key: cord-0993365-kkst08uc
authors: Taylor, Melina K.; Kinder, Karen; George, Joe; Bazemore, Andrew; Mannie, Cristina; Phillips, Robert; Strydom, Stefan; Goodyear-Smith, Felicity
title: Multinational primary health care experiences from the initial wave of the COVID-19 pandemic: A qualitative analysis
date: 2022-01-13
journal: SSM Qual Res Health
DOI: 10.1016/j.ssmqr.2022.100041
sha: 319e96d4a83b1802862aaad8cc4c562ae16a1090
doc_id: 993365
cord_uid: kkst08uc

OBJECTIVE: To learn from primary health care experts’ experiences from the COVID-19 pandemic across countries. METHODS: We applied qualitative thematic analysis to open-text responses from a multinational rapid response survey of primary health care experts assessing response to the initial wave of the COVID-19 pandemic. RESULTS: Respondents’ comments focused on three main areas of primary health care response directly influenced by the pandemic: 1) impact on the primary care workforce, including task-shifting responsibilities outside clinician specialty and changes in scope of work, financial strains on practices, and the daily uncertainties and stress of a constantly evolving situation; 2) impact on patient care delivery, both essential care for COVID-19 cases and the non-essential care that was neglected or postponed; 3) and the shift to using new technologies. CONCLUSIONS: Primary health care experiences with the COVID-19 pandemic across the globe were similar in their levels of workforce stress, rapid technologic adaptation, and need to pivot delivery strategies, often at the expense of routine care.

It is globally accepted that PHC is the most effective and sustainable health approach to address 37 community health problems, implement solutions, and work towards health equity (Starfield et al., 2005) . 38

However, PHC, which comprises both public health and first-contact primary care, was underutilized and 39 underinvested in most countries during the initial response to the COVID-19 pandemic, which focused The qualitative open-text responses were compiled in Excel for analysis. Thematic analysis was 77 conducted by three members of the research team, led by an experienced qualitative methodologist. An a During the early stages of the pandemic, respondents experienced a variety of primary care workforce 105 changes. These were broad sweeping and rapid, resulting in primary care clinicians having to adapt and 106 innovate solutions quickly to meet COVID-19 pandemic response plans while supporting routine care. 107

When lock-down requirements and quarantine measures were established, many primary care clinicians 108 lost their jobs, were furloughed, or had their hours dramatically reduced due to sudden reductions in 109 patient visits for usual care. One respondent commented, Furloughs and lay-offs produced primary care workforce reductions, but many respondents also 117 reported a shift in their daily responsibilities, location of work, or patient population focus. These shifts 118 included governments incentivizing medical students to volunteer for pandemic specific protocols (Brazil, 119 see Table 1 ), the utilization of more community health workers (South Africa), sending primary care 120 clinicians outside the clinic and into the communities to provide COVID-19 testing to migrant workers 121 (Singapore), the incorporation of military and naval officers to help with screenings (Fiji), or reassigning 122 clinicians to surveillance teams (Trinidad and Tobago), and organizing clinician shifts to two-week 123 periods to accommodate quarantine policies (Chile). Many respondents reported that their daily clinic 124 activities had shifted to meet pandemic needs: 

These primary care workforce changes impacted patient care at all levels. The majority of 159 respondents made a distinction between treating and handling essential COVID-19 patient care and 160 routine daily patient care, which in many countries had been deemed as non-essential in the early stages 161 of the pandemic. For many primary care clinicians, the pandemic response (screening, testing, triaging, 162 quarantining, and treatment) overran usual scopes of practice. One primary care clinician from Iraq 163 Because of the shift in primary care to COVID-19 focused essential care, many respondents 173 commented on how much routine patient care was being ignored or forced to be put on hold per 174 government mandates. One respondent from Switzerland stated, "All treatments except emergencies were 175 not allowed. The police make controls in primary care doctors and physiotherapists for example to make 176 sure that they did not treat "normal" patients!" (Switzerland, male PCC). Responses on what was being identified as non-essential patient care were grouped into three areas 178 (see Table 2 ): 1) concerns about cancer screenings being put on hold and care of chronic conditions being 179 stopped (Canada); 2) an absence of preventative care and health education around diabetes, food nutrition, exercise management, and mental health care services (Malaysia); 3) and the cessation of well-child visits 181 for specific age groups (Estonia). 182

These subthemes were shown in a response from the United Kingdom, 183

"Stopped a lot of routine work e.g. cervical smears and routine blood tests. Lots clinician relocation, as many reported being moved to COVID-19 only clinics or other specialty 248 departments such as the emergency room. Additionally, further stress and uncertainty was placed onto 249 clinicians who had to do double work to fill the gaps of personnel shortages in nursing staff or other 250 physicians being put under lockdown policies, or who had to quarantine after being exposed or infected. 251

Because of the generalist nature of primary care's scope of practice, several respondents mentioned being 252 thrown around or ordered to wherever they were needed, with little autonomy over daily scheduling 253 decisions. The ability for primary care clinicians to be utilized most effectively based on community 254 needs is an asset during a global public health crisis. Individuals providing patient care should not be 255 over-worked and taken advantage of, but should be consulted concerning what positions and workloads 256 they can handle best. Public health and national policy makers working collaboratively with primary care clinicians would provide deeper commitment from them and would increase perceived autonomy, likely 258 reducing some of the emotional burden clinicians feel during these periods of increased stress and 259 uncertainty (Huston et al., 2020) . 260

An emergent theme among primary care clinician respondents was the emotional toll rendered by 261 this pandemic, particularly with regards to their job security and ability to safely deliver patient care. screenings, chronic disease maintenance, and well-child visits were put on hold as COVID-19 policies 277 overtook patient access to 'non-essential' care. Our respondents stated the telehealth innovations helped 278 ameliorate some of these discrepancies in care, but technology-based care was still limited in places due 279 to technology access inequities. 280

Policy-makers, often without the input from primary care clinicians, established mandates on 281 essential versus non-essential care, which had the potential to hurt patients and add increased stress and 282 anxiety for clinicians. For future pandemics/epidemics, an ethical decision-making framework incorporating the concepts of autonomy, beneficence, non-malfeasance, and justice should be utilized to 284 protect both patients and clinicians, providing flexibility at the clinician level, while working 285 collaboratively with public health policies to meet patient and community needs (Arora & Arora, 2020; 286

Huxtable, 2020; Kramer et al., 2020). 287 288

In the interest of rapid data gathering amidst pandemic uncertainty, this project utilized a 290 convenience and snowball sampling methodology to capture individual experiences of handling the 291 COVID-19 pandemic. As such, respondents are not representative of their respective countries' policies 292 or protocols, nor are they necessarily representative of other primary care clinicians' experiences within 293 those countries. Additionally, as this project was focused on the early months of the pandemic it may not 294 reflect experience or concerns as the pandemic continued to evolve and as vaccination programs slowly 295 bring the national epidemics under control. 296 297

Primary care respondents, across countries that vary considerably in size, geography, political 299 ideology, per capita wealth, and type of health system, consistently reported high levels of stress, 300 unprecedented and rapid adaptation of their delivery systems, and tremendous uncertainty in response to 301 the COVID-19 pandemic, and provided lessons for response to future health crises. Primary health care 302 provides the opportunity to utilize both primary care and public health to approach pandemic plans that 303 reduce disparities for patients and communities, allow flexibility at the local level for treatments, and 304 incorporate mental health services as a key component of health care for both workers and patients. There 305

were differences in death rates, pandemic plans, and the utilization of health care systems, but primary 306 care experts felt COVID-19 impacts similarly across countries, regardless of socio-economic status and 307 political systems. Table 1 Illustrative quotes by impact on the primary care workforce subthemes 416 Table 2 Illustrative quotes by impact of patient care delivery subthemes 417 Table 3 Illustrative quotes by shifts to new technology subthemes 418 Primary health care should take steps to reduce these disparities now before the next pandemicthis includes governmental support through proper funding, workforce development, and securing patient access to care.

2. Pandemics apply unique uncertainty, stress, and anxiety which can contribute to or increase feelings of burnout, moral injury, or post-traumatic stress syndrome for primary care clinicians and staff.

Increased focus on mental health care services for healthcare workers starting at the beginning of the pandemic and continuing past its conclusion as needed is essential to maintain a healthy primary care workforce. 3. Primary care clinicians have a generalist scope of practice and therefore can be utilized more effectively than other specialists to fit specific community needs for pandemic plans and response.

Primary care clinicians should be incorporated as an integral part of pandemic planning from the beginning. Considerations on utilizing PCCs should adhere to ethical considerations of decision-making, including autonomy, beneficence, non-maleficence, and justice. 4. Deciding which patients deserve care (COVID-19 positive patients) versus those who do not (routine, continuity of care patients) places an ethical dilemma onto policy-makers, often leaving clinicians out of the decision-making process, with little room to shift care based on particular patient circumstances.

Public health guidelines should incorporate primary care perspectives on care delivery during a pandemic, including allowing clinicians flexibility to meet patient needs following the ethical guiding principles of decision-making (listed above).

5. Digital health was a benefit to patients and clinicians, provided both parties were able to access it and clinicians were able to be compensated for using it.

Digital health should remain a staple of facilitating primary care services. Expanding access is necessary for marginalized populations, and governments/payors should appropriately financially reimburse for services utilizing these technologies. 

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