stems from overestimated risk and ambiguity, it causes panic in the communities resulting in hoarding, social unrest and mental health problems.
Epidemic management not only includes minimizing disease spread, deaths and economic consequences, it also requires managing the sentiment of the communities, perceived risk of individuals and the community, their potential to deal with the situation as well as other second order impacts of the outbreak in the communities. Hospitals alone are not sufficient to deal with the given pandemic situation. Following behaviours, that have emerged during the pandemic, provide an insight of the key challenges with the current hospital centred healthcare system in dealing with pandemics.
BEHAVIOURAL CHALLENGES WITH THE CURRENT HEALTHCARE SYSTEM
1. Poor Response Rate - Care Seeking Behaviour
During the initial outbreak of Covid-19, most countries were testing either the self-reported or contact traced individuals. A couple of cases around the world revealed patients testing positive for coronavirus post their death which suggests these individuals may have been sick and contagious within their communities without reporting infection. While hospitals manage the self-reported or contact traced cases, they do not reach out to the communities at a local level to ensure care seeking behaviour. Learning from past epidemics, especially infectious diseases like Ebola and SARS, suggest poor response rates of initial care seeking being a major reason for increased transmission in the communities in the initial phases of epidemics.
Why?
- Low perceived risk at individual and community level
- Fear of disease within communities
- Lack of trust in healthcare systems
- Traditions, Beliefs and Cultural practices
- Stigma attached to the disease
2. Poor compliance and adherence behaviour
Epidemics require individuals and communities to adhere to treatments and comply to the advisory guidelines to avoid transmission of the disease. However, individuals do not always display such rational behaviours. Ensuring compliance to lockdowns, quarantines, wearing masks, etc. has been challenging during Covid-19 outbreaks throughout the world. Social distancing, though advised and promoted across the nations, has not resulted in communities being completely compliant. Non-compliance with the social distancing advisory by the government has been the reason for outbreaks and sudden increase in cases throughout the world.
3. Community distrust, resistance and violence
As the world is living through the lockdowns during Covid-19 outbreaks, parts of the U.S. have also witnessed protests against healthcare providers, extended lockdowns, masks usage, closed schools and restaurants. Being told what is to be done (e.g. wearing masks, social distancing) has been taken as restrictions against their individual rights. While resistance can be explained as a lack of trust in governments and the healthcare system, it can also be attributed to lack of perceived control over the situation. Thus, violence and resistance could be ways of exerting control over the situation. Studies suggest increased community engagement, giving them more control in planning and supporting in delivery care is the key to building trust in the community and increased trust is likely to reduce resistance within communities.
4. Mental Health
The current care delivery model includes tackling disease spread, reducing community transmission, providing care to the symptomatic patients and other disease containment strategies, however, it does not account for the second order impact of the pandemic. Studies on the Ebola outbreaks revealed trauma and psychological damage to individuals and communities as they were being overlooked during and following the epidemics. At an individual level, this caused, for example, insecurity, confusion, emotional isolation, and stigma. At a community level, this resulted in economic loss, work and school closures, inadequate resources for medical response, and deficient distribution of necessities. Experiences reported by healthcare workers treating Covid-19 patients have revealed stress and anxiety and communities have struggled while surviving lockdowns, quarantine and self-isolation.
5. Missing patients and Invisible patients
As the healthcare system, government policies and community efforts are working towards containing the Covid-19 outbreak, the non covid-19 patients (or the invisible patients) are being neglected. Health workers and hospitals are overburdened with the Covid-19 patients which has resulted in reduced bandwidth and resources to pay attention to the non-Covid-19 patients. The non-Covid-19 patients in the communities are now avoiding hospitals due to the fear of hospitals being an epicentre for disease spread. Current hospital designs do not provide avenues to manage the fear in the community. Hospital designs that provide separate areas for regular patients may help reduce delayed care seeking behaviour of non-pandemic patients. China, while dealing with Covid-19, quickly constructed temporary hospitals in the community to provide care to the Covid-19 patients and reduced the burden on existing hospitals so they could continue to provide care to other patients as well.
COMMUNITY CENTRED CARE: AN INTEGRATED APPROACH
The current approach to care involves more ownness on the individuals and communities. It is based on the theory of rational decision making which means that people are aware of their health concerns, regularly monitor their symptoms and seek care whenever they identify issues. However, there are social, mental and emotional barriers to decision making some of which have been listed above. In order to work with the updated model of human behaviour, a more integrated approach with high community involvement would work better. Developing world’s experiences of dealing with epidemics provides evidence for the need of an integrated approach to care for managing epidemics. Community based care integrated with primary care and hospitals has been effective in controlling the behavioural challenges and manage the impact of outbreaks in the community. Developing an integrated approach to healthcare would require:
1) Extending the reach in the communities by hiring and training CHWs.
CHWs can help in building trust and manage the sentiment of the community members and especially the vulnerable population to ensure increased testing and compliant behaviour towards lockdowns, self-isolations and quarantines. In parts of Kenya and South Africa, community sensitization started as a part of the COVID response in the initial phase itself. CHWs role, for example in Liberia, has also been extended to implementing prevention and control measures in the community during COVID response. Similarly, South Africa used its existing network of Community health workers for contact tracing and monitoring compliance to quarantines.
2) Restructuring the healthcare system and introducing Decentralised care.
Decentralisation of basic/primary care can also help in removing the burden from the hospitals by providing extended care to the patients within their community or within their home setup. Such a model integrated with the hospitals can help in increasing the outreach as well as ensure better compliance and adherence behaviour. South Korea reorganised the health system at a regional level based four-category risk-stratification system, which meant that asymptomatic and mildly symptomatic patients were admitted at community treatment centers and patients with a higher severity of illness were hospitalized at community or tertiary hospitals.
Image: South Korea model of care delivery during Covid response
3) Setting up community clinics for screening and providing primary care.
Clinics within communities can help segmenting potential patients early in their care journeys to avoid community transmission. In parts of rural India, community clinics can ensure screenings and referrals, diagnosis and follow ups, contact tracing, adherence to containment and distributing reliable information in the community. These clinics would serve best if they are set up within the communities for easy access and equipped to manage risk perception and fear in the communities. Learnings from Ebola response suggest, community members forming a part of the management of community clinics can help in increasing engagement and better trust building within communities. Similar community clinics/facilities have been set up around the world.
4) Re-examining the hospital designs to be better prepared for pandemics.
Hospital design must provide a conducive environment for both pandemic as well as the non-pandemic patients. It is essential to redesign the existing hospitals to overcome the challenges of stigma and reduce the physical contacts with the caregivers to prevent the spread of disease. One of ways of reducing the transmission is to reduce the sharing space between potential patients and other individuals in the hospital. Hospitals could be redesigned to have separated entrances and waiting areas for suspected patients. South Korean Covid response included splitting care for respiratory illness from others to decrease unnecessary contact between respiratory patients who might have COVID-19 and others. Further, hospital environment must be de-stigmatised by ensuring patient anonymity and providing avenues for patients to form ingroups (communities) to support each other.
5) Building capacity within communities to bridge the gap between the hospitals and communities especially during outbreaks.
Communities can help in overcoming the effects of second order impacts of pandemics. Community engagement and collaboration with community leaders, youth leaders and religious leaders can also helped to reduce community violence and increase self-reported cases in the community. These channels provide avenues to build trust, reduce stigma around diseases and improve compliance behaviour during epidemics. Community members who are highly regarded, have an existing network and who are intrinsically motivated to help in uplifting their communities can be ideal to be chosen to bridge the gap between hospitals and communities.
Efforts and investments must be focused to plan and implement an integrated approach to care which would enhance the performance of the current healthcare system and support during times of crises/pandemics. Learnings from previous epidemics have suggested success of community centered care approach in managing impact of outbreaks and containing them. This integrated approach would have certain specific design implications, along with implications on structural elements including policies, insurance, etc that need to be taken into account as this approach is piloted and eventually scaled up.