Health-care-seeking behaviours of the Japanese lay public during the COVID-19 pandemic: a cross-sectional study

KEYwords: COVID-19; health-care-seeking behaviour; internet survey.

In Japan, cases of COVID-19 have been increasing since the first case was reported on 14 January 2020.¹ To control the spread of COVID-19, the Japanese government issued a nationwide Declaration of Emergency for approximately 2 months (from 7 April to 25 May 2020), promoting voluntary isolation and business restriction for entertainment venues. However, even after these interventions, the outbreak remained uncontrolled and the Japanese government has continuously requested the public to take countermeasures against the infection such as “Avoid the three Cs” (closed spaces, crowded places, and close-contact settings) and “wear masks when going out”.

In the same period, the number of patients treated in community health-care facilities^2,3 and people receiving preventive services^4–6 decreased. This decline is probably partly due to the temporary suspension of medical care and preventive services by facilities with infected employees and partly due to lay public hesitancy in accessing services for fear of infection. Health-care facilities such as clinics and hospitals are generally considered to hold a high risk of infection as there are usually many elderly and immune-compromised patients in these facilities.⁷ Several nosocomial COVID-19 infection incidents have been reported in the press.⁸

Therefore, this study aimed to explore the health-care-seeking behaviour of the Japanese lay public during the COVID-19 pandemic in 2020.

A web-based questionnaire survey was conducted to identify the health-care-seeking behaviour of the Japanese lay public during the COVID-19 pandemic. The main topics of the questionnaire were: avoidance of outpatient visits generally, the types of non-hospital care they avoided (dentistry, general medicine, ophthalmology, and other medical specialties), reason(s) for avoiding them, whether they plan to continue avoiding this health care after COVID-19 has been controlled, and whether in normal circumstances they avoid preventive services such as health check-ups or cancer screening tests. The questionnaire was developed through discussion among the authors.

The study was conducted in accordance with the Declaration of Helsinki and with the Japanese Ethical Guideline for Medical and Health Research Involving Human Subjects and was approved by the Kyoto Pharmaceutical University Ethics Committee (No. 20-32).

Survey respondents were recruited from Japanese lay citizens who had voluntarily registered as monitors with the consumer research company that has the largest number of monitors in Japan (Intage Inc., Tokyo, Japan). We included people aged 20–84 years and excluded medical and welfare workers. Respondents’ age, sex, and place of residence were adjusted in analysis to provide results representative of Japan. We determined that the survey sample size should be 2000, following similar previous studies conducted in Japan.^9,10

Monitors were informed about the survey by an e-mail from Intage, Inc. in September 2020. People who received this email and were interested in participating in the survey accessed the designated recruitment website from their computers or smartphones. They read the survey information on the recruitment website and gave their informed consent by clicking “Agree” on the screen. The screen then moved to the survey website for participants to input their answers. When the survey’s sample size was reached (2000 people), the recruitment website was closed. We offered a small gift voucher for respondents who completed the questionnaire as a token of appreciation for their participation.

Respondents were asked to reply to the questionnaire about their experiences of visits to health-care facilities for disease treatment and preventive services (health check-ups or cancer screening tests) during two different periods: from mid-February to the end of May 2020 and in September 2020. The first time period was from the Japanese government’s announcement of the “Guidance for consultation and medical appointments” on 17 February 2020, ending when the “State of Emergency” was rescinded on 25 May 2020. The second time period reflected when the July–August second wave of COVID-19 began to decline.

Responses were sent to us with each monitor’s personal identification characteristics removed at Intage, Inc and data were weighted to reflect the Japanese population. Then, we tabulated the data and performed chi-square tests to determine if there were differences between the study groups (dentistry, general medicine, ophthalmology, and medical specialities), with a statistical significance level of P = 0.05.

A total of 2137 respondents responded to the survey (1041 men (48.7%) and 1096 women (51.3%)). Respondents’ age, residence, and pre-existing conditions are shown in Table 1.

Table 1.  Respondent demographic data (N = 2137)

The proportion of respondents who avoided visiting health-care facilities for health-care treatment other than COVID-19 was 31.1% (664 respondents) for new visits and 25.0% (534 respondents) for follow-up visits. Of 664 respondents who avoided new visits, the type of care most often avoided was dentistry (259 respondents, 39.0%), followed by general medicine, ophthalmology, and internal medicine specialties. Dentistry was also the most commonly avoided health-care type for follow-up visits (of the 217/534 respondents who avoided any follow-up visits, 40.6%), followed by general medicine, medical specialties, and ophthalmology (Table 2). The percentage difference between general medicine and medical specialties was statistically significant (P<0.001).

Table 2.  Health-care facilities avoided and not avoided during two periods of the COVID-19 pandemic in 2020

When asked why they avoided visiting health-care facilities, the most common reason was that “I was frightened of contracting COVID-19 at the clinics or hospitals” (new visits: 292 respondents, 44.0%; follow-up visits: 263 respondents, 49.3%), followed by “I wanted to avoid going out as much as possible” (new visits: 206 respondents, 31.0%; follow-up visits: 159 respondents, 29.8%) and “I did not think that health-care visits were warranted at present” (new visits: 104 respondents, 15.7%; follow-up visits: 70 respondents, 13.1%) (Table 3). For respondents avoiding visits to general medicine clinics, but not medical specialty clinics, more than half selected “I was frightened of contracting COVID-19 at the health facility” as the reason.

Table 3.  Main reasons for avoiding visits to health-care facilities by respondents

More than half of respondents who avoided visiting health-care facilities also indicated that they would avoid visits even after the spread of COVID-19 became controlled (new visits: 55.6%; follow-up visits: 55.6%; Table 4).

Table 4.  Future visits to health-care facilities after COVID-19 become controlled

Of the 736 respondents who confirmed having pre-existing conditions, 250 (34.0%) avoided visiting health-care facilities for new visits and 198 (26.9%) avoided follow-up visits. Slightly more than respondents with, than without, pre-existing conditions avoided visits. However, 481 respondents (65.4%) did not avoid visiting for follow-up visits, suggesting that most of the respondents preferred continuous treatment of their pre-existing conditions.

For visits to health-care facilities for preventive services, 80 (3.7%) responded that they did visit, 284 (13.3%) responded that they booked a visit but cancelled, 1448 (67.8%) intended to visit but did not, and 58 (2.7%) did not know or did not remember if they had visited outpatient facilities for follow-up visits (Table 5). Of the 1812 respondents who were booked in for a health-care visit, but cancelled, intended to visit but did not or never intended to make such a visit, the most common reason was that they did not think that health-care visits were warranted at present (617 respondents, 31.4%); however, approximately half (943 respondents, 52.0%) indicated that they intended to receive preventive services if the spread of COVID-19 became controlled.

Table 5.  Visits to health-care facilities for preventive services (N = 2137)

The proportion of respondents who avoided visiting health-care facilities for disease treatment other than for COVID-19 was 19.1% (409 respondents) for new visits and 12.5% (267 respondents) for follow-up visits. Of the 409 respondents who avoided new visits, dentistry was most often avoided (153 respondents, 37.4%), followed by general medicine (239 respondents, 36.0%), ophthalmology (105 respondents, 15.8%) and medical specialties (103 respondents, 15.5%). Similarly, of the 267 respondents who avoided follow-up visits, dentistry and general internal medicine were more often avoided than medical specialties and ophthalmology (Table 2). General medicine was avoided by significantly more respondents than medical specialties (P<0.001).

The most common reason for avoiding visits was fear of contracting COVID-19 during visits (new visits: 214 respondents, 52.3%; follow-up visits: 154 respondents, 57.7%), followed by general avoidance of leaving home (new visits: 83 respondents, 20.3%; follow-up visits: 46 respondents, 17.2%) and thinking that health-care visits were “not warranted at present” (new visits: 75 respondents, 15.7%; follow-up visits: 41 respondents, 15.4%) (Table 3). Among respondents avoiding visits to general medical clinics but not medical specialties, more than half indicated fear of contracting COVID-19 at the health facility as their reason for avoidance.

Regarding whether respondents would still avoid health-care visits even after the spread of COVID-19 becomes controlled, avoidance (new visits: 40.6%, follow-up visits: 50.9%) was slightly less common than in the first period when COVID-19 was not controlled (Table 4).

Of the 736 respondents who confirmed having pre-existing conditions, 19.8% (146 respondents) indicated they avoided visiting health-care facilities for new visits and 11.1% (82 respondents) avoided follow-up visits; however, the proportion of respondents who did not avoid health-care visits was high at 84.4% (621 respondents) for follow-up visits.

Health-care facilities had been attended for preventive services by 522 (24.4%) respondents, 29 (1.4%) had cancelled their appointment, 230 (10.8%) had intended to receive preventive services but did not, and 1263 (59.1%) never intended such visits (Table 5). Compared to the first period, the attendance for preventive services nearly doubled.

The most common reason for not receiving preventive services (1522 respondents) was “I do not think that health-care visits are warranted at present” (622 respondents, 40.9%). Approximately half (784 respondents, 51.5%) indicated that they will receive preventive services if the spread of COVID-19 became controlled.

Our survey clarified the motives of the Japanese lay public regarding health-care-seeking behaviours for two periods during the COVID-19 pandemic in 2020. Fear of contracting COVID-19 at the clinic and generally avoiding leaving home were the most common reasons for avoiding visiting health-care facilities. This confirms that the lay public chose to avoid health-care visits owing to fear of being infected by COVID-19.

Despite the higher probability of testing positive to COVID-19 during the second period than the first, the percentage of respondents avoiding visits in our sample was lower for the second period than for the first. This could be because the spread of COVID-19 was considered difficult to control, making respondents tired of avoiding visits and leading them to think that by using basic infection control measures (eg washing hands and wearing masks), there would be no need to be overly fearful. Furthermore, respondents’ medical needs might have become more pressing, making them conclude that health-care visits were necessary. The second period coincided with the containment of the second wave of infection in Japan (mid-July to August 2020), meaning that anxiety about COVID-19 may have been somewhat reduced.

Among respondents with pre-existing conditions, 34.0% avoided new visits in the first period; this was somewhat higher than the overall figures (31.1%), indicating that people with pre-existing conditions may be more concerned about infection prevention. However, in the second period, the proportion of respondents avoiding new visits declined to 19.8%. By contrast, the percentage of respondents who did not avoid follow-up visits was high in both the first and second periods (65.4% and 84.4%, respectively), indicating that treatment for pre-existing conditions continued regardless of the COVID-19 pandemic.

The most avoided types of health care were dentistry and general medicine. This may be due to the reduced need for urgent dental treatments compared with medical treatments, and the tendency for people tending to rely on general medicine more than organ-specific medical specialties. The most common reason for avoiding general medicine, but not medical subspecialties, was “I was frightened of contracting COVID-19 at the clinics or hospitals”. In Japan, most general medicine is practiced in small clinics, and patients may be afraid of becoming infected while sitting in a small waiting area before seeing their doctor. During the autumn of 2020, the Japanese government launched a framework for lay citizens to consult with local health-care providers (general internists) upon suspicion of a COVID-19 infection.¹¹ General practitioners may need to actively communicate their infection control measures, as this may reassure patients and diminish their hesitancy to attend appointments.

Nearly half of the respondents stated they would avoid visiting health-care facilities even if the spread of COVID-19 became controlled. The percentage of respondents answering “avoid” was higher than “not avoid” for both new and follow-up visits. It is possible that avoiding health-care visits due to the COVID-19 pandemic was a catalyst for reconsidering the necessity and efficacy of attending to health-care visits, overall. By undergoing self-care in the family environment (ie potentially greater exercise, dietary adjustments, and more sleep), respondents gained knowledge about how to stay well without the need for medical consultation or did not feel worsening symptoms despite non-attendance to health facilities. According to a recent survey by the National Federation of Health Insurance Societies (KENPOREN), approximately 70% of people with pre-existing conditions who refrained from visiting hospitals during the COVID-19 pandemic indicated that they “did not feel particularly ill”.¹² Before the pandemic, the number of outpatient visits in Japan was the second-highest of the Organisation for Economic Co-operation and Development (OECD) countries,¹³ suggesting that even if patients exhibit some restraint regarding medical visits, this may not evoke important health issues. It is also possible that respondents’ changes in health-care-seeking behaviours – triggered by the COVID-19 pandemic – may persist beyond the containment of the spread of the infection.

Overuse of health-care resources is a major issue worldwide,^14,15 and the “choosing wisely” campaign, which asks people to reconsider baseless, unnecessary health care, is gaining international attraction through dialogue between health-care providers and patients.¹⁶ In Japan, doctors recognise that 20% of the tests are unnecessary¹⁷ and that the COVID-19 pandemic may promote activities that reduce the prevalence of unnecessary health-care-seeking behaviour.¹⁸ Even so, more than half of the respondents in both periods (first period: 67.8%; second period: 59.1%) said “I never intended to attend” preventive services, such as health check-ups or cancer screening tests. However, more than half in both periods also stated that they “would attend” if the spread of COVID-19 was contained, suggesting an intention to attend preventive services.

A strength of this study was that it surveyed the lay public living throughout Japan regarding their health-care-seeking behaviours, at two periods during the COVID-19 pandemic. This study also has several limitations. First, responses may be affected by recall bias because the questions refer to past events (ie mid-February to May 2020). Second, the views of non-internet users (particularly elderly adults) may not have been adequately represented in this web-based survey. Furthermore, the varying degrees of COVID-19 infection in different regions of Japan were not considered.

Our results showed that during the COVID-19 pandemic in Japan in 2020, the lay public was willing to avoid new and follow-up visits to health-care facilities. The motivation behind this behaviour appeared to be a desire to avoid COVID-19 infection as much as possible. Approximately half of the respondents stated that they would continue to avoid medical appointments even after the infection became controlled, suggesting the possibility of long-term behaviour changes resulting from changes in health-care-seeking behaviour related to the COVID-19 pandemic.

All authors have no potential competing interests to declare.

This study was funded by the Japanese Ministry of Health, Labour and Welfare (19IA2022).

The data that support this study will be shared upon reasonable request to the corresponding author.

The following individuals qualify for authorship based on their substantial contributions to the manuscript’s intellectual content: Kyoko Kitazawa, Yasuharu Tokuda, and Shunzo Koizumi for conception and design; Kyoko Kitazawa and Yasuharu Tokuda for data analysis; Kyoko Kitazawa, Yasuharu Tokuda and Shunzo Koizumi have participated in writing the manuscript, and all have approved the manuscript.