Table 4 Coding tree—themes, categories, and codes emerged across three waves of COVID-19.
Themes | First wave (March–November 2020) | Second wave (March–May 2021) | Third wave (January—March 2022) | |||
|---|---|---|---|---|---|---|
Context | Responses | Context | Responses | Context | Challenges | |
Adapting clinical practice to ensure continuity of care | *COVID-19 was perceived as untreatable and life-threatening * RTPCR test started (Mar), but limited testing facilities *Patients could not be screened *No treatment guidelines for COVID-19 *No vaccination *Limited supply of protective equipment *Rapid antigen test & convalescent plasma therapy started (July), but not extensive | *Physicians feared getting infected and carrying the infection home *Every patient was a COVID-19 suspect, which brought fear *Extra precautions taken like wearing protective masks, face shields, and gloves *Continued work in unfavourable circumstances *Dissatisfied with the poor quality of patient consultations *Many experienced stress, disturbed sleep, anxiety, depression, and isolation *Chronic disease care was deprioritised *Most practices diverted for COVID-19 identification and care | *COVID-19 testing more available- RTPCR, Rapid antigen *COVID-19 screening could be done *Patients could be identified, and suspects isolated *COVID-19 is considered treatable for most, life-threatening for specific populations *Treatment guidelines for COVID-19 evolving *Most health workers getting vaccinated *Immunity against COVID-19 measured by antibody levels | *Fear of COVID-19 reduced after vaccination—but persisted for older physicians and those with multimorbidity *Patient care or chronic diseases resumed with precautions—Only extra care was needed for positive patients *COVID-19-positive screened to suggest emergency care and treatment at a COVID-19 facility or with home isolation | *COVID-19 testing is routinely done in suspected patients and before hospital admission *Effective treatment protocols for COVID-19 are followed *Most health workers and patients are vaccinated *Healthcare has opened up to deprioritise COVID-19 and consider other illnesses as well | *The COVID-19 virus is considered to have weakened *COVID-19 is compared to a Flu, with more severe symptoms *It is accepted as unavoidable in clinical practice *Physicians feel more protected by vaccinations |
Appreciation of the multifaceted vulnerability of multimorbidity and need for attention | *Statewide lockdown and transport restrictions *Healthcare systems reorganised—Resources and health workers diverted to address COVID-19-related care | *Emergency care and specialised daycare services like dialysis, blood transfusion, radiotherapy, and chemotherapy continued amid strict COVID-19 related precautions *Non-COVID-19 illnesses, particularly chronic conditions, are not prioritised | *Vulnerability of patients with multimorbidity and chronic diseases to COVID-19 established *Chronic illnesses received renewed attention *Interdepartmental and other referrals became less *Holistic care could not be possible | *Emergency and essential chronic illness care continued *Physicians proactively looked for diabetes, hypertension, and other chronic illnesses *Additional COVID-19 precautions taken for them and encouraged to avoid hospital visits *When COVID-19 positive, those with multimorbidity were advised admission and heightened care *Primary care physicians, familiar with their patient's illnesses and could guide treatment | *The importance of addressing chronic illness and multimorbidity established | *Care for chronic illness continued as before pandemic *There was continued treatment priority and extra precaution for patients with a chronic illness or multimorbidity *These patients were prioritised for vaccination *There was an increase in hospital visits for these patients |
Adopting innovations for reaching out to patients | *Routine consultations stopped *Lockdown, travel restrictions and precautionary measures reduced access to care | *Physicians could be approached remotely using mobile and internet networks *Primary physicians familiar with patient's illnesses guided patients in the absence of accessible medical records *This was considered a temporary solution for health emergencies | *Routine consultations are discouraged for chronic illness; remote consultations preferred *Consultations for chronic illness were limited to emergency and essential services such as dialysis and chemotherapy | *Physicians continued remote consultations could be reached out remotely through mobile phones, social media and WhatsApp *Hospitals started formal telemedicine facilities *Physicians guided home-based patient care and co-ordinated referrals *Specialist consultations in COVID-19 care settings used remote consultations *Remote consultations are considered an indispensable element in healthcare delivery *Having a patient database facilitated remote consultations *Remote consultations were extended to include counselling on home-based self-management of chronic illness | *Routine consultations resumed for chronic illness *Patients with chronic illness returned for formal consultations | *Physicians reduced the use of remote consultations *Hospitals-based formal telemedicine facilities continued to be used |
Aligning with rapidly changing public health guidelines and health system interventions | *First case in Odisha *Pandemic declared a state disaster *Closure of places of gatherings in public *Creation of isolation facilities *Declaration of statewide lockdown and travel restrictions *Pandemic preparedness of health systems *Disrupted NCD programmes | *Initiation of COVID-19 diagnostic facilities *Expanded hospital and ICU facilities *Reorganised healthcare *Prioritised care for patients with chronic illness—e.g., cancer under chemotherapy/radiotherapy, renal failure under dialysis, those needing a transfusion *Promoted transport and online delivery of medicines for these patients *Promoted COVID-19 related awareness and advisory *Provided treatment support for home-based COVID-19 patients | *Lockdown and travel restrictions imposed from time to time *Chronic illness and multimorbidity identified as vulnerable to COVID-19 | *Door-to-door surveillance of lung infection & comorbid chronic diseases Early diagnosis of COVID- 19 *COVID-19 vaccination was prioritised in older adults and those with multimorbidity *Rapid establishment of COVID-19 diagnostic labs across the state *Strengthening of healthcare facilities *Organising telemedicine consultations for all chronic diseases *Promoting the National digital health mission and emphasis on digital records | Lockdowns and travel restrictions less than before | *Extensive vaccination campaigns with a preference for older adults and those with multimorbidity *Widespread laboratory facilities set up for early COVID-19 identification and treatment * Health services were more intense than before NCD programmes resumed with a renewed focus |
