Covid-19 Tanısı ile Hacettepe Üniversitesi Erişkin Hastanesinde İzlenen Hastaların Hastalık ile İlgili Risk Algıları ve Yaşam Tarzı Değişikliği Planlarının Değerlendirilmesi
Özet
ABSTRACT
Zarnishanov Kamil. Evaluation of Disease-Related Risk Perceptions and Lifestyle
Change Plans of Patients Followed Up at Hacettepe University Adult Hospital with the
Diagnosis of COVID-19. Hacettepe University School of Medicine. Thesis in Internal
Medicine Department, Ankara, 2021
Introduction: Coronaviruses are a family of viruses known to cause both respiratory and
intestinal diseases in various animal species and humans. It is known that these viruses can
cause mild infections, as well as extremely severe infections such as Middle East Respiratory
Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS) (1). On December 31
2019, the World Health Organization (WHO) China Country Office reported cases of
pneumonia of unknown cause In Wuhan city of Hubei province. On 7 January 2020, it was
determined that a new coronavirus, which was not detected in humans before, caused the
disease. It was found that there is a close similarity between this new virus and SARS CoV
which made an epidemic in 2002, and due to this similarity, the originally named 2019-nCoV
was changed to SARS-CoV-2. The disease caused by SARS-CoV-2 has been defined as
Coronavirus Disease 2019 (COVID-19) (1). Despite global precaution and quarantine efforts,
the incidence of the virus has gradually increased and was declared as a pandemic by WHO
on March 11, 2020 (2).
Initial data showed that all age groups are at risk for SARS-CoV-2, with COVID-19
being generally reported to be more likely to occur in people with advanced age and / or
comorbidities. (3) In the study where descriptive and cross-sectional analysis of all cases
diagnosed in China in the initial period of the pandemic was made, it was seen that the case
fatality rate could change dramatically with age and accompanying comorbidities. In the study
including 72,314 patients, it was stated that there were 889 asymptomatic patients and the
case-fatality rate was found to be 2.3%. While the case fatality rate was less than 0.5% up to
the age of 50, the case fatality rate was 1.3% between the ages of 50-59, 3.6% between the
ages of 60-69, 8% between the ages of 70-79 and 14.8% between the ages of 80 and over.
While the highest case-fatality rate is observed in patients with cardiovascular disease
(10.5%), the case-fatality rates are significantly higher in the presence of diabetes (7.3%),
chronic respiratory disease (6.3%), hypertension (6.0%) and cancer (5.6%), respectively. (4)
Obesity and smoking were also associated with increased risk in subsequent studies. (5)
Chronic diseases; They are diseases that progress slowly, last for 3 months or longer,
are caused by more than one risk factor, usually have a complicated course and affect the
quality of life of the person. These diseases, which are risk factors that increase the case
fatality rates in the COVID-19 pandemic, have been the leading cause of death in all
developed or developing countries all over the world. (6) In fact, chronic diseases have
created a silent global pandemic, paving the way for increasing the effects of the pandemic
with the COVID-19 pandemic. Alcohol and cigarette consumption, physical inactivity and
unhealthy nutrition have been identified as modifiable risk factors that need to be urgently
tackled to prevent premature deaths due to chronic diseases. (7) Another issue that affects the
clinical course and is emphasized a lot is the differences between male and female genders.
Mortality rates in the male gender were reported higher in the Chinese and Italian studies.
Since chronic diseases are diseases that have a high economic and social burden on the
individual and society, there is a need for health policies and effective interventions for the
control of these diseases. If the existing scientific knowledge and experience on chronic
diseases and risk factors are combined with the opportunities of countries and put into
practice, the burden of diseases on society can be reduced significantly.
When we look at the clinic of the disease, besides asymptomatic cases, it can be seen
in a spectrum ranging from respiratory failure requiring mechanical ventilation to sepsis,
septic shock, and multiorgan failure. The severity of the clinical picture is variable in
symptomatic cases. Patients may present with mild symptoms or with a rather severe clinical
picture such as multiple organ failure. In an article in which approximately 72 thousand cases
from China were reported, the clinical picture was mild in 80% of the cases, severe in 15%,
and respiratory failure, shock, and multi-organ failure in 5%, with a very high risk of
mortality, severe It has been stated that there is a clinical picture
Patients who were still hospitalized at Hacettepe University Medical Faculty Hospital
with the diagnosis of COVID-19 and those who were previously hospitalized with the
diagnosis of COVID-19 in Hacettepe University Medical Faculty Hospital, were discharged
and applied to the COVID-19 Monitoring Polyclinic of Hacettepe University Faculty of
Medicine Hospital for control purposes were included in this study. After obtaining written
consent from the patients that they agreed to participate in the study, the changes they planned
to make in the general health status and lifestyle of those who had COVID-19 were
questioned using a questionnaire method. With this study, we have produced hypotheses
about the impact of COVID-19 disease on general health assessment and the changes it will
make in their future lives.
The main purpose of the study is to evaluate whether hospitalization due to COVID-19
will lead to behavioral change decisions such as quitting smoking, limiting alcohol
consumption, regular dieting, regular exercise, and regular follow-up of chronic diseases to
eliminate these risk factors which they are modifiable risk factors associated with both
premature death and poor endpoints of COVID 19.
Patients and Methods: The research was conducted between February 10, 2021 and May 10,
2021, after the ethics committee approval was obtained. It is planned to collect the data of the
patients within the first 2 months (February 10, 2021 - April 10, 2021), and it is planned to
analyze and write the data obtained within 1 month after the data collection process (April 10,
2021 - May 10, 2021). Patients who aged 18 and over were still hospitalized at Hacettepe
University Medical Faculty Hospital with the diagnosis of COVID-19 and those who were
previously hospitalized with the diagnosis of COVID-19 in Hacettepe University Medical
Faculty Hospital, were discharged and applied to the COVID-19 Monitoring Polyclinic of
Hacettepe University Faculty of Medicine Hospital for control purposes were included in this
study. Patients who could not be contacted, could not answer questions, or did not consent to
participate in the study were excluded.
Among the patients included in the study, those who had positive results of RT-PCR
and serological tests such as ELISA or rapid antibody tests, those whose RT-PCR result was
negative and whose CT result was typical for COVID-19 or COVID-19 could not be ruled
out, were diagnosed with COVID-19. COVID-19 diagnosis was excluded in patients whose
RT-PCR results were negative and CT results were reported to be incompatible with COVID 19 or as no sign of pneumonia.
The research was planned as a cross-sectional questionnaire study under the
main title of observational research. In the first part of the questionnaire, sociodemographic
information of the patients such as age, gender, height, weight, marital status, number of
children, educational status, job/occupation, chronic diseases, cohabitants over 65 years old
and/or having a chronic disease, whether they had pneumonia and influenza (seasonal flu)
vaccine and if they were not vaccinated, the reasons were questioned.
In the second part, in order to evaluate the risk perception of the patients, their
thoughts about why they got COVID 19 disease and their risk factors were questioned. (For
example; such as smoking, using alcohol, being overweight, having a chronic disease, not
getting vaccinated.) According to the perception of these risk factors, the patients were asked
about the changes they want to make in their future lives (such as quitting smoking, limiting
alcohol consumption, regular sports and exercise, regular vaccination) and the methods (such
as smoking cessation clinics, family medicine) they will apply to make these changes.
In the third part of the questionnaire, the smoking history of the patients was asked. In
order to determine how the awareness and smoking behaviors of patients diagnosed with
COVID-19 will change, the patients were asked about the duration and amount of smoking,
the date they last smoked, other tobacco products they regularly use, the presence of a smoker
at home, and previous attempts to quit smoking.
The Fagerström Test for Nicotine Dependence was planned to determine nicotine
addiction in patients with active smokers. The test was first proposed by Fagerström in 1978,
what the Fagerström Tolerance Test was, and this test was reconsidered by Heatherton et al.
in 1991 and FBNT emerged. Turkish validity of the test Uysal et al.[11] and it was found
moderately reliable, and attention was drawn to the questions that needed attention. FBNT
consists of six questions and each question is given a different score. The purpose of the test
was accepted as determining the nicotine addiction levels of the patients and observing the
effect on their smoking cessation behaviors. The purpose of the Fagerström Nicotine
Dependence Test was to evaluate the smoking addiction of people who decided to quit
smoking after the COVID-19 disease before being referred to the Smoking Cessation
Polyclinics.
In addition to lifestyle changes, it was also aimed to conduct a General Health
Questionnaire (GHQ), which was developed by the patient and adapted to many languages
and cultures, especially in primary care, in order to distinguish mental illness in those who
had COVID-19 disease. SPSS 23 program was used for statistical analysis.
In this study, no additional examinations were made except for the examinations that
should be done about the disease of the patients. No additional blood tests were taken, no
additional imaging tests were performed. No treatment was undertaken in addition to the
standard treatments they were receiving. There was no additional cost for patients.
Discussion and Results: The COVID-19 pandemic has emerged suddenly and has affected
people of all genders, races and countries indiscriminately. Unfortunately, the prognosis can
be poor in individuals with chronic diseases. (3) In fact, chronic diseases have created a silent
global pandemic, paving the way for increasing the effects of the pandemic with the COVID 19 pandemic. Alcohol and cigarette consumption, physical inactivity and unhealthy nutrition
have been identified as modifiable risk factors that need to be urgently tackled to prevent
premature deaths due to chronic diseases. (7)
212 Patients who aged 18 and over were still hospitalized at Hacettepe University
Medical Faculty Hospital with the diagnosis of COVID-19 and those who were previously
hospitalized with the diagnosis of COVID-19 in Hacettepe University Medical Faculty
Hospital, were discharged and applied to the COVID-19 Monitoring Polyclinic of Hacettepe
University Faculty of Medicine Hospital for control purposes were included in this study.
Patients who could not be contacted, could not answer questions, or did not consent to
participate in the study were excluded. Later, 12 patients who did not give their consent, did
not accept the study and could not communicate, were excluded, and 200 patients were
descended. The patients were classified according to their demographic data, then their
thoughts about why they got COVID-19 disease and risk factors were asked with the
questionnaire method, and the level of awareness created by the disease was ensured to be
understood. In addition, the general health questionnaire was evaluated, as well as the lifestyle
changes. When the demographic characteristics of the patients participating in the study were
examined, the mean age in our study was 45.61±16.82 while the median age was 37.2 in
Turkey. (8) The reason for choosing a higher age population in our study was to see more
clearly the effect of chronic diseases that increase in parallel with increasing age, and
especially the impact of COVID 19 on the risk perception and general health assessment of
patients. As a matter of fact, 72% of the patients participating in our study had 1 or more
chronic diseases and 63% were using at least 1 drug. Considering the distribution of chronic
diseases of the patients who participated in our study, it was seen that the prevalence of
chronic diseases seen worldwide was higher. Although coronary artery disease was present in
168 patients in our study, it was the first among diseases with 41.17%. According to
TEKHARF 1990 study; In our country, the prevalence of CAD in adults aged 20 and over is
3.8%, the reason why the prevalence of CAD is higher in our study is that COVID-19 disease
is more prevalent in chronic diseases, and patients diagnosed with COVID-19 and have
chronic diseases, were followed up in our hospital rather than outpatient follow-up. (9) Thus,
patients with chronic diseases were hospitalized and followed up in our hospital and thus
included in the study. The same situation was also present in type 2 DM. However, the
percentage of patients who stated that they had a diagnosis of HT among the patients
participating in the study was seen to be 11.2%, meaning it was lower than the world. This
has been attributed to the low awareness of hypertension in the population. Considering
previous studies, the prevalence of obesity was high and the prevalence of overweight was
similar in our study. However, we were able to say that our patient group was not chosen and
we thought to be an example that represents the society and that we are not in a bad place in
terms of obesity prevalence. A low percentage of patients diagnosed with COVID-19 with
high body mass index are aware of obesity, and statistically a small proportion will only lose
weight, diet and exercise after discharge.
A significant majority of 146 patients with chronic diseases (81.5%) thought that their
chronic diseases caused COVID-19. Although the majority of the patients had chronic
diseases and many of them obey the COVID-19 preventive rules such as masks and personal
hygiene, it was concluded that they were the general health levels that they thought of due to
their chronic diseases in the first place, causing COVID-19 disease. In the interviews with the
patients, 63% of the patients stated that they would follow up their chronic diseases more
regularly from now on, while 19% stated that they would not continue their follow-up. When
the reason for refusal of the patients who refused to follow-up was questioned, it was noticed
that there were thoughts that, should stay away from hospitals and healthcare workers, could
be described as "Corona phobia" even in the literature. (10)
In the second part of the study, it was seen that the majority of patients did not receive
pneumococcal and seasonal influenza vaccines before being diagnosed with COVID-19. It
has been observed that failure to administer pneumococcal and seasonal influenza vaccines,
especially by patients over 65 years of age and with chronic diseases, is thought to cause
COVID-19 disease. It was observed that the main reason why the patients were not vaccinated
was that they had problems in obtaining the vaccine, especially in the pneumococcal vaccine.
This problem can be solved by improving health policies. In the second place of patients not
being vaccinated, almost one-fourth – one-fifth (21.77% and 23.61%) of patients do not know
that they should be vaccinated. The solution to this social unawareness is especially through
the physicians in the primary health care institutions. Among the third and fourth most
common causes of the patients who did not receive the vaccine in both vaccine groups, there
is not knowing whether the patients are in the risk group or not, and thinking that the vaccine
does not work. The fifth most common reason is the possible side effects of the vaccine,
which is similar in both groups (4.83% - 4.86%). However, in the latest guidelines, vaccines
are considered to be protective because the side effects of vaccines are maximum 2%,
including the mildest and most common side effects (11). Again, as it will be seen in the
second part of our study, it was seen that the majority of the patients (78% flu, 83%
pneumococcal) would get their vaccinations after they were diagnosed with COVID 19 and
discharged. The reason that increased this awareness and willingness to be vaccinated was the
fact that the vaccine is currently seen by patients as a concrete
pharmacological/immunological protection method and solution, apart from masks, social
distance and hygiene. In addition, knowing that the side effects of the vaccine are lower than
the side effects of other treatments whose effectiveness has not been proven (favipravir,
glucocorticoid ..) were also seen to affect the decision of the patients to have the vaccine. The
percentage of patients who are hesitant to get vaccinated is 11% for the pneumococcal
vaccine and 18% for the seasonal flu vaccine. The percentage of those who absolutely refused
the vaccine was still around 6% in the pneumococcal vaccine and 4% in the seasonal flu
vaccine. In this study, it was pleasing to see the positive effect of interviewing patients,
especially on undecided patients. They stated that although 54% of the patients had COVID
19, they would have the COVID 19 vaccine.
From the first days of the pandemic, it was understood from the answers to the
questions asked about mask and hygiene, which are two of the 3 main components of
protection from COVID 19, that the majority of patients pay attention to these two protection
measures. However, although the vast majority of patients follow the rules, they do not see
that non-compliance with these rules causes them to get COVID-19 disease. When we look at
the data, 12% of the patients think that the reason for not complying with the hand washing
and hygiene rules, 84% of the patients think that this is not the factor that causes them to catch
the disease, despite complying with the hand washing and hygiene rules. Despite these data,
the fact that the majority of the patients stated that they would comply with the hygiene and
mask-related measures was found interesting at first, but the information that the COVID 19
disease, which currently does not have a definite specific treatment, can be prevented by
following the mask and hygiene rules, which is considered as the absolute primary protection
method, by the physicians and during the hospitalization. It was thought that this awareness
was created by telling the patients through mass media and media after discharge. It has been
observed that there will be a significant increase in the percentage of personal hygiene and
mask wearing after discharge, and the disease process has a great impact on patients in this
regard. According to the data, 98% of the patients stated that they would/will start to obey the
hand washing and hygiene rules more. In addition, 76% of the patients stated that they wear
or will continue to wear masks. Although it was thought that the majority of the patients were
forced to enter crowded environments and their profession could cause the COVID-19
disease, the prediction that only a small number of them could change their profession, but the
majority would not enter crowded environments, except for compulsory situations, due to
socioeconomic level and the concern of not being able to find another job was confirmed. It
was observed that the disease process had a great impact on patients in this regard.
When the smoking status, which is the third subject of our study, was questioned, it
was seen that 31.51% of the smoking patients (n=76 patients) strongly thought that getting
COVID-19 disease was related to smoking, and 57.85% of the patients partially accepted or
disagreed with this issue. The fact that 38% of the patients were smokers and 63.14% of the
patients, especially those with one or more chronic diseases, stated that they would quit
smoking, showing that the effect of smoking on COVID-19 disease was understood by the
society, as in other respiratory diseases. The smoking rate of the patients participating in the
study was above the Turkey average (23.8%) (12). This confirmed the hypothesis that
smokers are more likely to have COVID-19 disease.
It was observed that the relationship between alcohol and COVID-19 in the society is
less known than cigarettes, just like cigarettes, and indecisive ideas are more prominent.
However, it was thought that 13,79% of patients who still consume alcohol, unlike cigarettes,
said that they would quit alcohol, and that the relationship between COVID-19 and alcohol
did not create a significant awareness in patients.
In addition to lifestyle changes, a General Health Questionnaire (GHQ) was also
conducted in those who had COVID-19. It was observed that GSA scores increased with the
age of the patients. It was observed that the incidence of mental problems was higher after
COVID-19, especially in individuals aged 65 and over. In addition, a similar correlation was
found with the number and severity of chronic diseases. The relationship between the state
and trait anxiety scores of the individuals participating in the study and their marital status and
education level was found to be statistically significant. It was observed that the level of
anxiety increased after COVID-19, especially in widowed, divorced, illiterate or primary
school graduates, and in patients who did not have individuals or children over the age of 65
at home.
Similarly, in the literature, we confirmed our hypothesis about the effect of COVID-19
disease on general health assessment and the changes it will make in their future lives with
this study. Combining data with different centers will provide more valuable information on
COVID-19 disease and general health activity.
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Keywords: COVİD-19, Chronic Disease, Cigarette General Health Questionnaire