STRENGTHS AND LIMITATIONS OF THIS STUDY

A community survey from a large cohort of people living with cardiovascular disease and/or associated risk factors in Australia highlighted the impacts of COVID-19 on health, self-management and access to health services experienced during the pandemic.

The majority of survey responses and semi-structured interviews were from individuals residing in one particular state in Australia (New South Wales) and from major cities, which may not have been reflective of experiences of individuals in other areas of the country who were subject to different public health measures and access to health services.

Changes in policies and public health measures were frequent during the pandemic in Australia, and the cross-sectional design of the current study only provides insights into the experiences during a specific timeframe.

This study did not include non-English speaking participants.

Introduction

The COVID-19 pandemic brought about a range of policies with broad societal impact but also had specific effects on high-risk populations like patients with cardiovascular disease (CVD).1 The national COVID-19 prevention strategy in Australia, alongside state and local policies, has averted many infections but may have caused unintended impacts on human health.2 Underlying CVD is associated with increased morbidity and mortality from COVID-19, and COVID-19 is linked to subsequent cardiac events, making those with CVD a particularly high-risk population.3

Surprisingly, the pandemic in Australia saw a reduction in cardiac presentations, when a rise in consultations and procedures was anticipated in this high-risk population.4 Clinicians worldwide perceived lower ST-elevation myocardial infarction (STEMI) admissions to their hospitals and delayed presentations during the pandemic.5 Those reporting late presentation of patients with STEMI outside of the optimal reperfusion window were more likely to be from a country with total lockdown, in a hospital with more than 100 COVID-19-related admissions and those with restructured cardiology services.5

These changes in access to healthcare services may have been influenced by public health polices and social isolation. A review on the impacts of social isolation and policies during public health crises (including COVID-19, SARS, Ebola, HIV/AIDS) identified key gaps in the evidence and warranted for in-depth studies of lived experiences of social isolation and distancing using qualitative methodology to provide richer insights into how enforced social restrictions transformed social lives and how individuals and their support networks responded and managed.6

Moreover, Australia’s response to COVID-19 varied across its states and territories. Initially, a complete suppression strategy was adopted, consisting of border closures, quarantine and localised lockdowns, along with rapid responses to high community transmission by implementing widespread testing and contact tracing.7 8 The ‘zero cases’ approach became unattainable with the emergence of highly transmissible SARS-CoV-2 variants and sub-variants.9 Towards the end of 2021, vaccination rates were high, allowing for states and territories to gradually lift lockdown restrictions in a stepwise manner.10 11

The early work highlights that the impacts on cardiovascular health and service utilisation are dependent on the severity of the pandemic, which is linked to introduction of differing policies and social restrictions. The impact observed may be a result of reduced provision of and access to CVD care, increased use of telehealth services or other phenomena. However, a more in-depth understanding of the impacts is required to further delineate quantitative data. The current mixed-methods study aims to explore the perceived impacts of COVID-19 and its associated policies and social restrictions on people with CVD in Australia.

Methods

We conducted a mixed-methods study which comprised a cross-sectional observational study using an online survey and a qualitative study with semistructured interviews. The online survey and interview guide were co-designed with researchers and cardiologists involved in the care of patients with CVD during the COVID-19 pandemic. This study adheres to the COnsolidated criteria for REporting Qualitative12 and Strengthening the Reporting of Observational Studies in Epidemiology13 research checklists.

Setting and participants

Participants were contacted to complete an online survey via social media, organisational websites and newsletters (September 2021 to January 2022). Those with a self-reported ‘heart condition’ (CVD and/or risk factors), residing in Australia and ≥18 years were eligible. Study sample is provided in online supplemental material S1.

In mid-2021, most Australian states and territories adopted localised lockdowns in areas with high levels of community transmission. Examples of lockdown measures included stay at home orders, closure of non-essential services (eg, restaurants, gyms), limiting people’s travel to 5–10 km radii, curfews and compulsory mask wearing. In the final quarter of 2021, a stepwise easing of restrictions had begun.10 11

Data collection techniques

The survey consisted of questions regarding the impact of COVID-19 on overall heart health, use of medication, impact on exercise and diet, access to services, use of telehealth, hospital admissions and emergency department presentations (online supplemental material S2). Respondents that opted in, by indicating ‘yes’ on a survey question, were contacted via phone and asked to participate in a phone interview. These participants were chosen using maximum variation sampling, such that, people of different sexes, ages, areas of residence (Australian state/territory) and type of CVD were interviewed. Semi-structured interviews were conducted by AT following a guide (online supplemental material S3). Interviews were conducted until data saturation was reached, and no new themes were emerging. Interviews were audio recorded and transcribed verbatim.

Analysis

Descriptive analyses of survey responses were conducted using Microsoft Excel. Self-reported postcodes were matched to the Australian Bureau of Statistics, Australian Statistical Geography Standard—Remoteness Area.14 Interviews were thematically analysed by two investigators (RT and LL) using NVivo Release V.1.6.1 (QRS International, Melbourne, Australia). Transcripts were first coded to identify all aspects related to the research question (first-cycle coding) and codes progressively added inductively.15 Codes were grouped based on thematic similarity, followed by axial coding to find patterns between codes.15 The codebook was refined every five interviews (RT and LL), and co-author input (RT, LL, CKC, AJ) regarding themes was gathered. The overall themes have been summarised with illustrative quotes below.

Patient and public involvement

The public was not involved in the design, reporting or dissemination of our research. Distribution of the online survey was conducted through social media, websites and newsletters of relevant organisational networks throughout Australia.

Results

Survey responses were collected from 690 individuals with CVD/risk factors (43.8% women, 40.1% over 65 years, 80.7% in New South Wales) (table 1). Commonly reported CVD/risk factors were atrial fibrillation (35.3%), coronary heart disease (28.3%) and hypertension (24.6%). Participants reported that the pandemic affected their heart health (26.3%), and they were less likely to exercise (47.1%), have a healthy diet (25.9%) and take medication (9.4%) (figure 1). A large proportion were admitted to hospital (46.2%) and presented to the emergency department (40.6%). The majority found it difficult to see healthcare providers (53.2%). Most respondents used telemedicine (63.6%). A detailed summary of survey responses and by sex analysis is provided in the online supplemental material S4.

Figure 1

Online survey responses of 690 people living with cardiovascular disease and/or risk factors in Australia during the COVID-19 pandemic. Disagree (includes strongly disagree and disagree options) and agree (includes strongly agree and agree options). A detailed summary of survey responses and by sex analysis is provided in online supplemental material S5.

Table 1

Characteristics of 690 online survey respondents with cardiovascular disease and/or risk factors residing in Australia during the COVID-19 pandemic

We conducted 16 interviews (range: 10–45 min) during February to April 2022. The majority of participants were women (8/16), over 65 years (8/16) and from New South Wales (7/16) (online supplemental material S5). Themes are summarised below, for illustrative quotes see online supplemental material S6.

Adding burden in seeking medical care

Exposed to risk of COVID-19 infection—Patients felt vulnerable to the additional “COVID risk” and hence avoided being “admitted to hospital”.

Contending with disruptions to care—Patients noticed a change in their hospital care and felt they were not “taken care of well” despite having a “heart condition”. Some reported that hospitals were “[more] worried whether [you] had COVID” and “treated you in the marquee area until they got the [negative test] results” meaning the wait was extended. The additional processes of getting “COVID tested, getting checked in-” meant that patients “postponed” their appointments.

Hesitancy in causing additional stress to the health system—Some patients “restricted” or “reduced the frequency” of seeking care, because they thought “[their] issues weren’t that important” and “the doctors were under enough pressure anyway”. Not having family support in hospital, “…my mum there to support me emotionally, [and] mentally”, meant that asking hospital staff for help felt like instigating burden; “I would’ve liked someone to help me instead of putting pressure on the nurse every five minutes”.

Impediments in accessing a readjusted health system

Inconvenienced by additional public health measures—Measures such as “COVID test beforehand”, a “full on screening process” caused delays and inconvenience for patients, “especially [for] ones who are not very mobile”.

Worry about extended wait times—Lengthy wait times were experienced, some having to “wait to have an angiogram” and “to see a heart specialist” was “a month to six weeks”, in that time patients were worried that “something could’ve happened”. For example, a patient reported that they were supposed to have “surveillance scans of [an] aneurysm every two years” and it “ended up being more like two and a half years” which caused worry—“a long time if you’ve got a fast-growing aneurysm”.

Low supply and slow distribution of medicines—Patients reported “access to medications became somewhat problematic because supply was an issue”, meaning that usually they would “go to one pharmacy and get all…scripts and medications filled” and now they are having to “pharmacy shop” to get all their required medicines.

Reduced availability of specialists in rural/regional areas—Patients reported that “[in] country areas… cardiologist[s] only come down here on certain days” and to see the doctor it can take “two, three days, up to a week”.

Exacerbating vulnerability and distress

Heightened apprehension—The risk of “having a chronic illness and wondering what impact COVID would have” weighed on patients, and resulted in them “sheltering a lot in terms of COVID risk” or it “influenced [them] not to leave the house” and caused worry if COVID-19 would cause “difficulties in breathing”.

Anxiety and stress provoking—COVID-19 caused additional stress and anxiety and worsened overall health: “[it] made me more anxious…increased my heart rate…more stressed out…let my pacemaker work more…I ended up going on anti-depressants and relaxants to calm me down”.

Confused by information—Patients did not have reliable information on how vaccination impacted them—“the conflict with…vaccination and my condition and how it affects me personally”. It was also the “stress of having a chronic illness” and “wondering what impact COVID would have if [they were] to contract COVID”.

Intensifying isolation—COVID-19 and lockdowns heighten isolation, especially for those living alone—“I live by myself…my daughter was going to be my buddy…she was in part…that got locked down further…that was hard”. Isolation also reduced interactions with other people—“I did feel isolated and even people that I would normally ring, I didn’t…you got that way where you didn’t want to talk to people”, “I’m lucky if I go out maybe once or twice a month”.

Coping with self-management

Waning fitness due to decreasing physical activity—Patients reported the “amount of steps” they did daily “declined” causing “gained weight”. Wearing a mask also impacted their exercise, due to “breathing difficult[ies]”. Closure of exercise facilities (“the pool”) impacted their “ability to do things and [their] mobility” from being more “sedentary”. The inability to see the “exercise physiologist” in person resulted in less motivation to complete exercises at home—“sometimes I did that, sometimes I didn’t…I just did less [exercise].”

Confusion from frequent changes in restrictions—Patients reported that the “policies keep on changing all the time” and it was “difficult” to follow what exercise was permitted.

Restricted diet options from limited food supply—Patients reported that there were food “supply chain issues” and the food that they would “normally eat” was “hard to get at times”, especially “fresh food” as it was “sold out” often.

Education and monitoring support from digital health technologies—Lifestyle “text messages” with “pointers and suggestions” in managing your health were reported to be helpful during COVID-19. Patients were able to send “heart rate” data to their “cardiologist”, using an app which monitored “[smartwatch]…heart rate data”, and the cardiologist was able to “adjust the medication based on that”.

Adapting to telehealth

Convenience and improved accessibility—Patients reported that telehealth was convenient in getting “e-prescriptions”, “referral[s]” and for “[psychologist] counselling…throughout [COVID-19]”.

Patient safety from infection while still receiving care—Telehealth provided “safety” from infection— “everyone’s coughing [at the GP]…I was glad to do telehealth”.

Technical issues in implementation—Technical issues such as “[online bookings] fall out or not accepted, or…accepted and not happen” were reported. Some patients found e-prescriptions took “longer” than anticipated due to lack of integration between health services—“…the doctors were okay in terms of knowing what to do…the pharmacies weren’t very well trained”.

Unfamiliarity with model of care—Some “still prefer face-to-face” because “that’s what [they’re] used to”. For certain situations such as “chatting to [the] cardiologist” and “GP” it was “great” but telehealth with the “exercise physiologist” was reported as “pointless”.

Lacking visual cues and personal interactions—Telehealth was reported as “less personal” because of the lack of “cues [from the doctor]”. In-person visits allowed patients to see if “…[the] doctor is concerned or interested”, “open up more and get to the root of what the problem is” and “get reassurance”, whereas telehealth missed the “personal touch”.

Discussion

Patients with CVD reported that their health was adversely influenced by the COVID-19 pandemic. This was due to the multiple healthcare access barriers, additional burden of navigating a readjusted health system, the heightened vulnerability and distress of accessing health services and the challenges of self-management. Telehealth was used by majority of patients with CVD during the pandemic, and although it provided convenience, issues with implementation were noted, as well as its inability to serve as a replacement to face-to-face care.

It is known that patients with CVD are at higher risk of complications from COVID-19, however, there has been an unexpected decrease in seeking medical attention1 5 16 which could be explained by patient reported barriers and disruptions in accessing healthcare found in the current study. In Australia, there was a decrease in emergency department presentations as well as a reduction in cardiology hospital presentations, reduced cardiology admissions but increased case complexity and an increase in-hospital mortality.1 17 Due to fear of infection from COVID-19 patients reported that they delayed hospital presentations, as well as decreased GP appointments and did not attend pathology or imaging appointments.1 Based on a well cited framework of access to healthcare,18 the domains that seemed to have been most disrupted were: the ability of patients to seek and reach healthcare and the availability of care. Major themes that arose from the qualitative analysis were that the ability of patients to seek care was compromised by COVID-19 related fears and hesitation, including fear of contracting the virus.1 16 Simultaneously, the ability to reach care was hampered by travel restrictions enforced by public health measures.16 Also exemplifying this was that the availability of care, impacted by the limited hours of service operation, ban of elective surgeries and changes in appointment mechanisms (eg, additional check-in procedures, telehealth booking systems).

Digital health adoption, specifically telehealth, has grown in popularity since the beginning of the pandemic.19 The current study found that most people with CVD in Australia had utilised telehealth. Prior to the pandemic, telehealth was mainly available to those living outside of major Australian cities. In March 2020, the Australian Government introduced a telehealth scheme that allowed subsidised telehealth consultations with healthcare providers (eg, general practitioners, specialists, nurses, allied health workers) to be available to patients at no cost and despite of geographical location.20 By April 2020, 36% of general practice appointments were delivered via telehealth.21 Many patients and healthcare providers had reported high satisfaction and interest in the continuation of these services beyond the pandemic. Specifically, the availability, choice and flexibility were reported as enablers to its adoption, supporting by the findings in the current study and previous literature.22 However, less personal interactions, inability for physical examinations and technology difficulties were reported as barriers.19 In addition to telehealth, other digital health technologies were utilised to manage chronic conditions during COVID-19—especially mobile applications and activity trackers, and their use was associated with higher levels of physical activity.23 The outreach of digital health technologies is scalable, however, implementation should focus on optimisation by reducing existing barriers.

There were significant reductions in physical activity, increases in sedentary behaviour, worsening of diet quality and increases in food intake and alcohol consumption due to COVID-19.24 Similar findings were reported in our study, Australians with heart disease were engaging less in healthy lifestyle behaviours such as exercise and healthy diet. The maximum suppression strategy adopted in Australia, combined with the strict lockdown policies to prevent community transmission in highly impacted states of New South Wales and Victoria (majority of the study population), further exacerbated social isolation and possibly impacted ability to maintain healthy lifestyle habits. Loneliness and social isolation are known to impact mental health.25 A rise in mental health issues during the pandemic has been associated with premature mortality, depression, CVD, cognitive decline and unhealthy behaviours.24 25 A post-pandemic increase in CVD events is likely, and hence a focus on scalable interventions for secondary prevention and risk factor control in this population are warranted to minimise these impacts.

This study has several strengths and limitations. By using a mixed-method approach, qualitative interview data was used to enrich survey findings of patient experiences. Existing research has mostly focused on the perspective of healthcare workers and on other patient populations.26 The study population was well-balanced in terms of the sexes, which is particularly important given the differences in perceptions of cardiovascular risk and responses to environmental stress.27 While the study included participants from around Australia, most respondents resided in New South Wales and were from major cities, potentially resulting in generalisability of perspectives not shared by those in other parts of country subject to different public health measures and access to health services. The limitations of a cross-sectional design include the inability to determine changes across time, and the current findings are indicative of experiences over a relatively short duration, this is particularly important as during COVID-19 there were many changes in policies and the impact of these may not have been captured. The sample size of 16 interviews may not have captured all experiences of people with CVDs, however, interviews were conducted until data saturation was reached and complimented the survey in this mixed-methods study. Further, the interviews were conducted in participants that ‘opted in’, which may have resulted in over proliferation of perspectives of certain subpopulations that is perhaps more inclined and motivated to participate. Moreover, this study was only conducted in English, and impacts on those with differing cultural backgrounds may have been missed. We did not involve patients or consumers in the design of the online survey and the interview guide, and this may have added complexity to the questions asked.

Our mixed-methods study has provided an in-depth understanding of the impact of COVID-19 from the perspective of patients with CVD. It informs thinking and planning for chronic health conditions and other vulnerable patient populations in a health system under strain. Additionally, the findings could guide the optimisation of telehealth and its implementation, particular for those with chronic health conditions to improve patient experience and further alleviate health system pressure.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved. Ethics was approved by The University of Sydney, Research Integrity and Ethics Administration (2021/031; 7 April 2021). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors would like to thank Desi Quintans for his assistance with the survey data analysis and Emma Charlston for her contributions as project manager for this study.