The second wave of the COVID-19 pandemic is sweeping through India at a ferocious pace. In recent weeks, the country has registered record-breaking numbers of new coronavirus cases and deaths, and its healthcare system is buckling as hospitals are running out of beds, oxygen, and anti-viral drugs. There are limited data, however, documenting how COVID-19 has affected people with chronic conditions in the country, especially underprivileged urban residents and underserved rural communities. A new study now sheds light on the impact of the pandemic on disparities in chronic disease management in India.

Published in the April 2021 issue of the journal BMC Public Health, the study — “Health, psychosocial, and economic impacts of the COVID-19 pandemic on people with chronic conditions in India” — reveals that people with chronic conditions such as diabetes and hypertension, particularly among poor, rural, and marginalized populations, have experienced difficulties in accessing healthcare and been severely affected both socially and financially by the pandemic.

We spoke with APARC’s Asia Health Policy Program (AHPP) Director and the Center’s Deputy Director Karen Eggleston, who is one of the study’s co-authors, about its underlying research, findings, and policy implications. Watch:

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The study is the product of collaboration with a group of scholars including Eggleston’s long-time research partners Dorairaj Prabhakaran of the Centre for Chronic Disease Control and Public Health Foundation of India, M. Venkat Narayan of Emory University, Kavita Singh of the Public Health Foundation of India, and Nikhil Tandon of the All India Institute of Medical Sciences. They have been working with Eggleston on issues related to broader research on innovation for healthy aging in Asia and net value in diabetes management.

In the current research, Eggleston and her collaborators studied adult participants with one or more chronic conditions (hypertension, diabetes, cardiovascular disease, or chronic kidney disease) from two large existing cohorts — the Centre for Cardiometabolic Risk Reduction in South Asia, CARRS, and the India-UDAY comprehensive program of diabetes and hypertension prevention and management — in four sites (Delhi, Chennai, Haryana, and Vizag). The strength of the research lies in its empirical mixed-methods study design, which combines a quantitative survey and qualitative interviews, and its focus on people with chronic conditions from both urban and rural populations. It is the first such study from a populous country like India.

“We thought we could try to provide some insight for policymakers, caregivers, and others by looking at these same individuals that we already know something about,” says Eggleston, “so that we could follow up and see how the pandemic was impacting them.”

— Watch AHPP webinars featuring speakers including the study's co-authors —

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Adverse Health Impacts

The results show that COVID-19-related restrictions implemented to control the pandemic had unforeseen adverse impacts on the health status, access to treatment, and achievement of care goals among people with chronic conditions in India. People with diabetes and hypertension were worst affected due to their difficulty in accessing health care and experienced worsening symptoms during the lockdowns, which might lead to poor health outcomes and avoidable micro- and macrovascular complications.

“Unsurprisingly but importantly,” notes Eggleston, “the most vulnerable are the ones who are suffering the most.” The researchers found that rural participants disproportionately experienced acute medical illnesses, difficulties in accessing healthcare, relatively less availability of functioning health facilities, poor treatment satisfaction, and reduced fruit and vegetable consumption.

Psychosocial and Economic Consequences

Beyond disparities in health management, the study highlights how the impacts of the pandemic extend to encompass adverse effects on household incomes, individual livelihoods, interpersonal relationships, coping skills, and other factors. The quantitative and qualitative data underscore significant economic impacts 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 impacts on health.

The pandemic has upended the lives of scores of people around the world, causing psychosocial distress due to loss of job or income, isolation, stress, and anxiety. Qualitative data collected by the researchers, however, suggest that those with preexisting chronic conditions have often experienced compounding psychosocial effects that exacerbate their illness “They were feeling fear and anxiety that many of us feel during the pandemic, but did not have the resources necessary to also address their chronic disease. And this, of course, could lead to delay in care and later to more severe outcomes,” notes Eggleston.

After COVID: Policy Implications

The study by Eggleston and her collaborators assists health authorities to redesign care delivery models to address the urgent needs of people with chronic conditions. The researchers emphasize the important role that social networks and family members play within the community and at home in monitoring and enhancing self-care behaviors among patients with chronic conditions. They also recommend a three-pronged approach to design resilient healthcare systems during and after COVID-19.

First, develop and implement digital campaigns to disseminate information on how to adopt healthy behaviors, better self-manage chronic conditions, and control COVID-19. Second, 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 to improve health care services. And third, provide effective social and economic support for people with chronic conditions, particularly rural communities, the elderly, and those with severe mental health problems.

The study underscores the need for greater investment in prevention efforts and strengthening primary care to reduce the burden of noncommunicable diseases and enhance resilience against future pandemics. "Whole health systems need to adjust and adopt a prevention-focused approach, which is a challenge everywhere," Eggleston says. Building upon strategies that have been proven to be successful during the pandemic may lead to more resilient, productive, and humane health systems going forward, she concludes.