**1. Introduction**

The outbreak of a novel coronavirus (COVID-19), first appeared in Wuhan [1,2] and has been a major public health threat worldwide. On 20 January, South Korea confirmed its first case [3], and an explosive increase in the number of COVID-19 patients appeared in late February in Daegu city, contributed by a religious group called Shincheonji [4]. In this time, South Korea was one of the hardest hit areas during the global outbreak of COVID-19. As the number of confirmed cases rapidly increased, the Korean government raised the alert level from orange to red on 23 February 2020, and mandated school closures [4]. As of 28 March 2020, the number of COVID-19 cases in Korea reached 9478, including 144 deaths. Among the public, the perceived risk of COVID-19 infection increased and became pervasive; widespread postponing or canceling of social events, avoiding crowded places, and reducing the use of public transportation, subsequently occurred [5].

Decrease in healthcare utilization occur frequently during pandemic outbreaks. In Korea, medical utilization (both admissions and outpatient treatments) decreased dur-

**Citation:** Lee, M.; You, M. Avoidance of Healthcare Utilization in South Korea during the Coronavirus Disease 2019 (COVID-19) Pandemic. *Int. J. Environ. Res. Public Health* **2021**, *18*, 4363. https://doi.org/10.3390/ ijerph18084363

Academic Editors: Paolo Roma, Merylin Monaro and Cristina Mazza

Received: 30 March 2021 Accepted: 14 April 2021 Published: 20 April 2021

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**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

ing the MERS epidemic in June and July of 2015 when compared to the numbers from 2014 and 2013 [6], along with visits to the emergency department [7]. The overall use of healthcare decreased by 18% during the peak of the Ebola Virus Disease (EVD) outbreak in West Africa [8,9]. Likewise, significant reductions in ambulatory care (23.9%), inpatient care (35.2%), and dental care (16.7%) were observed in Taiwan during the peak of the Severe Acute Respiratory Syndrome (SARS) outbreak [10]. However, a decrease in healthcare utilization patterns during outbreaks can adversely affect population health. Failure to access preventive and urgent life-saving treatments alike can lead to additional deaths [9], and the severity of illness or chronicity of disease, functional or physical disability, and even mortality, are predictable outcomes [11]. Previous studies have suggested that changes in healthcare utilization patterns due to public health emergencies have increased mortality rates from infectious disease as well as non-infectious diseases [12–14]. Moreover, increased expenditures related to healthcare as delayed diagnosis as well as more costly multimodal treatments, might be required. As a result, the burden associated with decreases in healthcare utilization may reduce the overall efficacy of a healthcare system.

Healthcare utilization may have declined for several reasons. First, the outbreak may have affected the supply of health due to closures of some health facilities during outbreaks. For example, in Korea, a 35-year-old man employed at a hospital developed symptoms of COVID-19 on February 2. He transmitted it to several patients between 2 and 17 February before he was discharged from his job. The hospital subsequently closed, and 14 additional confirmed cases from this hospital had been reported as of 2 March 2020 [4]. As another example, some hospitals were forced to close as some patients did not properly describe their symptoms of COVID-19 due to concerns of not being admitted and treated [15]. In West Africa, health workers experienced a particularly heavy death toll; many healthcare workers had died, and the supply of healthcare was affected during the EVD outbreak [9].

Second, the demand for healthcare might also have changed. Avoiding visits to healthcare facilities even when sick, or healthcare avoidance behavior, can negatively affect the population's well-being [11]. It might impede positive health-seeking behaviors and delay care, lead to non-adherence with treatment regimens, or result in a total lack of access to the healthcare system. According to a study in Korea, 34.5% of respondents reported that they avoided hospital visits even when they were ill during the MERS outbreak [16]. Potential patients may have avoided seeking care at health facilities because they feared contracting an infectious disease if they visited during outbreaks. Several studies have reported that concerns about the potential for nosocomial transmission of the disease led to beliefs that health facilities should be avoided. For instance, a Taiwanese study showed that the public's fears of SARS strongly influenced access to care [10] and a study of Hong Kong residents in the initial stage of the H1N1 outbreak reported that 63.4% of respondents avoided visiting hospitals due to perceived high risk [17].

The potentially severe impact of COVID-19 outbreak on people's access to healthcare is an important area of study. A critical challenge is to determine how healthcare agencies should respond to changes in healthcare utilization and possible barriers to access healthcare facilities for the public created by the COVID-19 outbreak. Moreover, the lessons learned from the MERS experience in Korea [6] and other countries demonstrate the importance of understanding the community response [17–23]. To our knowledge, no other study has evaluated the impact of COVID-19 on the demand of healthcare utilization among the general population. In this study, we focus on the avoidance of healthcare utilization or changes in healthcare-seeking behaviors of the public during the COVID-19 outbreak. The aims of the study are two-fold. First, we examine the prevalence of healthcare avoidance among the general population during the COVID-19 outbreak. Second, we investigate the factors associated with healthcare avoidance and identify the vulnerable populations. The results of this study can inform healthcare utilization patterns during infectious disease outbreaks and understanding the factors which affect the access of timely care will inform public health emergency management for implementing strategies necessary to improve the preparedness of the healthcare system.
