INTRODUCTION
Since the outbreak of the novel coronavirus disease 2019 (COVID-19) pandemic, emergency
health care utilization has acutely declined by 23% for heart attacks, 20% for strokes,
and 10% for hyperglycemic crises.
1
Ambulatory visits have also declined by nearly 60%.
2
The lack of health care utilization is concerning as it may result in significant
medical complications resulting from untreated medical problems.
1
Little is known about what is driving these declines in health care utilization. A
study from Italy suggested that fear of COVID-19 infection may be one such factor.
3
Recent research has documented pervasive anxiety and depression during the COVID-19
pandemic.
4, 5
We conducted this study to estimate the association between mental health symptoms
and medical care avoidance among US adults.
METHODS
We analyzed data from June 11–June 16, 2020, of the weekly, cross-sectional Household
Pulse Survey (HPS; n = 73,472) which is conducted by the US Census Bureau in collaboration
with five other federal agencies to produce data on the social and economic impacts
of COVID-19 among adults in the USA. The HPS questionnaire was reviewed by independent
experts at the Center for Behavioral Science Methods, as well as the Demographic Directorate
and subject matter representatives from the five partner federal agencies. To gather
the sample, HPS used the Census Bureau’s Master Address File as the primary sampling
frame to collect responses from a large sample that is sufficient for the anticipated
low responses rates. The Census Bureau used the online platform Qualtrics as the primary
data collection method. See the Census Bureau website (https://www.census.gov/householdpulsedata)
for more information and access to publicly available data.
We fitted modified multivariable Poisson regression models to estimate the associations
between four mental health symptoms (nervous, anxious, or on edge; not being able
to stop or control worrying; little interest or pleasure in doing things; feeling
down, depressed, or hopeless) in the past 7 days and medical care avoidance (delayed
medical care; needed non-coronavirus medical care but did not get it) due to the coronavirus
pandemic in the past 4 weeks. The use of robust estimates of variance permits straightforward
interpretation of the exponentiated regression coefficients as risk ratios. We adjusted
for potential confounding by age, sex, race/ethnicity, income, education, employment
loss, and marital status. Nonresponse sample weighing was applied. Analyses were conducted
using Stata 15.1.
RESULTS
Demographic and descriptive results are displayed in Table 1. Individuals who experience
all four symptoms of anxiety and depression had higher adjusted relative risk ratios
of delayed medical care and not receiving needed non-coronavirus medical care, after
adjustment for potential confounders (Table 2). Individuals who were nervous, anxious,
or on edge in the past 7 days had the highest adjusted relative risk ratio of delayed
medical care (1.95, 95% CI 1.83–2.09) and the highest adjusted relative risk ratio
of not receiving needed non-coronavirus medical care (2.08, 95% CI 1.93–2.25).
Table 1
Weighted Sample Characteristics of Week 7 of US Census Household Pulse Survey (n = 73,472)
Mean ± SE/%
Age
48.09 ± 0.20
Sex
Female
51.6
Race/ethnicity
Hispanic or Latino (may be of any race)
16.9
White alone, not Hispanic
62.8
Black alone, not Hispanic
11.2
Asian alone, not Hispanic
5.0
Two or more races + other races, not Hispanic
4.1
Income
Less than $25,000
16.5
$25,000–$34,999
12.0
$35,000–$49,999
12.5
$50,000–$74,999
18.1
$75,000–$99,999
12.9
$100,000–$149,999
14.8
$150,000–$199,999
6.4
$200,000 and above
6.7
Education
Bachelor’s degree or higher
30.4
Employment loss, past 7 days
Yes
47.8
Marital status
Not married
55.1
Medical care avoidance
Delayed medical care due to coronavirus, 4 weeks†
Yes
41.0
Needed non-coronavirus medical care but did not get it, past 4 weeks‡
Yes
32.2
Mental health symptoms
Nervous, anxious, or on edge, past 7 days§
Any days
65.0
Not being able to stop or control worrying, past 7 days‖
Any days
56.1
Little interest or pleasure in doing things, past 7 days¶
Any days
53.3
Feeling down, depressed, or hopeless, past 7 days#
Any days
52.2
June 11–June 16, 2020
†“At any time in the last 4 weeks, did you DELAY getting medical care because of the
coronavirus pandemic?”
‡“At any time in the last 4 weeks, did you need medical care for something other than
coronavirus, but DID NOT GET IT because of the coronavirus pandemic?”
§“Over the last 7 days, how often have you been bothered by the following problems
... Feeling nervous, anxious, or on edge?”
‖“Over the last 7 days, how often have you been bothered by the following problems
... Not being able to stop or control worrying?”
¶“Over the last 7 days, how often have you been bothered by ... having little interest
or pleasure in doing things?”
#“Over the last 7 days, how often have you been bothered by ... feeling down, depressed,
or hopeless?”
Table 2
Adjusted Relative Risk Ratios of Mental Health Symptoms and Medical Care Avoidance
Delayed medical care*
p
Did not get medical carea
p
Adjusted relative risk ratio (95% CI)
Adjusted relative risk ratio (95% CI)
Nervous, anxious, or on edge, past 7 days
1.95 (1.83–2.09)
0.001
2.08 (1.93–2.25)
0.001
Not being able to stop or control worrying, past 7 days
1.83 (1.73–1.94)
0.001
2.05 (1.92–2.00)
0.001
Little interest or pleasure in doing things, past 7 days
1.69 (1.60–1.79)
0.001
1.90 (1.78–2.03)
0.001
Feeling down, depressed, or hopeless, past 7 days
1.67 (1.58–1.76)
0.001
1.89 (1.77–2.02)
0.001
*Each column displays estimates from a single multivariable Poisson regression model
with additional covariate adjustment for age, sex, race/ethnicity, income, education,
employment loss, and marital status. As described by Zou (Am J Epidemiol. 2004;159:702–706),
the modified Poisson model permits interpretation of the exponentiated regression
coefficients as risk ratios rather than incidence rate ratios.
DISCUSSION
In this population-based study of US adults from June 11–16, 2020, we show that mental
health symptoms are strongly correlated with medical care avoidance amidst the COVID-19
pandemic. Our results revealed significantly higher adjusted relative risk ratios
of medical care avoidance among US adults who experience common symptoms of anxiety
and depression. Importantly, our results show that individuals who experience these
symptoms are more likely to avoid seeking non-coronavirus medical care despite needing
it, which is concerning as delayed medical care may result in significant adverse
short- and long-term health outcomes for many conditions.
1
Our results provide support for accurate and effective translation of knowledge to
the public about the risks and benefits of seeking needed medical care during the
ongoing COVID-19 pandemic. Of particular importance is the expansion of health insurance
policies to cover telehealth services
6
and continued efforts to implement telehealth services to address non-emergency medical
concerns. Additionally, a continued increase in telepsychiatry and telemental health
services is needed to assist US adults in managing mental health symptoms for the
duration of the COVID-19 pandemic.