The end of 2019 was marked by the outbreak of coronavirus disease 2019 (COVID-19) in Wuhan, China, which spread rapidly worldwide [1]. By March 2020, more than 499,648 confirmed COVID-19 cases and 37,558 deaths had been recorded [2]. The World Health Organization has declared it a pandemic [2]. During this pandemic, health professionals faced many challenges and difficulties in dealing with an extremely rapidly spreading and unprecedented disease [1]. In Tunisia, the first case of COVID-19 was reported on March 3, 2020, marking the start of the first wave of the COVID-19 pandemic in our country [3-5]. Since then, several waves have followed, which were as follows: a second wave from September 2020 to November 2020, a third wave from December 2020 to February 2021, and a fourth wave from March 2021 to October 2021 [3-5].

The kinetics of the COVID-19 epidemic disrupted the organization of healthcare systems worldwide. All healthcare sectors have been affected. Globally, multiple activities were disrupted by global confinement and social distancing measures [1]. Medical consultation units, particularly acupuncture clinics, were in turn affected by the pandemic, with a decline in the number of patients requesting this care, spacing out of appointments, and the adoption of strict measures during patient reception and consultations. No study has evaluated the impact of this pandemic on the acupuncture care activities in Tunisia.

The main objective of our study was to assess the impact of the COVID-19 pandemic on acupuncture care activities at Mongi Slim Hospital, La Marsa, Tunisia. Such a study would allow us to identify the problems in patient management during critical periods to ensure continuity of care during such circumstances.

1. Design and sample

This single-center, cross-sectional, descriptive study was designed to assess the impact of the COVID-19 pandemic on care activities in the acupuncture department of Mongi Slim Hospital, La Marsa.

Patients who had newly consulted the acupuncture department of Mongi Slim Hospital during the COVID-19 pandemic waves from February 03, 2020 to February 10, 2021 were included in this study. During the period from September to December 2020, corresponding to the 2nd wave of the COVID-19 pandemic, none of the patients received acupuncture care, as the department’s activity was suspended to give way forth COVID-19 care initiatives. Consequently, the cases during the 2nd wave of pandemic were not considered in our study. Random samples of 25 patients each were then drawn from those who consulted during the 1st, 3rd, and 4th waves of the COVID-19 pandemic. We excluded the initially randomized patients who were uncooperative or unreachable by telephone. These patients were replaced by other patients who visited the department during the same wave. These patients were in return randomly selected, so that 25 patients were included in the sample for each wave (Fig. 1).

Figure 1. Flow chart of the included patients.

The selection process was performed using a randomized sampling method, specifically the random draw method. This approach ensures that each patient had an equal chance of being selected, minimizing selection bias. The patients were numbered sequentially, and a random number generator was used to select the participants from the list.

2. Data collection

A questionnaire was used to collect the patients’ socio-demographic data to study the patient’s pathway before acupuncture, degree of patient satisfaction with care, degree of application of hygiene measures, and their suggestions for promoting quality of care in the department.

3. Ethical considerations

The present study was approved by the Human Research Ethics Committee of Mongi Slim Hospital (approval number: 01/2025). A written informed consent was obtained from the patients for the publication.

4. Statistical analysis

Data entry was performed using SPSS 11.5 (SPSS Inc.). We calculated the simple and relative frequencies (percentages) for the qualitative variables. We calculated the means and standard deviations and determined the range (extreme values = minimum and maximum values) for the quantitative variables.

The relationship between the qualitative and quantitative variables was examined using Student’s t-test for the comparison of means for the independent series. The Spearman rank correlation coefficient (r) was used to study the relationship between two quantitative variables. In all statistical tests, the p significance level was set at 0.05.

1. Evaluation of the number of acupuncture patients during the coronavirus disease 2019 pandemic

1) Distribution of patients by year

In 2019, the year before the COVID-19 pandemic, the total number of patients in the acupuncture department of Mongi Slim Hospital reached 15,864. In 2020, the number of patients decreased to 5,235, corresponding to a significant decrease of 67%, as compared with the number in 2019 (Fig. 2). In 2021, the number of patients was 6,209, corresponding to a significant decrease of 61%, as compared with the number in 2019 (Fig. 2).

Figure 2. Total number of acupuncture consultations per year.

2) Distribution of patients by months

A variation in the number of consultations by months was observed. During the month of April 2020, coinciding with the first total containment decreed by the Tunisian government, no patient visited the acupuncture department. There was a decrease in the number of acupuncture consultations during the different COVID-19 pandemic waves, as compared with the same period in 2019 (Fig. 3).

Figure 3. Number of acupuncture consultations by months in 2019, 2020, and 2021.

2. Characteristics of the study population

1) Socio-demographic characteristics

The patients’ mean age was 50.6 ± 12.3 years, with most of the patients aged between 50 and 59 years. Forty-eight patients were females (64.0%) and 27 were males (36.0%). All patients lived in urban areas, with 50 patients (66.7%) residing in the governorate of Tunis. During the COVID-19 pandemic, 45 patients (60.0%) had a university degree. Fifty-eight percent of the patients were professionals. Forty-one patients (54.7%) had an office job.

2) Pre-acupuncture journey of the patients during the coronavirus disease 2019 pandemic

During the COVID-19 pandemic, 68 patients (90.7%) consulted a physician (general practitioner or specialist) prior to the acupuncture therapy, and seven patients (9.3%) directly visited the acupuncture clinic. Sixty-four patients (85.3%) had previously received medical treatment before the acupuncture sessions.

During the COVID-19 pandemic, 27 patients (36.0%) were referred by a physician to the acupuncture clinic. Forty-seven patients (62.7%) were referred by a relative (word of mouth) and one patient (1.3%) consulted an acupuncturist on his own initiative after reading about the therapy online.

The motivating factors for visiting an acupuncturist during the COVID-19 pandemic were as follows: searching for a different therapeutic approach in 50 patients (66.7%); failure of medical treatment in 15 patients (20.0%); refusal to take medications in six patients (8.0%), and a belief in the efficacy of acupuncture in three patients (4.0%).

The pathologies prompting the patients to visit the acupuncture department were chronic rheumatologic diseases in 54 patients (72.0%), neurologic pathologies in seven patients (9.3%), oto-rhino-laryngological diseases in six patients (8.0%), varices in three patients (4.0%), a gynecological problem in two patients (2.7%), a psychological problem in two patients (2.7%), and smoking cessation in one patient (1.3%).

3. Impact of the coronavirus disease 2019 pandemic on acupuncture consultations

A mean of 11.0 ± 2.8 sessions were initially prescribed. Patients completed a mean of 8.0 ± 4.2 sessions. Thirty-three out of the 75 patients (44.0%) completed all the prescribed sessions despite the COVID-19 pandemic restrictions. Thirty-two of these patients felt very uncomfortable, which motivated them to adhere to and continue with the sessions. Only one patient was motivated to continue his sessions because he had received complete vaccinations against COVID-19. Forty-two patients (56.0%) have not completed the prescribed acupuncture sessions during the COVID-19 pandemic. Fear of contamination in the hospital or during transportation was the most frequently reported cause among all the reasons cited.

Table 1 summarizes the reasons for interrupting the acupuncture sessions during the COVID-19 pandemic.

Table 1 . Distribution of patients according to reason for stopping the acupuncture sessions.

Reason for stopping acupuncture sessions	Patient
Fear of contamination in the hospital or during transport	14 (33.3)
Unsatisfaction	7 (16.7)
Personal restrictions	7 (16.7)
Total confinement	4 (9.5)
Closure of the acupuncture department	4 (9.5)
Disappearance of symptoms	4 (9.5)
COVID-19 infection	1 (2.4)
Poor hygiene	1 (2.4)

Data are presented as n (%)..

COVID-19, coronavirus disease 2019..

4. Patients’ level of satisfaction with the acupuncture treatment during the coronavirus disease 2019 pandemic

During the COVID-19 pandemic, the patients scored their level of satisfaction with the overall care as (mean score) 8.7 ± 1.5 out of 10. Moreover, the patients rated how easy it was to book the first appointment and how long they had to wait for an appointment as (mean score) 9.0 ± 1.4 and 8.9 ± 1.6 out of 10, respectively. Moreover, regarding the level of satisfaction with the reception at the registration office and with the acupuncturist, the patients rated these as 8.8 ± 1.6 and 9.1 ± 1.6 out of 10, respectively.

The average waiting time in the consultation room before the acupuncture session was 16 ± 14 minutes during the COVID-19 pandemic. Patients felt that the protective measures were generally well respected and applied in the department during the pandemic; they scored this as (mean score) 8.3 ± 1.9 out of 10.

Table 2 summarizes the patient’s assessment of the degree of compliance and application of protective measures in the waiting and examination rooms.

Table 2 . Degree of application of protective measures in the waiting and examination rooms.

Protective measures	Number of patients (n = 75)
	Yes	No	Don't remember
Protective measures in the waiting room
Questions about fever	31 (41.3)	33 (44.0)	11 (14.7)
Signs of recent contamination	30 (40.0)	40 (53.3)	5 (6.7)
Notion of contact with a sick person	26 (34.7)	41 (54.7)	8 (10.6)
Notion of a recent trip	15 (20.0)	47 (62.7)	13 (17.3)
Taking the temperature before the session	40 (53.3)	33 (44.0)	2 (2.7)
Use of the hydroalcoholic gel	61 (81.3)	12 (16.0)	2 (2.7)
Wearing of masks by the medical staff	64 (85.3)	10 (13.3)	1 (1.3)
Protective measures in the examination room
Wearing of a mask by doctors	75 (100)	0 (0)	0 (0)
Wearing of over blouses by doctors	75 (100)	0 (0)	0 (0)
Wearing of mask by the patient in the waiting room	69 (92.0)	5 (6.7)	1 (1.3)
Wearing of mask by the patient in the examination room	68 (90.7)	6 (8.0)	1 (1.3)
Wearing of the mask by the patient after the session	69 (92.0)	5 (6.7)	1 (1.3)
Surface cleaning	59 (78.7)	12 (16.0)	4 (5.3)

Data are presented as n (%)..

Seventy-two patients (96.0%) felt that the acupuncturists were fairly confident and did not fear the risk of acquiring COVID-19. Patients rated their relationship with the acupuncturist during the COVID-19 pandemic period as 9.1 ± 1.6 out of 10. Thirty-one patients (41.3%) provided suggestions to improve the acupuncture center services, with 12 patients (38.7%) suggesting that the acupuncture department must improve their hygiene measures and equipment.

5. Factors influencing satisfaction with the overall care during the coronavirus disease 2019 pandemic

Satisfaction with the overall care was positively correlated with ease of booking the first appointment (p < 10⁻³, r = 0.554), reception at the registration office (p < 10⁻³, r = 0.667), reception by the acupuncturist (p < 10⁻³, r = 0.743), relationship with the acupuncturist (p = 0.032), and use of protective measures (p < 10⁻³, r = 0.600). Satisfaction with the overall care was negatively correlated with age (p = 0.002, r = −0.359) and time spent in the waiting room (p < 10⁻³, r = −0.392). There was no significant relationship between satisfaction with the overall care and adherence to acupuncture sessions (p = 0.486), sex (p = 0.413), governorate (p = 0.761), family situation (p = 0.514), occupation (p = 0.488), educational level (p = 0.317), or social security coverage (p = 0.894).

6. Patient suggestions for improving the quality of acupuncture care during a pandemic

Thirty-one patients (41.3%) provided suggestions for improving the quality of care in the acupuncture department of Mongi Slim Hospital, La Marsa during the COVID-19 pandemic (Table 3).

Table 3 . Patient suggestions for improving the quality of acupuncture care during a pandemic.

Patient suggestions to improve the quality of care	Patient (n = 31)
To improve the hygiene and equipment	12 (38.7)
Not to suspend the department’s activities	6 (19.3)
Planning larger waiting and examination rooms	6 (19.3)
To improve communication with the doctor	4 (12.9)
To add payment boxes	2 (6.4)
To reduce the waiting time	1 (3.2)

Data are presented as n (%)..

Our study assessed the impact of the COVID-19 pandemic on the course of consultations in the acupuncture department of Mongi Slim Hospital, La Marsa. The present study is the first to explore the impact of the COVID-19 pandemic on acupuncture consultations and to identify the problems inherent in inpatient management during a critical period.

In our study, during the COVID-19 pandemic, we found a significant decrease in the number of consultations in the acupuncture department of Mongi Slim Hospital, La Marsa, in 2020 and 2021, estimated at 67% and 61%, respectively, as compared with the number in 2019. No study conducted since the COVID-19 pandemic have investigated the impact of the pandemic on the course of acupuncture consultations.

However, some studies have shown a decrease in the activity in various emergency departments during the pandemic period. In the United States, during the first wave of the COVID-19 pandemic, a 42% decline in the number of patients was observed in 73% of the emergency departments, when compared to the number in the year 2019 [6]. Similarly, between January and April 2020, a multicenter study involving five different states in the United States showed a clear reduction in the number of patients in 24 emergency departments in the country [7]. Similar results have been noted in several European countries, showing a reduction in the number of patients attending emergency departments during the peak periods of the COVID-19 epidemic. Indeed, a 34.2% reduction in the number of patients per day in the emergency departments in Marseille during the first containment period, as compared with the same period in 2019, was observed [8]. During the period from March to April 2020, corresponding to the period of containment, a reduction in emergency department consultations of between 13% and 38% was reported in Germany [9] and between 31% and 54% in the United Kingdom [10]. Similarly, a decline in the number of emergency department patients of 50–68% was observed in Italy in February 2020 [11]. Ndiaye et al. [12] also observed a 19% to 33% drop in outpatient and inpatient activity in the pediatric department of the Albert Royer National Children’s Hospital in Dakar during the first quarters of 2019 and 2020. This drop has been explained by families’ fear of exposure to the COVID-19 virus in healthcare structures.

In our study performed during the COVID-19 pandemic, a clear female predominance was noted (64% of women versus 36% of men) with an average age of 50.6 ± 12.0 years. The 50 to 59 age group was the most represented. Our results are similar to those found in other studies conducted during periods preceding the COVID-19 pandemic. In a study conducted in 2002 in Tunisia, which assessed the motivation and behavior of 100 acupuncture patients at the Mongi Slim Hospital, 63% of the patients were women with an average age of 54, and an over-representation of the 51−60 age group [13]. In the United Kingdom, in a study carried out in 2002 on the characteristics of 9,408 patients who had received acupuncture treatment, 74% of the patients were female, with an average age of 51. The most common age group was 45−54 [14]. This predominance of women, even during the period of the COVID-19 pandemic, could be justified by a greater need to be listened to, greater attention to health problems and by the fact that certain problems are related to pathologies that tend to affect women (migraine, insomnia, infertility, etc.). The predominance of patients aged 50 and over in acupuncture consultations may be explained by the fact that this age group is more prone to chronic illnesses, particularly rheumatological ones, and that acupuncture represents a good alternative for relieving pain and reducing the need for medication in subjects who often take multiple medications [15].

In our study, patients underwent an average of 8.0 ± 4.2 sessions. Only 33 patients (44%) out of the 75 completed all the prescribed sessions, motivated by the fact that they were very embarrassed, except for one patient who was correctly vaccinated against COVID-19 and therefore did not suspend his sessions.

Of the 42 patients who interrupted their sessions, 33.3% were afraid of being contaminated in the hospital or during the transport. No study conducted since the COVID-19 pandemic has examined the impact of the pandemic on patients’ adherence to acupuncture care. A study performed in Hong Kong during the COVID-19 pandemic concluded that the fear of COVID-19 increased the delay in consulting a doctor [16]. Similarly, according to the Ndiaye et al.’s [12] study conducted in Dakar, there was a significant decrease in the number of visits to services, reaching 33% in March 2020. This decline was due to the fear of contacting the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the virus causing COVID-19, in healthcare structures [12]. In Italy, motivated by the same fear of getting infected by SARS-CoV-2, a significant decrease in the use of health services in various specialties was observed during the COVID-19 pandemic [17].

Patients provided an average score of 8.7 ± 1.5, 9.0 ± 1.4, 8.9 ± 1.6, and 8.8 ± 1.6 out of 10, respectively, for their level of satisfaction with the overall care, ease of booking the first appointment, waiting time for an appointment, and of satisfaction with the reception at the registration desk in the acupuncture department of Mongi Slim Hospital, La Marsa during the COVID-19 pandemic. A similar high level of satisfaction with the acupuncture sessions at the acupuncture department of Mongi Slim Hospital, La Marsa was also found in a Tunisian survey involving 100 patients that was conducted in 2011, which was several years prior to the COVID-19 pandemic.

Indeed, 84% of the patients reported being satisfied with the care received, with 51% of them reporting that they were moderately satisfied and 33% stating that they were very satisfied; this rate was lower than the rate obtained in our study, despite the fact that our study was conducted during a critical period [18]. Since its introduction in Tunisia in the 1990s, the role of acupuncture has evolved. Acupuncture has now become an alternative treatment modality, with an increasing demand in the Tunisian health system. Altogether, 96% of the patients reported that their Chinese acupuncturists were confident despite the risk of exposures during the COVID-19 pandemic. The patients provided a mean score of 9.1 ± 1.6 out of 10 for their relationship with the acupuncturist during the pandemic period. Our results are consistent with the findings of a previous study performed in 2017, which is several years prior to the COVID-19 pandemic period. The relationship with the acupuncturist was also rated by the patients as 9.1 [19].

The patients felt that, during the pandemic, the protective measures were generally well respected and applied in the department; hence, they provided an average score of 8.3 ± 1.9 out of 10. According to the results of the study conducted in 2017, before the COVID-19 pandemic, in the acupuncture department of Mongi Slim Hospital, La Marsa, Tunisia, the patients rated the conditions in the waiting and acupuncture rooms as 8.5 and 8.8, respectively [19].

In our study, the level of satisfaction with the overall care was positively correlated with the ease of booking the first appointment (p < 10⁻³, r = 0.554), reception at the registration office (p < 10⁻³, r = 0.667), reception of the acupuncturist (p < 10⁻³, r = 0.743), relationship with the acupuncturist (p = 0.032), and degree of application of the protective measures (p < 10⁻³, r = 0.600). However, the level of satisfaction with the overall care was negatively correlated with age (p = 0.002, r = −0.359) and time spent in the waiting room (p < 10⁻³, r = −0.392). No significant relationship was found between the level of satisfaction with the overall care and sex (p = 0.413), governorate (p = 0.761), family situation (p = 0.514), occupation (p = 0.488), educational level (p = 0.317), social security coverage (p = 0.894), and adherence to acupuncture sessions (p = 0.486). No study has assessed the link between patients’ level of satisfaction with overall management and the various parameters of care during acupuncture consultations. Additionally, a previous Chinese study has shown that the doctor–patient relationship improved during the COVID-19 pandemic, as compared with pre-pandemic period. This improvement was essentially due to better doctor–patient communication, patient satisfaction, shorter consultation time, doctor’s attitude, possibility of teleconsultation, and measures taken by the Chinese government to facilitate patient access to care [20].

Our study results indicated that the COVID-19 pandemic had a negative impact on the number of patients in the acupuncture department of Mongi Slim Hospital, La Marsa, without affecting the quality of care. The application and observance of hygiene measures made it possible to maintain a good quality of care that is comparable to that observed during the periods preceding the COVID-19 pandemic.

Conceptualization: AF. Data curation: RBM. Formal analysis: RBM. Investigation: AF, RBM. Methodology: AF, RBM. Project administration: AL. Supervision: AF. Validation: SM, KBA. Writing – original draft: OL. Writing – review & editing: YM, HB.

The authors declare no conflict of interest.

None.

The present study was approved by the Human Research Ethics Committee of Mongi Slim Hospital (approval number: 01/2025). A written informed consent was obtained from the patients for the publication.