The main result of our study was identifying COVID-19’s impact on the likelihood of individuals from areas with the highest level of ethnocultural diversity visiting the emergency department for low-acuity problems. Our study found that individuals living in the most ethnoculturally diverse areas disproportionately used the ED for low-acuity visits, potentially highlighting the negative impact the pandemic has had on ethnic minorities, recent immigrants, or those who report linguistic isolation. Our study demonstrates that using the ED for a low-acuity reason during the pandemic was associated with an increase in the odds of being considered Q5 in the ethnocultural domain. The strongest predictor of a low-acuity Q5 visit, however, was the type of facility used. If the facility being used was in one of the 3 largest urban centres (Fredericton, Moncton, and Saint John), it was associated with the largest increase in the odds of being considered Q5 for low-acuity visits (Table 3).
This is important because it shows that during the COVID-19 pandemic, individuals living in areas of higher immigration or visible minorities had to use the ED as a source of primary care to a higher degree than other groups, who in turn were more likely to avoid the ED. This could reflect a lack of primary care providers or a lack of access to primary care providers for ethnoculturally diverse individuals (Ahmed et al., 2016) even prior to the pandemic beginning, or the higher burden of illness on those who are considered an ethnic minority. It is also plausible that there was a concern for these individuals that the symptoms that led them to present to the ED were caused by COVID-19; however, further research is required to investigate this. This is evidence that our pandemic control policies may not adequately accommodate diverse populations, especially those in ethnoculturally diverse areas. Governments have an incentive to address this lack of primary care options for identifiable populations; a visit to the ED is much more costly than a visit to a primary care provider (Mehta et al., 2017). This phenomenon seems to be specific to urban facilities, which serve urban-dwelling individuals, and those regions were shown to have the most Q5 individuals in the ethnocultural domain.
Compared to the rest of Canada, New Brunswick is mostly white. According to the 2016 Canadian census, 3.28% of the New Brunswick population is considered a visible minority, while across Canada it increases to 21.83% (Statistics Canada, 2017). Our map shows that the most diverse regions represent the largest cities in New Brunswick (Fig. 2), which is consistent with the results from our logistic regression. The inequity in access is thus an urban phenomenon, and tactics to address COVID-19 in urban settings should have this inequity in mind. Such intervention can be targeted and need not require a complete change to pandemic-control policies.
For higher-acuity presentations (triage scores 1–3), COVID-19 was not a significant predictor of visits from Q5 individuals. Visits triaged as levels 1–3 likely have a higher perceived acuity to patients, and thus the pandemic would be less likely to discourage anyone from seeking care at the ED, explaining why our high-acuity presentations did not change. The lack of significance across both categories of acuity with our economic dependency domain tells us the pandemic did not alter the trends for economically deprived individuals. Individuals who are economically deprived might face barriers to accessing care that are independent of the pandemic. For example, other domains that impact access to care such as transportation, technological competency, and geographic location might have remained as persistent barriers such that policies to address COVID-19 had no observable effect on low-acuity visits.
One of the major innovations in healthcare made during the pandemic has been the push to virtual care formats. Many primary care providers began to incorporate or transition to virtual care formats with the onset of the pandemic (Glazier et al., 2021; Schipper, 2020). Consequently, individuals with less access to technology or less comfort with technology could have less access to their primary care providers. In the United States, ethnic minorities were identified as a group that experienced disparities in regard to accessing virtual care (Nouri et al., 2020). Thus, even if they had a primary care provider, access to providers may have still been limited for ethnoculturally diverse groups. While virtual care may increase access for some, it may also be exacerbating certain inequities in society, causing certain groups to seek care through other means such as the ED for primary care. Further research to investigate barriers to virtual care, the role these barriers had in the pandemic, and how to address any that exist is crucial. Furthermore, newcomers to Canada face many barriers when accessing primary care in Canada, including health-system, socioeconomic, and cultural factors (Ahmed et al., 2016). The reliance on the ED for ethnoculturally diverse groups during the pandemic could speak to the significance of these barriers, and investigating them further could work to address the inequities experienced by these individuals.
The fact that individuals living in ethnoculturally diverse regions rely on the ED for care during the pandemic is evidence that their ability to adopt infection control behaviours is limited by their environment. In other words, relying on people to bear the cost of infection control policies means that some simply will not have the capacity to prioritize infection control. Policies like the Canada Emergency Response Benefit (CERB) are useful interventions to address their needs, but even in the face of these universal interventions inequities persist. This underlines the importance of ongoing monitoring of inequitable trends during a pandemic and flexibility on the part of government to mitigate them. ED visits are one potential sentinel measure to determine whether specific groups are differentially unable to take up the encouraged infection control behaviours (e.g., avoiding the ED for low-acuity issues).
Our study has limitations. Our data are limited to English-speaking facilities in New Brunswick, and as a result may not accurately reflect trends across Canada, requiring more work to be done nationally to identify the degree to which pandemic policies have potentially exacerbated pre-existing inequities in other regions. We used an indicator of socioeconomic status that labels individuals based on their dissemination area rather than on individual characteristics; assuming that all individuals in a Q5 region are equally deprived is an ecological fallacy, so we are careful to interpret our results with this in mind. Finally, there are several factors which can influence an individual’s decision to access an ED, and if we had more information on medical history, socioeconomic characteristics of patients, or the environment they live within, we would have had a more fulsome picture of what was driving access issues. Regardless, we were able to identify that individuals living in areas of high ethnocultural diversity had a higher likelihood of making a low-acuity ED visit during a time when most people were actively avoiding the ED for minor issues, which points to a potential structural source for this difference. If this difference is driven by factors that governments could act on but choose not to, then it is a health inequity driven by government policy; thus, further study is required to prevent future universal policies from having unexpected and undesirable consequences.