| dc.description.abstract | Introduction:
The term "syndemic" refers to the interaction between two or more coexisting epidemics, where the interactions amplify the negative health outcomes. The COVID-19 pandemic can be considered a syndemic because it involves the convergence of multiple factors: the direct impact of the SARS-CoV-2 virus causing COVID-19, the exacerbation of pre-existing chronic health conditions, and the associated mental health challenges. These factors interact in complex ways, creating a situation where the combined effect is greater than the sum of its parts. The COVID-19 pandemic has triggered a surge in mental health challenges worldwide. The connection between COVID-19, mental health, and non-communicable diseases is bidirectional. Mental health issues can exacerbate existing chronic conditions, while pre-existing chronic conditions can increase the vulnerability to severe COVID-19 outcomes and also contribute to poor mental health. Recognizing the syndemic nature of the COVID-19 pandemic is crucial for holistic understanding and effective response. Approaches that solely focus on the virus itself or individual health conditions may overlook the complex interactions of other factors. A syndemic perspective not only highlights the synergy between COVID-19, chronic diseases, and mental health, but also emphasizes the need for comprehensive public health strategies that address not only the virus's spread but also consider the broader social, economic, and health implications.
Methods:
This dissertation utilized secondary data acquired from the Ontario Health Database Platform (OHDP) through the Institute for Clinical Evaluation Sciences (ICES) with adult Ontarians aged 18 years and above as the study population. The exclusion of individuals under 18 years old in the research was driven by the specific emphasis on chronic illnesses, which are typically more widespread in the 18+ age group. Despite the occurrence of COVID-19 in those under 18, the research focuses on individuals aged 18 and above, considering that younger individuals generally face milder complications compared to their older counterparts. Consequently, the inclusion of minors was deemed irrelevant to the research specific objectives. Various administrative health databases including the Discharge Abstract Database (DAD), National Ambulatory Care Reporting System (NACRS), Ontario Health Insurance Plan (OHIP), Ontario Mental Health Reporting System (OMHRS), and ICES-derived cohorts were used to identify variables of interest and address specific research objectives. The primary aim of this analysis was to evaluate the syndemic impact of COVID-19 and related anxiety and depression on health outcomes in the Ontario population. In Study I, Cox proportional hazards regression was utilized to assess the association of factors with time to anxiety and depression related health services utilization, and results were summarized using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). For comparison of morbidity and mortality before and during the pandemic, an interrupted time series study design was adopted in study II, using a segmented regression model to assess the monthly impact of COVID-19 on overall morbidity and mortality in the Ontario population. For every assessment period (defined as month), we determined the total number of morbidity episodes and mortality per month for each year. For Study III, multiple logistic regression analysis was utilized to identify important risk factors associated with the syndemic impact of COVID-19 and co-occurring anxiety or depression on morbidity, among the adult Ontario population
Results:
In the adjusted Cox proportional hazards model (Study I) for the sample, the individuals who had PCR tests had a higher risk of utilizing health services for anxiety and depression during the pandemic, (aHR, 6.37; 95% CI, 6.25-6.50 and aHR, 5.91; 95% CI, 5.87-5.95) for COVID-19 positive and COVID-19 negative respectively, as compared to those who had no PCR testing done for COVID-19. Study II noted that in the early stages of the COVID-19 pandemic's first wave in Ontario, there was a decrease in physician visits and hospitalizations among those with chronic conditions, possibly due to infection fears and disruption of health services. As time passed, there were later phases marked by significant rises in medical visits and hospitalizations. In the final adjusted regression model (Study III) for the sample, the individuals who were COVID-19 positive and had either anxiety or depression were more likely to utilize health services for chronic conditions of interest during the pandemic, as compared to those who were COVID-19 negative with mental health issues (ORs, 1.33; 95% CI, 1.12-1.58). A higher risk of morbidity was observed among males (ORs 1.28; CI,1.16-1.41), as well as in individuals with diverse ethnic backgrounds and low socioeconomic status.
Conclusion;
The individuals who had COVID-19 testing exhibited greater utilization of healthcare resources for anxiety and depression in comparison to those who were not tested, irrespective of COVID-19 disease status. Investigating the causes of psychological distress related to COVID-19, especially among individuals undergoing PCR testing, is essential for addressing its mental health impacts and improving readiness for future pandemics. We also noted the complex trajectory of healthcare utilization during the pandemic's waves. While the initial decline in physician visits and hospitalizations could be attributed to fear and healthcare system adjustments, subsequent periods witnessed increases in healthcare utilization and mortality rates, highlighting the evolving dynamics of the pandemic's impact. The shifts in healthcare utilization brought about by the pandemic carry significant clinical and public health implications. These include potential consequences such as missed diagnoses, delayed treatment, higher morbidity, and increased mortality. These challenges highlight the importance of healthcare system adjustments and preparedness for future pandemics. It is vital to tackle barriers to health care, ensuring that individuals, particularly those with chronic conditions, can access essential medical services, even when resources are constrained. Moreover, the individuals diagnosed with COVID-19 and co-occurring mental health issues of anxiety and depression exhibited increased healthcare service utilization. This points towards the interconnectedness of physical and mental health and emphasizes the importance of addressing both aspects for individuals' overall well-being, especially within the context of the COVID-19 pandemic. The impact of COVID-19 on mental health can be seen as a "syndemic," wherein its effects on susceptible individuals with chronic illnesses are exacerbated through synergistic interactions. This interplay underscores the significance of comprehensive public health strategies. Acknowledging this syndemic enables policymakers to develop focused measures aimed at mitigating adverse health effects among vulnerable groups. | en |
