key: cord-0828278-uqsh8mml
authors: Pujolar, Georgina; Oliver-Anglès, Aida; Vargas, Ingrid; Vázquez, María-Luisa
title: Changes in Access to Health Services during the COVID-19 Pandemic: A Scoping Review
date: 2022-02-03
journal: Int J Environ Res Public Health
DOI: 10.3390/ijerph19031749
sha: 3dd642f21680eebf20c3b6007354d89463ca73e0
doc_id: 828278
cord_uid: uqsh8mml

The COVID-19 pandemic and the measures adopted are having a profound impact on a major goal of public healthcare systems: universal access to health services. The objective is to synthesize the available knowledge on access to health care for non-COVID-19 conditions and to identify knowledge gaps. A scoping review was conducted searching different databases (Medline, Google Scholar, etc.) for original articles published between December 2019 and September 2021. A total of 53 articles were selected and analyzed using the Aday and Andersen framework as a guide. Of these, 37 analyzed changes in levels of use of health services, 15 focused on the influencing factors and barriers to access, and 1 studied both aspects. Most focused on specific diseases and the early stages of the pandemic, based on a review of records. Analyses of the impact on primary care services’ use, unmet needs or inequalities in access were scarce. A generalized reduction in the use of health services was described. The most frequent access barrier described for non-COVID-19 conditions related to the services was a lack of resources, while barriers related to the population were predisposing (fear of contagion, stigma, or anticipating barriers) and enabling characteristics (worse socioeconomic status and an increase in technological barriers). In conclusion, our results show a general reduction in services’ use in the early stages of the pandemic, as well as new barriers to access and the exacerbation of existing ones. In view of these results, more studies are required on the subsequent stages of the pandemic, to shed more light on the factors that have influenced access and the pandemic’s impact on equity of access.

The pandemic due to coronavirus SARS-CoV-2 (COVID-19), a novel virus initially reported in December 2019 [1] , was declared by the World Health Organization (WHO) on 11 March 2020. It has had an adverse effect worldwide on many different spheres of society, including the economy and public health. The current COVID-19 pandemic and the diverse strategies that have been adopted to tackle it are forcing changes in access to health services for other conditions, potentially producing an impact on the health of the population above and beyond that caused by COVID-19 itself [2] [3] [4] [5] [6] .

In this regard, some strategies taken to combat soaring COVID-19 infection rates may have negatively affected access to health services for other conditions. Firstly, at the health services level, one of the most influential measures was the classification of services as essential or non-essential, following WHO guidelines, which allowed resources to be redirected to the pandemic response. However, this has also caused cancellations or delays in elective and non-urgent procedures [3, [5] [6] [7] , despite many countries implementing strategies to mitigate the impact of these disruptions (e.g., online healthcare visits) [4, 5] , Another significant measure was social distancing to reduce interaction between people, including nationwide partial or complete lockdowns, schools and non-essential business closures, and instructions to stay at home, which in some cases has erected a barrier in terms of mobility to entry the health services [8] .

Another indirect effect of the pandemic, the economic crisis stemming from the substantial curtailment of economic activity, and the ensuing rise in unemployment and loss of household income, have aggravated associated access barriers (loss of health coverage, difficulties in making copayments or obtaining transport to services), thereby accentuating existing inequalities in access, as studies on previous economic crises have shown [9] . Although it is necessary to evaluate which population groups have been particularly affected in terms of access to care and how the determining factors interact with each other, there are some signs-including early evidence and experiences from previous crises-to indicate that vulnerable population groups (populations with low socioeconomic status, the elderly, chronic patients or those with severe conditions, migrants from low-income countries) suffer a greater impact [9] [10] [11] [12] [13] [14] .

In short, as in other epidemics and previous outbreaks, the health repercussions of the current pandemic are not confined solely to COVID-19 infection and mortality. They also include indirect negative effects on healthcare access and on the quality of curative and preventive care provided for other conditions, and the exacerbation of difficulties and barriers related to socioeconomic factors [15] [16] [17] . The scientific evidence accumulated from previous experiences, such as severe acute respiratory syndrome or SARS (2002) (2003) , Middle East respiratory syndrome or MERS (2012), Ebola (2014-2016; 2018-present) , and the Zika virus (2015-2016) [18] [19] [20] , shows a decrease in the utilization of health services (e.g. outpatient care, hospital admissions, elective surgeries [20] [21] [22] [23] ) that is attributed to changes made to the health services in response to public health emergencies, as well as to fear of contagion among the population [21, 24] . This may in turn have had an impact on increasing the burden of disease and mortality in the months following an epidemic outbreak [6, 20, [25] [26] [27] .

While a plethora of scientific papers have been published on COVID-19 since the start of the pandemic, studies on its impact on access to health services have not been so plentiful. A few literature reviews have been found that summarize changes in health services due to the pandemic, focusing mainly on the adoption of telemedicine [28] [29] [30] [31] [32] and the impact of the pandemic on different aspects, among others, the use of certain specific services, such as maternal and child health care [33] , child vaccination [34] , or chronic diseases [35, 36] , in the initial stages of the pandemic. Although we are still at the pandemic management stage, a synthesis of the scientific evidence accumulated to date on the impact on access to health care in different contexts, in addition to detailed monitoring of the performance of services, may help decision makers to make healthcare systems more resilient in current and future emergencies and protect public health and access to health care.

Access to care involves many highly interdependent factors and stakeholders at play [37] . This study takes as its framework of reference one of the most frequently used models for the analysis of access to health services [38] , that of Aday and Andersen [39] . This model distinguishes between realized access (effective utilization of the services) and potential access (determinants of access), differentiating between factors related to the services and to the population. The realized access analysis takes into account the type, place, motive of the visit (preventive or curative), and care outcomes, while potential access analysis takes into account the characteristics of the services (availability of resources and organization) and those of the population (predisposing factors: sociodemographic factors, beliefs, attitudes, and knowledge of the health system; enabling factors: income and type of insurance; health needs). Health policies, programs, or interventions can in turn affect access barriers related to the health services or changing (mutable) characteristics of the population [39, 40] . Aday and Andersen's framework is more comprehensive and exhaustive than other analytical models [41] [42] [43] , which focus either on the entry to health services or on the characteristics of services and how they adjust to the characteristics of the population. Thus, it offers an appropriate approach for identifying existing knowledge gaps in the literature on access and to analyzing different types of barriers and factors that influence the use of health services.

The aim of this article is to synthesize the knowledge accrued from the onset of the pandemic in March 2020 through to September 2021 on the impact of the COVID-19 pandemic on access to health services (including primary care, outpatient secondary care, and inpatient care) for non-COVID-related conditions, and to identify knowledge gaps on these subjects.

A scoping review of the scientific literature [44] was carried out, following the PRISMA guide [45] , to identify original articles on the impact of the COVID-19 pandemic on access to health services for non-COVID-related conditions.

In our bibliographic search, several digital databases were consulted to minimize the risk of overlooking any relevant studies: Medline, Google Scholar, SCiELO, and Web of Science. The search was performed over two separate periods: 22 January 2021-31 March 2021 and 22 September 2021-10 October 2021. In the Medline database, using a thesaurus, MeSH terms were employed for: (a) COVID-19: "Coronavirus Infections", "Coronavirus", "COVID-19", "SARS-CoV-2"; (b) access to health services: "Health services availability", "Health services needs and demand", "Healthcare disparities", "Needs assessment, healthcare", "Health policy", "Equipment and Supplies Utilization", "Facilities and Services Utilization" (see Appendix A for more detail). In the other databases free text terms were used: (a) COVID-19: "coronavirus disease", "COVID-19"; (b) access to health services: "health services accessibility", "accessibility", "accessing", "access", "utilization", "delivery of health care", "healthcare services", among others. Word groups were combined using Boolean operators "AND" and "OR" in order to identify the literature in the databases consulted and select those studies referring to the impact of COVID-19 on access to health services. The search was complemented with a manual review of references cited within the selected articles.

We selected original articles published in Spanish or English from December 2019 to September 2021-with no filters for geographical area or motive for access (apart from being unrelated to COVID-19)-that used qualitative and/or quantitative methods and analyzed or described changes in access to health services in the context of the COVID-19 pandemic. The initial selection of studies to review was performed through title and abstract screening. Where there was any doubt about whether to include a study, this was discussed with another researcher in the team.

Following Aday and Andersen's framework [39, 40] , the selected studies were classified into two groups: those that analyzed utilization of services (realized access) and those that explored factors that influence access (potential access). Any studies on realized access that did not use medical records, administrative/institutional databases, or patient surveys as their data source were excluded. A data extraction protocol was produced to include information related to methodological aspects (methods, period of analysis, study area, population, sample, type of health service) and study results (according to the variables or dimensions of analysis). This information was extracted from the articles and presented in tables, grouped according to type of access, and ordered by type of health service. The results were summarized according to the analytical framework, which was also used to identify any gaps in knowledge related to the aspects studied.

From the search results, 242 articles were identified for title and abstract screening, and 95 for full-text review. A total of 53 articles met the inclusion criteria for analysis ( Figure 1 ). Of the 53 articles selected, 37 analyzed changes in realized access applying quantitative methods , through the analysis of medical records (Table 1) , 8 analyzed changes in potential access [83] [84] [85] [86] [87] [88] [89] [90] via surveys of different population groups, except for one that did the same via analysis of medical records [90] (Table 2) , 7 used qualitative methods to analyze the impact on potential access [91] [92] [93] [94] [95] [96] [97] (Table 3) , and, finally, 1 study analyzed changes in both realized and potential access [98] using mixed methods (analysis of medical records and semi-structured interviews). Only six of the studies that explored changes in potential access included professionals from the health centers analyzed as a study population, [87, 89, 92, 93, 97, 98] , while the rest focused on patients or the general population. General Reduction in the number of childcare visits (50%), including preventive procedures, and sustained utilization of HIV services and adult outpatient clinics during the national lockdown (March-June 2020), compared to the previous periods. No significant changes were observed at a general level in the use of services. Childcare visits recovered over the following three months to pre-lockdown levels. Reduction in visits to pediatric emergencies (57 to 70%), especially during the peak of the pandemic (March-April 2020), compared to previous periods. Admission proportion almost doubled (4% pre-pandemic to 7% during the peak pandemic period). Average acuity of illness was higher during the pandemic period. Reduction in the monthly number of referrals for suspected cancer (63%) and for treatment (22%), colonoscopies (92%), and surgeries (31%) from April 2020, compared to 2019 and the preceding months. Relative increase in radiotherapy use (44%) due to increased use of short-course regimens.

Monthly rate of referrals and other procedures returned to 2019 levels by October 2020. Characteristics of the population: fear of contagion, perception of overuse of services or lack of need, fear of being judged for seeking care, poor understanding of government messages, concern regarding travel (avoiding public transport). Characteristics of the services: barriers to access essential services (difficulties in contacting services, procedures re-scheduled, lack of medical supplies, insufficient telemedicine care offered), restrictions on companions. Characteristics of the population: fear of COVID-19 contagion; impact on physical and mental health (stress due to not being able to receive treatment or as an aggravating factor of the disease). Characteristics of the services: reduced frequency of scans, redistribution of services in different "zoned areas" based on "COVID wards" and "non-COVID" wards, lack of information, ban on presence of partner. Characteristics of the population: fear of contagion, perception of "impersonal care" from virtual consultations. Semi-structured interviews by phone (12) and in-person (9) Nampula, Mozambique Health professionals (n = 9), traditional birth attendants (n = 6) and patients (n = 6) With regard to the type of service, of the studies on realized access, 5 focused on health services in general [46] [47] [48] [49] [50] ; 12 on emergencies [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] (of which 5 were related to pediatric emergencies [56] [57] [58] 60, 61] ); 15 on secondary care (SC) (outpatient visits, hospital admissions, etc., for nephrology [63] , oncology [64, 65] , pediatrics [66] , psychiatry [67, 68] , rehabilitation [69] , respiratory diseases [70] , sexual and reproductive health (SRH) [71, [73] [74] [75] , and traumatology [78, 79] ); two on primary care (PC) [80, 81] ; one on preventive services [82] . Of the studies on potential access, 1 focused on health services in general [91] , 13 on SC (endocrinology [83] , rare diseases [86] , pediatrics [84] , psychiatry [85] , SRH [87, 88, [93] [94] [95] , tuberculosis [89, 96] and urology [90] ); and 2 on PC [92, 97] . The study that analyzed changes in both realized and potential access focused on SC relating to SRH [98] .

In terms of geographical area, 19 studies were conducted in European countries [47, 51, 53, 55, 57, 62, 64, [67] [68] [69] [70] 75, 79, 83, 84, 88, 90, 92, 95] , 9 in North American countries [49, 58, 59, 77, 78, 80, 82, 85, 86] , 9 in Sub-Saharan Africa [46, 48, 71, 72, 76, 87, 93, 94, 98] , 3 in Latin America [60, 91, 96] , 5 in the East Asia-Pacific region [50, 56, 61, 66, 81] , 3 in South Asia [63, 65, 74] , 2 in the North Africa-Middle East region [52] , and, lastly, 3 studies covered various regions [54, 89, 97] .

With regard to the period of analysis, 38 of the selected studies were conducted over the first months of the pandemic (February to June 2020) [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [57] [58] [59] [60] 62, [65] [66] [67] [68] [69] [70] [72] [73] [74] [75] [76] [77] [78] [79] [80] 82, 84, 86, 88, 90, 92, 93, 98] ; 4 during the second stage of the pandemic (June to September 2020) [85, 89, 91, 96] ; 1 at a later stage (September to November 2020) [94] ; finally, 8 analyzed the whole period (February to December 2020) [56, 61, 63, 64, 71, 81, 83, 87] . No studies were found that analyzed periods after December 2020. All studies that analyzed realized access presented their results in comparison with a previous period: 32 of the first-stage studies compared the changes to pre-pandemic periods of reference [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [57] [58] [59] [60] 62, [65] [66] [67] [68] [69] [70] [72] [73] [74] [75] [76] [77] [78] [79] [80] 82, 98] , as did 6 of those that analyzed the whole period [56, 61, 63, 64, 71, 83] . One study did not specify the exact period of 2020 analyzed [95] .

Below is a summary of results found regarding changes in realized access and potential access, following the Aday and Andersen theoretical framework [39, 40] .

Of the 38 studies that analyzed changes in realized access 98] , 33 indicated a statistically significant descent in the use of services and only one reported an increase [78] , and 4 descriptive studies also found a reduction in the use of services [47, 61, 63, 65] (Table 1) . After the first few months of the pandemic, some studies described an increase in the utilization, without reaching levels previous to the COVID-19 pandemic [48, 61, 63, 71, 72, 82] . However, among the studies that extended their analysis to the end of 2020, there are reports of new drops in the utilization of services, coinciding with the onset of new waves of COVID-19 [61, 63, 71] .

By type of service analyzed, studies focusing on the health services in general [46, 47, 49, 50] described an overall drop in use, which varied in terms of magnitude. Among those that analyzed changes in emergency care [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] 66, 77] , it was reported that, although the volume of consultations fell, there was an increase in the number of cases with additional complications [53, 58, 66, 74, 77] and cases requiring admission to hospital [51, 55, 57, 59, 60, 67, 70] . Likewise, the studies on changes in SC services also reported a reduction in the use of services, while in some cases detecting an increase in the proportion of visits or hospital admissions in concrete healthcare areas (e.g., severe mental health cases [47] or trauma injuries [56, 58, 78] ). With respect to PC, both studies described a drop in the number of in-person visits and an increase in remote care consultations (via various mechanisms, such as consultation by telephone or videocall) [66, 80] . Lastly, the study that analyzed changes in the use of preventive services [82] , along with others that also assessed procedures classified as elective [49, 53, 63, 64, 77] , reported a drop in use but with less pronounced changes in urgent cases [57, 62, 82] .

In the studies that analyzed influencing factors in the use of services in the context of the pandemic, the probability of lower utilization levels was associated with different factors. With regard to predisposing characteristics of the population, women [56, 79] and ethnic minorities [49, 74] were less likely to access health services, with inconsistent results regarding the elderly [52, 79] . As for individual enabling characteristics, the likelihood of a lower use of services was associated with people with a low income and limited healthcare coverage [49, 74] , and for those enabling characteristics related to the type of area, a higher incidence of COVID-19 [50] . In terms of need, the probability of using health services was lower among patients who lacked a previous diagnosis [82] , had less severe conditions (without complications or adverse outcomes) [67] , and did not require hospitalization [52, 57, 67] .

The 16 studies that analyzed potential access [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94] [95] [96] [97] [98] described changes in the factors that influenced access before the COVID-19 pandemic and the emergence of new barriers, in terms of both the characteristics of the services and those of the population (Tables 2  and 3) .

Twelve studies described changes related to characteristics of the services [83, [85] [86] [87] [88] [89] [90] 92, 93, 95, 97, 98] . The most significant of these was a reported decrease in available resources, both in terms of materials and medical supplies [83, 86, 89, 93, 97] , and of staff to care for non-COVID patients [83, 85, 88, 89, 92, 95] , which in certain cases forced some health centers to close [93, 97] . Two studies pointed out increases in waiting times [90, 98] and one a rise in the cost of services [97] .

Fourteen studies identified barriers related to population characteristics [83] [84] [85] [86] [87] [88] [89] 91, [93] [94] [95] [96] [97] [98] . Among the predisposing factors identified, fear of contagion was one of the main reasons for not going to the health services [83] [84] [85] [86] 88, 89, [94] [95] [96] [97] [98] , as well as the stigma that receiving a COVID-19 diagnosis would create [89, 94, 97] . Other factors found included people misinterpreting government recommendations to avoid going to the health services [84] , perceiving that the services were of poor quality [94] , or believing they would have difficulties in gaining access [85, 86, 91, 93] during the pandemic. With respect to enabling factors, authors highlighted the worsening socioeconomic situation of the population [87, 89, 91, 93, 94, 96, 97] , a lack of support networks [93, 94] , and an increase in technological barriers [85, 88] as some of the main factors that hindered access to the health services. Lastly, they also underlined tendencies to play down the risk of health complications and the perceived need for medical attention [94, 98] as barriers that had the effect of reducing the use of services and delaying the decision to seek care during the pandemic.

The impact of the COVID-19 pandemic has been felt worldwide in many different spheres of society, but especially in access to health services for unrelated conditions. There is now a pressing need to evaluate the changes that have arisen in this regard, and their implications for equity of access and the resilience of national health systems to future pandemics. This is, to the best of our knowledge, the first scoping review to offer a general overview of the subject, taking in the current evidence and highlighting the areas that will require further research in future studies.

Most of the studies included in the analysis describe a lower level of health services' utilization and changes in potential access, as preexisting barriers have intensified and new ones have arisen. However, while investigations into the impact of the COVID-19 pandemic are still ongoing, the results of this review show that the studies conducted to date are limited in terms of scope and methodology, and that they are mainly centered on analyzing the impact on the use of services for specific diseases or population groups during the first stages of the pandemic, with a particular focus on secondary care.

Studies on the use of health services in general are very scarce, as are those on access to primary care, which in many countries has been the most overwhelmed care level due to having to take on more pandemic-related care duties (vaccination, case tracking, etc.). Likewise, there is a considerable lack of evidence so far on how changes have taken place over the course of the different waves of COVID-19, and according to geographical context. Although some studies with longer timeframes-to the end of 2020-have already described new drops in health services' activity following brief periods of recovery [61, 63, 71] , further evidence is required to confirm this trend. Moreover, we have yet to look into how the pandemic has affected unmet care needs, as some studies showed that one of the most commonly reported impact was that patients delayed seeking care due to factors such as fear of contagion, disinformation, etc. [83] [84] [85] [86] 88, 89, 94, 95, 97, 98] .

It is important to bear in mind that access to care involves multiple interdependent factors and numerous actors. However, the results of this review show that, so far, there are almost no published studies with a wide scope using mixed methods, and that the qualitative studies available to date are still limited in both number and perspective. In regard to the latter, few studies include, in addition to that of users, other viewpoints such as that of the health professionals or managers involved in the process of taking measures or adopting practices that influenced access to care. Furthermore, the population groups selected for study were generally sufferers of a specific condition or of vulnerable status. The number of qualitative studies is probably limited due to the complexity of their development in the pandemic context, in terms of time, resources, and restrictions imposed by the mitigation measures. Approaches that combine multiple sources of evidence and different perspectives are needed to shed more light on the factors and actors that have influenced access.

With regard to our main findings on the reduction in the use of services, this may be related to health systems prioritizing their response to the public health emergency, which differed according to context [4, 25, 99, 100] . Initial measures were generally centered on containing the spread of COVID-19 and providing the health services with the resources needed to meet the soaring demand for medical attention, which led to the classification of some services and procedures as non-essential, and a consequent reduction in the resources allocated to cover those health needs [3, 4, 7, 8] . There is a lack of evidence on how the measures were modified and adapted according to context as the pandemic progressed, and the patterns of utilization that they generated, although some studies have already revealed changes in use with recoveries and relapses, in the more advanced stages of the pandemic [61, 63, 71] .

Going into more detail, the reductions in access to services described appear to have brought with them an increase in medical complications and emergencies, especially in elective procedures [48, 49, 52, 53, 58, 59, 67, 71, 74, 77, 101] , and/or care delays (time passed between onset of symptoms and intervention) [53, 98] , although it is generally not specified whether the delays were due to patients putting off seeking medical attention or rather to an increase in barriers to access the services. Some studies also observed higher mortality rates [52, 70, 74, 76] and burden of disease [62] . However, while emergency care was one of the greatest causes for concern [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] , according to our results the downturns recorded for this type of service appear to be less pronounced or of lower impact than those reported in other fields.

In this regard, some studies highlight the difficulties involved in maintaining normal levels of activity in certain services, even in some classed as essential, such as maternal health, oncology, or mental health [71, 76, 85, 89, 93, 94, 97, 98] . The impact appears to have been felt worldwide but especially in middle-and low-income countries, a point that has also been stressed in various opinion articles [101] [102] [103] [104] [105] [106] [107] . Differences between health systems, and between geographical contexts, may both have acted as determining factors in the changes seen. Sexual and reproductive health services analyzed in African and South Asian countries, for example, have seen a significant downturn in access, not only to maternal and child health services but also other non-essential areas of health care (family planning, sexually transmitted diseases, etc.) [71, 74, 76, 93, 98] , despite the warnings given in various reports and opinion articles based on previous epidemic experience [2, 26, 101, 108] of the risk this poses in terms of burden of disease and mortality [2, 25, 26, [103] [104] [105] [106] [109] [110] [111] [112] [113] [114] . Another example can be found in the lack of care for patients at risk of a cancer diagnosis due to delays in screening and diagnostic programs caused by certain procedures being classified as elective [64, 65, 82] , which could also lead to an increase in the burden of disease and mortality due to the late detection of new cancer cases, as several studies pointed out [35, [115] [116] [117] [118] . As regards mental health, various studies mention anxiety and other disorders related to fear of contagion and the uncertainty that the pandemic generated in its first few months [35, 55, 77, [83] [84] [85] [86] 88, 91, [94] [95] [96] , as well as difficulties in access to mental health services [68, 85, 97] and an increase in acute cases of severe disorders [67] . These issues may have caused the burden of disease to increase, which could influence service utilization patterns in the years to follow, an aspect that was observed previously with the SARS epidemic in 2003 [119] and that should be taken into consideration in future studies on the impact of COVID- 19 .

The few studies that analyze the influencing factors on the lower utilization of services mainly highlight a greater downturn in use among low-income users, those with limited healthcare coverage, and ethnic minorities [49, 74] , as well as the female population [56, 79] , all of which signals greater inequalities with regard to more vulnerable populations.

As regards the changes in potential access detected in this review, the results indicate both the exacerbation of existing barriers, related above all to structural difficulties and situations of vulnerability, and the creation of new ones. In terms of existing barriers accentuated by the pandemic, some studies reported a shortage of resources in the services to meet all the incoming healthcare requests [83, 85, 86, 88, 89, 92, 93, 95, 97, 98] , which varied according to service and geographical context. One of the most serious problems was the lack of or alterations to the distribution of materials and medical supplies in lowincome countries [83, 87, 89, 93, 94, 97] , an aspect corroborated in other publications, both reports and opinion articles [4, 34, 104, [120] [121] [122] . The lack of materials and medical supplies may have contributed to increasing negative perceptions of the quality of the health services, especially in disadvantaged settings or situations with structural difficulties, another barrier to access found by some studies [93, 94, 97] . Lastly, several studies in this review [83, 85, 87, 89, 91, 93, 97] and some reports [12, 123] focusing on vulnerable population groups (such as migrants or refugees, sex workers, people at a severe socioeconomic disadvantage) highlight the worsening economic situation and the intensification of other barriers (legal, information-related, or discriminatory), as has also occurred in previous epidemics [19] . All this points to situations in which the ability of these groups to access the health services and receive care may have diminished yet further.

In addition, new barriers may have been created as a result of adopting alternatives to face-to-face visits (online consultation, telephone, video call, telemedicine, etc.) and changes in attitudes and beliefs developed as a result of the pandemic. In this regard, the use of online consultation has grown as a way to mitigate difficulties in access [4] , but not in the same way across all contexts [3, 124] . Several articles included in the review described inequalities in access, reporting access problems related to digital literacy (lack of understanding of digital devices) or a lack of material resources (Internet connection, mobile devices) [49, 85, 89] , a point also highlighted in other publications [125, 126] , alongside the perception that the care received in virtual consultation is impersonal [88] . These results are in keeping with numerous publications that have focused on the changes from face-to-face consultations to remote care and user satisfaction with the latter [29, 80, [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] . However, most studies are centered mainly on high-income countries, thus, further evidence in different contexts is required on the impact of remote care on access to the health services.

Likewise, one of the individual characteristics that has been most influential in terms of new barriers created by the pandemic is fear of contagion [83] [84] [85] [86] 88, 89, 94, 95, 97] , an aspect that has been discussed in many publications, including opinion articles [113, [137] [138] [139] [140] [141] [142] , and also played a highly significant role in previous epidemics as a factor causing problems or delays in seeking medical care [2, 21, 24, 26, 72, 76, 101, 108, 143, 144] . Other factors reported include the stigma associated with seeking care [84, 89, 93, 94, 97] , also described in other publications [109, 145] , and users playing down the need for medical treatment [84, 94, 98] and perceiving a lack of response on the part of the health services [85, 88] .

While it is true that various studies have identified both new barriers and the exacerbation of existing ones, the behavior of individuals in this type of public health emergency requires more in-depth analysis in order to steer the design of interventions to help counter these barriers, such as public health information campaigns or specific measures for vulnerable populations.

On a final note, this review has several limitations. In the first place the nature of the studies covered varies greatly, in terms of methodology (ways of measuring use of services, information sources, sample size, etc.), and of geographical areas and health systems analyzed; thus, it is not possible to draw comparisons between them. Secondly, articles that analyzed access to services due to COVID-19 in addition to other illnesses were excluded from the study. This decision was made in order to rule out bias towards activity and resources destined to the treatment of other diseases. Third, no studies focusing on the impact of the pandemic control measures on access to health services were found, probably due to the limited terms used in our search to capture this area. Moreover, it is also possibly due to the difficulties involved in distinguishing the impact of the measures from other effects of the pandemic. Finally, some articles may not have been considered on being published in other languages (Chinese, Arabic, etc.), so this analysis may have excluded relevant information and failed to consider certain contexts. In spite of these limitations, this is the first study to address changes in access from a global perspective, with a view to shedding light on gaps in knowledge that will require further research in the future.

This review analyzed studies that reported changes in health services' utilization, and the factors that influenced the use of services for non-COVID-19 conditions, during the COVID-19 pandemic. Results vary according to the context analyzed, although, in general terms, they reflect the same trend, describing a general reduction in the use of health services, the exacerbation of preexisting barriers, and the emergence of new ones. This scoping review has shown that most studies conducted to date are limited in terms of scope and methodology and are centered mainly on the impact on specific conditions or population groups during the early stages of the pandemic, focusing mostly on secondary care. Furthermore, a significant gap in knowledge was detected on whether the services have recovered to pre-pandemic levels of care use and, if not, in which areas and for what reasons. Future studies should go into greater depth on the pandemic-related changes that have influenced access to health services (e.g., fear and socioeconomic difficulties), according to context and over the course of the different stages of the pandemic. In any case, as an ongoing phenomenon, the real impact of the COVID-19 pandemic is yet to be determined. Funding: This research received no external funding. G.P. received the CSC grant to conduct this study as her thesis for the Master in Public Health (Universitat Pompeu Fabra).

Informed Consent Statement: Not applicable.

The authors declare no conflict of interest.

Organización Mundial de la Salud Cronología de la Respuesta de la OMS a la COVID-19

COVID-19: What implications for sexual and reproductive health and rights globally? Sex

La COVID-19 afectó el Funcionamiento de los Servicios de Salud para Enfermedades no Transmisibles en las Américas-OPS/OMS|Organización Panamericana de la Salud

Pulse Survey on Continuity of Essential Health Services during the COVID-19 Pandemic: Interim Report

Second Round of the National Pulse Survey on Continuity of Essential Health Services during the COVID-19 Pandemic

Global Health Cluster COVID-19 Task Team. Essential Health Services: A guidance Note. How to Prioritize and Plan Essential Health Services during COVID-19 Response in Humanitarian Settings

Emergency and essential surgical healthcare services during COVID-19 in low-and middle-income countries: A perspective

Impact of self-imposed prevention measures and short-term government-imposed social distancing on mitigating and delaying a COVID-19 epidemic: A modelling study

Changes in access to health care for immigrants in Catalonia during the economic crisis: Opinions of health professionals and immigrant users

Historical Insights on Coronavirus Disease 2019 (COVID-19), the 1918 Influenza Pandemic, and Racial Disparities: Illuminating a Path Forward

Axes of alienation: Applying an intersectional lens on the social contract during the pandemic response to protect sexual and reproductive rights and health

Impact of COVID-19 on the Health and Wellbeing of Persons Who Migrated to Finland: The MigCOVID Survey

Finnish Institute of Health and Welfare's: Helsinki

Transcending the known in public health practice: The inequality paradox: The population approach and vulnerable populations

The impact of economic crises on communicable disease transmission and control: A systematic review of the evidence

Can we apply lessons learned from Ebola experience in West Africa for COVID-19 in lower income countries? Glob

What makes health systems resilient against infectious disease outbreaks and natural hazards? Results from a scoping review

Learning from Exemplars in Global Health: A road map for mitigating indirect effects of COVID-19 on maternal and child health

Utilization of non-Ebola health care services during Ebola outbreaks: A systematic review and meta-analysis

Socio-Economic Impact of Ebola Virus Disease in West African Countries

The health impact of the 2014-15 Ebola outbreak

The Impact of the SARS Epidemic on the Utilization of Medical Services: SARS and the Fear of SARS

Effect of widespread restrictions on the use of hospital services during an outbreak of severe acute respiratory syndrome

Access to Care Matters: Remote Health Care Needs During COVID-19

Facility-Based Delivery during the Ebola Virus Disease Epidemic in Rural Liberia: Analysis from a Cross-Sectional, Population-Based Household Survey

2019-nCoV) Guidance Document 2020; UNFPA Asia-Pacific Regional Office

Impacto del COVID-19 en la salud sexual y reproductiva

The impact of a prolonged ebola outbreak on measles elimination activities in Guinea

The role of telehealth during COVID-19 outbreak: A systematic review based on current evidence

Satisfaction with the use of telehealth during COVID-19: An integrative review

Inequalities in General Practice Remote Consultations: A Systematic Review

Telehealth utilization during the COVID-19 pandemic: A systematic review

Telehealth-Based Services During the COVID-19 Pandemic: A Systematic Review of Features and Challenges. Front. Public Health

Restructuring maternal services during the COVID-19 pandemic: Early results of a scoping review for non-infected women

COVID-19 and Child Vaccination: A Systematic Approach to Closing the Immunization Gap

Cancer services during the COVID-19 pandemic: Systematic review of patient's and caregiver's experiences

Reduction in hospitalised COPD exacerbations during COVID-19: A systematic review and meta-analysis

What does "access to health care" mean?

Re-revisiting Andersen's Behavioral Model of Health Services Use: A systematic review of studies from

A framework for the study of access to medical care

Improving Access to Care in America: Individual and Contextual Indicators. In Changing the US Health Care System: Key Issues in Health Services Policy and Management

Aspects of Medical Care Administration: Specifying Requirements for Health Care

The concept of access. Definition and relationship to costumer satisfaction

El concepto y la medición de la accesibilidad

Scoping studies: Towards a methodological framework

PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation

Trends of follow-up clinic visits and admissions three-months before and during COVID-19 pandemic at Tikur Anbessa specialized hospital

Trends in healthcare utilisation during COVID-19: A longitudinal study from the UK

Access to primary healthcare during lockdown measures for COVID-19 in rural South Africa: An interrupted time series analysis

Changes in Health Services Use Among Commercially Insured US Populations During the COVID-19 Pandemic

Reduction in healthcare services during the COVID-19 pandemic in China

Non-COVID diseases during the pandemic: Where have all other emergencies gone

The impact of COVID-19 lockdown measures on ED visits in Lebanon

Acute Care Surgery during the COVID-19 pandemic in Spain: Changes in volume, causes and complications. A multicentre retrospective cohort study

Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on Acute Admissions at the Emergency and Cardiology Departments Across Europe

The mystery of "missing" visits in an emergency cardiology department, in the era of COVID-19.; a time-series analysis in a tertiary Greek General Hospital

Impact of COVID-19 on the visit of pediatric patients with injuries to the emergency department in korea

COVID-19 related reduction in pediatric emergency healthcare utilization-A concerning trend

Effect of the COVID-19 Pandemic on Patient Volumes, Acuity, and Outcomes in Pediatric Emergency Departments: A Nationwide Study

Paediatric patients seen in 18 emergency departments during the COVID-19 pandemic

Impact of the COVID-19 pandemic on the pediatric population with acute appendicitis: Experience at a general, tertiary care hospital

Pediatric emergency healthcare utilization during the COVID-19 pandemic in Tokyo

Monitoring indirect impact of COVID-19 pandemic on services for cardiovascular diseases in the UK

The impact of COVID-19 pandemic on nephrology and transplant services and clinical training in India

Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: A population-based study

Impact of nationwide lockdown on cancer care during COVID-19 pandemic: A retrospective analysis from western India

Impact of early Coronavirus Disease 2019 pandemic on pediatric cardiac surgery in China

Impact of the COVID-19 pandemic on psychiatric admissions to a large swiss emergency department: An observational study

Negative impacts of COVID-19 lockdown on mental health service access and follow-up adherence for immigrants and individuals in socio-economic difficulties

The consequences of COVID-19 outbreak on outpatient rehabilitation services: A single-center experience in Slovenia

The Impact of COVID-19 on Hospitalised COPD Exacerbations in Malta

Indirect effects of COVID-19 on maternal, neonatal, child, sexual and reproductive health services in Kampala

Child health services during a COVID-19 outbreak in

Lockdown with a Price: The impact of the COVID-19 Pandemic on Prenatal Care and Perinatal Outcomes in a Tertiary Care Center

Effect of the COVID-19 pandemic response on intrapartum care, stillbirth, and neonatal mortality outcomes in Nepal: A prospective observational study

Impact of COVID-19 on attendances for a 1stepisode of reduced fetal movements: A retrospective observational study

Resilience and vulnerability of maternity services in Zimbabwe: A comparative analysis of the effect of COVID-19 and lockdown control measures on maternal and perinatal outcomes, a single-centre crosssectional study at Mpilo Central Hospital

Where Have All the Emergencies Gone? The Impact of the COVID-19 Pandemic on Obstetric and Gynecologic Procedures and Consults at a New York City Hospital

Safer at home": The effect of the COVID-19 lockdown on epidemiology, resource utilization, and outcomes at a large urban trauma center

The impact of COVID-19 on trauma referrals to a National Neurosurgical Centre. Ir

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

The impact of COVID-19 pandemic on the utilization of ambulatory care for patients with chronic neurological diseases in Japan: Evaluation of an administrative claims database

Disruptions in preventive care: Mammograms during the COVID-19 pandemic

Invisible burden of COVID-19: Enzyme replacement therapy disruptions

Parental Hesitancy and Concerns around Accessing Paediatric Unscheduled Healthcare during COVID-19: A Cross-Sectional Survey

Access to refugee and migrant mental health care services during the first six months of the COVID-19 pandemic: A canadian refugee clinician survey

It seems like COVID-19 now is the only disease present on Earth": Living with a rare or undiagnosed disease during the COVID-19 pandemic

Effect of COVID-19 pandemic on provision of sexual and reproductive health services in primary health facilities in Nigeria: A cross-sectional study

Women's perceptions of COVID-19 and their healthcare experiences: A qualitative thematic analysis of a national survey of pregnant women in the United Kingdom

Mitigating the impact of COVID-19 on tuberculosis and HIV services: A cross-sectional survey of 669 health professionals in 64 low and middle-income countries

Impact of COVID-19 outbreak on urology surgical waiting lists and waiting lists prioritization strategies in the Post-COVID-19 era

The impact of COVID-19 on Venezuelan migrants' access to health: A qualitative study in Colombian and Peruvian cities

The impact of COVID-19 on chronic care according to providers: A qualitative study among primary care practices in Belgium

Access to Healthcare in a time of COVID-19: Sex Workers in Crisis in

Exploring COVID-19 Related Factors Influencing Antenatal Care Services Uptake: A Qualitative Study among Women in a Rural Community in Southwest Ethiopia

The experiences of pregnant women during the COVID-19 pandemic in Turkey: A qualitative study

Patients' perceptions regarding multidrugresistant tuberculosis and barriers to seeking care in a priority city in Brazil during COVID-19 pandemic: A qualitative study

Impact of the societal response to COVID-19 on access to healthcare for non-COVID-19 health issues in slum communities of Bangladesh, Kenya, Nigeria and Pakistan: Results of pre-COVID and COVID-19 lockdown stakeholder engagements

COVID-19 pandemic impact on maternal and child health services access in Nampula, Mozambique: A mixed methods research

Proteger la Salud y los Derechos Sexuales y Reproductivos y Promover la Igualdad de Género; United Nations Population Fund

World Health Organization. COVID-19 Pandemic Leads to Major Backsliding on Childhood Vaccinations, New WHO, UNICEF Data Shows

Impact of COVID-19 on reproductive health and maternity services in low resource countries

Maternal and newborn care during the COVID-19 pandemic in Kenya: Recontextualising the community midwifery model

Emerging infectious diseases and outbreaks: Implications for women's reproductive health and rights in resource-poor settings

Essential health services delivery in Zimbabwe during the COVID-19 pandemic: Perspectives and recommendations

Preparing for an Increased Need for Abortion Access in India during and after COVID-19: Challenges and Strategies

The impact of the COVID-19 crisis on meeting needs for family planning: A global scenario by contraceptive methods used

COVID 19 era: A beginning of upsurge in unwanted pregnancies, unmet need for contraception and other women related issues

Sexual and reproductive health (SRH): A key issue in the emergency response to the coronavirus disease (COVID-19) outbreak

COVID-19 and abortion: Making structural violence visible

Examining Inequities Associated With Changes in Obstetric and Gynecologic Care Delivery During the Coronavirus Disease 2019 (COVID-19) Pandemic

Endometrial Cancer Detection During the Coronavirus Disease 2019 (COVID-19) Pandemic

Family planning and abortion services in COVID 19 pandemic

The effect of the COVID-19 pandemic on maternal health due to delay in seeking health care: Experience from a tertiary center

Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review

The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: A national, population-based, modelling study

Healthcare utilization among breast cancer patients during the COVID-19 outbreak

Coma Redon, E. The impact of COVID-19 on cancer diagnosis delay: Possible consequences

Missing diagnoses during the COVID-19 pandemic: A year in review

History for some or lesson for all? A systematic review and meta-analysis on the immediate and long-term mental health impact of the 2002-2003 Severe Acute Respiratory Syndrome (SARS) outbreak

Doing things differently: What it would take to ensure continued access to contraception during COVID-19

Access to reproductive health care services in countries of conflict: The double impact of conflict and COVID-19

Neglecting the effect of COVID-19 on neglected tropical diseases: The Ethiopian perspective

Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-Based Violence, Female Genital Mutilation and Child Marriage; United Nations Population Fund

Organización Mundial de la Salud Los Servicios de Salud Mental se Están Viendo Perturbados por la COVID-19 en la Mayoría de los Países, Según un Estudio de la OMS

The social threats of COVID-19 for people with chronic pain

Providing equitable care to patients with limited dominant language proficiency amid the COVID-19 pandemic

The Impact of COVID-19 on Telemedicine Utilization Across Multiple Service Lines in the United States

Implementation of Obstetric Telehealth During COVID-19 and Beyond. Matern

Telemedicine: Patient-Provider Clinical Engagement During the COVID-19 Pandemic and Beyond

Patient satisfaction with telemedicine during the COVID-19 pandemic: Retrospective cohort study

Demand for Self-Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic

Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic

COVID-19 transforms health care through telemedicine: Evidence from the field

Differential Uptake of Telehealth for Prenatal Care in a Large New York City Academic Obstetrical Practice during the COVID-19 Pandemic

Addressing Disparities in Prenatal Care via Telehealth during COVID-19: Prenatal Satisfaction Survey in East Harlem

Practice-level variation in telemedicine use in a pediatric primary care network during the COVID-19 pandemic: Retrospective analysis and survey study

Estimates of the Potential Impact of the COVID-19 Pandemic on Sexual and Reproductive Health in Low-and Middle-Income Countries

Delayed access or provision of care in Italy resulting from fear of COVID-19

Health anxiety predicts postponing or cancelling routine medical health care appointments among women in perinatal stage during the COVID-19 lockdown

Treat all COVID 19-positive patients, but do not forget those negative with chronic diseases

Access to Maternal Health Services during COVID-19

Delayed emergency healthcare seeking behaviour by Dutch emergency department visitors during the first COVID-19 wave: A mixed methods retrospective observational study

Women and babies are dying but not of Ebola': The effect of the Ebola virus epidemic on the availability, uptake and outcomes of maternal and newborn health services in Sierra Leone

Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis

COVID-19 Highlighting Inequalities in Access to Healthcare in England: A Case Study of Ethnic Minority and Migrant Women

Access to health care services: (( (((((((((((((health services accessibility[MeSH Terms]) OR (health services accessibility)) OR (accessing)) OR (accessibility)) OR (access)) OR (utilization)) OR (delivery of health care)) OR (healthcare services)) OR (