Assessment of the global healthcare industry during COVID-19 pandemic: A content analysis approach

Introduction

Content analysis (CA) is a multipurpose research technique that deals with the objective, systematic, quantitative, qualitative, and general description of the manifest and latent content of communication.^1,2 As a research tool, CA determines the reoccurrence of words, themes, or concepts in qualitative data.³ It is a research technique that uses a set of formalized procedures to classify communication to draw valid inferences. CA provides researchers with the opportunity to unobtrusively study the values, intentions, and ideologies of any group.^4–8 Thus, CA enables researchers to quantify and analyze the presence, meanings, and relationships of concepts, words, or themes in various communication mediums.

Regardless of the diversity of CA definitions, many researchers agree on the objectivity, systematic, and generality of any CA analysis.⁹ Objectivity is maintained when data is collected based on explicitly formulated rules. Researchers tend to use professional judgment in making decisions about their data. Thus, enabling researcher biases or subjectivity to creep into the investigation can skew the results. It is important to minimize biases by establishing and following strict procedures and thus enabling those who duplicate the study to achieve similar results. The systematic requirement is the inclusion and exclusion of content according to a set of applied rules where the investigator biases are eliminated and multiple coders follow established procedures to ensure outcome validity and reliability. Generality entails that the findings must have theoretical relevance and is achieved when some form of harmony or similarity is found when findings are compared.

Most CA investigations center around three distinct approaches: conventional, directed, or summative approaches.⁴ Regardless of the approach, the outcome of CA is to interpret communication intents or meanings. Coding schemes represent the difference among the approaches, and the conventional technique is the most common coding technique where categories originate from words. Whereas in the directed approach there is a hypothesis and a theory to guide researchers to identify codes. In the summative approach, researchers count and compare words and then interpret the underlying theme.

The use of CA in health care literature is becoming prevalent.^10–14 A surge in the use of qualitative research is being witnessed in many fields including healthcare, medical, and biomedical literature.^15,16 Qualitative CA in healthcare research has been applied to draw interpretation from a variety of sources.^17–20 The application of CA in healthcare encompasses all disciplines including policies,²¹ genomic analysis,²² population health,²³ biomedical technology,²⁴ medical decision making.²⁵

Accordingly, content analysis was used to identify challenges in patients suffering of Hemophilia.²⁶ Also, it is also used to evaluate emergency and critical care in nursing settings.²⁷ Importantly, it is commonly used to evaluate the access to appropriate healthcare services and coverage.^28,29 Recently, content analysis evaluating stressors among health care found that 70% are experiencing burnout, which can hinder patient care. Finally, CA was used to evaluate professionalism among medical students and found that two core thematic aspects of professionalism on patients’ respect and physicians’ accountability. These findings highlight the important of CA in all aspects of the healthcare system.

The healthcare system throughout various regions confronted major challenges due to coronavirus disease 2019 (COVID-19) pandemic. The purpose of this study is to report on the challenges confronting the global healthcare industry. The study intends to enable health organizations, researchers, professionals, and governments to raise public awareness on the most challenging or critical healthcare issues confronting the industry throughout the various regions of the world.

Methods

The international periodicals were selected among USA based periodicals since the authors concluded that USA media have strong influences worldwide. The listed US periodicals were also chosen since online access to the periodical archives are easily accessible through Lebanese American University (LAU) online library, as well as librarian support about the search tools through these periodicals. The regional periodicals were chosen from two countries that have major influence in the Arabic region: Saudi Arabia and Egypt. As Jordan is a nearby Arabic country to Lebanon and share similar economic situation, thus Jordan times was also preferred and selected. The Lebanese periodicals were chosen to cover the language diversity (Arabic, French and English) that exists in Lebanon and taking into consideration free online access to the periodical archives. The availability of free online access to the periodical archives was also a crucial criterion. In order to minimize bias, students or “coders” were trained in advance on data collection and how to search for data as part of their EMBA course on content analysis. Furthermore, each student was not allowed to interact with the other members in order to prevent judgment bias about the coding process and the collected data. Each student collected data individually and didn’t communicate with any of the students before submitting the data to the corresponding author. Data gathering and analysis was carried out using Excel 2016, and chart lines were made in order to assess the trends of categories among each periodicals on a monthly basis.

The investigators have gathered data from 13 of the periodicals in various parts of the world from January 1, 2021 to December 31, 2021. This study uses the conventional CA “bottom-up” approach to a qualitative data set.³⁰ This approach enables researchers to collect, sort, and categorize data to identify emerging patterns or to develop theories.³¹ Briefly, in bottom-approach all the team members involved in data collection will work proactively in each step of the project execution process until the final goal of the project is reached. Therefore, all the team members are involved in decision-making about the process and the strategy to follow as well as the outcomes of the analysis.

The study was conducted by a collaborative research group of Executive Master in Business Administration (EMBA) and medical students at two universities. Students at the Lebanese American University (Beirut, Lebanon) and the University of Texas Medical Branch (Galveston, Texas) collaborated on this research initiative. The students were divided into three groups: The first group collected data from the following international periodicals: The New York Times, Financial Times, Boston Herald, The Wall Street Journal, and Los Angeles Times. The second group collected data from four of the Middle East’s top English printed periodicals: Saudi Gazette, The Jordan Times, Gulf Daily News, and Daily News Egypt. The third group collected data from four online Lebanese, two Arabic (Al Akhbar, An Nahar), one English (Daily Star) and one French (L’Orient Le Jour) periodicals (Table 1). The underlying data is available through the online repository.⁴²

Results

Discussion

Healthcare systems worldwide faced major challenges during COVID-19 pandemic. At the beginning of the pandemic, healthcare systems worldwide were chaotically responding to the outbreak and its consequences.³³ While healthcare is mostly focused on providing proper treatment to infected patients, soon after, healthcare managers recognized that existing intervention policies are not serving their purpose.³⁴

Our data showed that international periodicals served as a source of COVID-19 data input for local and regional COVID-19 news. Our data concluded that international periodicals act as “trendsetters” whereas regional and local news were followers. Such finding is highlighted by the fact that coverage of “vaccines” and other keywords that mentioned in local and regional periodicals at the early stages of COVID-19 only started to appear after their appearance/coverage in the international media. Accordingly, we believe that low-income countries will continue to rely on developed countries to prioritize healthcare spending. This was expected by the authors given the scarcity of resources allocated to R&D COVID-19, in addition to the lack of policies and health task forces to face challenges such as COVID-19 pandemic.

The development of new global and local COVID-19 prevention strategies (curfews, use of masks, limiting social contact, use of sanitizers) enabled the healthcare system to effectively use its scarce resources to serve the largest number of infected patients,^35,36 thus preventing the collapse of the healthcare systems. COVID-19 fightback strategies became a popular and a frequently reported healthcare issue, thus shifting attention from other diseases and negatively influencing the communication outflow for chronic illnesses (e.g. diabetes, cancer, kidney diseases).^37–39 The latter finding was highlighted with the reduced frequencies of “health diseases” that did not bypass 10% in international newspapers and was almost inexistent in Middle East and national periodicals (Figures 1, 2 and 3).

Figure 1. Trendline and frequency of categories of all international newspapers per month and year respectively.

Figure 2. Trendline and frequency of categories of all Middle East newspapers per month and year respectively.

Figure 3. Trendline and frequency of categories of all national newspapers per month and year respectively.

The scarcity of resources worldwide subjected countries with strong healthcare systems to experience COVID-19 transfer waves originating from less developed countries. At first, the USA, China, and Europe were interested in fighting COVID-19 within their borders. Due to the massive movement of people, such a strategy was not effective. Therefore, it was of utmost importance to find better and sustainable solutions not only to stop COVID-19 waves but also to establish better health policies worldwide, thus limiting the spread of COVID-19. In addition, many countries worldwide were convinced that the spread of infectious diseases could not be limited by geographical boundaries thus collective international efforts must be initiated in order to face not only COVID-19 but also future challenges.⁴⁰

Initially, in the beginning of data collection, it was observed by the authors that COVID-19 influence on the healthcare was worldwide and was not country specific. All countries were significantly affected by COVID-19 with various degrees, therefore it was expected that COVID-19 related news on health care were at the forefront. Our data corroborated these findings and further showed that the keyword “healthcare” was the most frequent keyword repeated in the study. A case in point, strategies to fight the pandemic started to surface in the periodicals in response to the collapsing Italian healthcare system in 2020. Accordingly, the category “strategic action plan for COVID-19” was the mostly reported with frequencies bypassing 25% international newspapers, 30% in Middle East newspapers and 35% in Lebanese periodicals. Fear from future collapse of other healthcare systems fueled the news with the importance of taking measures to fight the pandemic without compromising the efficacy of the healthcare system. Accordingly, strategies to reduce disease spread through vaccination as an alternative tool to reduce the pressure on the healthcare system were among the earliest measures adopted by the healthcare authorities.⁴¹ While strategies and policies to fight COVID-19 where among the repeated keywords in the study, other important keywords such as “healthcare budget” were not highly reported in the media and showed low frequency of reporting as compared to other keywords. All the chosen periodicals showed similar trend lines (health care, strategies), where the corresponding categories were reported at frequencies ranging 5–15% among all newspapers.

Discrepancies were found among surveyed periodicals, where the keyword “research and development” was frequently reported in international periodicals while it was mostly missing in local and regional periodicals (Figures 1, 2 and 3). The latter findings reflect the trend of developed countries to use R&D in fighting diseases and providing policies and procedures to develop their healthcare interventions, which is lacking in other studied countries. Also, the keyword “vaccines” appeared as one of the most frequent keywords in the study and the earliest in international periodicals (Figure 1). Accordingly, the keyword “vaccines” was not reported in regional and national periodicals at the beginning of the pandemic. The impact of COVID-19 on the healthcare system and the economies appeared early months of the studied year in the international periodicals where the keyword “healthcare” was reported at a very high frequency of 60% compared to the regional and local periodicals (around 30%). The above-mentioned data, showed that healthcare news are described first in international periodicals then appear in local and regional periodicals setting a trend of considering international periodicals as a source of data. Furthermore, theses data highlight the fact that local and regional periodicals are quick followers and stay current with the news as soon as it is published in the international periodicals. Accordingly. They use international periodicals as source of information, they identify the piece of information they are interested in and get it translated and immediately (1-2 days max) published in the local or regional media.

The limitation of the study is associated with the human factor as decoding the periodicals manually which may have created discrepancies among the coders. Such coding processes can be influenced by all the well-known human factors including emotions, language barriers, efficiency, and understanding of the objectives. However, reducing the workload on each team member and providing proper training before starting the research process greatly contributed to minimizing such bias. While the content analysis research approach is well-known in the literature, to our knowledge it is the first study that tackles COVID-19. Interestingly, in the era of artificial intelligence and the availability of powerful search engines on the web, the human factor remains essential in deciphering the quality and quantity of information needed to formulate proper policies that are compatible with nowadays challenges. Lastly, we believe that periodicals whether they are published at the local, regional or international level were found to have an important role in guiding and raising awareness about strategic health care issues that could be of great importance globally.

Conclusions

Our data showed that international periodicals served as sources of COVID-19 data input for local and regional COVID-19 news. Our data concluded that international periodicals act as “trendsetters” whereas regional and local news were followers. This is expected given the scarcity of resources allocated to R&D COVID-19, in addition to the lack of policies and health task forces to face challenges such as COVID-19 pandemic. Therefore, global media can be a crucial source of up-to-date healthcare policies originating for low income countries in order to respond fast and actively to future local and global health care challenges.