Document [original]

TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

Open access

Impact of COVID- 19 on health service

utilisation in sub- Saharan Africa:

protocol for a scoping review

Elliot Koranteng Tannor ,1,2 Wilm Quentin,3,4 Reinhard Busse ,3,4

Daniel Opoku ,1,2,3 John Amuasi1,2

To cite: TannorEK, QuentinW,

BusseR, etal. Impact of

COVID- 19 on health service

utilisation in sub- Saharan

Africa: protocol for a

scoping review. BMJ Open

2023;13:e074769. doi:10.1136/

bmjopen-2023-074769

►Prepublication history for

this paper is available online.

To view these files, please visit

the journal online (http://dx.doi.

org/10.1136/bmjopen-2023-

074769).

Received 16 April 2023

Accepted 30 August 2023

1School of Public Health, Kwame

Nkrumah University of Science

and Technology, Kumasi, Ghana

2Department of Global Health,

German- West African Center

for Global Health and Pandemic

Preparedness, Kumasi, Ghana

3Department of Health Care

Management, Technische

Universität Berlin, Berlin,

Germany

4Department of Health Care

Management, German- West

African Center for Global Health

and Pandemic Preparedness,

Berlin, Germany

Correspondence to

Dr Elliot Koranteng Tannor;

elliotktannor@ yahoo. co. uk

Protocol

employer(s)) 2023. Re- use

permitted under CC BY- NC. No

commercial re- use. See rights

and permissions. Published by

BMJ.

ABSTRACT

Introduction The COVID- 19 pandemic has exposed

weaknesses in health systems of many countries,

including those in sub- Saharan Africa. Despite

comparatively low rates of COVID- 19 admissions and

deaths in sub- Saharan Africa, the pandemic still had a

significant impact by disrupting health service utilisation

(HSU). The aim of this scoping review is to synthesise

the available evidence on HSU in sub- Saharan Africa

during the COVID- 19 pandemic, especially focusing on (1)

changes in HSU compared with the prepandemic period,

(2) changes in HSU among particular patient groups

studied and (3) identifying factors determining changes in

HSU as a result of the COVID- 19 pandemic.

Method and analysis The scoping review will be guided

by the methodological framework for conducting scoping

reviews developed by Arskey and O’Malley. We will identify

relevant studies on HSU in sub- Saharan Africa during the

COVID- 19 pandemic using PubMed (MEDLINE), Embase,

Scopus and Web of Science databases from 1 December,

2019 to 31 March 2023. We will search grey literature,

government and organisational websites for reports and

conference proceedings. Included studies will be restricted

to those reported in English or French. Two reviewers will

independently screen articles at the title and abstract

stage for inclusion into full text screening. We will provide

a general descriptive overview, tabular summaries and

content analysis for the extracted data.

Ethics and dissemination Ethical approval is not

required for the conduct of the scoping review. We will

disseminate our findings via open access peer- reviewed

journals and scientific presentations. Our scoping

review findings will help to determine the feasibility of a

subsequent systematic review (and meta- analysis) on HSU

during the COVID- 19 pandemic.

INTRODUCTION

The COVID- 19 pandemic has had devastating

consequences on health systems globally.1–3

It has exposed weaknesses in health systems

of many countries, especially in sub- Saharan

Africa, where health infrastructure is relatively

poor and density of skilled health workers is

low2 4 Despite reports showing comparatively

low rates of COVID- 19 hospitalisation and

death in sub- Saharan Africa,5–7 the pandemic

continues to significantly impact on health

systems and on health service utilisation

(HSU) in the region.8 9

HSU is the process of seeking professional

healthcare services, usually provided in the

form of healthcare contacts, with the purpose

of preventing or treating health prob-

lems.10–12 HSU was affected by disruptions in

health service provision during the COVID- 19

pandemic, especially in low- income coun-

tries.8 13 A WHO survey found that almost all

135 included countries experienced some

disruption of service provision, but the inten-

sity of disruptions differed across countries

(high income vs low income), service types

(eg, emergency care vs elective surgery) and

over the course of the pandemic (2020 vs

2021).14 Particularly in low- income countries,

it led to a substantial decrease in the provision

of essential healthcare services, including the

management of non- communicable diseases

(NCDs).13 These disruptions may ultimately

be contributing to higher mortality of

patients.15 Therefore, it is essential to better

understand the impact of COVID- 19 on HSU

in sub- Saharan Africa.

The Andersen behavioural model16 provides

a useful framework for the analysis of HSU

mainly from patient perspective and may

STRENGTHS AND LIMITATIONS OF THIS STUDY

⇒This scoping review will provide a comprehensive

overview of studies on health service utilisation

(HSU) during the COVID- 19 pandemic conducted in

sub- Saharan Africa.

⇒The review will describe the settings, study designs

and methods used by the included studies.

⇒The review will identify reasons for changes in HSU

in sub- Saharan Africa when reported.

⇒The study will provide an overview of studies on

communicable diseases, non- communicable dis-

eases and injuries during the COVID- 19 pandemic.

⇒A potential limitation of our scoping review may be

the inability to synthesise our findings to draw useful

conclusions due to the broad research questions.

2TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

Open access

sometimes be contextualised based on the study popula-

tion.17 18 It includes both individual and contextual factors.

Individual factors can be grouped into predisposing factors,

enabling factors and need factors.16 19 20 The enabling

factors such as socioeconomic status, income status and

employment status changed during the pandemic and

influenced HSU in sub- Saharan Africa.21 Fear of infection

with COVID- 19 may have also decreased the perceived

need for HSU. Contextual factors may have included prior-

itisation of emergency services, introduction of COVID- 19

services and increase in staff workload as well as lockdown

measures prohibiting public transport or reducing available

incomes.22

The Andersen’s conceptual model, however, has some

context- specific challenges Law et al23 argue the model

may not give enough attention to cultural dimensions and

social interactions but it is still a widely used conceptual

framework for most studies on HSU.24–26 The Andersen’s

conceptual model over the years has undergone modi-

fications to include those for vulnerable populations,27

which may be relevant for sub- Saharan Africa. However, it

has been used in describing HSU in patients with commu-

nicable diseases such as HIV/AIDS in Ghana,24 antenatal

care utilisation in sub- Saharan Africa25 and to assess

factors associated with COVID- 19 testing in low- income

countries in sub- Saharan Africa.26

Previous research has shown changes in HSU glob-

ally28–32 with very few studies from sub- Saharan Africa. For

example, a systematic review of 81 studies across 20 coun-

tries found that HSU decreased by about a third during the

pandemic, but it included no study from Africa.33 A mixed-

methods study from Sierra Leone found that mean hospital

admissions decreased by 14.7% in the first quarter of the

pandemic, with the largest changes in surgical admissions

(49.8%) and medical admission (28.7%). Another study

involving six hospitals in four sub- Saharan Africa countries

(Ethiopia, Sierra Leone, Tanzania and Uganda) reported

a decrease in routine vaccinations, outpatient visits and

hospital admissions but neither in antenatal visits nor insti-

tutional deliveries.8 A study in the Democratic Republic of

Congo also reported a rapid reduction in HSU at the begin-

ning of the pandemic with the size of the reduction being

directly correlated with the intensity of the lockdown.9

However, other studies have also shown some increases in

HSU34 35 or did not report any significant change in the

reported HSU.36 37

However, to the best of our knowledge, there is no

systematic overview of the available literature on the

impact of the COVID- 19 pandemic on HSU in sub-

Saharan Africa. In this scoping review, we aim to assess

available evidence on HSU in sub- Saharan Africa during

the COVID- 19 pandemic especially focusing on (1)

changes in HSU compared with the prepandemic period,

(2) changes in HSU among particular patient groups

studied and (3) factors determining changes in HSU as a

result of the COVID- 19 pandemic.

METHOD AND ANALYSIS

We will be guided by the methodological framework devel-

oped by Arksey and O’Malley in 2005 for conducting

scoping reviews.38 This framework has been approved by

others including the Joanna Briggs Institute International

Committee.39–42 It includes five main stages with an optional

sixth stage. These stages are (1) identifying the research

question, (2) identifying the relevant studies, (3) study

selection,; (4) charting the data, (5) reporting the results

and (6) consultation with stakeholders (optional). We will

follow best practices for conducting and reporting system-

atic reviews, that is, we will apply the Preferred Reporting

Items for Systematic Reviews and Meta- Analyses for Proto-

cols extension for Scoping Reviews (PRISMA- ScR) checklist

for reporting our findings.43 44

Stage 1: identifying the research question

Based on preliminary searches of the available literature,

we have framed our research question in terms of the

population to study, health service settings, measures and

changes in HSU. The main research question is: ‘What

has been published about changes in HSU during the

COVID- 19 pandemic in sub- Saharan Africa?’ We also aim

at identifying the factors that determine the changes in

HSU during COVID- 19 in sub- Saharan Africa. We will

use key themes expressed by Andersen16 20 to explore the

determinants of HSU in sub- Saharan Africa including

predisposing factors, enabling factors and need factors as

discussed by the studies. Other questions to be addressed

in this scoping review will be:

1. What populations have been studied in the published

literature on HSU in sub- Saharan Africa during the

COVID- 19 pandemic? (eg, country of study, rural or

urban, in- patient or outpatient, whole country or re-

gions, categories of disease conditions, ie, NCDs such

as diabetes, hypertension, heart disease, stroke and

mental health programmes, etc, communicable diseas-

es such as malaria, pulmonary TB and HIV/AIDS or

injuries).

2. What methods have been used to study HSU in sub-

Saharan Africa and measure the impact of COVID- 19

on HSU? This includes definitions and measures of

HSU (eg, preventive health (vaccination), outreach

services, curative, surgical, rehabilitative health, tele-

medicine or telehealth; service utilisation reported in-

creased, decreased or unchanged).

3. What factors have been explored as potential determi-

nants of HSU during the COVID- 19 pandemic in sub-

Saharan Africa? These may include individual factors,

community factors, health system factors or political

factors, demand and supply related factors, predispos-

ing, enabling and need related factors according to

Anderson in the included studies.20

Stage 2: identifying the relevant studies

To help answer our research questions, a comprehensive

research strategy will be developed with the aim to exten-

sively review all existing literature from 2019 to date.

TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

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We will identify relevant studies through a search

of PubMed (MEDLINE), Embase, Scopus and Web of

Science. We will also search grey literature, including

government and organisational websites for reports on

HSU during the pandemic, and conference proceedings

using relevant resources. We will handsearch information

from policy papers and position papers on HSU reports

in all countries in sub- Saharan Africa. We will develop

a comprehensive search strategy for PubMed and will

refine this for the other databases.

Our search strategy will be built on the basis of

synonyms related to three key concepts (see table 1): (1)

“COVID- 19 pandemic”, (2) “health service utilisation”

and related synonyms and (3) “sub- Saharan Africa” as the

population of interest. We will employ the Boolean opera-

tors ‘AND’ or ‘OR’ to combine and refine terms as appro-

priate. We will use truncations and field tags to improve

the efficiency of the search. Given the complex nature of

HSU, we will use synonyms which capture various health

services such as prescription, surgeries, antenatal clinic

Table 1 Key concepts, synonyms and related terms to be used in the search strategy

What is the impact of Covid- 19 pandemic

on health services utilisation in sub- Saharan

Africa? MESH terms Search terms

Concept 1 Covid- 19 pandemic #1 MeSH

“COVID- 19”[Mesh]

OR SARS- CoV- 2

OR COVID- 19 OR Coronavirus OR 2019-

nCoV

AND

Concept 2 Health Services utilisation #2 MeSH

“Facilities and service utilisation”

[Mesh]

“Health Services”[Mesh]

“Patient Admission”[Mesh]

“Ambulatory Care”[Mesh]

“Immunisation Programmes” [Mesh]

“Surgical Procedures,

Operative”[Mesh]

“Telemedicine”[Mesh]

OR “Facilities and service utilisation” OR

“Health Services” OR “Patient Admission”

OR “Ambulatory Care” OR surgery OR

Telemedicine OR “Health service” OR

“Health service utilisation” or “Health

service utilisation” OR “Hospital care” OR

Admission OR Out- patient OR outpatient

OR outreach service* OR Vaccination*

OR immunisation OR Prescription OR

medicine OR pharmac* OR antenatal OR

postnatal OR “family planning” OR “Dental

service” OR Nursing OR “nursing care” OR

Telemedicine OR Telehealth OR Clinic OR

Emergenc* OR Hospital OR Hospitalisation

OR hospitalisation OR Endoscop* OR Scan

OR Imaging OR Laboratory

AND

Concept 3 Sub- Saharan Africa #3 “Africa South of the Sahara”[Mesh] OR “sub- Saharan Africa” OR Angola OR Burundi

OR “Central African Republic” OR Chad

OR “Democratic Republic of Congo” OR

Congo OR Rwanda OR Comoros OR Eritrea

OR Ethiopia OR Kenya OR Madagascar

OR Mauritius OR Seychelles OR Somalia

OR Sudan OR Tanzania OR Uganda OR

Botswana OR Eswatini OR Lesotho OR

Malawi OR Mozambique OR Namibia OR

“South Africa” OR Zambia OR Zimbabwe OR

Benin OR “Burkina Faso” OR Cabo Verde

OR Cameroon OR “Cote d Ivoire” OR “Ivory

Coast” OR Equatorial Guinea OR Gabon OR

Gambia OR Ghana OR Guinea OR Guinea-

Bissau OR Liberia OR Mali OR Mauritania

OR Niger OR Nigeria OR “Sao Tome and

Principe” OR Senegal OR “Sierra Leone” OR

Togo

Final strategy #4 #1 AND #2 AND #3

MeSH, Medical Subject Headings .

4TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

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or care, dental services, clinic, admissions, consultations,

emergency visits, hospital visits, nursing services, endos-

copy, scan and imaging (table 1). The Medical Subject

Headings (MeSH) for sub- Saharan Africa and the list of

all the 46 countries in sub- Saharan Africa will be included

in the search. The COVID- 19 pandemic will be the

COVID- 19 (MeSH) and synonyms including SARS- CoV- 2

used in the search (table 1).

The Covidence systematic review software45 will be

used for the screening of titles and abstracts as well as

full text review. All reviewers will be given access to the

software for independent screening of the articles for

inclusion.

Stage 3: study selection

Title and abstract screening

We will include studies, in English or French, that report

on HSU in sub- Saharan Africa during the COVID- 19

pandemic. The period of the COVID- 19 pandemic will be

operationally defined as from 11 March 2020 (when the

WHO declared the pandemic)46 to 31 March 2023. Arti-

cles to be included in the study should satisfy the criteria

given in table 2.

Following the PRISMA- ScR, we will illustrate the process

of study identification and selection as in figure 1.

Two reviewers will independently screen all identified

citations from the databases after duplicates are removed

for potential inclusion into the scoping review. Disagree-

ments between the two reviewers will be resolved by

the involvement of a third reviewer who will vote inde-

pendently. The screening of titles and abstracts will be

used to decide which studies will be eligible for full text

review at this stage. The detailed full text review will be

done after the screening for extraction of the relevant

data with the Covidence Software.45

Stage 4: data extraction

Results from the search extracted from the Covi-

dence Software45 will be exported to Microsoft Excel

for analysis. We will follow the recommended data

charting method proposed by Arksey and O’Malley38 to

extract the relevant details of included studies. Double

extraction will be used for a randomly selected 10% of

the included studies, and any conflicts will be resolved

by a third reviewer.

We will follow three main themes:

1. The population of study: country of study, region in

sub- Saharan Africa, World Bank country classifica-

tion, rural or urban, hospital based or outside hospi-

tal setting or outreach services, inpatient admission

or outpatient contacts; categories of disease; non-

communicable (eg, cardiovascular diseases, diabetes

and cancers), communicable diseases (eg, HIV/AIDS,

tuberculosis, Malaria) or injuries.

2. Methods of studies: definition, measures of HSU used,

quantitative and/or qualitative analyses performed

and measures of impact: patient or provider perspec-

tive, qualitative or quantitative study; study on preven-

tive health (vaccination and screening) or curative

health or rehabilitative health. Reported change in

HSU (increase, decrease or unchanged).

3. Factors associated with or determinants of changes in

HSU: determinants and factors associated with HSU

(individual factors, community factors, health system

factors, political factors) or predisposing, enabling and

need factors according to Anderson.20

All the extracted data will be reviewed to ensure

completeness and accuracy before analysis. Any themes

that might emerge from the search will be included in the

extraction and analysis.

Table 2 Inclusion and exclusion criteria for the scoping review

Criteria Inclusion criteria Exclusion criteria

Types of publications Original research studies on health service utilisation Guidelines, letters to the editor, research

protocols and abstracts, recommendation

Types of studies Single and multicentre studies

Quantitative, qualitative and mixed- methods studies, grey

literature reports

Multicentre studies with one country outside sub-

Saharan Africa

Population of studies Patients, healthcare providers and healthcare managers

Types of interventions Any reported intervention

Comparators Pre- pandemic health service utilisation if reported

Types of outcomes Health service utilisation

Change in health service utilisation

Patient reported outcomes

No clear report of health service utilisation

Language English or French All other languages

Data collection Primary and secondary data Systematic review, scoping review and literature

reviews

Location of study Sub- Saharan African countries

Hospital based, community based or online studies

Timelines 1 December 2019–31 March 2023 Studies before 1 December 2019

TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

Open access

Stage 5: collating, summarising and reporting of the results

We will follow the recommendation to extend the

scoping review process by adding thematic analysis.39 We

will analyse the extracted data both quantitatively using

both deductive (predefined themes above) and induc-

tive approaches, incorporating any new themes that will

emanate from the included studies in the scoping review.

The primary analysis data will be based on the three main

themes:

►Population and study characteristics.

►Definition, measures and impact of HSU.

►Determinants and factors associated with change in

HSU.

This approach recommended by Levac et al39 will enable

us to answer broader questions based on the available data

and get new findings which we previously did not anticipate.

Although we will collect specific quantitative data when avail-

able, we will not pool the data for further analysis but will—if

there is a sufficiently large number of studies using similar

methods—explore the potential for a further systematic

review with possible meta- analysis. We would report most of

the finding as categorical data and describe the findings with

text and/or figures as deemed appropriate.

Patient and public involvement

None.

Figure 1 Template PRISMA diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses.

6TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

Open access

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review

as the data used for the analysis will be extracted from

published studies. We will disseminate our findings

through scientific presentations at local and international

conferences, open access peer- reviewed journals and a

report.

DISCUSSION

Findings from our scoping review will enable us to

examine the extent, range and nature of available studies

on HSU in sub- Saharan Africa and enable us to determine

the changes in HSU during the COVID- 19 pandemic. We

will also be able to identify the populations and character-

istic of studies on HSU. The number of studies conducted

in sub- Saharan Africa will determine the feasibility of a

follow- up full systematic review after the scoping review.

The findings of our scoping review will also enable us

to understand the methods used to assess HSU in sub-

Saharan Africa, the settings studied, the disease catego-

ries reported (NCDs, communicable diseases or injuries),

level of management (preventive, curative, rehabili-

tative and palliative) and the scope of HSU. We antici-

pate that this study will help identify the factors that can

potentially influence HSU from both the patients’ and

health service providers’ perspectives. The findings from

this scoping review will enable us to ask more specific

questions to inform further studies on HSU for better

pandemic preparedness for governments, policy- makers

and healthcare providers in sub- Saharan Africa. This may

lead to changes in healthcare policies that will lead to

improved HSU even in pandemic situations to improve

health outcomes. Possibly, we will be able to contribute to

harmonisation of definitions and measurements of HSU

in sub- Saharan Africa.

Finally, findings from our study will contribute to under-

standing the effects that the pandemic had on specific

populations, which may help to better prepare for future

pandemics by putting in place safeguards for these popu-

lation groups.

A potential limitation to our scoping review may be the

inability to synthesise our findings to draw useful conclu-

sions from included studies due to the broad nature of

research questions and concepts. Another limitation

could be that we may miss relevant studies due to publi-

cation bias in our literature search and the exclusion

of studies not available in English or French. Addition-

ally, there might very few rigorously conducted studies

reporting changes in HSU in sub- Saharan Africa during

the COVID- 19 pandemic among the included studies. A

further limitation of our study is that we will not engage

any stakeholder or beneficiary as part of the scoping

review, although the Andersen model chosen as the

conceptual framework is primarily a patient perspective

framework.

Twitter Elliot Koranteng Tannor @elliotktannor

Acknowledgements We would like to acknowledge the staff of the German-

West African Centre for Global Health and Pandemic Preparedness (G- WAC) at the

Kwame Nkrumah University of Science and Technology and Jean Jacques Noubiap

of the University of California, San Francisco for helping to refine the search

strategy.

Contributors EKT, WQ, RB and DO conceived the study design. The first version

of the protocol was drafted by EKT and was revised by EKT, WQ, RB, DO and JA.

Search strategy was developed by EKT and revised by WQ and RB. EKT and DO

will perform the screening, study selection and extraction of data of the included

studies. All authors revised and critically reviewed the manuscript and approved

before submission.

Funding This study was funded by German- West African Centre for Global Health

and Pandemic Prevention, Award/Grant number: NA. German Academic Exchange

Service (DAAD), Award/grant number: NA and German Federal Foreign Office,

Award/Grant number: NA

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in

the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Not applicable.

Provenance and peer review Not commissioned; externally peer reviewed.

Open access This is an open access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which

permits others to distribute, remix, adapt, build upon this work non- commercially,

and license their derivative works on different terms, provided the original work is

properly cited, appropriate credit is given, any changes made indicated, and the use

is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.

ORCID iDs

Elliot KorantengTannor http://orcid.org/0000-0002-5978-0510

ReinhardBusse http://orcid.org/0000-0003-4961-9130

DanielOpoku http://orcid.org/0000-0002-6562-1583

REFERENCES

1 Paintsil E. COVID- 19 threatens health systems in sub- Saharan Africa:

the eye of the crocodile. J Clin Invest 2020;130:2741–4.

2 Hopman J, Allegranzi B, Mehtar S. Managing COVID- 19 in low- and

middle- income countries. JAMA 2020;323:1549–50.

3 Sohrabi C, Alsafi Z, O’Neill N, etal. World health organization

declares global emergency: a review of the 2019 novel Coronavirus

(COVID- 19). Int J Surg 2020;76:71.

4 Mills A. Health care systems in low- and middle- income countries. N

Engl J Med 2014;370:552–7.

5 Bamgboye EL, Omiye JA, Afolaranmi OJ, etal. COVID- 19 pandemic:

is Africa different? J Natl Med Assoc 2021;113:324–35.

6 Africa C Coronavirus disease 2019 (COVID- 19) latest updates on the

COVID- 19 crisis from Africa CDC; 2020. Available: https://africacdc.

org/covid-19/ [Accessed 12 Apr 2023].

7 Lone SA, Ahmad A. COVID- 19 pandemic–an African perspective.

Emerging Microbes & Infections 2020;9:1300–8.

8 Quaglio G, Cavallin F, Nsubuga JB, etal. The impact of the

COVID- 19 pandemic on health service use in sub- Saharan Africa.

Public Health Action 2022;12:34–9.

9 Hategeka C, Carter SE, Chenge FM, etal. Impact of the COVID- 19

pandemic and response on the utilisation of health services in public

facilities during the first wave in Kinshasa, the democratic republic of

the congo. BMJ Glob Health 2021;6:e005955.

10 Leclere FB, Jensen L, Biddlecom AE. Health care utilization, family

context, and adaptation among immigrants to the United States. J

Health Soc Behav 1994;35:370–84.

11 Da Silva RB, Contandriopoulos A- P, Pineault R, etal. A global

approach to evaluation of health services utilization: concepts and

measures. Healthc Policy 2011;6:e106–17.

12 Fernández- Olano C, Hidalgo JDL- T, Cerdá-Díaz R, etal. Factors

associated with health care utilization by the elderly in a public health

care system. Health Policy 2006;75:131–9.

13 Tannor EK, Bieber B, Aylward R, etal. The COVID- 19 pandemic

identifies significant global inequities in hemodialysis care in low and

lower- middle income countries—an ISN/DOPPS survey. Kidney Int

Rep 2022;7:971–82.

14 Organization WH. Second round of the national pulse survey

on continuity of essential health services during the COVID- 19

TannorEK, etal. BMJ Open 2023;13:e074769. doi:10.1136/bmjopen-2023-074769

Open access

pandemic: January- March 2021: interim report. World Health

Organization; 2021.

15 Nikoloski Z, Alqunaibet AM, Alfawaz RA, etal. Covid- 19 and non-

communicable diseases: evidence from a systematic literature

review. BMC Public Health 2021;21:1068.

16 Andersen R. A behavioral model of families' use of health services

research series no. 25. Chicago: Center for Health Administration

Studies, University of Chicago, 1968.

17 Bradley EH, McGraw SA, Curry L, etal. Expanding the andersen

model: the role of psychosocial factors in long‐term care use. Health

Serv Res 2002;37:1221–42.

18 Travers JL, Hirschman KB, Naylor MD. Adapting andersen's

expanded behavioral model of health services use to include older

adults receiving long- term services and supports. BMC Geriatr

2020;20:58.

19 Andersen R, Newman JF. Societal and individual determinants of

medical care utilization in the United States. Milbank Mem Fund Q

Health Soc 1973;51:95–124.

20 Andersen RM. Revisiting the behavioral model and access to medical

care: does it matter J Health Soc Behav 1995;36:1–10.

21 Danquah M, Schotte S, Sen K. Covid- 19 and employment: insights

from the sub- Saharan African experience. Indian J Labour Econ

2020;63(Suppl 1):23–30.

22 Sevalie S, Youkee D, van Duinen AJ, etal. The impact of the

COVID- 19 pandemic on health service utilisation in sierra leone.

Infectious Diseases (except HIV/AIDS) [Preprint] 2021.

23 Law M, Wilson K, Eyles J, etal. Meeting health need, accessing

health care: the role of neighbourhood. Health Place 2005;11:367–77.

24 Seidu A- A. Using anderson’s model of health service utilization to

assess the use of HIV testing services by sexually active men in

Ghana. Front Public Health 2020;8:512.

25 Tesfaye G, Chojenta C, Smith R, etal. Application of the

andersen- newman model of health care utilization to understand

antenatal care use in Kersa district, Eastern Ethiopia. PLoS One

2018;13:e0208729.

26 Pengid S, Peltzer K, de Moura Villela EF, etal. Using andersen's

model of health care utilization to assess factors associated with

COVID- 19 testing among adults in nine low- and middle- income

countries: an online survey. BMC Health Serv Res 2022;22:265.

27 Gelberg L, Andersen RM, Leake BD. The behavioral model for

vulnerable populations: application to medical care use and

outcomes for homeless people. Health Serv Res 2000;34:1273–302.

28 Xiao H, Dai X, Wagenaar BH, etal. The impact of the COVID- 19

pandemic on health services utilization in China: time- series analyses

for 2016- 2020. Lancet Reg Health West Pac 2021;9:100122.

29 Pujolar G, Oliver- Anglès A, Vargas I, etal. Changes in access to

health services during the COVID- 19 pandemic: a scoping review. Int

J Environ Res Public Health 2022;19:1749.

30 Aranda Z, Binde T, Tashman K, etal. Disruptions in maternal health

service use during the COVID- 19 pandemic in 2020: experiences

from 37 health facilities in low- income and middle- income countries.

BMJ Glob Health 2022;7:e007247.

31 Xu S, Glenn S, Sy L, etal. Impact of the COVID- 19 pandemic on

health care utilization in a large integrated health care system:

retrospective cohort study. J Med Internet Res 2021;23:e26558.

32 Abdou MS, Kheirallah KA, Aly MO, etal. The Coronavirus disease

2019 (COVID- 19) vaccination psychological antecedent assessment

using the Arabic 5c validated tool: an online survey in 13 Arab

countries. PLoS One 2021;16:e0260321.

33 Moynihan R, Sanders S, Michaleff ZA, etal. Impact of COVID- 19

pandemic on utilisation of healthcare services: a systematic review.

BMJ Open 2021;11:e045343.

34 Sarfo FS, Mensah NO, Opoku FA, etal. COVID- 19 and stroke:

experience in a Ghanaian healthcare system. J Neurol Sci

2020;416:117044.

35 Boyd AT, Jahun I, Dirlikov E, etal. Expanding access to HIV services

during the COVID- 19 pandemic- Nigeria, 2020. AIDS Res Ther

2021;18:62.

36 Carter ED, Zimmerman L, Qian J, etal. Impact of the early stages of

the COVID- 19 pandemic on coverage of reproductive, maternal, and

newborn health interventions in Ethiopia: a natural experiment. Front

Public Health 2022;10:778413.

37 Altare C, Kostandova N, OKeeffe J, etal. COVID- 19 epidemiology

and changes in health service utilization in Uganda’s refugee

settlements during the first year of the pandemic. BMC Public Health

2022;22:1927.

38 Arksey H, O’Malley L. Scoping studies: towards a methodological

framework. Int J Soc Res Methodol 2005;8:19–32.

39 Levac D, Colquhoun H, O’Brien KK. Scoping studies: advancing the

methodology. Implement Sci 2010;5:69.

40 Colquhoun HL, Levac D, O’Brien KK, etal. Scoping reviews: time

for clarity in definition, methods, and reporting. J Clin Epidemiol

2014;67:1291–4.

41 Daudt HML, van Mossel C, Scott SJ. Enhancing the scoping

study methodology: a large, inter- professional team's experience

with Arksey and O'Malley's framework. BMC Med Res Methodol

2013;13:48.

42 Peters MDJ, Marnie C, Tricco AC, etal. Updated methodological

guidance for the conduct of scoping reviews. JBI Evid Synth

2020;18:2119–26.

43 Tricco AC, Lillie E, Zarin W, etal. PRISMA extension for scoping

reviews (PRISMA- SCR): checklist and explanation. Ann Intern Med

2018;169:467–73.

44 Peters M, Godfrey C, McInerney P, etal. Chapter 11: Scoping

reviews (2020 version). In: Aromataris E. JBI Manual for Evidence

Synthesis. JBI, 2020.

45 Covidence systematic review software. Available: www.covidence.

org

46 World Health Organization. WHO Director- General’s opening remarks

at the media briefing on COVID- 19. Geneva, Switzerland, 2020.