Taylor Carty | Medical mistrust and HIV testing among South Africans who consulted a traditional healer | |
Rohini Chakravarthy, M.D. | Leveraging the Pediatric Health Information System Database to Characterize Hospital Readmissions Following Pediatric Allogeneic Stem Cell Transplantation | |
Ryan Dalforno | The Jackson Water Crisis: A Complex Systems Approach | |
Robert Dambrino, M.D. | The 21st Century Cures Act Information Blocking Rule Affect on Unsolicited Patient Complaints | |
Meredith Denney | Mobile Flu Fighter!: Development and implementation of a mobile vaccination initiative to reduce pediatric influenza vaccination disparities in Nashville, Tennessee | |
Laura Ernst | Unwinding without Unraveling: State Approaches to Medicaid Redetermination When Continuous Enrollment Ends | |
Kelsey Gastineau, M.D. | One Step Closer to Safer: Counseling Outcomes from AAP Firearm Safe Storage Education Training | |
Kevin Gibas, M.D. | Association of delayed HIV diagnosis with demographic disparities based on geographic residence: A target for innovative screening interventions | |
Caroline Godfrey, M.D. | Creation of a Clinically Useful High-Risk Lung Nodule Calculator | |
Kyle Hart | Prescriptions for Non-Opioid Medications in Combination with Opioids on the Development of Persistent Opioid Use among Patients Hospitalized for Long Bone Fracture | |
Layan Ibrahim | Childhood Epilepsy in Northern Nigeria: Comparing Epilepsy Knowledge and Trust in Providers Among Children Enrolled in the BRIDGE Trial | |
Sofia Ludwig | Improving Relationship Empathy Among HIV+ Seroconcordant Couples in Rural Mozambique: A cluster-randomized study on the Homens Para a SaĂşde+ (HoPS+) program | |
Ellen McMahon, M.D. | The Relationship Between Resilience and Positive Child Health Behaviors in a Large, Nationally Representative Dataset | |
Maria Padilla Azain, M.D. | A nested case-control study of opioid analgesics and antidepressant prescriptions during pregnancy and the risk for preterm birth | |
Chelsea Rick, D.O. | Frailty as a Predictor of Catatonia in the Critically Ill Patient | |
Elsa Rodriguez, M.D. | Antibiotic treatment compliance among Fracture related infections in Orthopaedic trauma | |
Barrett Smith | Assessing Bedside Nurse Pain Management Recommendations and Their Associations with Inpatient Opioid Use in Women who Have Undergone a Cesarean Birth | |
Allison Stranick | Lung Cancer Screening Eligibility Among United States Veterans: Results from a National Smoking History Survey Jennifer Lewis, M.D., M.P.H. | |
Claire Umstead | Comparing ICU Admission between Influenza- and SARS-CoV-2-Positive Pregnant Women in Middle Tennessee | |
Noor Ali | The Effect of Biased Language in Emergency Transfers | |
James Antoon, M.D., Ph.D. | Factors Associated with Guideline Concordant Antiviral Use in Children at High Risk for Poor Influenza Outcomes | |
Katherine Black | Pediatric CYP2D6 Metabolizer Status and Post-Tonsillectomy Nausea and Vomiting After Ondansetron Administration | |
Christina Boncyk | The Impact of Increased Prescribing on ICU Survivors | |
Miaya Blasingame | The Combined Effects of Social Determinants of Health on Childhood Overweight and Obesity | |
Alison Carroll | Decreasing Pre-Procedural Fasting Times in Hospitalized Children | |
Augustine Chung | The effect of movement-based disorders on long term care informal caregiver burden | |
Tavia Gonzalez Pena, M.D. | Legal Outcomes among Postpartum Women with Opioid Use Disorder | |
Sarah Grossarth | Infant Mortality Associated with Prenatal Opioid Exposure in Tennessee | |
Rachael Jameson | Equity Implications of the Tennessee Fetal Assault Law | |
Shani Jones, M.D. | Access Equity: Trust and Telemedicine Use in Diverse Pediatric Primary Care Populations | |
Emily Kack | Incidence of Invasive Group B Strep by Census Tract Level Socioeconomic Status Among the Adult Population in TN | |
Rebecca Lee | The Impact of Timely Access to Care on Breast Cancer Survival Among Young Black Women | |
Kevin Liu, M.D. | A Retrospective Analysis on the Impact of an Integrated Palliative Care Approach during the COVID-19 Pandemic | |
Kristyne Mansilla | HIV Knowledge among Postpartum Women in South Africa | |
Cooper March | Lung Cancer Screening Eligibility Among United States Veterans: Results from a National Smoking History Survey Michael Ward, M.D.,Ph.D, MBA | |
Hannah Marmor, M.D. | Comparing ICU Admission between Influenza- and SARS-CoV-2-Positive Pregnant Women in Middle Tennessee | |
Marshae Nickelberry | Prenatal Omega-3 Fatty Acids and Child Asthma | |
Alexandra Odenthal | Post Discharge Opioid Prescribing and Use after Vaginal Birth | |
Laura Rausch, M.D. | Surgical Resident Involvement in Renal Transplantation, Evaluating Anastomosis Time and Outcomes | |
Isaac Schlotterbeck | Disparities in Loss to Follow-Up/Mortality Before vs. After Registry Linkage in Brazil, Mexico, and Peru | |
Daniel Tilden, M.D. | Prolonged Lapses in Care Associated with Pediatric to Adult Care Transfer are Associated with Rise in HbA1c Among Patients with Type 1 Diabetes | |
Avirath Vaidya | Effects of Mixed-Income Redevelopment on Low-Income Families: Evidence from Envision Cayce | |
Sarah Welch, D.O. | The Age-Friendly Initiative: Outcomes from Vanderbilt Acute Care for Elders Unit | |
Anna Wisotzkey | Obstetric Provider Opioid Prescribing Perspectives after Childbirth in Tennessee, June-July 2019 | |
Jacy Weems | Federal Nursing Home Civil Monetary Penalties, 2009-2019 | |
Bentley Akoko, M.D. | HIV-related stigma and psychological distress in a cohort of patients receiving anti retroviral therapy in Nigeria | |
Lin Ammar | Third trimester electronic cigarette use and the risk of pre-term birth, low birthweight and small-for-gestational age | |
Laura Baum, M.D. | Post-Traumatic Stress Symptoms, Financial Toxicity, and Health-Related Quality-of-Life in Caregivers and Young Adult Patients with New Cancer Diagnoses | |
Wubishet Belay, M.D. | Secondary Prophylaxis for Rheumatic Heart Disease in Ethiopia | |
Ryan Belcher, M.D. | The Demographics and Trends of Patients with Cleft Lip and Palate Born in the State of Tennessee from 2000-2017 | |
Mary-Margaret Fill, M.D. | The Impact of Electronic Laboratory Reporting on Public Health Communicable Disease Surveillance in Tennessee | |
Chloe Hurley | Advanced Practice Providers Improve Quality: Accountable Care Organizations Enrolled in the Medicare Shared Savings Program | |
Wali Johnson, M.D. | The Impact of Social Determinants on Abdominal Solid Organ Transplant Wait-Lists | |
Ali Manouchehri, M.D. | Cardiovascular toxicities associated with Ponatinib: a pharmacovigilance study | |
Mina Nordness, M.D. | The Impact of Surgery and Anesthesia on the Development of Alzheimer’s Disease or Related Dementia (ADRD) after Injury | |
Allan Peetz, M.D. | Resuscitating the Dying Donation: A Qualitative Analysis of Trauma Surgeons’ Resuscitation Practices | |
India Pungarcher | A Descriptive Analysis of Caseworker Status Among People Experiencing Homelessness in Nashville, Tennessee | |
Milner Staub, M.D. | Veteran satisfaction and expectations for antibiotics in outpatient upper respiratory tract infections | |
Lindsay Sternad, M.D. | Parental Primary Language, Access to Care, and Developmental Delays in Neonates | |
Bo Stubblefield, M.D. | COVID-19 Surveillance Among Frontline Healthcare Personnel | |
Teris Taylor | Prenatal Care Use Among Women in the 2017-2019 National Survey of Family Growth | |
Victoria Umutoni | The association between smoking and anal human papillomavirus in the HPV in Men Study | |
Jasmine Walker, M.D., M.A.T. | Early Impact of MISSION Act on Utilization of Veterans Affairs Transplant Centers | |
Ni Ketut Wilmayani, M.D., M.B.B.S. | Inappropriate Antibiotic Prescriptions in United States Hospital Emergency Departments, 2011-2018 | |
Amanda Abraham | Impact of Food Insecurity on Engagement in HIV Care for Female vs. Male Head of Household | |
Justin Banerdt | Delirium Prevalence and Outcomes at a Resourced-Limited Referral Hospital in Lusaka, Zambia | |
Edson Bernardo, M.D. | Estimation of Levels and Patterns of Migration among People Living with HIV in the District of Manhiça, Southern Rural Mozambique | |
Sean Bloos | Retrospective Multi-Center Cohort Study Comparing Timeliness of Emergency Department Care in Younger Versus Older Patients with ST-Elevation Myocardial Infarction | |
Evan Butler | The Impact of Rural Hospital Closures on Local Economies | |
Keerti Dantuluri, M.D. | Prevalence and Factors Associated with Inappropriate Antibiotic Prescription among Children Enrolled in Tennessee Medicaid | |
Gretchen Edwards, M.D. | Assessing Quality of Colorectal Cancer Care in a National VA Cohort | |
Lei Fan, Ph.D., M.D. | Magnesium Intake and Opioid Use in the National Health and Nutrition Examination (NHANES) 2005-2016 | |
Mary-Margaret Fill, M.D. | The Impact of Electronic Laboratory Reporting on Public Health Communicable Disease Surveillance in Tennessee | |
Carleigh Frazier | Measuring Trust in Biomedical Research: Trust Survey Pilot Study and Validation | |
Hannah Griffith | Changes in Time to First Occurrence of Otitis Media in Young Children in Tennessee and Associated Antibiotic Prescriptions Following the Introduction of the 13-valent Pneumococcal Conjugate Vaccine | |
Heather Grome, M.D. | Association of STI Diagnosis with Incident HIV Diagnosis: A Target for PrEP Intervention | |
Diane Haddad, M.D. | Vertical Integration and Post Acute Care Use after Major Surgery | |
Sarah Homann, M.D. | Select Medication Exposure and Risk of Hip Fracture in Veterans with Rheumatoid Arthritis (RA) | |
Arlyn Horn, Pharm.D. | Initial Postpartum Opioid Exposure and Risk of Death Among TN Medicaid Opioid Naive Women: A Retrospective Cohort Study | |
Peter Hsu, M.D. | Provider Network Breadth under the Affordable Care Act Between Marketplace Insurance Plans Versus Medicaid Managed Care Plans | |
Tamee Livermont | The Effect of Substance Use on Postpartum Contraception | |
Alexandria Luu | Traditional Healers as a Treatment Partner for PLHIV in Rural Mozambique | |
Muna Muday | Engaging with the Community: Exploring Community Development and Program Evaluation in the Context of Health Promotion | |
Harriett Myers | Improving Child Diet Quality through a Family-Based Behavioral Intervention for Childhood Obesity | |
Madelynne Myers | Antipsychotic Usage and Prescribing Patterns amongst the Med-SHEDS Population Diagnosed with Dementia | |
Katelyn Neely, M.D. | Genotype and Adverse Events During Citalopram, Escitalopram and Sertraline Treatment in Children and Adolescents | |
Allan Peetz, M.D. | Resuscitating the Dead: A Qualitative Analysis of Trauma Surgeons’ Resuscitation Decisions for Organ Preservation | |
Varvara Probst, M.D. | AdV Detection Alone vs. AdV Co-detected with Other Respiratory Viruses in Children with Acute Respiratory Illnesses | |
Sarah Rachal | A Longitudinal Analysis of Relationships between Neighborhood Context and Underserved Children’s Sedentary Behavior in a Rapidly Growing City | |
Sonya Reid, M.B.B.S. | The Role of Tumor Biology in Bridging the Survival Disparity Gap in Young Black Women with Breast Cancer | |
Emmanuel Sackey, M.B.Ch.B. | Cervical Cancer Screening History of Davidson County Women, 2008 – 2018 | |
Emily Sedillo | Contraception and Unplanned Pregnancies in Migori County, Kenya | |
Sadie Sommer | Comparative Review of Maternal Mortality | |
Fatima Yadudu | Prevalence of Febrile Seizures in children between 6 and 60 months from Northern Nigeria | |
Ben Acheampong, M.B.Ch.B | Evaluation of a Miniaturized Handheld Device for Ventricular Structure and Function in Children: A Pilot Study | |
Jim Barclay | Predictors of Increased Post-Training Knowledge among Current and Prospective Members of the HIV Clinical Workforce in the Southeast United States | |
Morgan Batey | A Systematic Review of NCAA Concussion Management Plans | |
Celso Give | If Ebola Were to Happen Tomorrow in Mozambique, Would We be Ready for the Various Ethical Issues Raised in the Ebola Outbreak in West Africa in 2014-2015? | |
Selorm Dei-Tutu, M.D. | Correlating Maternal Iodine Status with Infant Thyroid Function in Two Hospital Settings in Ghana | |
Jennifer Erves Ph.D. | Factors Influencing Parental HPV Vaccine Hesitancy from the Provider and Clinic Level: A Cross-Sectional Study | |
Djamila Ghafuri, M.D. | Severe Acute Malnutrition in Children with Sickle Cell Anemia in Northern Nigeria | |
David Isaacs, M.D. | Longitudinal Outcomes for Deep Brain Stimulation in Parkinson’s Disease | |
Sophie Katz, M.D. | An Assessment of Pediatric Outpatient Antibiotic Prescriptions Across Tennessee | |
Tom Klink | Predicting Severe Illness using WHO Severe Acute Respiratory Infections (SARI) Criteria in a Jordanian Cohort | |
Delaney Lackey | Predictors of late presentation to antenatal care among pregnant women living with HIV in Johannesburg, South Africa | |
Jennifer Lewis, M.D. | A Difference-In-Difference Study of Low-Dose CT Utilization in the VA | |
Taylor Matherly | Development and Assessment of a Mentoring Curriculum for Junior Faculty in Health Sciences at the University of Zambia | |
Lindsey McKernan, Ph.D. | Patient-Centered Treatment for Interstitial Cystitis/Bladder Pain Syndrome | |
Andrew Medvecz, M.D. | Long Term Outcomes Following Obstruction from Small Bowel Adhesive Disease: Longitudinal Analysis of a Statewide Database | |
Kelsey Minix | What are the Determinants of Breastfeeding Initiation and Duration in a Group of Pregnant Hispanic Women Participating in a Research Study from 10/1/14 – 9/30/16? | |
Sarah Moroz | The Effectiveness of a Brief ACEs Educational Intervention on Low-Income Parents at Risk for Exposing their Children to Harmful Stress | |
Miller Morris, M.A. | Prevalence and Predictors of Interpersonal Violence Against Women in Migori County, Kenya | |
Didier Mugabe, M.D. | Determinants of Self-Report not Receiving HIV Test Results after HIV Testing in Mozambique: Results from a Nationally Representative Survey | |
Sylvie Muhimpundu | Racial Differences in Liver Cancer Risk | |
Meghana Parikh, V.M.D. | Temporal and Genotypic Associations of Sporadic Acute Norovirus Gastroenteritis in an Active Surveillance System Compared to Reported Norovirus Outbreaks in Middle Tennessee | |
Mariah Pettapiece-Phillips | Multidimensional Poverty in Migori County, Kenya: Analysis from a Population-based Household Survey | |
Nicole Quinones | Contraception Choice of Postpartum Women in the 2011-2015 National Survey of Family Growth | |
Jennifer Robles, M.D. | Variation in Urology Post-Operative Opioid Prescription Patterns using a National Veterans Health Administration Cohort | |
Laura Sartori, M.D. | Pneumonia Severity in Children: Reducing Variation in Management Through Analysis of Procalcitonin | |
Shailja Shah, M.D. | The Association of Calcium, Magnesium, and Calcium Magnesium Intakes with Incident Gastric Cancer, a Prospective Cohort Study of the NIH-AARP Diet and Health Study | |
Emily Smith, R.N. | The Prevalence of Opioid Use and Factors Contributing to Opioid Therapy Among a Hospitalized Elderly Population | |
Maggie Smith | Gender Differences in Research Participation and the Association with Perceived Health Competence | |
Kayla Somerville | Long-term Effects of Antiretroviral Therapy on Pediatric Cohort in Latin America | |
Lucy Spalluto, M.D. | Assessing the Impact of a Community Health Worker on Hispanic/Latina Women’s Reported Measures of Processes of Care in the Screening Mammography Setting | |
Jeremy Stelmack | Identifying Risk Factors for Opioid Misuse in Employed Populations |
Rachel Apple, M.D. | Relationship Between Weight Trajectory and Health-Related Quality of Life Among a General Adult Population | |
Sade Arinze, M.D. | Immunodeficiency at the Start of Combination Antiretroviral Therapy: Data from Zambézia Province, Mozambique | |
Beto Arriola Vigo, M.D. | Qualitative Analysis: Community Involvement in the new model of care during Mental Health Reform in Peru | |
Shawna Bellew, M.D. | Prospective Evaluation of Indications for Obtaining Pneumococcal and Legionella Urinary Antigen Tests in Adults with Community-acquired Pneumonia | |
Sydney Broadhead | High Competition and Low Premiums—Key Components of the ACA’s Narrow Physician Networks | |
Emily Castellanos, M.D. | Health Literacy and Healthcare Use in the Southern Community Cohort Study | |
Heather Ewing | Knowledge of Tuberculosis is Associated with Greater Expression of Stigma in Brazil | |
Erin Gillaspie, M.D. | Tumor Response in Patients with Advanced Stage Lung Cancer Treated with Immunotherapy | |
Birdie Hutton | Evaluation of behavioral, environmental and genetic risk factors for gastric cancer: a population-based study in Central America | |
Chelsea Isom, M.D. | Does Increased Arachidonic Acid Levels Lead to an Increased Risk for Colorectal Adenoma? | |
Justin Liberman, M.D. | Post-Discharge Opioid Prescriptions and Their Association with Healthcare Utilization in the VICS Cohort | |
Salesio Macuacua, M.D. | Assessment of the Determinants of Non-adherence to Antiretroviral Therapy during Pregnancy in the District of Manhiça, Mozambique | |
Adoma Manful | Latent TB Among Refugees in Middle Tennessee | |
Cassie Oliver | Substance Use and Post-Partum Retention in Care among Women with Human Immunodeficiency Virus (HIV) Infection in Prenatal Care at the Vanderbilt Comprehensive Care Clinic, 1999-2016 | |
Mindy Pike | Effects of Social Support on Physical and Mental Quality of Life in Heart Failure Patients: The Vanderbilt Inpatient Cohort Study (VICS) | |
Juanita Prieto Garcia, M.D. | Determinants of Full Immunization in Children under Five Years Old in the Rongo Sub-County of Migori County, Kenya | |
J.W. Randolph | Addressing Parenting Related Adverse Childhood Experiences (‘PRACES’) in the Pediatric Primary Care Setting | |
Lauren Sanlorenzo, M.D. | Identifying Severe Neonatal Abstinence Syndrome Among Polysubstance Exposed Infants | |
Joey Starnes | Reduction in Under-Five Mortality in the Rongo Sub-County of Migori County, Kenya: Experience of the Lwala Community Alliance 2007-2017 with Evidence from a Cross-Sectional Survey | |
Rui Wang, M.Ed. | Risk Factors for Depression among Women in Rural Western Kenya and Implications for Designing Future Surveys | |
Hannah Weber | Food Insecurity Among Older Adults |
Julia Allen | Diabetes Services Utilization under the Affordable Care Act Medicaid Expansion: Evidence from the Behavioral Risk Factor Surveillance System | |
Frances Anderson | Evaluation of the Minnesota TB Screening Program: Immigrants and Refugees with TB Class conditions Arriving in the State of Minnesota, 2012-2014 | |
Jimmy Carlucci, M.D. | Prevalence and Risk Factors for Malaria among Children in Zambezia Province, Mozambique | |
Alaina Davis, M.D. | Depression and Medication Non-Adherence in Childhood-onset Systemic Lupus Erythematosus | |
Cherie Fathy | Ophthalmologist Age and Patient Complaints | |
Grace Fletcher | Maternal Conception of Gestational Weight Gain Among Latinas: A Qualitative Study | |
Sarah Greenberg | Evaluation of the Home Health Market: Impact of Chain Status on Quality Care | |
Aamer Imdad, M.B.B.S. | Pathogenic Escherichia coli (E. coli) As Cause Of Acute, Moderate To Severe Gastroenteritis In A Geographically Defined Pediatric Population In Colombia, South America. A Case Control Study | |
Kailey Lewis | Variation in Tennessee Outpatient Antibiotic Prescribing by County of Practice and Provider Specialty in 2013 | |
Katie McGinnis | An Exploratory Investigation Into Parent/Caregiver and Hospital Staff Perceptions About Children and Families’ Psychosocial Needs and Hospital Experiences in Two Kenyan Children’s Hospitals | |
Rany Octaria, M.D. | Using Administrative and Surveillance Data to Target Carbapenem Resistant Enterobacteriaceae Response and Prevention Strategies in Tennessee | |
Ezequiel Ossemane | Assessment of Guardians’ One-Day Recall of Elements of Informed Consent to a Mozambican Study of Pediatric Bacteremia | |
Caroline Presley, M.D. | Validation of an Algorithm to Identify Heart Failure Hospitalization and Retrospective Assessment of Frailty Status | |
Jason Pryor, M.D. | Pregnancy Intention and Maternal Alcohol Consumption | |
Markus Renno, M.D. | Toward High-Value Utilization of Pediatric Echocardiography: Foundations for a Robust Quality Improvement Initiative | |
Kidane Amare Sarko | Influence of HIV Status Disclosure on Facility-based Delivery and Postpartum Retention of Mothers in a Prevention Clinical Trial in Rural Nigeria | |
Cassie Smith | Evaluating the Frequency and Dispersion of ACOs with Multiple Payer Contracts | |
Shanel Tage | Determinants of Breastfeeding Self Efficacy Among Mexican Immigrant Women | |
Grace Umutesi | Evaluation of the Impact of the 2014 Ebola Outbreak on the Acute Flaccid Paralysis (AFP) Surveillance Programs of Guinea and Liberia | |
Christopher Wahlfeld, Ph.D. | HIV Rapid Diagnostic Test Inventories in Zambézia Province, Mozambique: A Tale of Two Test Kits | |
Katherine Watson, M.D. | Measuring Health Literacy in Parents of Young Children |
Lealani Acosta, M.D. | Error Frequency in Category Fluency in Mild Cognitive Impairment | |
Jillian Balser | Impact of Adverse Childhood Experiences on Long-term Outcomes in Vulnerable Populations: Retrospective Analysis | |
Mary Bayham | Predictors of Healthcare Utilization Among Children 6-59 months in Zambezia Province, Mozambique | |
Angela Boehmer, R.N. | Patient and Clinician Satisfaction with Task Shifting of Prevention of Mother-to-Child HIV Transmission (PMTCT) Services in rural North-Central Nigeria | |
Mariu Carlo, M.D. | Executive Function, Depression, and Mental Health-Related Quality of Life in Survivors of Critical Illness | |
Erin Graves, R.N. | Prevention of mother-to-child transmission (PMTCT) outcomes in Zambézia, Mozambique | |
Erin Hamilton | Evaluation of a School Nutrition Education and Fruit Delivery Intervention in Santiago, Chile | |
Bryan Harris, M.D. | Preventing Infection-Related Ventilator-Associated Complications | |
Jessica Hinshaw | Food Security and Dietary Diversity of a Peri-urban Community in Nicaragua | |
Savannah Hurt | Pediatric Perioperative Mortality Rates in a Sample of Urban Kenyan Hospitals | |
Mary Allyson Lowry, M.D. | An Innovative Mucosal Impedance Device Differentiates Active Eosinophilic Esophagitis From Inactive Disease, Nerd, and Controls | |
Joseph Maloney | Microenterprise in Croix-des-bouquets, Haiti: Program Evaluation to Evaluate Affects on Poverty and Health | |
Brett Norman, M.D. | 30-day Readmission Rates Associated with Survivors of Severe Sepsis | |
Bhinnata Piya | An Early Impact Assessment of Health Systems Strengthening Initiatives on Tuberculosis Outcomes: A 6 Month Prospective Cohort Study in Southeast Liberia | |
Nicholas Richardson, D.O. | Adverse Health Outcomes of Contemporary Survivors of Childhood & Adolescent Hodgkin Lymphoma | |
Caitlin Ridgewell | Prematurity as a mitigating factor in the relationship of adverse family events and adolescent depression: Analysis of the 2011/2012 National Survey of Children’s Health | |
Althea Robinson-Shelton, M.D. | Problem Behaviors in Pediatric Narcolepsy | |
Emily Sheldon | Strategic Planning with the Turner Family Center for Social Ventures at Vanderbilt University | |
Shellese Shemwell | Vaccine and Vitamin A Compliance in Children Ages 12-13 months in Zambezia Province | |
Thomas Spain, Jr, M.D. | History of Physician Complaints and Risk of Hospital Readmission | |
Krystal Tsosie, M.A. | Epidemiology of Essential Hypertension and Uterine Fibroids | |
Zachary Willis, M.D. | Risk Factors for Persistent and Recurrent Clostridium difficile Infection among Pediatric Oncology Patients | |
Jo Ellen Wilson, M.D. | Catatonic Signs in Patients with Delirium in the ICU: A nested prospective cohort study | |
Kathleene Wooldridge, M.D. | Social Isolation and Hospital Length of Stay in Acute Decompensated Heart Failure |
Amma Bosompem, M.S. | Evaluation of Treatment Completion Rates for Latent Tuberculosis Infection in Refugees in Davidson County | |
Mary DeAgostino-Kelly | Analysis of Sex Differences within the Nutritional Support for Africans Starting Antiretroviral Therapy Study Results | |
Annabelle de St. Maurice, M.D. | Invasive Pneumococcal Disease in Tennessee: Regional Differences in Rates, Racial Distribution and Antibiotic Susceptibility | |
Jay Doss, M.D. | A Study of Rheumatoid Arthritis by Serotype in a Clinical Electronic Health Record | |
Najibah Galadanci, M.B.B.S. | Acceptability and Safety of Hydroxyurea for Primary Prevention of Stroke in Children with Sickle Cell Disease in Nigeria | |
Dupree Hatch, M.D. | Endotracheal Intubation Safety and Outcomes in the Neonatal Intensive Care Unit | |
Caleb Hayes | A Focus Group Study on the Barriers to Type 2 Diabetes Self-management among Latinos in Middle Tennessee | |
Colleen Kiernan, M.D. | Utilization of Radioiodine After Thyroid Lobectomy In Patients with Differentiated Thyroid Cancer: Does it Change Outcomes? | |
Sahar Kohanim, M.D. | Risk Factors and Patterns of Unsolicited Patient Complaints in Ophthalmology: an Analysis of a Large National Patient Complaint Registry | |
Kristy Kummerow, M.D. | Inter-hospital Transfer for Acute Surgical Care: Does Delay Matter? | |
Paula McIntyre, M.S. | Multidimensional Poverty in Dominican Bateyes: A Metric for Targeting Public Health Interventions | |
Alicia Morgans, M.D. | Patient-Centered Treatment Decision-Making in Advanced Prostate Cancer | |
Thomas O’Lynnger, M.D. | Standardizing the Initial and ICU Management of Pediatric Traumatic Brain Injury Improves Outcomes at Discharge: A Pre- and Post-Implementation Comparison Study | |
Cristin Quinn | Changes in the Comprehensiveness of Care Provided at HIV Care and Treatment Programs in the IeDEA Collaboration from 2009 to 2014 | |
Scott Revey, M.A. | Women’s Agency in Rural Mozambique: Multidimensional Poverty and The Decision to Bear Children | |
Katie Rizzone, M.D. | Development of a Survey to Study Sports Specialization and Injury Risk in College Athletes | |
Elizabeth Rose, M.Ed. | Determinants of undernutrition among children aged 6 to 59 months in rural Zambézia Province, Mozambique: Results of a population-based cross-sectional survey | |
Jay Shah, D.O. | Association Between Disease Activity and Fatigue in Adolescents with Crohn’s Disease | |
Ebele Umeukeje, M.B.B.S. | Increasing Autonomous Motivation in End Stage Renal Disease to Enhance Phosphate Binder Adherence | |
Andrew Wu | Incidence and Risk Factors for Respiratory Syncytial Virus and Human Metapneumovirus Infections Among Children in the Remote Highlands of Peru |
Jay Bala | Diagnostic trends in rural health clinics in Southern, Zambia, 2003-2009: Informatics for clinic data management | |
Imani Brown | Positive prevention in Zambézia province, Mozambique: How effective/useful is the messaging? | |
Charlotte Buehler, M.S. | Using Geographic Information Systems (GIS) to examine spatial patterns and clustering of HIV knowledge withing three districts of Zambézia Province, Mozambique | |
Lanla Conteh, M.D. | Radiologic-Histologic concordance for hepatocellular carcinoma: comparing lesions treated with locoregional therapy versus untreated lesions | |
Liz Dancel, M.D. | Acculturation and Infant Feeding Styles in a Latino Population: Results from an Ongoing Randomized Controlled Trial of Obesity Prevention | |
Eileen Duggan, M.D. | Patterns of Care, Outcomes and Healthcare Utilization for Patients with Perforated Appendicitis at Children’s Hospitals | |
Laura Edwards | Evaluation of a health management mentoring program in rural Mozambique: successes and challenges of year one of implementation | |
Ditah Fausta, M.D. | Pharmacogenomics of Anti-Retroviral Drug-Induced Hepatoxicity | |
Monique Foster, M.D. | Prevalence of Enterotoxigenic Escherichia coli and Analysis of Classical and Non-Classical Virulence Factors | |
Oliver Gunter, M.D. | Teaching Status is Associated with Early Postoperative Complications in Emergency Abdominal Operations | |
Bill Heerman, M.D. | Parent Health Literacy and Injury Prevention Behaviors for Infants | |
Angela Horton-Henderson, M.D. | Predictors of Acute Care Transfers from Inpatient Rehabilitation | |
Jessica Islam | Knowledge, Attitudes and Perceptions of Cervical Cancer and the HPV Vaccine in a Cohort of Bangladeshi Women | |
Yaa Kumah-Crystal, M.D., M.A. | Technology Use for Self-Management Problem Solving in Adolescent Diabetes and its Relationship to Hba1C | |
Chrispine Moyo, M.B.Ch.B. | WHO 2007 Policy Recommendation to Initiate Anti-Retroviral Therapy with Tenofovir instead of Stavudine: Implementation Status in Zambia and 12-months Outcome Evaluation | |
Elizabeth Murphy | Youth Violence Prevention in the Sierra Region of Chiapas, Mexico; Identifying Relevant Positive Youth Development Approaches to Promote Healthy Relationships | |
Christopher Nyirenda, M.B.Ch.B. | Plasma Polyunsaturated Fatty Acids in Zambian Adults with HIV/AIDS: Relation to Dietary Intake and Cardiovascular Risk Factors | |
Colby Passaro | MSM HIV/Syphilis Testing and Sexual Risk Behaviors at a Lima CBO: A Cross-Sectional Retrospective Study | |
Heather Paulin, M.D. | Antenatal Care Uptake in Zambézia Province, Mozambique | |
Matthew Resnick, M.D. | Self-referral for Advanced Imaging in Urolithiasis: Implications for Utilization and Quality of Care | |
Cecelia Theobald, M.D. | Improving Quality of Care for Patients Transferred to VUH: Targeting Provider Communication | |
Christopher Tolleson, M.D. | Motor Timing in Parkinson’s Disease Patients with Freezing of Gait | |
Yuri van der Heijden, M.D. | Missed Opportunities for Tuberculosis Screening in Pediatric Primary Care | |
Ellen Zheng, PhD, M.S. | HIV infection and related risk factors among men who have sex with men (MSM) with commercial sex activities in China |
Dwayne Dove, M.D., Ph.D. | Neuroimaging Young School-Age Children: Brain Connectivity and Pre-Reading Skills in Kindergarten | |
Leigh Howard, M.D. | A Phase I Study in Healthy Adults to Assess the Safety, Reactogenicity, and Immunogenicity of Influenza A/H5N1 Virus Vaccine Administered With and Without Adjuvant System 03 | |
Eiman Jahangir, M.D. | The Socioeconomic and Sociodemographic Determinants to Awareness, Treatment, and Control of Hypertension in the Southern Cone | |
Ashley Karpinos, M.D. | Prevalence of Hypertension Among Collegiate Male Athletes | |
Pat Keegan, M.D. | Patterns of Care Regarding Active Surveillance for Prostate Cancer | |
Dzifaa Lotsu, M.D. | Role of Omega Fatty Acids in Colorectal Cancer | |
Andre Marshall, M.D. | Socioeconomic Disparities of 30-day Readmissions Following Surgical Treatment of Appendicitis in Children | |
Leigh Anne Dageforde, M.D. | Health Literacy Assessment in Dyads of Primary Support Persons and Patients being Evaluated for Kidney Transplantation | |
Rebecca Snyder, M.D. | Patterns of Care in Perioperative Therapy for Resectable Gastric Cancer | |
Jose Tique, M.D. | Assessing Literacy and Numeracy in Patients with HIV Infection in Mozambique: Validation of the HIV Literacy Test | |
Eduard Vasilevskis, M.D. | Developing a Daily Prediction Model for Acute Brain Dysfunction in Older Patients: A New Tool for Quality Measurement and Improvement | |
Joshua Warolin, D.O. | Factors in Adolescent Weight Gain, a Prospective Cohort | |
Candice Williams, M.D. | Rural Residence and Access to Mental Health Care for Children and Adolescents after a Suicide Attempt | |
Elizabeth Williams, M.D. | Educational Intervention to Improve Acceptance of the Recommended Childhood Vaccine Schedule in Vaccine Hesitant Parents | |
Jessica Young, M.D. | Severe Dysmenorrhea in Adolescence and its Association with Somatization, Mood Symptoms, and Chronic Pain |
Alex Diamond, D.O. | Determining the effects of participation in organized physical activity as a youth on a variety of short as well as long-term patient and societal-oriented outcome measures | |
Richard Epstein, Ph.D. | Sudden cardiac death risk and psychotropic drug use in young women | |
Jennifer Esbenshade, M.D. | Surveillance of influenza shedding in healthcare workers in a pediatric intensive care unit | |
Sara Horst, M.D. | Evaluating a cohort of patients diagnosed with different chronic abdominal pain syndromes as children or adolescents now being evaluated as young adults | |
Tera Howard, M.D. | Health literacy defined as the degree to which patients can obtain, process and understand basic health information and services they need to make appropriate health decisions | |
Matthew Landman, M.D. | Effects of organ allocation strategies in liver transplantation | |
Christopher Lee, M.D. | Development of muscle imaging as a biomarker in amyotropic lateral sclerosis | |
Alessandro Morandi, M.D. | The role of pre-hospital use of statins on delirium and long-term cognitive impairment prevention in critically ill patients | |
Wesley Self, M.D. | Comparing the results of a real-time polymerase chair reaction (PCR) test targeting Methicillin-Resistant Staphylococcus aureus (MRSA) and culture results from purulent material isolated from skin and soft tissue (SST) abscesses | |
Julia Shelton, M.D. | Effects of wound classification on the incidence of abdominal wall incisional hernias | |
Anees Siddiqui, M.B.B.S. | Preventing HIV/AIDS transmission among female sex workers (FSWs)in Nawabshah, Sindh by assessing prevalence of sexually transmitted infections (STIs)and knowledge regarding HIV/AIDS transmission |
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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 ).
Flow chart of study selection process.
Of the 53 articles selected, 37 analyzed changes in realized access applying quantitative methods [ 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 ], 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.
Changes in the utilization of health services and influencing factors during the COVID-19 pandemic in 2020.
First Author, Year | Data Source | Study Area | Study Population and Sample | Study Period | Health Service | Main Results |
---|---|---|---|---|---|---|
Abebe, 2021 | Medical records from Tikur Anbessa Specialized Hospital | Ethiopia | Follow-up visits ( = 7717) and admissions ( = 3310) between December 2018–June 2019 and follow-up visits ( = 4597) and admissions ( = 2383) between December 2019–June 2020 | December–June 2018–2019 vs. 2019–2020 | General | Reduction in follow-up visits (40%) and admissions (28%) from March 2020, compared with the same period in 2019. Visits reduced especially among patients receiving renal, neurological, cardiac, and antiretroviral treatment (68–51.4%). No significant changes were observed among pediatric and adult admissions. |
Howarth, 2021 | Private health insurer claims records | United Kingdom (UK) | Claims to private health centers in the United Kingdom ( = aggregated data) | January 2018–August 2020 | General | Reduction in healthcare claims in general (70%) from March 2020 (lockdown), undergoing an increase over the following months without reaching the pre-pandemic levels. Visits in mental health differed from the general pattern, with increased utilization (20%) compared to previous years. |
Siedner, 2020 | Africa Health Research Institute Demographic Health Surveillance System | KwaZulu Natal, South Africa | Visit to rural clinics ( = 46,523) | January–March vs. March–April vs. May–June 2018 vs. 2019 vs. 2020 | 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. |
Whaley, 2020 | Aggregate data on health insurance claims | United States of America (USA) | Population with health insurance in 2018 ( = 5.6 million), 2019 ( = 6.4 million), and 2020 ( = 6.8 million) | January–February and March–April 2018 vs. 2019 vs. 2020 | General | Reduction in the utilization of a number of preventive services, elective procedures, and in-person office visits (different values according to the type of service or procedure) in March and April 2020. No significant changes in emergency care, maternal health, or medication prescription were observed. Utilization of telemedicine visits increased. Associated factors (AF): patients living in poor areas and most ethnic/racialized minorities were less likely to experience a reduction in in-person visits but also to have fewer visits of telemedicine. |
Zhang, 2020 | Aggregate data on China UnionPay Healthcare bank transactions | China | Health care transactions ( = 300 million) | January–March 2019 vs. December 2019–February 2020 vs. November 2019–April 2020 | General | Reduction in daily expenditure on health (37.8%) and in number of visits to health services (40.8%) from January 2020. AF: higher probability of utilization of health services was associated with cities with lower rates of COVID-19 cases, less strict measures, and not located in the western region of the country. |
Ojetti, 2020 | Medical records from an urban tertiary teaching hospital | Italy | Admissions to the emergency department (ED) ( = 16,281) | February–March 2019 vs. 2020 | ED | Reduction in ED admissions (37.6%) for several diseases in 2020 compared to 2019. There was an increase in triage emergency levels for ED admissions and in hospitalization rates (different values according to the type of admission). |
Mahmassani, 2021 | Administrative records of the emergency department of the American University of Beirut Medical Center | Beirut, Lebanon | ED visits, between November 2019–February 2020 ( = 16,271) and February–May 2020 ( = 8587) | November 2019–February 2020 vs. February–May 2020 | ED | Reduction in general (47.2%) and pediatric (66.6%) ED visits from February 2020, compared to previous months.AF: higher probability of utilization was associated with elderly patients and those who required hospital admission and/or critical care, with a higher mortality rate, and with non-communicable diseases and bacterial infections. |
Cano-Valderrama, 2020 | Medical records from 3 hospitals | Spain | Patients who underwent emergency surgery in 2019 ( = 285) and 2020 ( = 117) | May–April 2019 vs. 2020 | ED (Acute Surgery Care) | Reduction in surgeries (58.9%) during lockdown (March–May 2020). Longer waiting time between the onset of symptoms and arrival at the emergency room and a greater number of complications (especially in elective procedures) were observed. |
Sokolski, 2021 | Medical records from cardiology departments of 15 health centers in 12 countries | 15 centers in 12 European countries and USA | Patients admitted to the emergency and cardiology departments ( = 54,331) | March–April 2019 vs. 2020 | ED (cardiology) | Reduction in patient admissions (IRR 0.68) in 2020, compared to 2019, across the various pathologies treated (different levels of reduction that vary from IRR 0.66–0.68). |
Tsioufis, 2020 | Medical records from a tertiary General Hospital | Athens, Greece | Visits to the Emergency Cardiology Department and admissions to Cardiology Wards and Intensive Care Unit ( = aggregated data) | January–April 2018 vs. 2019 vs. 2020 | ED (cardiology) | Reduction in visits to the emergency cardiology department during March (41.1%) and April (32.7%) 2020, compared to previous periods. |
Ball, 2020 | Aggregate data on hospital activity from 9 NHS hospitals | UK | Admissions and visits to ED for cardiovascular disease October 2018–May 2019: admissions ( = 599,372) and ED visits ( = 506,516); October 2019–May 2020: admissions ( = 513,703) and ED visits ( = 435,653) | October–May 2018–2019 vs. 2019–2020 | ED (cardiovascular diseases) | Reduction in admissions (57.9%) and ED visits (52.9%) from March 2020, compared to the previous period. |
Choi, 2021 | Medical records from 6 hospitals | South Korea | Patients under 18 years of age seen in pediatric ED ( = aggregated data) | January 2017–November 2020 | ED (pediatrics) | Reduction in pediatric ED visits (43.6%) in 2020 compared to previous years, although a significantly increased proportion of visits for injuries (9.4%) during the COVID-19 outbreak. AF: higher probability of use was associated with male patients. |
Dopfer, 2020 | Medical records from the University Hospital of Hannover | Hanover, Germany | Pediatric ED visits ( = 5424) | January–April 2019 vs. 2020 | ED (pediatrics) | Reduction in pediatric ED visits (63.8%) from lockdown in 2020. AF: higher probability of using services was associated with patients under one year of age and cases requiring hospitalization, although not with intensive care admissions. |
Finkelstein, 2021 | Medical records from the Pediatric Emergency Research Network | Canada | Patients under 18 years of age who attended the ED in 2018 ( = 211,085), 2019 ( = 207,673), and 2020 ( = 159,049) | January 2018–January 2020 vs. January–March 2020 vs. March–April 2020 | ED (pediatrics) | Reduction in weekly pediatric ED visits (58%), in re-visits (55%), in visits to trauma (increase in proportion of total visits), and to mental health (56 to 60% depending on the age group) from March 2020, compared to previous years. Increase in the proportion of ward (OR 1.39) and ICU (OR 1.2) admissions. |
Goldman, 2020 | Medical records from 18 pediatric emergency departments | British Columbia, Canada | Pediatric ED visits (0–16 years): March–April 2019 ( = 22,654); December 2019–January 2020 ( = 31,525); January–March 2020 ( = 26,654); March–April 2020 ( = 7535) | March–April 2019 vs. December 2019–January 2020 vs. January–March 2020 vs. March–April 2020 | ED (pediatrics) | 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. |
Percul, 2021 | Medical records from the Italian Hospital of Buenos Aires | Buenos Aires, Argentina | Patients under 18 years of age treated for appendicitis in 2019 ( = 117) and 2020 ( = 50) | March–August 2019 vs. 2020 | ED (pediatrics) | Reduction in appendicitis admissions (25%) in 2020 compared to 2019, with no significant differences in the mean time to consultation. An increase in peritonitis cases was observed, although the incidence of complications decreased (not significant in both cases). |
Yamamoto, 2021 | Medical records from the Tokyo Metropolitan Children’s Medical Center | Tokyo, Japan | Patients under 18 years of age seen in pediatric ED between January–September 2017–2019 (mean = 26,948 *) and January–September 2020 ( = 15,998) | January–September 2017–2019 vs. 2020 | ED (pediatrics) | Reduction in pediatric ED visits (40.6%) in 2020 compared to previous periods, with an increase in the proportion of visits for exogenous causes (6.6% vs 3%). Visits increased slightly as of May until September2020, without reaching levels of previous years. |
Kute, 2021 | Medical records from the Kidney Disease Institute and Research Center | India | Patients treated in kidney disease services in 2019 ( = 109,572) and 2020 ( = 87,714) | January 2019–December 2020 | SC: nephrology | Reduction in visits and admissions, transplants, and other elective procedures (different values according to the type of service or procedure) in 2020, compared to 2019. Slight increase in activity between July and October, without reaching previous levels, with a further reduction starting in November 2020. |
Morris, 2021 | NHS population-based datasets | UK | Patients referred for suspected or diagnosed colorectal cancer ( = monthly average mean) | January–December 2019 vs. January–October 2020 | SC: oncology | 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. |
Pareek, 2021 | Medical records from the Gujarat Cancer Research Institute | Gujarat, India | Cancer patients visits to the oncology department between January–March ( = 4363) and March–May ( = 895) 2020 | January–March vs. March–May 2020 | SC: oncology | Reduction in visits from lockdown (different values according to the type of cancer) in March 2020, compared to the previous months. |
Shi, 2021 | Medical records from 13 pediatric tertiary cardiac centers | China | Patients who underwent cardiac surgery in 2018 ( = 19,398), 2019 ( = 19,620) and 2020 ( = 4740) | January–April 2018 vs. 2019 vs. 2020 | SC: pediatric surgery | Reduction in the total surgical volume median (25 cases) compared to 2018 (148 cases) and 2019 (158 cases). Increase in the proportion of emergency operations (6.3%) during 2020, compared to previous years. Increase in patients followed-up via the internet or phone (26.4% in 2020 vs 9.5% and 8.9% in 2019 and 2018). |
Ambrosetti, 2021 | Medical records from the University Hospital of Geneva | Geneva, Switzerland | Admissions to the psychiatric ED from April to May 2016 ( = 702) and 2020 ( = 579) | April–May 2016 vs. 2020 | SC: psychiatry | Reduction in admissions (17.5%) in psychiatric ED in 2020 compared to 2016. AF: the probability to be admitted was more associated with severe psychopathologies and single patients, who arrived by ambulance, with suicidal behaviors, behavioral disorders, and psychomotor agitation, and were more likely to be involuntarily hospitalized after consultation in ED. |
Aragona, 2020 | Medical records from the National Institute for Health, Migration and Poverty | Italy | Patients in a vulnerable situation who received at least one psychiatric intervention from February ( = 286) or March ( = 269) from 2017 to 2020 | February–March 2017 vs. 2018. vs. 2019 vs. 2020 | SC: psychiatry | Reduction in visits (46.6%) to mental health in March 2020. Follow-up visits of patients from February to March decreased more (17.5% patients), compared to previous years (30% patients). |
Jesenšek, 2021 | Medical records from the Institute of Physical Medicine and Rehabilitation | Slovenia | Patients referred to rehabilitation in 2019 ( = 4132) and 2020 ( = 2317) | March–August 2019 vs. 2020 | SC: rehabilitation | Reduction in the global volume of patients (44%), first visits (42%), and follow-ups (60.9%), as well as number of sessions (71.1%), from lockdown in March 2020, compared to 2019. |
Farrugia, 2021 | Medical records from Mater Dei Hospital | Malta | Admissions for acute exacerbations of chronic obstructive pulmonary disease in 2019 ( = 259) and 2020 ( = 119) | March–May 2019 vs. 2020 | SC: respiratory diseases | Reduction in admissions (54.2%) in 2020 compared to 2019. Increase in the mortality of admitted patients (19.3% vs. 8.4%). |
Burt, 2021 | Medical records from Kawempe National Referral Hospital | Kawempe, Uganda | Visits to antenatal ( = 14,401), maternal health ( = 33,499), childcare ( = 111,658) and SRH ( = 57,174) services | July 2019–December 2020 | SC: sexual and reproductive health (SRH) (antenatal, maternal, pediatrics, and family planning) | Reduction in antenatal, childcare, and family planning visits, as well as hospital deliveries (different values according to the type of service or procedure), during the lockdown months (March–June 2020), compared to previous months, without clear subsequent recovery. Increase in pregnancy complications and fetal and infant outcomes. |
Das Neves, 2021 | Medical records from Marrere Health Center and monthly official statistics from the Ministry of Health | Nampula, Mozambique | Visits to SRH services ( = aggregated data) | March–May 2019 and 2020 | SC: SRH (maternal and child health) | Reduction in family planning visits (28%), elective C-sections (28%), first antenatal visits (26%), hospital deliveries (4%) (increase in out-of-hospital deliveries by 74%), and child vaccination (20%). Only hospital deliveries drops were statistically significant. |
Jensen and McKerrow, 2020 | Medical records from the KwaZulu-Natal District Health Information System | KwaZulu-Natal district, South Africa | Visits to child health services (aggregated data) | January 2018–June 2020 | SC: SRH (maternal and child health) | Reduction in clinical visits (36%), hospital admissions (50%), delivery of services (from 6% to 54% depending on the service) in children under 5 years of age from March 2020. Modest increase in clinic visits as of May 2020, without reaching levels of preceding years. Among delivery of services, immunization coverage increased almost to pre-pandemic levels. |
Justman, 2020 | Medical records from a tertiary referral center | Haifa, Israel | Pregnant women ( = aggregated data) | March–April 2019–2020 | SC: SRH (maternal and child health) | Reduction in visits (from 18.1% to 36.4% according to the type of visit), deliveries (17.1%) and admissions (22.3%) to the obstetrics and gynecology department in 2020 compared to 2019. No significant changes were observed in the rate of C-sections, although a greater number of vaginal births during the outbreak (16.7% in 2020 vs. 6.8% in 2019), between the two periods. |
KC, 2020 | Data collected from a prospective observational study in 9 hospitals (SUSTAIN and REFINE studies) | Nepal | Pregnant women ( = 21,763) | January–March vs. March–May 2020 | SC: SRH (maternal and child health) | Reduction in hospital deliveries (52.4%), especially vaginal births, from lockdown in March 2020. Increase in preterm births (24.5% before lockdown vs. 26.2% during lockdown), neonatal deaths (13 per 1000 livebirths vs. 40 per 1000 livebirths) and women admitted with complications during labor (6.7% vs. 8.7%, not statistically significant). AF: lower utilization of SRH services was less likely among users of disadvantaged ethnic groups and poor perceived quality of care. |
Marqués, 2021 | Medical records from the Cambridge University Hospitals NHS Foundation Trust | Cambridge, UK | Women complaining of a 1st episode of reduced fetal movements in 2019 ( = 810) and 2020 ( = 803) | March–April 2019 vs. 2020 | SC: SRH (maternal and child health) | Reduction in 1st visits for reduced fetal movements (RFM) during 2020, compared to the same period in 2019 (18% vs. 22%). AF: primiparous women were more likely to attend with RFM. |
Shakespeare, 2021 | Medical records from Mpilo Central Hospital | Zimbabwe | Women who gave birth from January to June 2020 ( = aggregated data) | January–March vs. April–June 2020 | SC: SRH (maternal and child health) | Reduction in visits (5.8%) for hospital deliveries from April 2020, compared to previous months. No significant changes were observed in maternal or perinatal mortality and morbidity, nor in workload, although the number of deliveries and C-sections fell. Neonatal deaths increased, not significantly. |
Spurlin, 2020 | Medical records from the New York Presbyterian—Columbia University Irving Medical Center | New York, USA | Patients who attended OB-GYN (obstetrics–gynecology) services from February to March 2020 for emergency visits ( = 275), GYN surgeries ( = 212), OB surgeries ( = 237), and from March to April 2020 for emergency visits ( = 79), GYN surgeries ( = 79), OB surgeries ( = 181) | February–March vs. March–April 2020 | SC: SRH (obstetrics and gynecology) | Reduction in the average weekly OB-GYN ED consults (60.3%) and GYN surgeries (79.3%), whereas OB surgeries remained stable, from March 2020 compared to the previous period. No significant differences in the proportion of OB-GYN ED consults and GYN surgeries were observed, although the proportion of OB surgeries increased significantly (54.6% before March vs. 79.7% from March 2020). |
Chiba, 2021 | Medical records from the Medical Center of the University of Southern California and Los Angeles County | Los Angeles, USA | Patients admitted to trauma in 2019 ( = 1143) and 2020 ( = 1202) | March–June 2019 vs. 2020 | SC: traumatology | Increase in the number admissions (different values according to the type of trauma) during the analyzed period of 2020, compared to 2019. Increase in admissions due to falls (32.4%) (especially elderly), injuries from the use of weapons (39.3%), suicides (38.5%, not statistically significant), and positivity in the use of substances (52.1% in 2020 vs. 40.2% in 2019). Reduction in severe trauma (38.7% vs. 46.7%), mortality (4.1% vs. 5.9%), and ICU admission rates (26.3% vs. 31.5%). There were non-significant reductions in admissions due to traffic accidents (pedestrian or motor). |
Horan, 2021 | Medical records from the National Neurosurgical Center at Beaumont Hospital | Dublin, Ireland | Referrals to the trauma department in 2019 ( = 527) and 2020 ( = 437) | March–May 2019 vs. 2020 | SC: traumatology | Reduction in trauma referrals (17.1%) in 2020 compared to 2019. No significant changes were observed between the profiles most associated with shunts between the two years, although there were changes in the type of diagnosis (fewer brain and spinal injuries and cranial fractures). AF: referrals were more likely among men, people over 60, alcohol consumers. |
Alexander, 2020 | IQVIA National Disease and Therapeutic Index | USA | Visits to primary care ( = 875.6 million) | January 2018–June 2020 | PC | Reduction in PC health services (21.4%) in 2020 compared to 2018 and 2019. Decreases in in-person visits (50.2%) and increases in telemedicine visits (1.1%) were observed. Evaluations and medication prescriptions were less frequent. |
Sato, 2021 | Administrative claims from the DeSC database (health insurance claims) | Japan | Patients with chronic neurological diseases | March–November 2020 | PC | Reduction in visits for different chronic neurological diseases (RR 0.9), except one that increased (migraines, RR 1.15), from April 2020. Telephone appointments were most frequently used in April–May (representing 5% of the visits), especially in the case of migraines (OR 2.08). The changes yielded different effects depending on the disease. |
Song, 2021 | Medical records from the Independence Blue Cross | USA | Women who had mammograms from January 2018 to March 2020 for screening ( = 213,168) and diagnosis ( = 55,879), and from March to July 2020 for screening ( = 27,970) and diagnosis ( = 10,233) | January 2018–March 2020 vs. March–July 2020 | Preventive services | Reduction in the volume of screening (58%) and diagnostic (38%) mammograms from March 2020, compared to the preceding months and to the previous years. Increase in activity from May 2020, remaining 14% below previous months levels. : greater use was associated with women with a previous diagnosis. |
1 : General health services include different levels of care or type of service; 2 : aggregated data and/or no specification of the different periods of analysis; 3 : studies that did not analyze whether the changes were statistically significant (the rest of articles presented results statistically significant); AF: associated factors; ED: emergency department; ICU: intensive care unit; IRR: incidence rate ratio; OB-GYN: obstetrics–gynecology; OR: odds ratio; PC: primary care; RR: relative risk; SC: secondary care; SRH: sexual and reproductive health.
Quantitative studies on potential access related to the characteristics of the services and the population during the COVID-19 pandemic in 2020.
First Author, Year | Data Collection Method | Study Area | Study Population and Sample | Study Period | Health Service | Main Results |
---|---|---|---|---|---|---|
Kahraman et al., 2021 | Online survey | Turkey | Patients with lysosomal storage disease in enzyme replacement therapy ( = 75) | July–October 2020 | SC: endocrinology | Characteristics of the services: lack of resources (hospital beds) Characteristics of the population: fear of contagion, difficulties in obtaining medication, transport difficulties |
Nicholson et al., 2020 | Online survey | Ireland | Parents of children under 16 ( = 1044) | June 2020 | SC: pediatrics | 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). |
Benjamen et al., 2021 | Online survey ( = 77, of which 11 were interviewed in depth) | Ottawa, Canada | Doctors with experience caring for refugee populations ( = 77) | May–August 2020 | SC: psychiatry | Characteristics of the services: limited availability of providers and community resources, slight increase in the offer of virtual care psychotherapy. Characteristics of the population: fear of contagion, perceived lack of services, technological barriers |
Halley et al., 2021 | Online surve | USA | Relatives ( = 139) and patients affected by undiagnosed rare diseases ( = 275) | April–June 2020 | SC: undiagnosed rare diseases care | 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). |
Adelekan et al., 2021 | Semi-structured interviewer-administered questionnaire | Nigeria | Head nurses and midwives in primary health centers ( = 307) | March–September 2020 | SC: SRH (maternal and child health) | Characteristics of the services: difficulties regarding out-of-stock drugs and contraceptives. Characteristics of the population: economic difficulties (not being able to afford cost of transportation). |
Karavadra et al., 2020 | Online survey | UK | Women who were pregnant or gave birth during the COVID-19 pandemic ( = 1451) | May 2020 | SC: SRH (maternal and child health) | 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. |
Khan et al., 2021 | Online survey | 64 middle- and low-income countries of Africa, Asia, and Latin America | Health professionals from tuberculosis treatment ( = 567) and HIV ( = 346) services | May–August 2020 | SC: tuberculosis and HIV care | Characteristics of the services: lack of material and medical supplies, difficulties in obtaining medical treatment, lack of alternatives for non-face-to-face care (e.g., telemedicine), postponement of visits for diagnoses and treatments. Characteristics of the population: fear of contagion, stigma, difficulties in accessing health services (alterations in transportation, restrictions), worsening economic situation. |
García-Rojo et al., 2021 | Medical records (Hospital 12 de Octubre) | Spain | Patients on the waiting list for urological surgery ( = 350) | May 2020 | SC: urology | Characteristics of the services: increased waiting times for urological surgeries (designated as elective). |
SC: secondary care; SRH: sexual and reproductive health.
Qualitative studies on potential access related to the characteristics of the services and the population during the COVID-19 pandemic in 2020.
First Author, Year | Data Collection Method | Study Area | Study Population and Sample | Study Period | Health Service | Main Results |
---|---|---|---|---|---|---|
Zambrano et al., 2021 | Online semi-structured interviews and life histories | Colombia and Peru | Venezuelan migrant populations living in large cities in Colombia ( = 96) and Peru ( = 34) | July–September 2020 | General | Characteristics of the services: access to health services linked to legal immigration status. Characteristics of the population: severe economic difficulties, perceived discrimination of healthcare services on the basis of nationality |
Das Neves et al., 2021 | Semi-structured interviews by phone (12) and in-person (9) | Nampula, Mozambique | Health professionals ( = 9), traditional birth attendants ( = 6) and patients ( = 6) | March–May 2019 and 2020 | SC: SRH (maternal and child health) | Characteristics of the services: limited resources (workforce), increase in waiting times Characteristics of the population: fear of contagion, avoiding healthcare except in emergencies |
Gichuna et al., 2020 | Semi-structured interviews via mobile phone (phone call or videocall) | Kariobangi, Roysambu, and Jogoo Road areas (Nairobi, Kenya) | Sex workers from the study areas ( = 117), and health professionals from the Bar Hostess Empowerment and Support Program Centers ( = 15) | April–May 2020 | SC: SRH (family planning) and HIV care | Characteristics of the services: reduced activity, lack of medical supplies Characteristics of the population: economic difficulties, stigma |
Hailemariam et al., 2021 | Online focal groups (6) and semi-structured interviews (9) | Kebeles, Ethiopia | Pregnant women who did not attend SHR services and health workers | September–November 2020 | SC: SRH (maternal and child health) | Characteristics of the population: perceived low quality of services, fear of contagion, stigma, playing down care needs, refusal to attend antenatal services. |
Mizrak Sahin, and Nur Kabakci, 2020 | Semi-structured interviews by phone | Turkey | Pregnant women | During 2020, months not specified | SC: SRH (maternal and child health) | Characteristics of the services: elective visits were cancelled or postponed, difficulties in getting first visits. Characteristics of the population: fear of contagion, difficulties in contacting services for first visits. |
Dos Santos et al., 2021 | 7 semi-structured interviews by phone | Ribeirão Preto, Brazil | Patients over 18 years old undergoing treatment for tuberculosis | June–August 2020 | SC: tuberculosis care | Characteristics of the population: economic difficulties, fear of contagion |
Ahmed et al., 2020 | Workshops and in-person meetings in three pre-pandemic phases (semi-structured interviews, group and individual meetings), and a fourth phase via mobile phone | Bangladesh, Kenya, Nigeria, Pakistan | Health professionals (medical doctors, nurses, community health workers and assistants, pharmacists, and patent medicine vendors), pregnant women and women with children, health service managers | March 2018–May 2020 | PC | Characteristics of the services: worse access to services that were difficult to access before the pandemic (mental health, gender-based violence services), and preventive services, increase in cost of healthcare, lack of drugs and medical supplies. Characteristics of the population: fear of contagion, economic difficulties. |
Danhieux et al., 2020 | Online semi-structured interviews | Belgium | General practitioners, nurses, and dieticians ( = 21) in primary care who work individually, monodisciplinary or in multidisciplinary groups | April–June 2020 | PC | Characteristics of the services: limited resources to treat, identify, and contact non-COVID-19 patients because of the redistribution of resources, especially among high-risk and vulnerable patients. |
PC: primary care; SC: secondary care; SRH: sexual and reproductive health.
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 [ 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82 , 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 ( Table 2 and Table 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 low-income 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.
G.P. designed the research protocol, under the supervision of A.O.-A., I.V. and M.-L.V. In collaboration with her three supervisors, she carried out the bibliographic search and wrote the first version of the manuscript. They all participated in decisions on which studies to include in the analysis, and in the interpretation of results and the writing of the final version of the manuscript. All authors have read and agreed to the published version of the manuscript.
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).
Not applicable.
Conflicts of interest.
The authors declare no conflict of interest.
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Learning objectives.
Have you ever known a person who was not very good at telling stories? You probably had trouble following his train of thought as he jumped around from point to point, either being too brief in places that needed further explanation or providing too many details on a meaningless element. Maybe he told the end of the story first, then moved to the beginning and later added details to the middle. His ideas were probably scattered, and the story did not flow very well. When the story was over, you probably had many questions.
Just as a personal anecdote can be a disorganized mess, an essay can fall into the same trap of being out of order and confusing. That is why writers need a thesis statement to provide a specific focus for their essay and to organize what they are about to discuss in the body.
Just like a topic sentence summarizes a single paragraph, the thesis statement summarizes an entire essay. It tells the reader the point you want to make in your essay, while the essay itself supports that point. It is like a signpost that signals the essay’s destination. You should form your thesis before you begin to organize an essay, but you may find that it needs revision as the essay develops.
For every essay you write, you must focus on a central idea. This idea stems from a topic you have chosen or been assigned or from a question your teacher has asked. It is not enough merely to discuss a general topic or simply answer a question with a yes or no. You have to form a specific opinion, and then articulate that into a controlling idea —the main idea upon which you build your thesis.
Remember that a thesis is not the topic itself, but rather your interpretation of the question or subject. For whatever topic your professor gives you, you must ask yourself, “What do I want to say about it?” Asking and then answering this question is vital to forming a thesis that is precise, forceful and confident.
A thesis is one sentence long and appears toward the end of your introduction. It is specific and focuses on one to three points of a single idea—points that are able to be demonstrated in the body. It forecasts the content of the essay and suggests how you will organize your information. Remember that a thesis statement does not summarize an issue but rather dissects it.
A strong thesis statement contains the following qualities.
Specificity. A thesis statement must concentrate on a specific area of a general topic. As you may recall, the creation of a thesis statement begins when you choose a broad subject and then narrow down its parts until you pinpoint a specific aspect of that topic. For example, health care is a broad topic, but a proper thesis statement would focus on a specific area of that topic, such as options for individuals without health care coverage.
Precision. A strong thesis statement must be precise enough to allow for a coherent argument and to remain focused on the topic. If the specific topic is options for individuals without health care coverage, then your precise thesis statement must make an exact claim about it, such as that limited options exist for those who are uninsured by their employers. You must further pinpoint what you are going to discuss regarding these limited effects, such as whom they affect and what the cause is.
Ability to be argued. A thesis statement must present a relevant and specific argument. A factual statement often is not considered arguable. Be sure your thesis statement contains a point of view that can be supported with evidence.
Ability to be demonstrated. For any claim you make in your thesis, you must be able to provide reasons and examples for your opinion. You can rely on personal observations in order to do this, or you can consult outside sources to demonstrate that what you assert is valid. A worthy argument is backed by examples and details.
Forcefulness. A thesis statement that is forceful shows readers that you are, in fact, making an argument. The tone is assertive and takes a stance that others might oppose.
Confidence. In addition to using force in your thesis statement, you must also use confidence in your claim. Phrases such as I feel or I believe actually weaken the readers’ sense of your confidence because these phrases imply that you are the only person who feels the way you do. In other words, your stance has insufficient backing. Taking an authoritative stance on the matter persuades your readers to have faith in your argument and open their minds to what you have to say.
Even in a personal essay that allows the use of first person, your thesis should not contain phrases such as in my opinion or I believe . These statements reduce your credibility and weaken your argument. Your opinion is more convincing when you use a firm attitude.
On a separate sheet of paper, write a thesis statement for each of the following topics. Remember to make each statement specific, precise, demonstrable, forceful and confident.
Each of the following thesis statements meets several of the following requirements:
You can find thesis statements in many places, such as in the news; in the opinions of friends, coworkers or teachers; and even in songs you hear on the radio. Become aware of thesis statements in everyday life by paying attention to people’s opinions and their reasons for those opinions. Pay attention to your own everyday thesis statements as well, as these can become material for future essays.
Now that you have read about the contents of a good thesis statement and have seen examples, take a look at the pitfalls to avoid when composing your own thesis:
A thesis is weak when it is simply a declaration of your subject or a description of what you will discuss in your essay.
Weak thesis statement: My paper will explain why imagination is more important than knowledge.
A thesis is weak when it makes an unreasonable or outrageous claim or insults the opposing side.
Weak thesis statement: Religious radicals across America are trying to legislate their Puritanical beliefs by banning required high school books.
A thesis is weak when it contains an obvious fact or something that no one can disagree with or provides a dead end.
Weak thesis statement: Advertising companies use sex to sell their products.
A thesis is weak when the statement is too broad.
Weak thesis statement: The life of Abraham Lincoln was long and challenging.
Read the following thesis statements. On a separate piece of paper, identify each as weak or strong. For those that are weak, list the reasons why. Then revise the weak statements so that they conform to the requirements of a strong thesis.
Often in your career, you will need to ask your boss for something through an e-mail. Just as a thesis statement organizes an essay, it can also organize your e-mail request. While your e-mail will be shorter than an essay, using a thesis statement in your first paragraph quickly lets your boss know what you are asking for, why it is necessary, and what the benefits are. In short body paragraphs, you can provide the essential information needed to expand upon your request.
Your thesis will probably change as you write, so you will need to modify it to reflect exactly what you have discussed in your essay. Remember from Chapter 8 “The Writing Process: How Do I Begin?” that your thesis statement begins as a working thesis statement , an indefinite statement that you make about your topic early in the writing process for the purpose of planning and guiding your writing.
Working thesis statements often become stronger as you gather information and form new opinions and reasons for those opinions. Revision helps you strengthen your thesis so that it matches what you have expressed in the body of the paper.
The best way to revise your thesis statement is to ask questions about it and then examine the answers to those questions. By challenging your own ideas and forming definite reasons for those ideas, you grow closer to a more precise point of view, which you can then incorporate into your thesis statement.
You can cut down on irrelevant aspects and revise your thesis by taking the following steps:
1. Pinpoint and replace all nonspecific words, such as people , everything , society , or life , with more precise words in order to reduce any vagueness.
Working thesis: Young people have to work hard to succeed in life.
Revised thesis: Recent college graduates must have discipline and persistence in order to find and maintain a stable job in which they can use and be appreciated for their talents.
The revised thesis makes a more specific statement about success and what it means to work hard. The original includes too broad a range of people and does not define exactly what success entails. By replacing those general words like people and work hard , the writer can better focus his or her research and gain more direction in his or her writing.
2. Clarify ideas that need explanation by asking yourself questions that narrow your thesis.
Working thesis: The welfare system is a joke.
Revised thesis: The welfare system keeps a socioeconomic class from gaining employment by alluring members of that class with unearned income, instead of programs to improve their education and skill sets.
A joke means many things to many people. Readers bring all sorts of backgrounds and perspectives to the reading process and would need clarification for a word so vague. This expression may also be too informal for the selected audience. By asking questions, the writer can devise a more precise and appropriate explanation for joke . The writer should ask himself or herself questions similar to the 5WH questions. (See Chapter 8 “The Writing Process: How Do I Begin?” for more information on the 5WH questions.) By incorporating the answers to these questions into a thesis statement, the writer more accurately defines his or her stance, which will better guide the writing of the essay.
3. Replace any linking verbs with action verbs. Linking verbs are forms of the verb to be , a verb that simply states that a situation exists.
Working thesis: Kansas City schoolteachers are not paid enough.
Revised thesis: The Kansas City legislature cannot afford to pay its educators, resulting in job cuts and resignations in a district that sorely needs highly qualified and dedicated teachers.
The linking verb in this working thesis statement is the word are . Linking verbs often make thesis statements weak because they do not express action. Rather, they connect words and phrases to the second half of the sentence. Readers might wonder, “Why are they not paid enough?” But this statement does not compel them to ask many more questions. The writer should ask himself or herself questions in order to replace the linking verb with an action verb, thus forming a stronger thesis statement, one that takes a more definitive stance on the issue:
4. Omit any general claims that are hard to support.
Working thesis: Today’s teenage girls are too sexualized.
Revised thesis: Teenage girls who are captivated by the sexual images on MTV are conditioned to believe that a woman’s worth depends on her sensuality, a feeling that harms their self-esteem and behavior.
It is true that some young women in today’s society are more sexualized than in the past, but that is not true for all girls. Many girls have strict parents, dress appropriately, and do not engage in sexual activity while in middle school and high school. The writer of this thesis should ask the following questions:
In the first section of Chapter 8 “The Writing Process: How Do I Begin?” , you determined your purpose for writing and your audience. You then completed a freewriting exercise about an event you recently experienced and chose a general topic to write about. Using that general topic, you then narrowed it down by answering the 5WH questions. After you answered these questions, you chose one of the three methods of prewriting and gathered possible supporting points for your working thesis statement.
Now, on a separate sheet of paper, write down your working thesis statement. Identify any weaknesses in this sentence and revise the statement to reflect the elements of a strong thesis statement. Make sure it is specific, precise, arguable, demonstrable, forceful, and confident.
Collaboration
Please share with a classmate and compare your answers.
In your career you may have to write a project proposal that focuses on a particular problem in your company, such as reinforcing the tardiness policy. The proposal would aim to fix the problem; using a thesis statement would clearly state the boundaries of the problem and tell the goals of the project. After writing the proposal, you may find that the thesis needs revision to reflect exactly what is expressed in the body. Using the techniques from this chapter would apply to revising that thesis.
Writing for Success Copyright © 2015 by University of Minnesota is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.
Reference management. Clean and simple.
Is a thesis statement a question, how do you write a good thesis statement, how do i know if my thesis statement is good, examples of thesis statements, helpful resources on how to write a thesis statement, frequently asked questions about writing a thesis statement, related articles.
A thesis statement is the main argument of your paper or thesis.
The thesis statement is one of the most important elements of any piece of academic writing . It is a brief statement of your paper’s main argument. Essentially, you are stating what you will be writing about.
You can see your thesis statement as an answer to a question. While it also contains the question, it should really give an answer to the question with new information and not just restate or reiterate it.
Your thesis statement is part of your introduction. Learn more about how to write a good thesis introduction in our introduction guide .
A thesis statement is not a question. A statement must be arguable and provable through evidence and analysis. While your thesis might stem from a research question, it should be in the form of a statement.
Tip: A thesis statement is typically 1-2 sentences. For a longer project like a thesis, the statement may be several sentences or a paragraph.
A good thesis statement needs to do the following:
Once you have written down a thesis statement, check if it fulfills the following criteria:
As previously mentioned, your thesis statement should answer a question.
If the question is:
What do you think the City of New York should do to reduce traffic congestion?
A good thesis statement restates the question and answers it:
In this paper, I will argue that the City of New York should focus on providing exclusive lanes for public transport and adaptive traffic signals to reduce traffic congestion by the year 2035.
Here is another example. If the question is:
How can we end poverty?
A good thesis statement should give more than one solution to the problem in question:
In this paper, I will argue that introducing universal basic income can help reduce poverty and positively impact the way we work.
A thesis statement is part of the introduction of your paper. It is usually found in the first or second paragraph to let the reader know your research purpose from the beginning.
In general, a thesis statement should have one or two sentences. But the length really depends on the overall length of your project. Take a look at our guide about the length of thesis statements for more insight on this topic.
Here is a list of Thesis Statement Examples that will help you understand better how to write them.
Every good essay should include a thesis statement as part of its introduction, no matter the academic level. Of course, if you are a high school student you are not expected to have the same type of thesis as a PhD student.
Here is a great YouTube tutorial showing How To Write An Essay: Thesis Statements .
What this handout is about.
This handout describes what a thesis statement is, how thesis statements work in your writing, and how you can craft or refine one for your draft.
Writing in college often takes the form of persuasion—convincing others that you have an interesting, logical point of view on the subject you are studying. Persuasion is a skill you practice regularly in your daily life. You persuade your roommate to clean up, your parents to let you borrow the car, your friend to vote for your favorite candidate or policy. In college, course assignments often ask you to make a persuasive case in writing. You are asked to convince your reader of your point of view. This form of persuasion, often called academic argument, follows a predictable pattern in writing. After a brief introduction of your topic, you state your point of view on the topic directly and often in one sentence. This sentence is the thesis statement, and it serves as a summary of the argument you’ll make in the rest of your paper.
A thesis statement:
If your assignment asks you to take a position or develop a claim about a subject, you may need to convey that position or claim in a thesis statement near the beginning of your draft. The assignment may not explicitly state that you need a thesis statement because your instructor may assume you will include one. When in doubt, ask your instructor if the assignment requires a thesis statement. When an assignment asks you to analyze, to interpret, to compare and contrast, to demonstrate cause and effect, or to take a stand on an issue, it is likely that you are being asked to develop a thesis and to support it persuasively. (Check out our handout on understanding assignments for more information.)
A thesis is the result of a lengthy thinking process. Formulating a thesis is not the first thing you do after reading an essay assignment. Before you develop an argument on any topic, you have to collect and organize evidence, look for possible relationships between known facts (such as surprising contrasts or similarities), and think about the significance of these relationships. Once you do this thinking, you will probably have a “working thesis” that presents a basic or main idea and an argument that you think you can support with evidence. Both the argument and your thesis are likely to need adjustment along the way.
Writers use all kinds of techniques to stimulate their thinking and to help them clarify relationships or comprehend the broader significance of a topic and arrive at a thesis statement. For more ideas on how to get started, see our handout on brainstorming .
If there’s time, run it by your instructor or make an appointment at the Writing Center to get some feedback. Even if you do not have time to get advice elsewhere, you can do some thesis evaluation of your own. When reviewing your first draft and its working thesis, ask yourself the following :
Suppose you are taking a course on contemporary communication, and the instructor hands out the following essay assignment: “Discuss the impact of social media on public awareness.” Looking back at your notes, you might start with this working thesis:
Social media impacts public awareness in both positive and negative ways.
You can use the questions above to help you revise this general statement into a stronger thesis.
After thinking about your answers to these questions, you decide to focus on the one impact you feel strongly about and have strong evidence for:
Because not every voice on social media is reliable, people have become much more critical consumers of information, and thus, more informed voters.
This version is a much stronger thesis! It answers the question, takes a specific position that others can challenge, and it gives a sense of why it matters.
Let’s try another. Suppose your literature professor hands out the following assignment in a class on the American novel: Write an analysis of some aspect of Mark Twain’s novel Huckleberry Finn. “This will be easy,” you think. “I loved Huckleberry Finn!” You grab a pad of paper and write:
Mark Twain’s Huckleberry Finn is a great American novel.
You begin to analyze your thesis:
Think about aspects of the novel that are important to its structure or meaning—for example, the role of storytelling, the contrasting scenes between the shore and the river, or the relationships between adults and children. Now you write:
In Huckleberry Finn, Mark Twain develops a contrast between life on the river and life on the shore.
After examining the evidence and considering your own insights, you write:
Through its contrasting river and shore scenes, Twain’s Huckleberry Finn suggests that to find the true expression of American democratic ideals, one must leave “civilized” society and go back to nature.
This final thesis statement presents an interpretation of a literary work based on an analysis of its content. Of course, for the essay itself to be successful, you must now present evidence from the novel that will convince the reader of your interpretation.
We consulted these works while writing this handout. This is not a comprehensive list of resources on the handout’s topic, and we encourage you to do your own research to find additional publications. Please do not use this list as a model for the format of your own reference list, as it may not match the citation style you are using. For guidance on formatting citations, please see the UNC Libraries citation tutorial . We revise these tips periodically and welcome feedback.
Anson, Chris M., and Robert A. Schwegler. 2010. The Longman Handbook for Writers and Readers , 6th ed. New York: Longman.
Lunsford, Andrea A. 2015. The St. Martin’s Handbook , 8th ed. Boston: Bedford/St Martin’s.
Ramage, John D., John C. Bean, and June Johnson. 2018. The Allyn & Bacon Guide to Writing , 8th ed. New York: Pearson.
Ruszkiewicz, John J., Christy Friend, Daniel Seward, and Maxine Hairston. 2010. The Scott, Foresman Handbook for Writers , 9th ed. Boston: Pearson Education.
You may reproduce it for non-commercial use if you use the entire handout and attribute the source: The Writing Center, University of North Carolina at Chapel Hill
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Final Paper
There is one writing assignment, which incorporates the concepts covered in the book. The paper should be 7 to 10 pages in length, double-spaced, using Times Roman Font 12, with standard 1” margins. List any articles, publications or websites used to gather information. Cite the publication, date, and page number or the website address in your list of references. A minimum of 3 credible references are required. All papers must be submitted via Blackboard or submitted at the beginning of class on the due date.
The paper should cover a contemporary healthcare topic. You should incorporate seminal information included in the text to formulate your thesis and guide the direction of your paper. A list of possible topics is listed below:
Electronic Medical Records
Niche Hospitals
Affordable Care Act
Reproductive therapy
Patient-Safety
Evidence-Based Medicine
Health Disparities
Entrepreneurship in Healthcare
Biotechnology
RESEARCH REPORT EVALAUATION CRITERIA
HCM 400: Healthcare Management
INTRODUCTION or EXECUTIVE SUMMARY (5 points)
_____ Develops comprehensive overview of the main ideas of the text in a clear and concise introduction (5pts) .
Develops an overview that captures most of the main ideas of the text (3pts) .
Presents a vague summary that misses main points or includes details as main points (0-1pt).
BACKGROUND OF THE ISSUE (3 points)
_____ Clearly presents relevant historical information that provides context for the issue to be analyzed (3pts) .
Presents a context that highlights numerous key factors behind the issue at hand (2pts) .
Provides little relevant information and/or elaborates upon irrelevant facts that aren’t connected to the issue (0-1pt) .
THESIS STATEMENT (4 points)
_____ Clearly identifies the purpose of the report, articulating the central theme of the analysis (4 pts) .
The thesis statement is identified but not well explained or understood (2-3pts) .
Fails to state the purpose or lacks clear thesis statement (0-1pt) .
CRITICAL ANALYSIS or ANALYSIS OF THE FACTS (20 points)
_____ Interpretations of facts pose reasonable arguments, demonstrating clear coherence and progression of ideas that are well tought out and supported with evidence. Analysis consistently conveys critical thinking and personal insight (16-20pts) .
Shows forethought in organization of ideas which speak to the assignment and are fairly well explained with supporting evidence and logical arguments (10-15pts) .
Thesis and organization need improvement. Ideas are relevant, but not well explained or consistently supported (5-9pts) .
Thesis is unclear, organization is lacking, with no clear structure. Ideas are generally underdeveloped, redundant, irrelevant, or illogical (0-4pts) .
CONCLUSION (5 points)
_____ Revisits thesis statement and accurately summarizes key points of argument in concise, fresh restatements (4-5pts) .
Key points of the analysis are identified, but are loosely or not sufficiently tied together in support of the central thesis (2-3pts) .
Summary of argument is missing or new ideas are introduced (0-1pt) .
REFERENCE LIST (3 points)
_____ Research is fully annotated, including at least three credible references that are cited throughout the paper in a consistent format (3pts) .
At least three credible sources are referenced, with minor errors in citation and formatting (2pts) .
Less than three sources identified and/or numerous errors in citation and formatting (0-1pt) .
GRAMMAR, SPELLING, AND MECHANICS (10 points)
_____ Presents paper employing words with fluency, using varied and accurate vocabulary, and is practically free of errors in sentence structure, grammar, spelling and punctuation (8-10pts) .
Paper exhibits adequate but inconsistent use of language, with some errors in sentence structure and use of grammatical conventions, such as work choice, usage, spelling and punctuation (4-7pts) .
Paper displays fundamental errors in word choice, usage and sentence structure, containing pervasive errors in mechanical conventions of grammar, spelling, and punctuation (0-3pts) .
Total Score /50
IMAGES
VIDEO
COMMENTS
What are good healthcare thesis statement examples? 🏥 The issue of universal health care provision in the United States is very debatable. 🧑‍⚕️ Try formulating a thesis statement for universal healthcare and read our essay sample on this topic!
Your Roadmap to Compelling Health Essays: Discover how to write compelling health thesis statements with our comprehensive guide, featuring unique examples and essential tips for presenting your ideas effectively.
Thesis statement 1 To plan and fund healthcare, local health networks are better at improving the patient experience and access to care than a large central body.
A thesis submitted to Johns Hopkins University in conformity with the requirements for the degree of Master of Arts in Government
An Abstract of the Thesis of Kaleigh Jodice for the degree of Bachelor of Arts in the Department of Planning, Public Policy and Management to be taken June 2020
This article provides information on thesis statement, structure, and style, as well as tips on how to write an effective nursing essay thesis statement and nursing essay thesis statement examples.
100+ Healthcare Research Topic Ideas To Fast-Track Your Project Finding and choosing a strong research topic is the critical first step when it comes to crafting a high-quality dissertation, thesis or research project. If you've landed on this post, chances are you're looking for a healthcare-related research topic, but aren't sure where to start. Here, we'll explore a variety of ...
These analyses document a significant and persistent problem in access to health care in the U.S. Findings suggest that transportation to health facilities should remain an important consideration in health care delivery at the federal level, at the level of state and local governments in North Carolina, and among new and existing ...
A thesis statement is a sentence that sums up the central point of your essay. It usually comes at the end of the introduction.
We then discuss structural racism's continued impact on modern health care policy in the areas of health care coverage, finance, and quality.
Thesis Statement: It is imperative to prioritize mental health and provide support for individuals struggling with mental illness in order to promote overall well-being and prevent the negative consequences of neglecting mental health. Body. 1. The Importance of Mental Health Awareness and Support.
Examples of thesis statements related to science. Thesis Statement: Wind turbines need to be replaced with alternative sources of green energy due to their hazardous effect on human health and wildlife. The above statement makes a case against wind turbines.
A thesis is a substantive and original body of work that allows the student to synthesize and integrate knowledge from their public health course work and practicum experiences, apply it to a particular topic area, and communicate their ideas and findings through a scholarly written product. The thesis represents the culmination of the student's educational experience...
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 ...
defines health as "a state of complete physical, mental and social well- the absen ld Health Organization defines health holistically, m health care professionals are still treating patients with a reductionist approach. Complementary and alternative therapies offer holistic ing methods
This handout describes what a thesis statement is, how thesis statements work in your writing, and how you can discover or refine one for your draft.
For example, health care is a broad topic, but a proper thesis statement would focus on a specific area of that topic, such as options for individuals without health care coverage.
Figure 6.6: Thesis skeleton Begin by writing a working thesis statement. You will need this working thesis statement when you begin to outline and organize your assignment. As you continue to develop your paper, you can limit the working thesis statement if it is too broad or expand it if it proves too narrow for what you want to say.
How do you write a good thesis statement? Learn all you need to know about thesis statements in our guide with examples.
The document discusses the challenges of crafting a thesis statement on the complex topic of healthcare reform. It notes that developing a thesis requires understanding diverse perspectives, conducting extensive research, and effectively synthesizing arguments. The document recommends seeking assistance from experienced writers and researchers to streamline the process and produce high-quality ...
This handout describes what a thesis statement is, how thesis statements work in your writing, and how you can discover or refine one for your draft.
The paper should cover a contemporary healthcare topic. You should incorporate seminal information included in the text to formulate your thesis and guide the direction of your paper. A list of possible topics is listed below:
Abstract List of Figures Introduction Chapter 1: Examination of Healthcare Prices in the United States and Potential Cost-Control Measures. Chapter 2: A Comparison of the Affordable Care Act and the Massachusetts Health Reform Law. Chapter 3: A Comparison of Healthcare Systems in the United Kingdom and Germany. Conclusion.
Mental health as the basis. Mental health serves as the foundation for achieving comprehensive well-being. The World Health Organization (WHO, Citation 2020) defines mental health as a condition of well-being where a person recognises their own capabilities, manages everyday life stresses, functions effectively and constructively in work (studies), and contributes positively to their community.