**4. Discussion**

Our findings provide useful insights for understanding the under-utilization of healthcare services in terms of demand by investigating the avoidance of healthcare associated with the COVID-19 pandemic, an emerging infectious disease. Among respondents, 73.2% avoided healthcare utilization, while only 26.8% did not. There was no statistically significant difference in the prevalence of healthcare avoidance between those with (72.0%) and without (74.9%) an underlying disease. The results indicate that the general population avoided visiting health facilities as a response to the COVID-19 outbreak, regardless of whether public health authorities recommended that they do so. We also identified sociodemographic factors (i.e., gender, age, income level, residential area) influencing the avoidance of healthcare utilization. The present study shows that not all societal groups share the burden of healthcare avoidance equally, as it disproportionately affects those with certain sociodemographic characteristics.

A few interesting findings should be highlighted. First, avoiding hospitals was prominent during the peak of the COVID-19 outbreak, which can potentially damage the overall health of the population and disrupt daily life. During the outbreak, the Korean government and public health authorities had not given any public health advice about postponing or avoiding visits to hospitals. Instead, officials made efforts to ensure access to safe and reliable care by encouraging the public to utilize healthcare when needed. The Korean government has designated a "National Relief Hospital," that operates a screening clinic to separate potential COVID-19 infected patients and treats patients with respiratory infections in a separate place. Moreover, the transmission of the COVID-19 virus mostly occurred by community-acquired infection, not in hospitals.

Widespread healthcare avoidance might relate to the South Koreans' experience with the Middle East Respiratory Syndrome (MERS) in 2015, as the COVID-19 outbreak brings back memories of MERS. Between the first documented occurrence of MERS infection (20 May 2015) and diagnosis of the last case (4 July 2015), there were 186 confirmed cases, with 38 deaths and 16,752 people quarantined [26]. All confirmed cases of MERS were suspected to be hospital-acquired infections except for one case of household transmission, and hospital-to-hospital transmission occurred in 17 hospitals, all of which originated in one hospital [26]. Avoiding hospitals even when sick during the 2015 South Korean MERS outbreak may have been a strategy for reducing the perceived risk of infection, as most MERS infections occurred at hospitals; the uncertainty about viral spread was very high. However, unlike the MERS virus, the spread of the COVID-19 virus has occurred primarily in communities. Although there is a distinct difference between the two viruses, the public might fear a nosocomial infection, and hold other misconceptions about the virus. This should be investigated further.

Second, socio-demographic characteristics (i.e., gender, age, income level) and especially residential area, were highly related to healthcare avoidance. Women, older people, those with a lower income level, and those living in highly affected residential areas were more likely to avoid healthcare utilization than other groups were. These results are similar to prior research investigating the association between social determinants and healthcare avoidance during public health emergencies such as epidemic outbreaks [18,23,27]. Therefore, the avoidance of behaviors of subpopulation members during a pandemic warrant the attention of health policy officers and public health authorities. Especially, elderly people in need of care need the support of family and friends or caregivers [27].

Among the investigated influencing factors, residential area had the most significant effect on healthcare avoidance. In particular, living in Daegu or Gyeongbuk (North Gyeongsang Province) regions, where COVID-19-confirmed patients exploded at the time of this study, have been found to be the strongest influencing factor in avoiding hospital visits. For example, among men, respondents living in the Daegu and Gyeoungbuk region were 4.87 times more likely to avoid healthcare than those living in Seoul. In the peak of the outbreak, the daily new patient count in Daegu had reached 741 by February 29, and thousands waited for hospital beds as cases surged [28]. At the time of this study, cumulative cases in Daegu had reached 6456 (25 March). One can reasonably expect that citizens of Daegu/Gyeongbuk were at increased risk due to healthcare under-utilization during the COVID-19 outbreak. Fortunately, many medical staff and volunteers both local and from all over the country have come and participated voluntarily to help overcome the crisis in Daegu [15].

There are a number of implications that have emerged from this study. First, health authorities must make efforts to sustain the efficacy of the healthcare systems by providing sufficient support for the public to utilize proper healthcare services on both the demandside and the supply-side. For the demand-side, instructions on how and when to visit the hospital should be provided to patients with non-infectious diseases in order to prevent inappropriate healthcare avoidance. While controlling the spread of infectious disease quickly is the urgent primary goal of the public health authorities, guidelines for people in terms of maintaining their health is also very important [29]. At the same time, standards and procedures should be prepared to treat non-infected patients in all possible clinical situations. On the supply-side, human resources of medical experts, experts in public health and epidemics, along with new policies are needed to improve the resilience of highly affected communities. Second, it is expected that the number of patients visiting hospitals has drastically decreased, causing financial losses in the healthcare facilities. Negative financial impacts of outbreaks have been reported in previous studies [30,31]. Various support plans should be prepared, including financial arrangements to compensate for the loss of medical institutions.

Our study has several limitations. First, the analyses did not extensively explore psychological factors such as the perceived risk or fear of visiting hospitals and trust in public health authorities. Therefore, we did not investigate the psychological factors influencing healthcare avoidance, so further research is needed. Second, we could not identify whether healthcare avoidance resulted from misconceptions about the spread of COVID-19, which some might perceive as a nosocomial infection. Future studies should measure and analyze knowledge of the virus as an independent variable. Third, this study is based on questionnaires which investigated the self-reported healthcare service avoidance. Moreover, this study design is cross-sectional and is not available to examine the trend of healthcare avoidance during the pandemic. Further research using national data, such as Korea National Health Insurance (KNHI) Claims Database, would be able to investigate actual numbers of healthcare utilization and change over time during the pandemic. Finally, this study did not investigate the avoidance of healthcare service for reasons other than COVID-19, which can confound the findings of this study.

#### **5. Conclusions**

In conclusion, the results of this study documented that a noticeable proportion of the public avoided healthcare visits who under-utilized healthcare resources that had not been advised by the government during the COVID-19 outbreak. Subgroups who were more likely to avoid visiting hospitals were identified, with residential areas playing a significant role in respondents' behaviors. This study offers guidance for developing public health policy making to establish customized healthcare utilization policies and health promotion for specific groups of individuals. Prioritizing policies and efforts will be necessary for these vulnerable populations to reduce unmet healthcare needs. Understanding the patterns of healthcare utilization during infectious disease outbreaks would be valuable for facilitating appropriate responses and reducing the negative impact on population health.

**Author Contributions:** M.L. and M.Y. conceptualized the study. M.L. was responsible for the methodology and conducted a formal analysis. M.Y. was responsible for data acquisition. M.L. wrote the initial draft of the manuscript, and M.Y. assisted with the writing, review, and editing of the manuscript. Both authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the National Research Foundation of Korea (BK21 Center for Integrative Response to Health Disasters, Graduate School of Public Health, Seoul National University); National Research Foundation of Korea Grant funded by the Korean Government (No. 21B20151213037); and Rainbow Communication and Consulting.

**Institutional Review Board Statement:** The present study protocol was reviewed and approved by the Institutional Review Board (IRB) at Seoul National University (IRB No. 2003/002-005). Informed consent was submitted by all subjects when they were enrolled.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** The datasets used and analyzed in the current study are available from the corresponding author on reasonable request.

**Acknowledgments:** We would like to thank Hyemin Yeo, Junghoon Shin, and Yeunhoon Jang for assistance with survey development and data collection.

**Conflicts of Interest:** The authors declare no conflict of interest.
