Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future

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Perry" }, { "@type": "Person", "name": "Mary R. Cahill" } ], "publisher": { "@type": "Organization", "name": "HRB Open Research", "logo": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 566, "width": 60 } }, "image": { "@type": "ImageObject", "url": "https://hrbopenresearch.org/img/AMP/HRB_image.png", "height": 1200, "width": 127 }, "description": " Background Implementation of public health measures during the first wave of the coronavirus disease (COVID-19) pandemic, including travel restrictions and physical distancing, may have impacted population behaviour in seeking medical care. Identifying factors associated with healthcare avoidance is important, especially for vulnerable groups. Methods A nationally representative cross-sectional telephone survey addressing the impact of public health restrictions on physical, mental and social wellbeing, was conducted during the first period of easing of COVID-19 restrictions in May and June 2020. Secondary data analysis of the dataset was carried out to examine the factors associated with self-reported deliberate/conscious avoidance of General Practitioner (G.P.) and hospital-based care. Poisson regression analyses were conducted to estimate risk ratios with robust variance estimation of the association between selected demographic and self-reported health factors and the risk of avoiding G.P. and hospital-based healthcare. Results Of the 969 participants, 152 (15.7%) deliberately avoided contacting their G.P. about non COVID-19 related concerns while 81 (8.4%) reported avoiding hospitals. In multivariate analyses, three groups, women (Rate Ratio(RR): 1.77, 95% Confidence Interval (CI): 1.30 – 2.43), individuals who reported experiencing an adverse life event within the previous 3 months (RR: 1.70, 95% CI: 1.27 – 2.28), and those with self-reported poor health status (trend p < 0.001) were more likely to report that they avoided contact with their G.P. Individuals at a higher risk of avoiding hospital-based care were older (trend with age, p = 0.063), those who tended to agree they were “likely to catch COVID-19” (trend p = 0.052), and those with self-reported poor health status (trend p <0.001). Conclusion These findings highlight the importance of public health awareness and education regarding accessing healthcare during a pandemic and should be considered in future pandemic preparedness. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/7-11/v2", "name": "Factors associated with self-reported healthcare utilization avoidance..." } } ] } Home Browse Factors associated with self-reported healthcare utilization avoidance... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Buggy P, Joyce M, Perry IJ and Cahill MR. Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.12688/hrbopenres.13829.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Revised Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] Padraig Buggy 1 , Mary Joyce https://orcid.org/0000-0003-0560-4260 2 , Ivan J. Perry 3 , Mary R. Cahill 4 Padraig Buggy 1 , Mary Joyce https://orcid.org/0000-0003-0560-4260 2 , Ivan J. Perry 3 , Mary R. Cahill 4 PUBLISHED 24 Oct 2025 Author details Author details 1 School of Medicine, University College Cork, Cork, County Cork, Ireland 2 National Suicide Research Foundation, Cork, County Cork, Ireland 3 School of Public Health, University College Cork, Cork, County Cork, Ireland 4 Department of Haematology, Cork University Hospital, University College Cork, Cork, Ireland Padraig Buggy Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation Mary Joyce Roles: Data Curation, Formal Analysis, Investigation, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ivan J. Perry Roles: Funding Acquisition, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Review & Editing Mary R. Cahill Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Coronavirus (COVID-19) collection. Abstract Background Implementation of public health measures during the first wave of the coronavirus disease (COVID-19) pandemic, including travel restrictions and physical distancing, may have impacted population behaviour in seeking medical care. Identifying factors associated with healthcare avoidance is important, especially for vulnerable groups. Methods A nationally representative cross-sectional telephone survey addressing the impact of public health restrictions on physical, mental and social wellbeing, was conducted during the first period of easing of COVID-19 restrictions in May and June 2020. Secondary data analysis of the dataset was carried out to examine the factors associated with self-reported deliberate/conscious avoidance of General Practitioner (G.P.) and hospital-based care. Poisson regression analyses were conducted to estimate risk ratios with robust variance estimation of the association between selected demographic and self-reported health factors and the risk of avoiding G.P. and hospital-based healthcare. Results Of the 969 participants, 152 (15.7%) deliberately avoided contacting their G.P. about non COVID-19 related concerns while 81 (8.4%) reported avoiding hospitals. In multivariate analyses, three groups, women (Rate Ratio(RR): 1.77, 95% Confidence Interval (CI): 1.30 – 2.43), individuals who reported experiencing an adverse life event within the previous 3 months (RR: 1.70, 95% CI: 1.27 – 2.28), and those with self-reported poor health status (trend p < 0.001) were more likely to report that they avoided contact with their G.P. Individuals at a higher risk of avoiding hospital-based care were older (trend with age, p = 0.063), those who tended to agree they were “likely to catch COVID-19” (trend p = 0.052), and those with self-reported poor health status (trend p <0.001). Conclusion These findings highlight the importance of public health awareness and education regarding accessing healthcare during a pandemic and should be considered in future pandemic preparedness. READ ALL READ LESS Keywords COVID-19, Health, Public Health, Hospital, General Practitioner, Healthcare avoidance Corresponding Author(s) Mary Joyce ( [email protected] ) Close Corresponding author: Mary Joyce Competing interests: No competing interests were disclosed. Grant information: Health Research Board [COV19-2020-117]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Buggy P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Buggy P, Joyce M, Perry IJ and Cahill MR. Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.12688/hrbopenres.13829.2 ) First published: 26 Feb 2024, 7 :11 ( https://doi.org/10.12688/hrbopenres.13829.1 ) Latest published: 25 Dec 2025, 7 :11 ( https://doi.org/10.12688/hrbopenres.13829.3 ) Revised Amendments from Version 1 We have updated the manuscript to address the feedback and suggestions of the reviewers. The main changes that have been made relate to data analyses: 1. We performed tests for trend to comprehensively explore associations between variables of interest and the outcome variables. 2. Based on these results, the multivariate analyses were re-run and the corresponding tables (4 & 5) have been updated accordingly. We have provided further detail and appropriate references in the Method section. We have revised the title to more accurately reflect the outcome variables which focused on healthcare utilisation avoidance. We have shorted the discussion related to blood cancer in the Discussion section. We have also made made some text edits throughout the manuscript to improve the overall readability of the paper. We have updated the manuscript to address the feedback and suggestions of the reviewers. The main changes that have been made relate to data analyses: 1. We performed tests for trend to comprehensively explore associations between variables of interest and the outcome variables. 2. Based on these results, the multivariate analyses were re-run and the corresponding tables (4 & 5) have been updated accordingly. We have provided further detail and appropriate references in the Method section. We have revised the title to more accurately reflect the outcome variables which focused on healthcare utilisation avoidance. We have shorted the discussion related to blood cancer in the Discussion section. We have also made made some text edits throughout the manuscript to improve the overall readability of the paper. See the authors' detailed response to the review by Anthony Kwame Morgan See the authors' detailed response to the review by Noel McCarthy See the authors' detailed response to the review by Arkalgud Ramaprasad READ REVIEWER RESPONSES  There is a newer version of this article available. Suppress this message for one day. Introduction The World Health Organization (WHO) declared coronavirus disease (COVID-19) a global pandemic in March 2020. Between March 1 st 2020, and January 7 th 2023, Ireland registered 1,697,775 COVID-19 cases and 8,309 deaths from COVID-19 1 . Ireland implemented a range of public health measures to suppress the spread of the virus, including instructions to stay at home, travel restrictions, and physical distancing, consistent with WHO and other international guidelines 2 . The focus of this research was on the impact of these measures on self-reported health seeking behaviour in the population. While it was anticipated that these measures would reduce presentations with non COVID-19 related illness in both primary care and hospital settings, the magnitude and distribution of these effects is not well described. A decrease in the number of attendances to Irish public hospitals providing emergency care was reported in March 2020 compared to January and February of the same year and compared with figures from March 2019 3 . This trend has also been reported in other countries. A study of one million medical admissions in the U.S. revealed a decline in non COVID-19 related admissions of 20% at the beginning of the pandemic between February and April 2020, including reductions in presentations of serious life-threatening conditions such as sepsis (25% reduction in the 3 month period), acute ST-elevation myocardial infarction (22%), and pneumonia (40%) 4 . A similar trend was observed in another US study, where during the pandemic, a 23% reduction was observed in ED presentations of myocardial infarction, 20% for strokes, and a 10% reduction in hyperglycaemic crises. The authors suggested that the most plausible explanation was that patients could not access care or avoided or delayed seeking care 5 . A study in the UK revealed that 45% of the population reported having potential malignancy-related symptoms during the pandemic (n=3025) and did not seek medical attention 6 . These findings suggest that individuals’ health-seeking behaviours changed during the pandemic, even in the context of significant conditions that would normally result in an emergency presentation to the hospital. In a further US-based study, higher COVID-19 risk perception was a strong predictor of medical avoidance 7 . Risk perception was assessed using participants’ responses to three questions in an online survey: risk of COVID-19 to their community, perceived risk of infection, and perceived severity if the respondent became infected. Significant predictors of higher risk perceptions included female sex, knowing someone with COVID-19, older age, and poorer health. In the aftermath of the pandemic, the consequences of health care avoidance became evident. A study in the US compared the first presentations of early- and late-stage breast and colorectal cancer before and during the COVID pandemic (comparing 2019 figures to 2020). That study reported a statistically significant decrease in the number of women presenting with stage 1 breast cancer but a significant increase in those presenting with stage 4 breast cancer during the pandemic. A continuation of this trend during the early months of 2021 was also observed 8 . A further study in the UK also demonstrated that patients presented with higher stages of breast cancer and more node-positive and metastatic disease on initial presentation and diagnosis in 2020 than in the pre-pandemic period in 2019 9 . This study aimed to examine the influence of socio-demographic factors, self-reported health status, health related behaviours and exposures, and COVID-19 risk perception on self-reported health-seeking behaviours, specifically the likelihood of avoiding primary care, i.e. general practice (G.P.) and hospital-based healthcare, in the Irish population during the initial stages of the COVID-19 pandemic. Methods Study design This study is based on secondary analyses of a larger study aimed at estimating the effects of public health measures in the Republic of Ireland during the COVID-19 pandemic 10 . A nationally representative cross-sectional telephone survey was conducted to assess knowledge, attitudes, and compliance with physical distancing measures as well as physical, mental, and social well-being. The survey was conducted between May 26 th – June 17 th , 2020, during the initial easing of restrictions in Ireland. The marketing company IPSOS MRBI conducted a telephone survey on behalf of the School of Public Health at UCC. Participants Participants in the survey were sampled from the general population. The inclusion criteria were as follows: aged ≥ 18 years, residing in Ireland, and having a telephone (landline or mobile telephone number). To achieve a nationally representative sample, surveys were conducted using random digit-dialling (approximately 80% mobile, 20% landline) with an estimated response rate of 43.6% based on non-operational and non-answering numbers 11 . Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey 12 . Measures The survey gathered information related to participants’ physical health, mental health, and social well-being as well as their socio-demographic characteristics 10 . A full list of the primary data items can be found in Troya et al. 2020 13 . The following sociodemographic variables were included in this secondary data analysis: gender, age group, education level, employment status, and income level. Health-related variables extracted included general health status, alcohol and tobacco consumption, recent stressful life events, participants’ perceptions of COVID-19 (as a serious illness), and perception of the likelihood of contracting the virus. During the pandemic, the Irish Government asked persons aged over 70 years and those highly vulnerable to COVID-19 infection for other reasons such as chronic disease to “cocoon”, i.e. remain confined to home with minimal face-to-face contact with those from outside their home. Data on whether participants cocooned during the restrictions and reasons for cocooning were also extracted from the dataset. A new variable was created to identify individuals who were at an increased risk of infection. This variable was created based on responses to the questions asked about cocooning. Individuals were categorized as having an increased risk of infection if they cocooned because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The outcome variables in these analyses were self-reported healthcare-avoidant behaviours specifically related to G.P. and hospital care based on the following questions: During the period of restricted movement/lockdown, have you done any of the following: “Deliberately/consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” and “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital .” Statistical analyses The statistical software packages IBM SPSS Version 27 and Stata Version 15.1 were used to analyse the data. Descriptive statistics summarized the selected sociodemographic characteristics as well as proportions of those who (a) avoided contact with G.P. and (b) avoided hospital-based healthcare. Poisson regression analyses were conducted to estimate the risk ratios and 95% CIs with robust variance estimation of the association between selected demographic factors, health- and lifestyle-related factors, and the risk of avoiding G.P. or hospital-based healthcare in both univariate and multivariate analyses. Survey commands were used and the estimates were weighted to account for the survey sampling design. The significance level was set at p < 0.05. In the multivariate analyses presented in Table 4 and Table 5 , each variable was adjusted for all of the other factors presented in these tables. There were a small number (<5) of ‘Don’t know’ responses for the following variables which were coded as missing and removed for the analyses: general health status, healthcare avoidance behaviours related to G.P. and hospital care. Ethics Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals (Ref: EMC4 (b)05/05/20) in April 2020. Informed verbal consent was obtained by the interviewer before proceeding with the survey. Further information regarding ethical considerations and informed consent can be found in Troya et al. 10 . Ethics approval for the secondary data analysis was obtained from the Clinical Research Ethics Committee of the Cork Teaching Hospitals in November 2021 (Ref: & ECM 3 (fff) 16/11/2021). Results Data from 969 participants were analysed. The sociodemographic characteristics of the participants are provided in Table 1 . Table 1. Socio-demographic characteristics of participants. Frequency (%) Gender Men 466 (48.1) Women 501 (51.7) Other 2 (0.2) Age group 18–29 years 167 (17.2) 30–39 years 167 (17.2) 40–49 years 182 (18.8) 50–59 years 157 (16.2) 60–69 years 157 (16.2) 70 years + 127 (13.1) Missing 12 (1.2) Highest level of education Primary Level 41 (4.2) Group/ Inter/ Junior Certificate 76 (7.8) Leaving Certificate 188 (19.4) Other Second Level/ PLC Cert or similar 92 (9.5) Third Level Degree/ Postgraduate Course 566 (58.4) Other/ don't know 6 (0.6) Employment status Working as employee (full-time or part-time) 500 (51.6) Self-employed 90 (9.3) Unemployed/ Seeking work 81 (8.4) Not working due to permanent illness/ disability 41 (4.2) Retired 186 (19.2) Full-time homemaker/ looking after family 29 (3.0) Student 34 (3.5) Other/ don't know 8 (0.8) Annual combined net income for household Under €19,999 115 (11.9) €20,000 to €29,999 109 (11.2) €30,000 to €49,999 227 (23.4) €50,000 to €79,999 206 (21.3) €80,000 or greater 128 (13.2) Don’t know/ Refused to answer 184 (19.0) There were similar proportions of men (48.1%) and women (51.7%). Participants ranged in age from 18–91 years, with a mean age of 47.9 (SD = 17.2). Over half of the sample had completed third-level education and worked as employees (either full-time or part-time). Healthcare seeking behaviour during COVID-19 restrictions Of the 969 participants, 152 (15.7%) reported that they deliberately/consciously avoided contact with their G.P. about non COVID-19 related concerns while 81 (8.4%) reported that they avoided going to the hospital with a non COVID-19 related concern or health problem. The sociodemographic characteristics of the participants who avoided G.P. and hospital-based healthcare are outlined in Table 2 . Table 2. Socio-demographic characteristics of participants who avoided G.P. and hospital-based healthcare. Avoided G.P. (n=152) N (%) Avoided hospital-based healthcare (n=81) N (%) Gender Men ( n = 466) 51 (10.9) 28 (6.0) Women ( n = 501) 100 (20.0) 53 (10.6) Age group 18–29 years ( n = 167) 23 (13.8) 7 (4.2) 30–39 years ( n = 167) 29 (17.4) 14 (8.4) 40–49 years ( n = 182) 37 (20.3) 16 (8.8) 50–59 years ( n = 157) 28 (17.8) 19 (12.1) 60–69 years ( n = 157) 20 (12.7) 7 (4.5) 70 years + ( n = 127) 13 (10.2) 17 (13.4) Highest level of education Primary Level & Group/ Inter/ Junior Certificate ( n = 117) 12 (10.3) 16 (13.7) Leaving Certificate ( n = 188) 27 (14.4) 19 (10.1) Other Second Level/ PLC Cert or similar ( n = 92) 11 (12.0) 8 (8.7) Third Level Degree/ Postgraduate Course ( n = 566) 101 (17.8) 38 (6.7) Employment status Working as employee (full-time or part-time) ( n = 500) 79 (15.8) 37 (7.4) Self-employed ( n = 90) 12 (13.3) 10 (11.1) Unemployed/ Seeking work ( n = 81) 18 (22.2) 3 (3.7) Not working due to permanent illness/ disability ( n = 41) 11 (26.8) 5 (12.2) Retired ( n = 186) 21 (11.3) 17 (9.1) Full-time homemaker/ looking after family ( n = 29) 6 (20.7) 5 (17.2) Student ( n = 34) 4 (11.8) 4 (11.8) One-fifth of all female participants ( n = 100; 20.0%) and those aged 40–49 years ( n = 37; 20.3%) reported avoiding contact with their G.P. More than a quarter of the participants who were not working due to illness/disability ( n = 11; 26.8%) also avoided contact with their G.P., although the overall number of participants in this grouping was small. Just over 10% of all female participants ( n = 53) and 13% of those aged 70 years and above ( n = 17) reported avoiding going to hospital for non COVID-19 related concerns. Table 3 shows data on self- reported health status, health related behaviours and exposures, perceived risk of COVID-19 and perceived susceptibility of contracting COVID-19 by self-reported health care avoidance status. Table 4 presents the findings from univariate and multivariate analyses on associations between these variables and avoidance of G.P. care. Similarly, Table 5 presents the findings from univariate and multivariate analyses on associations between these variables and avoidance of hospital care. Table 3. Health status, health related behaviours and exposures and COVID-19 risk perceptions of participants who avoided G.P. and hospital-based healthcare. Avoided G.P. (n=152) N (%) Avoided hospital-based healthcare (n=81) N (%) General health status Excellent ( n = 163) 17 (10.4) 7 (4.3) Very good ( n = 335) 48 (14.3) 18 (5.4) Good ( n = 321) 48 (15.0) 28 (8.7) Fair ( n = 118) 27 (22.9) 19 (16.1) Poor ( n = 31) 12 (38.7) 9 (29.0) Alcohol consumption Do not drink alcohol ( n = 227) 40 (17.6) 19 (8.4) Occasional drinker ( n = 471) 63 (13.4) 43 (9.1) Moderate drinker ( n = 251) 45 (17.9) 17 (6.8) Heavy drinker ( n = 20) 4 (20.0) 2 (10.0) Smoking Yes ( n = 151) 28 (18.5) 18 (11.9) No ( n = 818) 124 (15.2) 63 (7.7) Adverse life event (<3 months) Yes ( n = 287) 70 (24.4) 32 (11.1) No ( n = 682) 82 (12.0) 49 (7.2) Increased risk of infection Yes ( n = 56) 18 (32.1) 14 (25.0) No ( n = 910) 134 (14.7) 67 (7.3) Perceived likelihood of contracting coronavirus disease (COVID-19) Strongly agree ( n = 123) 21 (17.1) 12 (9.8) Tend to agree ( n = 292) 55 (18.8) 32 (11.0) Tend to disagree ( n = 365) 52 (14.2) 27 (7.4) Strongly disagree ( n = 165) 20 (12.1) 9 (5.5) Don’t know ( n = 24) 4 (16.7) 1 (4.2) Perceived likelihood that COVID-19 would be serious illness Strongly agree ( n = 406) 69 (17.0) 48 (11.8) Tend to agree ( n = 283) 52 (18.4) 19 (6.7) Tend to disagree ( n = 199) 19 (9.5) 11 (5.5) Strongly disagree ( n = 68) 10 (14.7) 3 (4.4) Don’t know ( n = 13) 2 (15.4) 0 (0) Female gender, self-reported health status and an adverse life event in the preceding 3-months were associated with avoidance of G.P. care in both univariate and multivariate analyses, whereas the association with increased risk of infection observed in univariate analyses was not observed in multivariate analyses, reflecting collinearity with self-reported health status, Table 4 . Table 4. Risk ratios (RR) for factors associated with self-reported avoidance of GP based healthcare in univariate and multivariate analyses. Univariate Multivariate Variable Risk ratio (confidence interval) P value Risk ratio (confidence interval) P value Gender Men Reference Women 2.03 (1.41 – 2.93) <0.001 1.77 (1.30 – 2.43) <0.001 Age group 18–29 Reference 30–39 1.32 (0.73 – 2.39) 0.366 1.36 (0.83 – 2.23) 0.223 40–49 1.62 (0.92 – 2.86) 0.097 1.49 (0.91 – 2.43) 0.110 50–59 1.37 (0.75 – 2.50) 0.305 1.14 (0.67 – 1.93) 0.628 60–69 0.91 (0.48 – 1.74) 0.784 0.90 (0.50 – 1.61) 0.722 70–100 0.71 (0.35 – 1.47) 0.361 0.70 (0.36 - 1.35) 0.282 Trend 0.94 (0.84 – 1.04) 0.218 0.92 (0.84 – 1.01) 0.085 Self-rated health status Excellent Reference Very good 1.45 (0.80 – 2.60) 0.219 1.35 (0.81 – 2.26) 0.250 Good 1.52 (0.84 – 2.73) 0.166 1.29 (0.76 – 2.21) 0.347 Fair 2.55 (1.32 – 4.93) 0.006 1.95 (1.05 – 3.61) 0.033 Poor 5.42 (2.25 – 13.08) <0.001 2.83 (1.32 – 6.09) 0.008 Trend 1.39 (1.18 – 1.65) <0.001 1.21 (1.02 – 1.43) 0.025 Alcohol consumption Do not drink Reference Occasional drinker 0.72 (0.46 – 1.10) 0.130 0.68 (0.47 – 0.97) 0.035 Moderate drinker 1.01 (0.63 – 1.62) 0.966 1.13 (0.77 – 1.67) 0.525 Heavy drinker 1.16 (0.37 – 3.64) 0.804 0.79 (0.26 – 2.41) 0.678 Smoking No Reference Yes 1.28 (0.81 – 2.01) 0.284 1.07 (0.74 – 1.56) 0.711 Adverse life event (<3 months) No Reference Yes 2.38 (1.67 – 3.39) <0.001 1.70 (1.27 – 2.28) <0.001 Increased risk of infection No Reference Yes 2.74 (1.52 – 4.95) 0.001 1.24 (0.75 – 2.08) 0.402 COVID would be a serious illness for me Strongly disagree Reference Tend to disagree 0.61 (0.27 – 1.39) 0.241 0.44 (0.22 – 0.91) 0.027 Tend to agree 1.32 (0.63 – 2.75) 0.463 0.91 (0.47 – 1.75) 0.776 Strongly agree 1.19 (0.58 – 2.45) 0.634 0.86 (0.44 – 1.70) 0.672 Trend 1.19 (0.98 – 1.44) 0.078 1.14 (0.94 – 1.37) 0.186 I am likely to catch COVID Strongly disagree Reference Tend to disagree 1.20 (0.69 – 2.09) 0.509 1.19 (0.72 – 1.90) 0.494 Tend to agree 1.69 (0.97 – 2.93) 0.063 1.56 (0.94 – 2.58) 0.085 Strongly agree 1.52 (0.78 – 2.96) 0.214 1.21 (0.65 – 2.23) 0.544 Trend 1.20 (0.99 – 1.45) 0.062 1.09 (0.93 – 1.28) 0.305 In univariate analyses, the following factors were associated with avoidance of hospital-based care: female gender, older age-group, poorer self-reported health status, an adverse life event in the preceding 3-months and those at an increased risk of infection, Table 5 . In multivariate analyses, only individuals aged over 70 years were more likely to report avoidance of hospital-based care and the overall trend with age was non-significant. Poor self-rated health status was the only other factor that remained significant (trend p = 0.004), Table 5 . Table 5. Risk ratios (RR) for factors associated with self-reported avoidance of hospital-based healthcare in univariate and multivariate analyses. Crude Adjusted Variable Risk ratio (confidence interval) P value Risk ratio (confidence interval) P value Gender Men Reference Women 1.85 (1.15 - 2.99) 0.011 1.50 (0.94 – 2.41) 0.091 Age 18–29 Reference 30–39 2.11 (0.83 – 5.36) 0.118 1.87 (0.81 – 4.31) 0.144 40–49 2.20 (0.88 – 5.50) 0.090 1.83 (0.80 – 4.20) 0.151 50–59 3.15 (1.28 – 7.71) 0.012 2.08 (0.94 – 4.60) 0.072 60–69 1.07 (0.37 – 3.11) 0.906 0.82 (0.30 – 2.23) 0.694 70–100 3.53 (1.42 – 8.80) 0.007 2.42 (1.08 – 5.44) 0.032 Trend 1.14 (0.99 – 1.31) 0.063 1.08 (0.95 – 1.23) 0.241 Health status * Excellent Reference Very good 1.27 (0.52 - 3.10) 0.601 1.14 (0.48 – 2.60) 0.768 Good 2.13 (0.91 - 4.99) 0.082 1.69 (0.73 – 3.93) 0.220 Fair 4.28 (1.73 - 10.55) 0.002 2.42 (0.98 – 6.00) 0.056 Poor 9.12 (3.08 - 26.95) <0.000 3.46 (1.30 – 9.10) 0.013 Trend 1.78 (1.42 – 2.26) <0.001 1.38 (1.11 -1.71) 0.004 Alcohol consumption Do not drink Reference Occasional drinker 1.10 (0.63 – 1.93) 0.741 1.18 (0.71 – 1.96) 0.512 Moderate drinker 0.80 (0.40 – 1.58) 0.517 0.98 (0.52 – 1.80) 0.951 Heavy drinker 1.22 (0.26 – 5.64) 0.802 1.11 (0.30 – 4.06) 0.873 Smoking No Reference Yes 1.62 (0.93 – 2.82) 0.089 1.49 (0.88 – 2.55) 0.141 Adverse life event (<3 months) No Reference Yes 1.62 (1.01 – 2.59) 0.044 1.28 (0.83 – 1.97) 0.269 Increased risk of infection No Reference Yes 4.20 (2.19 – 8.09) <0.001 1.57 (0.86 – 2.87) 0.140 COVID would be a serious illness for me Strongly disagree Reference Tend to disagree 1.27 (0.34 – 4.69) 0.722 0.69 (0.19 – 2.45) 0.563 Tend to agree 1.57 (0.45 – 5.45) 0.481 0.74 (0.22 – 2.46) 0.624 Strongly agree 2.91 (0.88 – 9.61) 0.081 1.14 (0.35 – 3.75) 0.825 Trend 1.52 (1.16 – 2.01) 0.003 1.18 (0.87 – 1.61) 0.287 I am likely to catch COVID Strongly disagree Reference Tend to disagree 1.39 (0.64 – 3.02) 0.408 1.87 (0.85 – 4.10) 0.118 Tend to agree 2.13 (0.99 – 4.59) 0.052 2.71 (1.20 – 6.10) 0.016 Strongly agree 1.87 (0.76 – 4.60) 0.170 1.81 (0.76 – 4.33) 0.182 Trend 1.28 (1.00 – 1.64) 0.052 1.21 (0.99 – 1.48) 0.061 Discussion This study of sociodemographic and health related factors associated with self-reported healthcare avoidance during the initial months of the COVID pandemic in Ireland has a number of significant findings with actionable lessons for the future. Women, those with self-reported poorer health status and those reporting the experience of an adverse life event in the previous three months, were at a higher risk of avoiding contact with their G.P. about non COVID-19 related concerns. Individuals at a higher risk of avoiding hospital-based care were those aged 70 years or older and who had poorer self-reported health status. These findings are similar to those from a US study, in which women, older adults and those with a higher perceived risk of infection which likely reflects poorer self-assessed health status were more likely to avoid seeking healthcare 7 . The findings are also consistent with those from a cross-sectional study embedded within the ongoing population-based Rotterdam Cohort Study. In the latter study, women and individuals with lower perceived overall health and mental health issues (depression and anxiety) avoided seeking hospital-based healthcare, even when these groups had potentially serious symptoms (limb weakness, palpitations, and chest pain) 14 . There is also evidence from a UK study of failure to seek medical attention during the pandemic among individuals with potential malignancy-related symptoms 6 . Thus the findings from this study complement and extend the available international literature on the impact of stay-at-home orders and related public health measures in response to a pandemic on healthcare utilisation avoidance in the population. In particular, the findings augment the available evidence that the adverse effects of public health restrictions are more pronounced in those at greatest need for healthcare. For individuals to feel safe and able to access healthcare in future pandemics in Ireland, it is crucial that we note and learn the lessons from our experience with COVID-19. It seems clear that a significant proportion of vulnerable individuals weigh the risk of attending hospitals or GP surgery as higher than the risk of remaining at home with potentially serious issues. Post-pandemic studies have shown that these issues include late-stage, potentially curable, cancers 8 . In Ireland, the National Cancer Registry reported a 10% shortfall in expected new diagnoses of cancer in 2020, improving to a 6% shortfall in 2021 15 . These issues may be especially relevant to patients with blood cancer, where the nature of the cancer, which affects the bone marrow and immune system, means that they are the most vulnerable group to opportunistic infections. Our data provide important information specific to Ireland on behaviours during the pandemic. Because this study was carried out during periods of lockdown, recall bias was minimized and respondents answered regarding behaviours in real time. These valuable data provide the basis for targeted campaigns, specific information, and encouragement for vulnerable groups to help improve outcomes in future pandemics. The findings from this study suggest that people who may be most in need of health care are those who are least likely to access it. This study had several limitations. The estimated response rate, although relatively high for a population-based telephone survey (43.6%), is clearly sub-optimal and the weighted sample of respondents may not be adequately representative of the underlying base population. In particular, it is likely that specific vulnerable sub-groups such as the homeless community are underrepresented in the study. Lessons can be drawn for future pandemic preparedness in Ireland. Our data supports the use of advance planning to target vulnerable groups with appropriate public information campaigns on the appropriate response to potentially significant symptoms and concerns. Planning could also include work on the infrastructure required to pivot quickly to telephone clinics and video consultations, including work on data sharing issues, where appropriate. Data availability Underlying data Zenodo: Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future. https://doi.org/10.5281/zenodo.10073077 12 This project contains the following underlying data: National Household Survey – Wave 1, Ver. 2.sav Extended data Harvard Dataverse: Questionnaires for Surveys WP1 and WP2. https://doi.org/10.7910/DVN/EKUTFF 11 This project contains the following extended data: Survey 1 questionnaire in DOCX format (Appendix I) Survey 2 questionnaire in DOCX format (Appendix II) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0). Acknowledgments We would like to thank Dr. Ali Khashan and Dr Paul Corcoran for providing statistical guidance for the analyses conducted in this study. Faculty Opinions recommended References 1. Report on COVID-19 deaths reported in Ireland. Report produced by Health Protection Surveillance Centre. on 09/01/2023- Health Protection Surveillance Centre. Reference Source 2. World Health Organization: Considerations in adjusting public health and social measures in the context of Covid-19: interim guidance. 2020; Accessed June 2, 2020. Reference Source 3. Sharp fall in emergency department attendances at the start of the COVID-19 crisis in Ireland. ESRI. 2021; [cited 29 May 2021]. 4. Birkmeyer J, Barnato A, Birkmeyer N, et al. : The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020; 39 (11): 2010–2017. PubMed Abstract | Publisher Full Text | Free Full Text 5. Lange SJ, Ritchey MD, Goodman AB, et al. : Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions - United States, January-May 2020. Am J Transplant. 2020; 20 (9): 2612–2617. PubMed Abstract | Publisher Full Text | Free Full Text 6. Quinn-Scoggins HD, Cannings-John R, Moriarty Y, et al. : Cancer symptom experience and help-seeking behaviour during the COVID-19 pandemic in the UK: a cross-sectional population survey. BMJ Open. 2021; 11 (9): e053095. PubMed Abstract | Publisher Full Text | Free Full Text 7. Lu P, Kong D, Shelley M: Risk perception, preventive behavior, and medical care avoidance among American older adults during the COVID-19 pandemic. J Aging Health. 2021; 33 (7–8): 577–584. PubMed Abstract | Publisher Full Text 8. Zhou JZ, Kane S, Ramsey C, et al. : Comparison of early- and late-stage breast and colorectal cancer diagnoses during vs before the COVID-19 pandemic. JAMA Netw Open. 2022; 5 (2): e2148581. PubMed Abstract | Publisher Full Text | Free Full Text 9. Borsky K, Shah K, Cunnick G, et al. : Pattern of breast cancer presentation during the COVID-19 pandemic: results from a cohort study in the UK. Future Oncol. 2022; 18 (4): 437–443. PubMed Abstract | Publisher Full Text | Free Full Text 10. Troya MI, Khashan A, Kearney P, et al. : Covid-19 Estimating the burden of symptomatic disease in the community and the impact of public health measures on physical, mental and social wellbeing: a study protocol [version 1; peer review: 2 approved]. HRB Open Res. 2020; 3 : 49. PubMed Abstract | Publisher Full Text | Free Full Text 11. Troya MI, Joyce M, Khashan A, et al. : Mental health following an initial period of COVID-19 restrictions: findings from a cross-sectional survey in the Republic of Ireland [version 2; peer review: 2 approved]. HRB Open Res. 2022; 4 : 130. PubMed Abstract | Publisher Full Text | Free Full Text 12. Central Statistics Office: Labour force survey. 2020; (22 June 2021, date last accessed). 13. Troya MI: Questionnaires and Information Sheets for Surveys WP1 and WP2. [Dataset]. Harvard Dataverse, V2, 2020. http://www.doi.org/10.7910/DVN/EKUTFF 14. Splinter M, Velek P, Ikram M, et al. : Prevalence and determinants of healthcare avoidance during the COVID-19 pandemic: a population-based cross-sectional study. PLoS Med. 2021; 18 (11): e1003854. PubMed Abstract | Publisher Full Text | Free Full Text 15. Tierney P, McDevitt J, Brennan A, et al. : Covid-19 impact on cancer incidence in Ireland in 2021; a preliminary analysis. The National Cancer Registry, Cork, Ireland. Reference Source Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 26 Feb 2024 ADD YOUR COMMENT Comment Author details Author details 1 School of Medicine, University College Cork, Cork, County Cork, Ireland 2 National Suicide Research Foundation, Cork, County Cork, Ireland 3 School of Public Health, University College Cork, Cork, County Cork, Ireland 4 Department of Haematology, Cork University Hospital, University College Cork, Cork, Ireland Padraig Buggy Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation Mary Joyce Roles: Data Curation, Formal Analysis, Investigation, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ivan J. Perry Roles: Funding Acquisition, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Review & Editing Mary R. Cahill Roles: Conceptualization, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board [COV19-2020-117]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (3) version 3 Revised Published: 25 Dec 2025, 7:11 https://doi.org/10.12688/hrbopenres.13829.3 version 2 Revised Published: 24 Oct 2025, 7:11 https://doi.org/10.12688/hrbopenres.13829.2 version 1 Published: 26 Feb 2024, 7:11 https://doi.org/10.12688/hrbopenres.13829.1 Copyright © 2025 Buggy P et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. 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HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50942 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50942 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 21 Nov 2025 Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, IL, USA Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15553.r50942 The authors have addressed one of my comments well but decided that addressing the second is beyond ... Continue reading READ ALL The authors have addressed one of my comments well but decided that addressing the second is beyond the scope of the paper. I defer to the authors' judgment and accept the paper without reservation. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Healthcare, information systems, ontologies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ramaprasad A. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50942 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50942 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Morgan AK. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50944 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50944 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 08 Nov 2025 Anthony Kwame Morgan , Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15553.r50944 The revisions have ... Continue reading READ ALL The revisions have been integrated. Thank you. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health services research, ageing, geriatrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Morgan AK. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50944 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50944 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: McCarthy N. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50943 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50943 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 08 Nov 2025 Noel McCarthy , Trinity College Dublin, Dublin, Ireland; University of Warwick, Coventry, England, UK Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15553.r50943 Recommended changes on more explicit description of methods were not made. This ... Continue reading READ ALL Recommended changes on more explicit description of methods were not made. This is in the context of approving the work overall at the first stage. Competing Interests: No competing interests were disclosed. Reviewer Expertise: Epidemiology, I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT McCarthy N. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50943 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50943 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 26 Feb 2024 Views 0 Cite How to cite this report: Ramaprasad A. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39734 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39734 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 31 May 2024 Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, IL, USA Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15148.r39734 The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; ... Continue reading READ ALL The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model. The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Healthcare, information systems, ontologies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ramaprasad A. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39734 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39734 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper ... Continue reading The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. Response: We thank the reviewer for these insightful comments and we fully accept the thrust of his argument that the paper is primarily descriptive with limited explanatory value. In the title of the revised manuscript we have substituted factors influencing.. with factors associated with…., as detailed in the response to reviewer #2. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model.The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Response: Response to points 2 & 3: While we agree that the suggested conceptual models would be interesting and useful, we believe that they are beyond the scope of the current paper. The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. Response: We thank the reviewer for these insightful comments and we fully accept the thrust of his argument that the paper is primarily descriptive with limited explanatory value. In the title of the revised manuscript we have substituted factors influencing.. with factors associated with…., as detailed in the response to reviewer #2. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model.The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Response: Response to points 2 & 3: While we agree that the suggested conceptual models would be interesting and useful, we believe that they are beyond the scope of the current paper. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper ... Continue reading The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. Response: We thank the reviewer for these insightful comments and we fully accept the thrust of his argument that the paper is primarily descriptive with limited explanatory value. In the title of the revised manuscript we have substituted factors influencing.. with factors associated with…., as detailed in the response to reviewer #2. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model.The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Response: Response to points 2 & 3: While we agree that the suggested conceptual models would be interesting and useful, we believe that they are beyond the scope of the current paper. The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. Response: We thank the reviewer for these insightful comments and we fully accept the thrust of his argument that the paper is primarily descriptive with limited explanatory value. In the title of the revised manuscript we have substituted factors influencing.. with factors associated with…., as detailed in the response to reviewer #2. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model.The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Response: Response to points 2 & 3: While we agree that the suggested conceptual models would be interesting and useful, we believe that they are beyond the scope of the current paper. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Morgan AK. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39062 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39062 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 May 2024 Anthony Kwame Morgan , Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana Not Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15148.r39062 I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your ... Continue reading READ ALL I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health services research, ageing, geriatrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Morgan AK. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39062 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39062 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection ... Continue reading I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Response: We thank the reviewer for this observation. The focus of the study was on healthcare utilisation avoidance, based on responses to the following two questions: During the period of restricted movement / lockdown, have you done any of the following? - “Deliberately / consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” - “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital.” In the revised manuscript we have changed the title from “ Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future ” to “ Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future”. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Response: The primary focus of this paper is on the magnitude and distribution of the effects of pandemic restrictions on health care utilisation avoidance. In the current manuscript, we refer briefly in the discussion to the likely impact on behaviour of differential weighting of the risk of staying at home versus presenting for primary or secondary care and the associated need for relevant public information campaigns. We believe that further speculation on psychological determinants of health care avoidance and the relevant behaviour change implications of the findings is beyond the scope of this paper. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Response: We have carefully reviewed and revised the manuscript in the light of these comments. I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Response: We thank the reviewer for this observation. The focus of the study was on healthcare utilisation avoidance, based on responses to the following two questions: During the period of restricted movement / lockdown, have you done any of the following? - “Deliberately / consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” - “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital.” In the revised manuscript we have changed the title from “ Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future ” to “ Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future”. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Response: The primary focus of this paper is on the magnitude and distribution of the effects of pandemic restrictions on health care utilisation avoidance. In the current manuscript, we refer briefly in the discussion to the likely impact on behaviour of differential weighting of the risk of staying at home versus presenting for primary or secondary care and the associated need for relevant public information campaigns. We believe that further speculation on psychological determinants of health care avoidance and the relevant behaviour change implications of the findings is beyond the scope of this paper. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Response: We have carefully reviewed and revised the manuscript in the light of these comments. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection ... Continue reading I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Response: We thank the reviewer for this observation. The focus of the study was on healthcare utilisation avoidance, based on responses to the following two questions: During the period of restricted movement / lockdown, have you done any of the following? - “Deliberately / consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” - “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital.” In the revised manuscript we have changed the title from “ Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future ” to “ Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future”. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Response: The primary focus of this paper is on the magnitude and distribution of the effects of pandemic restrictions on health care utilisation avoidance. In the current manuscript, we refer briefly in the discussion to the likely impact on behaviour of differential weighting of the risk of staying at home versus presenting for primary or secondary care and the associated need for relevant public information campaigns. We believe that further speculation on psychological determinants of health care avoidance and the relevant behaviour change implications of the findings is beyond the scope of this paper. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Response: We have carefully reviewed and revised the manuscript in the light of these comments. I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Response: We thank the reviewer for this observation. The focus of the study was on healthcare utilisation avoidance, based on responses to the following two questions: During the period of restricted movement / lockdown, have you done any of the following? - “Deliberately / consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” - “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital.” In the revised manuscript we have changed the title from “ Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future ” to “ Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future”. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Response: The primary focus of this paper is on the magnitude and distribution of the effects of pandemic restrictions on health care utilisation avoidance. In the current manuscript, we refer briefly in the discussion to the likely impact on behaviour of differential weighting of the risk of staying at home versus presenting for primary or secondary care and the associated need for relevant public information campaigns. We believe that further speculation on psychological determinants of health care avoidance and the relevant behaviour change implications of the findings is beyond the scope of this paper. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Response: We have carefully reviewed and revised the manuscript in the light of these comments. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: McCarthy N. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39055 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39055 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 May 2024 Noel McCarthy , Trinity College Dublin, Dublin, Ireland; University of Warwick, Coventry, England, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15148.r39055 This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as ... Continue reading READ ALL This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Epidemiology, I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT McCarthy N. Reviewer Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39055 ) The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39055 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the ... Continue reading We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the reviewers comments below and outline how these have been addressed in the revised paper. Response to Noel McCarthy This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Response: We apologise for the lack of information and confusion created about the weights. This information was originally outlined in Troya et al. (2022) but was inadvertently omitted from this manuscript. Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey. We applied the same weights for this analysis. The manuscript has been updated to include this information. We now cite both the Troya 2022 paper and the Irish Labour Force Survey in the Methods section. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. Response: We thank the reviewer for this observation. In the first instance we should clarify that the “risk of infection” variable is based on objective criteria, specifically cocooning because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The definition of this variable is now clearly described in the Measures section of the Method. As one would anticipate, this variable is highly correlated with self-rated health status, with those characterised as at increased risk of infection more likely to rate their health as ‘fair’ or ‘poor’ when compared with those not at increased risk of infection, see table below: Increased risk of infection Health Status No (n = 913) Yes (n = 56) Total (n = 968) Excellent 163 (18%) 0 (0%) 163 (17%) Very Good 325 (36%) 10 (18%) 335 (35%) Good 307 (34%) 14 (25%) 321 (33%) Fair 100 (11%) 18 (32%) 118 (12%) Poor 18 (2%) 13 (23%) 31 (3%) Each of these variables (self-rated health status and increased risk of infection) was associated with GP and hospital avoidance in multivariate analyses when the other variable was excluded. However, in multivariate analyses with inclusion of both variables, only self-rated health status was associated with GP and hospital avoidance. With the benefit of hindsight, we made assumptions about multicollinearity in the data that were not adequately tested, and it is now clear that self-rated health is an important predictor of GP and hospital avoidance in these data. The relevant text in the manuscript, including the abstract, has been revised accordingly. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. Response: We agree with the reviewer that we should have tested for and reported on the overall association with the COVID-19 susceptibility variable and age in these analyses. In further analyses which included tests for linear trend, age and COVID-19 susceptibility was non-significant for G.P. avoidance and hospital avoidance. The relevant text in the manuscript, including the abstract, has been revised accordingly. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Response: We understand that the reference to patients with blood cancer in the discussion seems arbitrary and that the “actionable lessons for the future” that arise from these data apply to all patient groups. However, in the overall context of cancer care during a pandemic, we believe that the unique vulnerability of patients with blood cancers arising from the bone marrow and immune system merits highlighting. This specific issue is not generally understood and appreciated. However, in the revised manuscript, the relevant section has been shortened considerably. We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the reviewers comments below and outline how these have been addressed in the revised paper. Response to Noel McCarthy This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Response: We apologise for the lack of information and confusion created about the weights. This information was originally outlined in Troya et al. (2022) but was inadvertently omitted from this manuscript. Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey. We applied the same weights for this analysis. The manuscript has been updated to include this information. We now cite both the Troya 2022 paper and the Irish Labour Force Survey in the Methods section. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. Response: We thank the reviewer for this observation. In the first instance we should clarify that the “risk of infection” variable is based on objective criteria, specifically cocooning because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The definition of this variable is now clearly described in the Measures section of the Method. As one would anticipate, this variable is highly correlated with self-rated health status, with those characterised as at increased risk of infection more likely to rate their health as ‘fair’ or ‘poor’ when compared with those not at increased risk of infection, see table below: Increased risk of infection Health Status No (n = 913) Yes (n = 56) Total (n = 968) Excellent 163 (18%) 0 (0%) 163 (17%) Very Good 325 (36%) 10 (18%) 335 (35%) Good 307 (34%) 14 (25%) 321 (33%) Fair 100 (11%) 18 (32%) 118 (12%) Poor 18 (2%) 13 (23%) 31 (3%) Each of these variables (self-rated health status and increased risk of infection) was associated with GP and hospital avoidance in multivariate analyses when the other variable was excluded. However, in multivariate analyses with inclusion of both variables, only self-rated health status was associated with GP and hospital avoidance. With the benefit of hindsight, we made assumptions about multicollinearity in the data that were not adequately tested, and it is now clear that self-rated health is an important predictor of GP and hospital avoidance in these data. The relevant text in the manuscript, including the abstract, has been revised accordingly. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. Response: We agree with the reviewer that we should have tested for and reported on the overall association with the COVID-19 susceptibility variable and age in these analyses. In further analyses which included tests for linear trend, age and COVID-19 susceptibility was non-significant for G.P. avoidance and hospital avoidance. The relevant text in the manuscript, including the abstract, has been revised accordingly. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Response: We understand that the reference to patients with blood cancer in the discussion seems arbitrary and that the “actionable lessons for the future” that arise from these data apply to all patient groups. However, in the overall context of cancer care during a pandemic, we believe that the unique vulnerability of patients with blood cancers arising from the bone marrow and immune system merits highlighting. This specific issue is not generally understood and appreciated. However, in the revised manuscript, the relevant section has been shortened considerably. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 27 Oct 2025 Mary Joyce , National Suicide Research Foundation, Cork, Ireland 27 Oct 2025 Author Response We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the ... Continue reading We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the reviewers comments below and outline how these have been addressed in the revised paper. Response to Noel McCarthy This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Response: We apologise for the lack of information and confusion created about the weights. This information was originally outlined in Troya et al. (2022) but was inadvertently omitted from this manuscript. Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey. We applied the same weights for this analysis. The manuscript has been updated to include this information. We now cite both the Troya 2022 paper and the Irish Labour Force Survey in the Methods section. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. Response: We thank the reviewer for this observation. In the first instance we should clarify that the “risk of infection” variable is based on objective criteria, specifically cocooning because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The definition of this variable is now clearly described in the Measures section of the Method. As one would anticipate, this variable is highly correlated with self-rated health status, with those characterised as at increased risk of infection more likely to rate their health as ‘fair’ or ‘poor’ when compared with those not at increased risk of infection, see table below: Increased risk of infection Health Status No (n = 913) Yes (n = 56) Total (n = 968) Excellent 163 (18%) 0 (0%) 163 (17%) Very Good 325 (36%) 10 (18%) 335 (35%) Good 307 (34%) 14 (25%) 321 (33%) Fair 100 (11%) 18 (32%) 118 (12%) Poor 18 (2%) 13 (23%) 31 (3%) Each of these variables (self-rated health status and increased risk of infection) was associated with GP and hospital avoidance in multivariate analyses when the other variable was excluded. However, in multivariate analyses with inclusion of both variables, only self-rated health status was associated with GP and hospital avoidance. With the benefit of hindsight, we made assumptions about multicollinearity in the data that were not adequately tested, and it is now clear that self-rated health is an important predictor of GP and hospital avoidance in these data. The relevant text in the manuscript, including the abstract, has been revised accordingly. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. Response: We agree with the reviewer that we should have tested for and reported on the overall association with the COVID-19 susceptibility variable and age in these analyses. In further analyses which included tests for linear trend, age and COVID-19 susceptibility was non-significant for G.P. avoidance and hospital avoidance. The relevant text in the manuscript, including the abstract, has been revised accordingly. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Response: We understand that the reference to patients with blood cancer in the discussion seems arbitrary and that the “actionable lessons for the future” that arise from these data apply to all patient groups. However, in the overall context of cancer care during a pandemic, we believe that the unique vulnerability of patients with blood cancers arising from the bone marrow and immune system merits highlighting. This specific issue is not generally understood and appreciated. However, in the revised manuscript, the relevant section has been shortened considerably. We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the reviewers comments below and outline how these have been addressed in the revised paper. Response to Noel McCarthy This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Response: We apologise for the lack of information and confusion created about the weights. This information was originally outlined in Troya et al. (2022) but was inadvertently omitted from this manuscript. Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey. We applied the same weights for this analysis. The manuscript has been updated to include this information. We now cite both the Troya 2022 paper and the Irish Labour Force Survey in the Methods section. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. Response: We thank the reviewer for this observation. In the first instance we should clarify that the “risk of infection” variable is based on objective criteria, specifically cocooning because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The definition of this variable is now clearly described in the Measures section of the Method. As one would anticipate, this variable is highly correlated with self-rated health status, with those characterised as at increased risk of infection more likely to rate their health as ‘fair’ or ‘poor’ when compared with those not at increased risk of infection, see table below: Increased risk of infection Health Status No (n = 913) Yes (n = 56) Total (n = 968) Excellent 163 (18%) 0 (0%) 163 (17%) Very Good 325 (36%) 10 (18%) 335 (35%) Good 307 (34%) 14 (25%) 321 (33%) Fair 100 (11%) 18 (32%) 118 (12%) Poor 18 (2%) 13 (23%) 31 (3%) Each of these variables (self-rated health status and increased risk of infection) was associated with GP and hospital avoidance in multivariate analyses when the other variable was excluded. However, in multivariate analyses with inclusion of both variables, only self-rated health status was associated with GP and hospital avoidance. With the benefit of hindsight, we made assumptions about multicollinearity in the data that were not adequately tested, and it is now clear that self-rated health is an important predictor of GP and hospital avoidance in these data. The relevant text in the manuscript, including the abstract, has been revised accordingly. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. Response: We agree with the reviewer that we should have tested for and reported on the overall association with the COVID-19 susceptibility variable and age in these analyses. In further analyses which included tests for linear trend, age and COVID-19 susceptibility was non-significant for G.P. avoidance and hospital avoidance. The relevant text in the manuscript, including the abstract, has been revised accordingly. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Response: We understand that the reference to patients with blood cancer in the discussion seems arbitrary and that the “actionable lessons for the future” that arise from these data apply to all patient groups. However, in the overall context of cancer care during a pandemic, we believe that the unique vulnerability of patients with blood cancers arising from the bone marrow and immune system merits highlighting. This specific issue is not generally understood and appreciated. However, in the revised manuscript, the relevant section has been shortened considerably. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 3 VERSION 3 PUBLISHED 26 Feb 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 Version 3 (revision) 25 Dec 25 read Version 2 (revision) 24 Oct 25 read read read Version 1 26 Feb 24 read read read Noel McCarthy , Trinity College Dublin, Dublin, Ireland; University of Warwick, Coventry, UK Anthony Kwame Morgan , Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, USA Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Dec 2025 | for Version 3 Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, IL, USA 0 Views copyright © 2026 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The revisions are satisfactory. Thank you, Competing Interests No competing interests were disclosed. Reviewer Expertise Healthcare, information systems, ontologies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Ramaprasad A. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15766.r52454) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v3#referee-response-52454 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Nov 2025 | for Version 2 Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, IL, USA 0 Views copyright © 2025 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have addressed one of my comments well but decided that addressing the second is beyond the scope of the paper. I defer to the authors' judgment and accept the paper without reservation. Competing Interests No competing interests were disclosed. Reviewer Expertise Healthcare, information systems, ontologies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Ramaprasad A. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50942) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50942 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Morgan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 Nov 2025 | for Version 2 Anthony Kwame Morgan , Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana 0 Views copyright © 2025 Morgan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The revisions have been integrated. Thank you. Competing Interests No competing interests were disclosed. Reviewer Expertise Health services research, ageing, geriatrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Morgan AK. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50944) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50944 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 McCarthy N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 08 Nov 2025 | for Version 2 Noel McCarthy , Trinity College Dublin, Dublin, Ireland; University of Warwick, Coventry, England, UK 0 Views copyright © 2025 McCarthy N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Recommended changes on more explicit description of methods were not made. This is in the context of approving the work overall at the first stage. Competing Interests No competing interests were disclosed. Reviewer Expertise Epidemiology, I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) McCarthy N. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15553.r50943) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v2#referee-response-50943 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 31 May 2024 | for Version 1 Arkalgud Ramaprasad , University of Illinois at Chicago, Chicago, IL, USA 0 Views copyright © 2024 Ramaprasad A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model. The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Healthcare, information systems, ontologies I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 27 Oct 2025 Mary Joyce, National Suicide Research Foundation, Cork, Ireland The title of the paper is: “Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future.” The strength of the paper is its description of the factors influencing the object of the study; the weakness is that it does not explore or explain how these factors exert their influence. How do these factors result in drivers of access, set norms for access, or barriers to access? Thus, while the descriptive value of the research is high, its explanatory value is low. Consequently, its predictive value for managing access in the future, intervention value for improving access in the future through feedback is low. Thus, the paper as is it now is more about factors describing … and not factors influencing…. Response: We thank the reviewer for these insightful comments and we fully accept the thrust of his argument that the paper is primarily descriptive with limited explanatory value. In the title of the revised manuscript we have substituted factors influencing.. with factors associated with…., as detailed in the response to reviewer #2. The data the authors have will not allow them to analyze the influencing factors. However, could they do the following: (a) integrate the factors they have discovered into a coherent conceptual model, and (b) infer the potential barriers, norms, and drivers to access based on the model.The following are illustrative of the questions that may be insightful: Gender Why do a greater percentage of women avoid both GP visit (20%) and hospital-based healthcare (10.6%) than men (10.9% GP Visit, 6.0% Hospital). What are the gender-based drivers of, norms for, barriers to men/women visiting the GP/Hospital? Highest level of education Why do more educated people avoid GP visits (17.8%) and less educated people avoid hospital care (13.7%). What are the education-based drivers of, norms for, and barriers to visiting the GP/Hospital? Similar questions may be posed with reference to the other parameters in Tables 2-5. A coherent framework and answers to such questions derived from the study could help fulfill the promise of the title, at least partly. Response: Response to points 2 & 3: While we agree that the suggested conceptual models would be interesting and useful, we believe that they are beyond the scope of the current paper. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Ramaprasad A. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39734) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39734 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Morgan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 May 2024 | for Version 1 Anthony Kwame Morgan , Kwame Nkrumah University of Science and Technology, Kumasi, Ashanti Region, Ghana 0 Views copyright © 2024 Morgan A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Health services research, ageing, geriatrics I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (1) Author Response 27 Oct 2025 Mary Joyce, National Suicide Research Foundation, Cork, Ireland I have carefully reviewed your manuscript, and I would like to offer some constructive feedback for improvement. Alignment of Topic and Objective: There seems to be a disconnection between the topic and the objective of your study. It is unclear whether you examined healthcare utilization avoidance or healthcare utilization during COVID-19. I recommend clarifying this to ensure coherence between the topic and objective. Response: We thank the reviewer for this observation. The focus of the study was on healthcare utilisation avoidance, based on responses to the following two questions: During the period of restricted movement / lockdown, have you done any of the following? - “Deliberately / consciously avoided contacting your GP (General Practitioner) about non-coronavirus concerns or problems that you would normally bring to his/her attention.” - “Deliberately/consciously avoided going to the hospital with a non-coronavirus concern or health problem that would in normal circumstances require a visit to the hospital.” In the revised manuscript we have changed the title from “ Factors influencing the likelihood of accessing healthcare during the COVID-19 pandemic in Ireland: lessons for the future ” to “ Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future”. Discussion Content: The discussion section lacks depth and fails to provide a thorough analysis of the results. Merely citing other studies without providing an explanation of why the results occurred is insufficient. I suggest expanding the discussion to include plausible reasons for the observed outcomes, drawing on relevant health behavior theories to strengthen the implications of your findings. Response: The primary focus of this paper is on the magnitude and distribution of the effects of pandemic restrictions on health care utilisation avoidance. In the current manuscript, we refer briefly in the discussion to the likely impact on behaviour of differential weighting of the risk of staying at home versus presenting for primary or secondary care and the associated need for relevant public information campaigns. We believe that further speculation on psychological determinants of health care avoidance and the relevant behaviour change implications of the findings is beyond the scope of this paper. Grammar and Construction: There are several grammatical and construction errors throughout the manuscript that need to be addressed for clarity and readability. I recommend thorough proofreading and revision to improve the overall quality of the writing. I believe that addressing these issues will significantly enhance the clarity and impact of your manuscript. I look forward to seeing the revised version. Response: We have carefully reviewed and revised the manuscript in the light of these comments. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Morgan AK. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39062) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/7-11/v1#referee-response-39062 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 McCarthy N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 May 2024 | for Version 1 Noel McCarthy , Trinity College Dublin, Dublin, Ireland; University of Warwick, Coventry, England, UK 0 Views copyright © 2024 McCarthy N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Epidemiology, I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 27 Oct 2025 Mary Joyce, National Suicide Research Foundation, Cork, Ireland We thank the three reviewers for their positive and constructive engagement with our work and for their commentary which has considerably enhanced the paper. We provide our responses to the reviewers comments below and outline how these have been addressed in the revised paper. Response to Noel McCarthy This is a good study generally clearly reported and with data and instruments in the public domain. The results are useful, my suggestions for edits are relatively minor as given below. The study design is described as “A nationally representative cross-sectional telephone survey was conducted …” while in the analysis it states that - “the estimates were weighted to account for the survey sampling design”. These seem to contradict each other. Looking at the cited methodology paper by Troya et al I again cannot find any methodological reference to weights. I think that this could be made clearer. Response: We apologise for the lack of information and confusion created about the weights. This information was originally outlined in Troya et al. (2022) but was inadvertently omitted from this manuscript. Data were weighted by age, gender, and region, with population estimates based on the Irish Labour Force Survey. We applied the same weights for this analysis. The manuscript has been updated to include this information. We now cite both the Troya 2022 paper and the Irish Labour Force Survey in the Methods section. Self-rated health is dropped from the model due to reported collinearity with self-perceived risk of infection. No processes for this, or generally for model building, are given in the methods. On univariate analysis both had strong and statistically significant associations with healthcare avoidance including a dose response association for self-rated health. At a guess - if the other decision had been made the authors would be reporting that self-rated health strongly and perhaps in a dose response fashion predicted healthcare avoidance. Given that this effectively steers what is concluded and communicated so substantially it would be good to describe the process leading to the decision on which to drop. Response: We thank the reviewer for this observation. In the first instance we should clarify that the “risk of infection” variable is based on objective criteria, specifically cocooning because of diabetes, cancer, a severe respiratory condition, a condition with a very high risk of infections, or being on medication that increased the likelihood of contracting infections. The definition of this variable is now clearly described in the Measures section of the Method. As one would anticipate, this variable is highly correlated with self-rated health status, with those characterised as at increased risk of infection more likely to rate their health as ‘fair’ or ‘poor’ when compared with those not at increased risk of infection, see table below: Increased risk of infection Health Status No (n = 913) Yes (n = 56) Total (n = 968) Excellent 163 (18%) 0 (0%) 163 (17%) Very Good 325 (36%) 10 (18%) 335 (35%) Good 307 (34%) 14 (25%) 321 (33%) Fair 100 (11%) 18 (32%) 118 (12%) Poor 18 (2%) 13 (23%) 31 (3%) Each of these variables (self-rated health status and increased risk of infection) was associated with GP and hospital avoidance in multivariate analyses when the other variable was excluded. However, in multivariate analyses with inclusion of both variables, only self-rated health status was associated with GP and hospital avoidance. With the benefit of hindsight, we made assumptions about multicollinearity in the data that were not adequately tested, and it is now clear that self-rated health is an important predictor of GP and hospital avoidance in these data. The relevant text in the manuscript, including the abstract, has been revised accordingly. The authors emphasise in the results text and even note in the abstract that “participants who agreed that they were likely to catch COVID-19 were at a higher risk of avoiding going to hospital than those who strongly disagreed (RR: 2.80 (1.25 – 6.25)”. However, this was the result for “tend to agree” while those who “strongly agree” had a non-significant and substantially weaker (RR 1.91) association. This feels like cherry picking. If the process had included an overall assessment for association with the variable before drilling into the specific association in this band it might be more convincing. Somewhat similarly for age where e.g. the significant, but marginally so in the context of extensive testing, association between being 50-59 years old and avoiding healthcare is picked out and even mentioned in the abstract. Here again an overall test of whether the age categories used showed association with outcome before going into individual band would seem a more solid statistical approach. Response: We agree with the reviewer that we should have tested for and reported on the overall association with the COVID-19 susceptibility variable and age in these analyses. In further analyses which included tests for linear trend, age and COVID-19 susceptibility was non-significant for G.P. avoidance and hospital avoidance. The relevant text in the manuscript, including the abstract, has been revised accordingly. In the discussion the highlighting of these findings as “especially relevant to patients with blood cancer” appears arbitrary to me for a study that related to self-perceived risk. Additionally, agreeing with the authors claim in general that their results give “actionable lessons for the future” this perhaps applies least so such a patient group which has such direct supervision and intense support evidenced by the anecdotal evidence for such that the authors note in the discussion. Response: We understand that the reference to patients with blood cancer in the discussion seems arbitrary and that the “actionable lessons for the future” that arise from these data apply to all patient groups. However, in the overall context of cancer care during a pandemic, we believe that the unique vulnerability of patients with blood cancers arising from the bone marrow and immune system merits highlighting. This specific issue is not generally understood and appreciated. However, in the revised manuscript, the relevant section has been shortened considerably. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern McCarthy N. Peer Review Report For: Factors associated with self-reported healthcare utilization avoidance during the COVID-19 pandemic in Ireland: lessons for the future [version 2; peer review: 2 approved, 1 approved with reservations] . HRB Open Res 2025, 7 :11 ( https://doi.org/10.21956/hrbopenres.15148.r39055) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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