Background: Prescription redemption or primary medication compliance is defined as the proper purchasing of prescribed medications and medical supplies. It does not include over-counter drugs or informal dispensed prescriptions. Attaining a better redemption of prescription has the power to alleviate the pain, severity, and speed up the prognosis of the diseases among the patients. But patients usually tend to miss or skip or omit to dispense the prescribed drugs and medical supplies either intentionally or unintentionally. Moreover, socio-demographic vulnerability worsen the problem. Subsequently, it is very crucial to scrutinize the reason behind the nonredemption of prescribed medications among SRCs versus CAs. On the other hand, a continuum of HCU is a basic approach to ensure the wellbeing of nations. They include both preventive and curative services provided by HCS units. They have a chain-like feature starting from visiting frontline professionals; general practitioners (GP), specialist levels, getting proper curative services for health ill conditions. The better utilization of HCS had an extra benefit on reducing severity, incidence, prevalence, complications and quickening the prognosis of the illness. Thus, better GP or specialist care has a lower possibility of facing medical emergencies and admission to hospitals. Besides this, redeeming the pre-scribed medications and medical supplies has equal importance in relieving the further negative consequences of diseases among the patients. However, there is a paucity of explicit understanding regarding the variation due to the segregated areas of residence, ethnicity, and other sociodemographic and clinical predictors on uptake of the continuum of health care services. Furthermore, the COVID-19 pandemic caused an imbalance in the HCU dynamics and created vulnerable social strata throughout the globe. But this dynamics of HCU has not been investigated yet in Hungary or elsewhere. Objectives: The general objective of this study was to investigate the effect of segregated settlement and COVID-19 pandemic on the dynamics of basic HCU among the vulnerable population in Hungary. Accordingly, our specific objectives were (1) to investigate the crude prescription redemption among Roma living in segregated settlements versus complementary areas, (2) to investigate the indirect age-sex standardized redemption ratio of Roma living in segregated settlements versus complementary areas, (3) to estimate the GP visit, specialist care, hospitalization and CRPNR pre-pandemic and during the COVID-19 pandemic (4) to investigate the effect of the pandemic on GP visit, specialist care, hospitalization and CRPNR controlled for established predictors and (5) to determine subgroups susceptible to the GP visit, specialist care, hospitalization and CRPNR provoked by the pandemic in Hungary. Methods: Data were obtained from NIHIFM-2012, EHIS-2019 and ISSP-2021 for SRCs vs CAs, pre-pandemic and pandemic periods, respectively. All age groups [for SRCs vs CAs], and 18 years and above [for pre-pandemic and pandemic periods] were included in the study. The indirect adjusted age-sex standardized redemption ratios [SRR] were calculated for SRCs vs CAs. Whereas descriptive and analytic computations were done for pre-pandemic and pandemic data. Tables, figures, and proportions were displayed for sociodemographic and clinical characteristics for each outcome variable. Under the analytic section, multivariable logistic regression along with 95% CI was calculated to control the confounding factors in the pre-pandemic and pandemic data analysis. The COVID-19 lockdown was found to be the effect modifier or interaction variable on outcome variables of HCU for some sociodemographic strata that were more susceptible to the pandemic lockdown/restrictions. Results: The crude redemption ratio of national, SRC and CAs were 84,323,051/126,223,796 (66. 8%), 46,107/33,720 (73.13%) and 901,901/640,950 (71.15%), respectively. SRC has the highest CRR than both CAs and national figures. Females dispensed more than males in both settlements. From 45-64 and 65 years and above redeemed more than other age strata in SRCs and CAs, respectively. The age-sex standardized redemption ratio was 1.028 [1.018-1.038] SRCs to CAs. The impact of the settlement showed an excess of 2.8% or extra 920 redemptions per year among SRCs compared to the CAs. The COVID-19 pandemic lockdown caused drastic reductions in the HCU compared to the pre-pandemic period; GP visit (79.2% vs 56%, p<0.001), specialist care (64.4% vs 38%, p<0.001), hospital admission (13.5% vs 6.8%, p<0.001) but not for CRPNR (5.6 vs 5.2%, p=0.662). The pandemic lockdown modified the effect on GP and specialist care among wid-owed strata. It significantly shifted the uptake of GP visits from 90.8% to 92.1% aOR=2.284 (1.043-4.998). While positively from provoked the effect of widowed on the specialist care from unadjustedOR=1.338 (1.136-1.576) to aOR=1.915 (1.157-3.168) after controlling for pertinent sociodemographic and clinical factors. Conversely, the effect of educational attainment [highly educated levels] were negatively dragged by the pandemic lockdown on GP visits and specialist care from unadjustedOR=0.710 (0.590-0.855) to aOR=0.434 (0.243-0.776), and aOR=1.288 (1.097-1.513) to aOR= 0.331 (0.179-0.611), respectively. The important social inequities observed in this study was that the subjects with lower academic levels had higher CRPNR than others due to the pandemic lockdown. Practical implications: The main practical interpretation of better-prescribed medication redemption means quickening the prognosis of the disease and maintaining the well-being of the subjects. Compared to the earlier research about the Roma and their poor health status, lifestyle and HCU, our current findings disproved that Roma were poor healthcare utilizers from a prescription redemption viewpoint. This has been supported by both CRR of 73.13% which was greater than national (66.8%) and CAs (71.15%) and age-sex adjusted SRR with an excess of 2.8% redemption among Roma. If culturally adapted preventive models are applicable, other pillars of HCU and lifestyle could be improved based on our current findings. Meantime, the continuum of HCU was significantly affected by the pandemic lockdown. The uneven influence of the pandemic was seen for GP visits and specialist care among marital while CRPNR among educational attainment strata were provoked in positive and negative directions, respectively. These are prominent findings are that the widowed stratum effect on GP and specialist visits were significantly modified as a protective role. This seemed an ade-quate reaction as the disadvantaged groups in the prepandemic era got more opportunities to utilize HCS during the pandemic. In addition, serious health crises among the widowed sub-group may increase GP and specialists during the lockdown. Then again, the higher educational attainment stratum effect on the specialist care was shifted from protective to exposing role. But the CRPNR was significantly reduced among less-educated patients attributed to the pandemic lockdown needs further mitigations in the next epidemic waves.
Conclusion and recommendations: Nearly a three-fourth of Roma living in the SRCs re-deemed their prescriptions accordingly. They had a significant portion of excess redemption than CAs for in a year. It shows that Roma contradicted the previous findings which prejudiced and marked them for poor health and lifestyle.
The pandemic dramatically dragged down the continuum of HCS care in Hungary. Several sociodemographic and clinical factors played an exposing and protective role subject to the interaction of the pandemic lockdown. Some social strata were mainly victims or susceptible to the pandemic lockdown. Lower educational attainment was found to be improved for GP and specialist care attributed to the pandemic lockdown. This indicated that the preexisting sociality inequality was manifested during the pandemic lockdown restrictions. Remarkably, the widowed stratum played a protective role for GP and specialist care attributed to the pan-demic. These effects seem to be adequate reactions since the pandemic regulations allow only serious medical conditions. But the lower CRPNR among the less-educated subgroup was an inadequate reaction. A Roma had a higher likelihood of CRPNR than a non-Roma population regardless of the lockdown. Thus, our finds suggested that culturally adapted approaches mainly ABA and in-depth inter-view studies are important for investigating the HCS uptake of the Roma population in SRCs. The basic reason for applying the ABA for Roma in the SRCs it enables well exploring and understanding of their needs, demands, gaps and opportunities through their active involvement from beginning to the end of the intervention program in the future. This could enhance and empower them more than the usual or standard public health intervention model or top-down approach. So at the end of the day, a better prescription redemption and other HCU push them for an improved healthy lifestyle and health status. Also, the continuum of HCU needs close monitoring mainly for susceptible social strata under each studied outcome component. Inadequate reactions among the predisposed social strata (less educated subgroup) should be mitigated in the next phase of the epidemic. We also recommend further studies on the new insights which played a protective role in the utilization of GP and specialist care among the widowed subgroup in Hungary.