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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 271-275

Paradigm shift in health-care seeking behavior: A report from central Kerala, India, during COVID-19 pandemic

1 Scientist, Jubilee Centre for Medical Research, Thrissur, Kerala, India
2 Professor of Psychiatry and Principal, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
3 Project Manager, Jubilee trust, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India

Date of Submission14-Sep-2020
Date of Acceptance22-Oct-2020
Date of Web Publication8-Apr-2021

Correspondence Address:
Kezia Kuruvilla
Jubilee Centre for Medical Research, Jubilee Mission Medical College and Research Institute, Thrissur - 680 005, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_132_20

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Context: Coronavirus is a novel public health problem, which has influenced the mindset of people and restricted the community mobility. These changes influence the health-care seeking behavior of people. Aim: This study analyzes the changing trend in patients coming for hospital based non-COVID care in the context of COVID-19. Settings and Design: This is a retrospective study based on hospital records of patients attending a tertiary care center, attached to a private medical college. Materials and Methods: Age, gender, and department wise daily registrations of patients from January 1 to June 30 of 2 consecutive years, 2019 and 2020 were considered, with new and review cases noted separately. Statistical Analysis Used: Data analyzed using Excel 2007. Results: The number of patients seeking hospital-based care during the year 2020 decreased by 31.01% compared to 2019 (P < 0.001). Maximum patient fall was noticed in the month of April. Patient decline was highest in the age group ≤14 (37.22%) and least in the senior citizen group (29.26%). The outpatient departments showed higher fall percentage (31.52%) compared to emergency services (26.65%), with highest fall in pediatrics (40.76%) and minimum in surgical allied super specialty (20.04%). Conclusions: A fall in patients occurred during COVID-19 and the associated restrictions implemented to contain the virus, which might be the result of an altered approach to morbidity and health care. This will disrupt the health care services to the vulnerable groups with complex health needs, influencing their health outcome in the long run.

Keywords: COVID-19, health care, non-COVID

How to cite this article:
Kuruvilla K, Kuttichira P, Varghese PR, Vinu EV, Gopi IK. Paradigm shift in health-care seeking behavior: A report from central Kerala, India, during COVID-19 pandemic. CHRISMED J Health Res 2020;7:271-5

How to cite this URL:
Kuruvilla K, Kuttichira P, Varghese PR, Vinu EV, Gopi IK. Paradigm shift in health-care seeking behavior: A report from central Kerala, India, during COVID-19 pandemic. CHRISMED J Health Res [serial online] 2020 [cited 2022 Nov 28];7:271-5. Available from: https://www.cjhr.org/text.asp?2020/7/4/271/313172

  Introduction Top

The health care seeking behavior (HCSB) is the outcome of a potential risk-benefit assessment, often influenced by social circumstances. It comprises the decision followed by action taken by an individual to attain, maintain, or regain health. HCSB includes self-care, use of home remedies or attending a health-care facility; but the usage of the term in the present context will be limited to the care seeking behavior in relation to health-care facility alone.

HCSB can be considered from an endpoint aspect (utilization of health-care system) or by the process itself like the perception of the illness or the response to being sick.[1] It can be influenced by external and internal stimuli, with the decision making process guided by individual behavior, house hold or community norms and one's own perception about health.[2] Knowledge about illness, socio-economic factors, accessibility and quality of services also influence the care seeking behavior.[3],[4]

Decrease in the number of patients seeking essential health care during the time of pandemic were reported during severe acute respiratory syndrome,[5] Ebola[6] and Middle East respiratory syndrome-“coronavirus.[7] Similar reports relating to health-care measures are available from countries which are severely affected by the current pandemic. A survey by the American College of Emergency Physicians found that more than one-third of US adults delayed or avoided hospital care due to the fear of contracting corona virus disease of 2019 (COVID-19).[8] Observations from Europe was also similar, including negatively affected vaccination rates in children.[9] A report from Spain showed a drop of 40% in the cardiac catheterization for ST-segment elevation myocardial infarction.[10]

This study, first of its kind from this state/country assessed the changing pattern in the utilization of health care facility for non-COVID care in the context of COVID-19 pandemic.

  Materials and Methods Top

This was an observational study based on hospital records, from a tertiary care center attached to a private medical college, receiving patients from three districts of central Kerala. The hospital data from January 1 to June 30 of 2 consecutive years, 2019 and 2020 were considered for the day-wise data of patients seeking hospital based care. The number of patients attending outpatient departments (OP) and emergency services (ED) were noted separately. Registrations of new and review cases from each department were also noted. Grouping of departments for the study was done as follows:

  1. General medicine

  2. General surgery
  3. Pediatrics
  4. Obstetrics and gynecology
  5. Medical allied specialty - dermatology, psychiatry, pulmonology, geriatrics, radiology, nutrition and dietetics
  6. Surgical allied specialty - ophthalmology, ENT, orthopedics, dental and maxillofacial surgery
  7. Medical allied super specialty - cardiology, neurology, nephrology, gastroenterology, oncology
  8. Surgical allied super specialty - cardiothoracic surgery, neuro surgery, plastic surgery, urology, surgical oncology.

Data were entered into Excel 2007 and analysis was done. The daily registrations (including hospital holidays and Sundays with ED registrations only) for the year 2019 and 2020 were plotted in the graph and the relative trends analyzed. The data of February 29 2020 was excluded in comparative analysis as there was no corresponding date in previous year. Fall percentage for OP and ED from 2019 to 2020 was studied. Data were analyzed on age and gender basis. The fall percentage was calculated separately for new cases and review cases and also for the departments.

  Results Top

A significant fall in the number of patients was observed from January 1 to June 30 2020, compared with the registrations of 2019. Hospital record data showed the number of patients seeking hospital based care in 2019 as 262001, while the same in 2020 declined to 180750 [Table 1]. A sharp decline of 81251 patients (31.01%) occurred during the 6 months' period. The fall noticed was statistically significant (P < 0.001). The fall started from January and continued throughout the study period [Figure 1]. The sharp drop in the graph corresponding to hospital OP holidays and Sundays were ignored. The graph plot points of 2020 were much lower than that of 2019, with a dip noticed from March 11, 2020. The last week of March and first 2 weeks of April 2020 showed the maximum fall. The curve showed a rise from later half of April, but dropped steeply in the 2nd week of June.
Table 1: Age and gender wise percentage decrease in patients attending a health care facility

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Figure 1: Day wise attendance of patients in the hospital during the period January to June in 2019 and 2020. The sharp drop noticed every week represents Sundays with ED attendance alone

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Age-wise categorization of the patients into pediatric group (up to the age of 14), youth (15-“34), young adults (35-64) and senior citizens (65 and above) is shown in [Table 1]. Age wise fall percentage was highest in the pediatric group (37.22%) and lowest in senior citizen group (29.26%). The down trend in the number of patients seeking hospital based care was observed among male and female groups. Male patients decreased from 123089 to 86813 (29.47%) during the study, while females showed a slightly higher decline of 32.38%. Except for the age group 15-“34 years, all other age groups showed higher fall rate for females [Table 1].

The analysis of data showed that the fall percentage for OP and ED reached the maximum in April 2020 [Table 2]. The maximum difference between fall percentage of OP and ED was also observed in the month of April, and the values leveled off by June. The average decrease percentage for ED was 26.65% and for OP was 31.52%. The patients attending different departments [Table 2] showed the highest decrease percentage in pediatrics followed by general surgery and lowest in surgical allied super-specialties.
Table 2: Department wise decrease percentage in patients during 2020 compared to 2019

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New cases dropped from 70622 in 2019 to 48096 in 2020, while the review cases showed a decline from 164159 to 112688 in respective years. The percentage decrease during the study period for new cases was 31.90% and for review cases 31.35%.

  Discussion Top

The low mortality - high morbidity paradox of Kerala[11] and the “Kerala model of development” with improved education, healthcare and social sector has facilitated increased care seeking behavior in the state.[12] The present pandemic situation has influenced this behavior negatively, with a prolonging or avoidance of hospital visits, except in the case of critical ailments. Health conscious citizens achieved through high literacy and related scientific temperament[13] responsibly conforming to the directions from health authorities could be the reason for the drop in hospital attendance noticed in this study. Limiting hospital visits and consultations were an integral part of social distancing publicized.

The Government of Kerala declared high alert in the context of increasing COVID cases[14] and by March 10 2020, implemented a partial shutdown with a curb on mass gatherings.[15] Sensitization and restrictions imposed by the Government sources as part of precautionary measures, along with the cancellations of elective surgical procedures and interventions at the study site resulted in the fall of patients noticed from March 11, 2020. The maximum drop in patients occurred during the last week of March and first 2 weeks of April -“ the phase of complete lock-down (March 25-“April 14) by the Government of India. The strain experienced due to decline in social support,[16] along with the need for medical help for serious health conditions, which had been put off might have resulted in a rise in the number of patients after this period of strict compliance. Giving up and accepting the strain with its consequences - the “learned helplessness of Seligman”[17] could explain this behavior. Moreover, Kerala is battling a double burden of diseases, both lifestyle as well as infectious diseases.[18] Nearly half of Kerala population have multiple non communicable disease risk factors, with raised blood pressure in 30.4% and dysglycemia in 54.5%, all with increased health care needs.[19] A drop in the graph noticed during the 2nd week of June 2020 coincided with the admission of first patient at the study site for COVID care.

The difference in fall noted between the OP and ED is self-explanatory. Sudden and unexpected onset of a health condition which requires immediate medical attention results in health care seeking in a hospital of assured standard, a choice often influenced by the care takers. The perception of illness,[20] awareness of health and diseases and easy accessibility of health care facility influence this care seeking behavior.[21] Kerala with its improved purchasing power exhibit increased care seeking from private hospitals.[22]

The fall in review cases comparable to that of new cases observed in our study do not support enhanced hospital visits from the emotional dimensions of diseased condition. The enhanced HCSB due to psychological distress as described by Ezra et al.,[23] is likely to experience a greater fall during pandemic times.

Highest fall rate in pediatrics is explainable on the basis of reverse quarantine advised by the Government sources. Kerala being a state with high child well-being indicators in health, nutrition and education[24] ensures greater care for children. The schools remaining closed would have inversely affected the chances of children contracting infectious diseases. The same operating procedure of Ministry of Health for ≥65 years of age group was not observed in our study. The elderly population of Kerala constitute 13.1%[25] and the odds of hospitalization is 3.39 times higher in ≥60 years as compared with 15-“34 age group.[21] The lower fall rate of HCSB among the aged can be explained on this basis. The decreased fall percentage among women compared to men in the age group of 15 to 34 years, might be due to the timely care required during their reproductive years. Institutional deliveries account for more than 96% of child birth in Kerala, with almost 100% in urban areas.[26] It is also supported by the fact that majority of prenatal and postnatal care in Kerala is provided by the private sector.[26] Availability of super-specialty services in limited centers account for the least fall noticed in surgical allied super-specialty departments in this study.

This study showed deferring and delaying of non-COVID care during COVID times, manifesting as a behavioral change in addressing the health problem. Cancellations and missed appointments during the period may be the result of anxiety and fear of contracting the disease along with the restrictions imposed by the Government. The WHO survey at the global level showed that the treatment for noncommunicable diseases were severely disrupted during COVID-19 pandemic, with the low-income countries being the worst affected.[27] A general lowering of patient strength noticed from the month of January may be partially due to a shift that occurred toward local health-care seeking, the transition supported by Universal Health Care functioning through an effective network of public health system in Kerala.[13] The strengthening of state health services including the local care delivery points like primary health centers could satisfy the demand for quality care. An altered approach in HCSB utilizing tele-consultation or opting for alternate or home remedies is also quite possible. The economic crisis during COVID times may also have dissuaded the patient from seeking timely health care.[28] The mandatory COVID protocols to be followed during hospital based treatment adds up to the expenses incurred. Kerala's healthcare system with the challenge of large out-of-pocket expenditure,[18] also augments the impaired health-care delivery. All these can lead to compromising on the essential health care services for patients with complex health needs, which might negatively impact the health status of Kerala.


This is a retrospective study based on electronic records from a single tertiary care referral center.

  Conclusions Top

A fall in HCSB occurred during COVID-19 pandemic and the related restrictions from the authorities to contain the virus. In times of shifting challenges, many of the norms of life undergo drastic change, resulting in an altered or modified mindset of the people. The compounding effect of factors associated with COVID-19 result in an attitudinal change towards morbidity and its management, raising concern about the disease burden and high risk profile of chronic diseases in the state.


We would like to thank Unnikrishnan UG, Lecturer in Biostatistics, Department of Community Medicine, Jubilee Mission Medical College and Research Institute, Thrissur for the statistical assistance.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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University of Manchester Health Systems Development Programme. A review of Health Seeking Behaviour: Problems and Prospects. Available from: https://www.assets.publishing.service.gov.uk/media/57a08d1de5274a27b200163d/05-03_health_seeking_behaviour.pdf. [Last accessed on 2020 Aug 01].  Back to cited text no. 2
Pillai RK, Williams SV, Glick HA, Polsky D, Berlin JA, Lowe RA. Factors affecting decisions to seek treatment for sick children in Kerala, India. Soc Sci Med 2003;57:783-90.  Back to cited text no. 3
Sudha G, Nirupa C, Rajasakthivel M, Sivasusbramanian S, Sundaram V, Bhatt S, et al. Factors influencing the care seeking behaviour of chest symptomatics: A community-based study involving rural and urban population in Tamil Nadu, South India. Trop Med Int Health 2003;8:336-41.  Back to cited text no. 4
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Lee SY, Khang YH, Lim HK. Impact of the 2015 Middle East respiratory syndrome outbreak on emergency care utilization and mortality in South Korea. Yonsei Med J 2019;60:796-803.  Back to cited text no. 7
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First Post. Kerala on High Alert After Five Fresh Coronavirus Cases Detected; Union Health Ministry Directs Hospitals to Increase Isolation Facilities. Available from: https://www.firstpost.com/india/kerala-on-high-alert-after-five-fresh-coronavirus-cases-detected-union-health-ministry-directs-hospitals-to-increase-isolation-facilities-8131601.html. [Last accessed on 2020 Jul 30].  Back to cited text no. 14
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  [Figure 1]

  [Table 1], [Table 2]


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