INSIGHT

How COVID-19 Impacts People with Chronic Conditions in India

Rural participants in the study had difficulties accessing health facilities during the COVID-19 pandemic. Photo credit: ADB.
Rural participants in the study had difficulties accessing health facilities during the COVID-19 pandemic. Photo credit: ADB.

Published: 12 May 2021

The pandemic worsened disparities in chronic disease management among vulnerable groups, exerting adverse psychosocial and economic effects.

Introduction

The spread of the coronavirus disease (COVID-19) in India is of great concern due to the country’s large and densely populated areas with widespread poverty and high migration rates, coupled with a high prevalence of chronic conditions that are generally poorly controlled. Furthermore, the progression of COVID-19 from urban to rural areas, the lockdown measures, and the associated economic shocks are likely to impede efforts to address other health scourges in India, such as diabetes, hypertension, and cardiovascular diseases. Policymakers should consider the asymmetrical psychosocial and economic impacts of the pandemic on people with chronic conditions, especially underprivileged urban residents and underserved rural communities.

Analysis

Measures to control the spread of COVID-19, including lockdowns, may have serious economic consequences and the unintended effect of exacerbating rather than mitigating health disparities. However, to date, few data document the impact of the pandemic on disparities in chronic disease management in India. Given the unprecedented and rapidly evolving COVID-19 spread in India, a collaboration of researchers aimed to assess the health, psychosocial, and economic impacts of the pandemic on people with chronic conditions in the country.

To describe these impacts, we conducted a cross-sectional study between July and August 2020, using sequential mixed methods design, comprising a quantitative survey and qualitative interviews by phone. The participants were adults with one or more chronic conditions (hypertension, diabetes mellitus, cardiovascular disease, or chronic kidney disease) from the two large existing cohorts: the Centre for Cardiometabolic Risk Reduction in South Asia and the India-UDAY comprehensive diabetes and hypertension prevention and management program. We randomly selected nearly 2,400 participants across four urban and rural sites (Delhi, Chennai Haryana, and Vizag). We also selected a diverse sample of 40 participants for the qualitative interviews.

Rural versus urban comparison

We found that rural participants were disproportionately affected by the COVID-19 lockdowns compared with urban participants. A greater proportion of rural participants experienced acute medical illness (rural 14.2%; urban 6.4%), difficulties in accessing health facilities (rural 95.0%; urban 75.0%) and medicines (rural 36.9%; urban 10.9%), worsened diabetes or hypertension symptoms (rural 16.0%; urban 11.0%), lower treatment satisfaction rate (rural 3.5%; urban 23.8%), reduced fruit or vegetable consumption (rural 68.8%, urban 28.7%), and loss of household income (rural 67.3%, urban 56.9%).

Health impacts

Across the four sites, 8% of study participants experienced an acute medical illness during the COVID-19-related lockdowns with higher proportions being affected in rural sites (14%). Participants’ average health status score was significantly lower in rural Vizag. Uncontrolled diabetes was reported by 19.3% of participants and uncontrolled blood pressure by 15.7%. Having diabetes and hypertension and experiencing loss of income were significantly associated with rural participants’ difficulty in accessing medicines. We also found that rural participants and females had higher odds of worsening diabetes or hypertension symptoms compared with urban or male counterparts.

Psychosocial and economic impacts

One-third of respondents did not adhere to their recommended diet plan and reduced fruit and vegetable consumption during the lockdowns. About two-thirds of respondents did not perform physical activity and reported loss of household income, and one-third had lost jobs. Overall, 45% of participants had received financial support from the government, with large variation by site (93% in Chennai vs. 8% in Delhi).

Qualitative study results

Most participants faced financial difficulties during the COVID-19 lockdowns. Several participants reported difficulty getting to work because of lack of public transportation, and some lost their jobs due to the pandemic. Some participants had difficulty accessing inpatient services, since many hospitals were full or refused new admissions due to COVID-19 cases. Many participants were concerned about visiting the hospital or doctor and delayed testing of their blood sugar because of fear and anxiety about the pandemic.

Summary

Our study shows that people living in India’s rural areas and underserved communities in urban areas faced greater challenges due to the pandemic. Its impacts extend beyond health to encompass adverse effects on household incomes, individual livelihoods, interpersonal relationships, sleep, stress and anxiety, coping skills, nutritional intake, and physical activity. Our quantitative and qualitative data underscore significant economic consequences from loss of employment and household income in the study population, due at least in part to restrictions preventing workers from returning to work. Those repercussions may in turn lead to further stress and additional health impacts.

Rural residents and those of lower educational attainment experienced more difficulties in accessing medicines. Difficulty in access to medicines, in turn, was associated with worsening of diabetes or hypertension symptoms. Global supply chain disruptions during the pandemic contributed to reported shortages of essential medicines for chronic conditions. People with diabetes and hypertension were worst affected due to their difficulty in accessing health care and experienced worsening symptoms or uncontrolled blood pressure or blood sugar during the lockdowns, which might lead to poor health outcomes and avoidable micro- and macrovascular complications. Government aid was associated with fewer difficulties in access to medicines, but varied significantly across locations, demonstrating the importance of appropriate policies at the state and local levels.

Implications

The pandemic exposed disparities in chronic disease management but also provides opportunities to close gaps with innovations in post-COVID India. To mitigate the disparities in chronic disease management and reduce the potential longer-run health impacts of the crisis, a promising approach is to focus on enabling access to medicines for vulnerable populations, i.e., those in rural areas and those experiencing poverty exacerbated by loss of jobs and household income.

New models of healthcare delivery, combined with new skills (e.g., patient-centered orientation and leveraging consumer-facing technologies) for the health workforce, can promote patient engagement and health literacy, ultimately improving health outcomes. Moreover, social networks and family members have an important role to play within the community and at home in monitoring and enhancing self-care behaviors among patients with chronic conditions.

Our data may assist health authorities to redesign care delivery models to address the urgent needs of people with chronic conditions. We recommend a three-pronged approach to design resilient healthcare systems during and after the COVID-19 pandemic:

  1. Develop and implement digital campaigns to disseminate information on how to adopt healthy behaviors, better self-manage chronic diseases, and control COVID-19.
  2. Decentralize healthcare delivery for people with chronic conditions by involving trained community health workers and using technology-assisted medical interventions along with home monitoring devices for blood pressure and blood glucose monitoring to improve health care services.
  3. Provide effective social and economic support for people with chronic conditions, particularly rural communities, older persons, and those with severe mental health problems. 

Greater investment in prevention efforts and strengthening primary care can help save future healthcare costs, reduce the burden of chronic diseases, and enhance resilience against future pandemics. Also, the long-term impacts of the current surge in COVID-19 cases during the second wave in India are yet unknown and require further evaluation.

This article is based on the study “Health, Psychosocial, and Economic Impacts of the COVID-19 Pandemic on People with Chronic conditions in India: A Mixed Methods Study,” published in the April 2021 issue of the journal BMC Public Health.

The study’s co-authors are

  • Kavita Singh, Public Health Foundation of India and Centre for Chronic Disease Control, New Delhi, India;
  • Dimple Kondal, Public Health Foundation of India;
  • Sailesh Mohan, Public Health Foundation of India, Centre for Chronic Disease Control, New Delhi, India, and Deakin University, Melbourne, Australia;
  • Suganthi Jaganathan, Centre for Chronic Disease Control, New Delhi, India;
  • Mohan Deepa, Madras Diabetes Research Foundation, Chennai, India;
  • Nikhil Srinivasapura Venkateshmurthy, Public Health Foundation of India and Centre for Chronic Disease Control, New Delhi, India;
  • Prashant Jarhyan, Public Health Foundation of India;
  • Ranjit Mohan Anjana, Madras Diabetes Research Foundation, Chennai, India;
  • K. M. Venkat Narayan, Emory University;
  • Viswanathan Mohan, Madras Diabetes Research Foundation, Chennai, India;
  • Nikhil Tandon, All India Institute of Medical Sciences, New Delhi, India;
  • Mohammed K. Ali, Emory University, Atlanta, Georgia, USA;
  • Dorairaj Prabhakaran, Public Health Foundation of India, Centre for Chronic Disease Control, New Delhi, India, and London School of Hygiene and Tropical Medicine; and
  • Karen Eggleston, Stanford University, Stanford, California, USA.

Resources

India State-Level Disease Burden Initiative Collaborators. 2017. Nations within a Nation: Variations in Epidemiological Transition Across the States of India, 1990-2016 in the Global Burden of Disease Study. The Lancet. 390 (10111). 2437–60.

K. Singh et. al. 2021. Health, Psychosocial, and Economic Impacts of the COVID-19 Pandemic on People with Chronic conditions in India: A Mixed Methods Study. BMC Public Health.

M.A.N. Saqib et al. 2020. Effect of COVID-19 Lockdown on Patients with Chronic Diseases. Diabetes Metabolic Syndrome: Clinical Research and Reviews. 14 (6). 1621–3.

N. Ronkin. 2021. How COVID-19 Disproportionately Impacts People with Chronic Conditions in India. News Release. 28 April.

Shorenstein APARC. Health, Psychosocial, and Economic Impacts of COVID-19 on People with Chronic Conditions in India: Video Interview with Karen Eggleston. YouTube video. 8:50. 28 April 2021.

The Lancet. COVID-19 in India: The Dangers of False Optimism. 2020. The Lancet. 396 (10255). 867.

World Health Organization. 2020. The Impact of the COVID-19 Pandemic on Noncommunicable Disease Resources and Services: Results of a Rapid Assessment. Geneva.

Y. Chudasama et al. 2020. Impact of COVID-19 on Routine Care for Chronic Diseases: A Global Survey of Views from Healthcare Professionals. Diabetes Metabolic Syndrome: Clinical Research & Reviews. 14 (5). 965–7.

Z. Wang et. al. 2020. Coronavirus Disease 2019 (COVID-19) Pandemic: How Countries Should Build More Resilient Health Systems for Preparedness and Response. Global Health Journal. 4 (4). 139–45.

Ask the Experts

  • Karen Eggleston
    Deputy Director, Shorenstein Asia–Pacific Research Center, Stanford University

    Karen Eggleston is a senior fellow at the Freeman Spogli Institute for International Studies and Director of the Asia Health Policy Program. Her research focuses on government and market roles in the health sector and Asia health policy, especially in the People’s Republic of China, India, Japan, and the Republic of Korea; healthcare productivity; and the economics of the demographic transition. She holds a PhD in Public Policy from Harvard University and MA degrees in Economics and Asian Studies from the University of Hawaii.

    Follow Karen Eggleston on

  • Walter H. Shorenstein Asia–Pacific Research Center (Shorenstein APARC)

    Founded in 1983, Shorenstein APARC addresses critical issues affecting the countries of Asia, their regional and global affairs, and U.S.–Asia relations. As Stanford University’s hub for the interdisciplinary study of contemporary Asia, it produces policy-relevant research and provides education and training to students, scholars, and practitioners. It also strengthens dialogue and cooperation between counterparts in the Asia–Pacific and the United States. 

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