Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.     

The impact of digital competence on telehealth utilization

ObjectivesTelehealth use has increased steadily since the mid-2000′s when technology shifted from voice-only systems to live video-conferencing and other technologies supported by broadband Internet. More recently, the COVID-19 pandemic has resulted in exponential growth in telehealth use. As telehealth systems become increasingly complex and gain widespread adoption, this study explores how users’ digital competences affect telehealth use.MethodsWe apply a series of multivariate logit models to a representative sample of California adults with Internet access surveyed in early 2021. We estimate the impact of self-reported digital competence–using items from the digital skills assessment scale–on a participant's likelihood of telehealth use during the COVID-19 pandemic as well as the likelihood to continue using telehealth beyond the pandemic.ResultsThe findings show that a one-unit increase in digital competence is associated with 72.8% greater odds of telehealth use (p <0.001) and 71.6% greater odds of willingness to continue using telehealth services beyond the pandemic (p<.01). We also found that greater social and economic capital generally were associated with increased odds of telehealth use.ConclusionsImproving access to telehealth will require solutions addressing both the first level (i.e., access to broadband and devices) and the second level (i.e., skills and attitudes towards the internet) of digital inequality. Policies and programs seeking to expand internet access must be coupled with investments in digital upskilling and training. Those with limited digital competence will face continued barriers in navigating telehealth systems, further exacerbating disparities in healthcare access and outcomes.Public Interest SummaryDigital competence is the ability and confidence to apply one's knowledge and skills to perform tasks through information technology, including computing devices and the internet. This study explores the relationship between digital competence and telehealth use among those with broadband internet access at home. Telehealth has become increasingly common due to its cost-effectiveness and accessibility for patients unable to visit healthcare facilities. Though the COVID-19 pandemic has contributed to a significant increase in telehealth use, it is expected that telehealth services will continue to expand after the pandemic subsides. In our analysis of California adults, a year into the pandemic, we find those with greater digital competence are more likely to have used telehealth during the pandemic. Further, among telehealth users, those with greater digital competence are more likely to continue using telehealth beyond the pandemic. Addressing disparities in healthcare access and outcomes will require improving potential users’ digital competence.     

Health and health care status of African-born residents of Metropolitan Washington, DC

This study examines health status, health behaviors, and health care access and utilization among African-born residents of the metropolitan Washington, DC area. A telephone survey was administered to a random sample of 525 African-born adults. Results are compared to those for the general local and regional population. Twenty-nine percent of respondents were uninsured; 24% lacked a usual, appropriate source of primary care. Among female respondents, 44% and 34% reported never having had a mammogram or pap smear, respectively. Most health status indicators demonstrated relatively good health, but 15% of respondents reported one of the infectious diseases we investigated. Consumption of alcohol and tobacco was relatively low. African-born residents are generally at risk regarding access to health care, and certain segments (the uninsured, recent arrivals) face critical access barriers. Infectious diseases are a notable feature of health status, and use of some preventive and dental services is considerably lower than for the general population.     

Utilization of Health Care Services Among Adults Attending a Health Fair in South Los Angeles County

A bilingual survey was developed to collect information regarding socio-demographics, access to medical and dental care, health insurance coverage, perceived health status, and use of folk medicine providers from 70 adults presenting to a health fair in South Los Angeles County. Ninety-seven percent of respondents were foreign-born. Seventy-nine percent reported having no health insurance during the year prior to survey. Of the uninsured, 61 percent lacked a doctor visit and 76 percent lacked a dental visit during the previous year. The high cost of care was the most frequently cited barrier to seeking medical (58 percent) and dental (67 percent) care even when respondents felt it was necessary. Respondents who felt they needed medical attention but did not seek it had a lower perceived health status (7.0 ± 2.2) than those who did (8.0 ± 2.0). Among respondents perceiving themselves in poor health, only 17 percent were insured. Relatively few respondents (7.2 percent) reported seeing a folk healer during the past year. Our results support the argument that the medically indigent in some localities face serious financial, as well as less salient, barriers to access. These local conditions reflect inadequate enforcement by local governments in correcting the difficult problems indigent populations face in accessing medical and dental care.     

“The Closer,the Better:” The Role of Telehealth in Increasing Contraceptive Access Among Women in Rural South Carolina

Background

Rural populations face unique health disparities that prevent women from accessing reproductive health care services. Telehealth initiatives offer a health care delivery tool to increase access to contraception.

Objective

To understand women’s contraceptive needs and perceptions of accessing contraception through telehealth services.

Methods

Researchers conducted 52 in-depth interviews with women ages 18–44 years living in five rural counties in South Carolina from May to July 2015. Researchers employed constant comparative data analysis using HyperRESEARCH 3.7.2.

Results

Most participants identified as Black (62%) or White (28%). Findings suggest successful telehealth interventions should accommodate women’s complex and nuanced community views, including benefits and barriers of telehealth, to improve access to contraceptive methods in rural locations. In addition, telehealth initiatives should frame contraception as contributing to women’s overall health and well-being.

Conclusions for Practice

Telehealth initiatives may address barriers to contraceptive access in rural locations. Findings from this study offer theoretical and practical opportunities to guide telehealth interventions that support and empower women’s access to contraceptive methods in rural areas.

     

Telehealth Utilization for Chronic Illness and Depression Among Home Health Agencies: A Pilot Survey

This pilot survey study explores current telehealth use among home health care agencies for chronic illness and depression care, and identifies factors associated with agencies’ perception and intention to use telehealth. Between June and August 2014, 73 directors and 13 staff nurses (N = 86) from the Pennsylvania Homecare Association member agencies participated in an online survey. Eighty-five percent of telehealth provider agencies reported utilizing telehealth for monitoring health status while only 7.7% reported use for depression care. Telehealth technology was more positively perceived for chronic illness care (90.7%) than for depression care (53%) services. Factors associated with positive perceptions of telehealth were identified, including: (a) intention to use or continuing to use telehealth, (b) the size of the agency, (c) the participant’s agency role, and (d) existence of depression services. These pilot findings have been used to inform the theoretical framework and the survey instrument for our U.S. national survey.     

Telehealth for elders and their caregivers in rural communities

The use of technological strategies in providing care for patients and their families at distant locations has been available since the 1950s. Today's telehealth approaches are proposed to offer considerable promise for enhanced service delivery in rural and other underserved communities. Technology-based delivery methods, such as videophone skill training, and one- and two-way interactive computer networks, are envisioned as contributors for improving rural residents' access to services, individualizing rural health care, increasing rural health practitioners' continuing education opportunities, and improving quality and cost-efficiency of care.     

Contraceptive Use Patterns among Women of Reproductive Age in Two Southeastern States

BackgroundUnintended pregnancies remain an important public health issue. Modern contraception is an important clinical service for reducing unintended pregnancy. This study examines contraception use among a representative sample of women residing in two southeastern U.S. states.MethodsA cross-sectional statewide survey assessing women's contraceptive use and reproductive health experiences was conducted in Alabama and South Carolina. Characteristics of the study population were compared across contraceptive use categories and multivariable regression analysis was performed examining relationships between covariates of interest and contraceptive use outcomes.ResultsApproximately 3,775 women were included in the study population. Overall, 26.5% of women reported not using any contraception. Short-acting hormonal methods were the most commonly reported (26.3%), followed by permanent methods (24.4%), long-acting reversible contraception (LARC; 14.3%), and barrier/other methods (8.5%). Nonuse was more prevalent among women with some college or an associate's degree, incomes between $25,000 and $50,000, no health insurance, and longer gaps in care. LARC use among women with Medicaid as a pay source was higher than use among privately insured women and higher in South Carolina than Alabama. Both nonuse and LARC use were higher among women with no insurance.ConclusionsStudy findings are largely consistent with previous research using similar population-based surveys. LARC use was higher among the study population relative to what is observed nationally. Factors enabling access to contraceptive services, particularly for lower income women, were associated with contraception use patterns. These findings provide important context for understanding individuals’ access to resources and are important for fostering increased access to contraceptive services among women in these two states.     

Report on Honduras: ripples in the pond--the financial crisis and remittances to chronically ill patients in Honduras

The U.S. financial crisis has affected employment opportunities for Latino immigrants, and this could affect their ability to send financial assistance, or "remittances", to chronically ill family members in their home country. In a cross-sectional survey of 624 chronically ill adults conducted in Honduras between June and August 2009, respondents reported their receipt of remittances, health service use, and cost-related access barriers. Fifty-four percent of respondents reported relatives living outside the country, and of this group, 66 percent (37% of the overall sample) received remittances. Seventy-four percent of respondents receiving remittances reported a decrease over the prior year, mostly due to job losses among their relatives abroad. Respondents reporting reductions in remittances received significantly less per month, on average, than those without a reduction (US $170 vs. $234; p = 0.01). In multivariate models, respondents experiencing a reduction in remittances used fewer health services and medications due to cost concerns. Remittance payments from relatives resident in the United States are a major source of income for chronically ill individuals in Latin America. Most recipients of remittances reported a reduction during the financial downturn that affected their access to care.     

The Lab: How to Set up a Parasitology Department

Introduction: While for adults in Pennsylvania, obesity rates tripled from less than 10% in 1990 to 30% in 2015, the combined rates of overweight, obese, and severely obese children and adolescents in Pennsylvania are projected to approach 37.11% by the end of 2018.

Method: Pediatric obesity rates in rural areas tend to be even higher than those in urban areas. Pediatric obesity needs to be addressed, since it is strongly correlated with several chronic diseases. Given the scarcity of resources to manage this trend, innovative population-based approaches are needed. Web-based telehealth, telemedicine, mobile health (mHealth), and telephone conferences have been proposed as solutions to treat and prevent childhood obesity in rural areas; the most suitable solution is through a family-based telemedicine intervention. The purpose of this study is to explore the feasibility of such a telehealth application especially for rural Pennsylvania.

Results: Telehealth use in healthcare organizations in Pennsylvania is scarce; however, 92% of Pennsylvania’s school districts meet the minimum internet connectivity standards.

Discussions: This article, while acknowledging barriers to the adoption of the internet-based telemedicine resources, discusses solutions for increasing their availability and dissemination in rural Pennsylvania. Current internet connectivity standards in Pennsylvania schools reflect ability to participate in telehealth programs in terms of technological background, but schools are not engaged in such programs. An appraisal of the real-life challenges to implement this modality is critical and will pave the way for advocacy and implementation of useful telehealth services in low-resource areas.     

Evidence of Social and Structural COVID-19 Disparities by Sexual Orientation,Gender Identity,and Race/Ethnicity in an Urban Environment

The ongoing COVID-19 pandemic has had widespread social, psychological, and economic impacts. However, these impacts are not distributed equally: already marginalized populations, specifically racial/ethnic minority groups and sexual and gender minority populations, may be more likely to suffer the effects of COVID-19. The COVID-19 Resiliency Survey was conducted by the city of Chicago to assess the impact of COVID-19 on city residents in the wake of Chicago’s initial lockdown, with particular focus on the experiences of minority populations. Chi-square tests of independence were performed to compare COVID-19-related outcomes and impacts on heterosexual vs. sexual minority populations, cisgender vs. gender minority populations, and White vs. racial/ethnic minority subgroups. Marginalized populations experienced significant disparities in COVID-19 exposure, susceptibility, and treatment access, as well as in psychosocial effects of the pandemic. Notably, Black and Latinx populations reported significant difficulties accessing food and supplies (p = 0.002). Healthcare access disparities were also visible, with Black and Latinx respondents reporting significantly lower levels of access to a provider to see if COVID-19 testing would be appropriate (p = 0.013), medical services (p = 0.001), and use of telehealth for mental health services (p = 0.001). Sexual minority respondents reported significantly lower rates of using telehealth for mental health services (p = 0.011), and gender minority respondents reported significantly lower levels of primary care provider access (p = 0.016). There are evident COVID-19 disparities experienced in Chicago especially for Black, Latinx, sexual minority, and gender minority groups. A greater focus must be paid to health equity, including providing increased resources and supplies for affected groups, adapting to inequities in the built environment, and ensuring adequate access to healthcare services to ameliorate the burden of COVID-19 on these marginalized populations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-020-00497-9.     

Rapid Transition to Telehealth and the Digital Divide: Implications for Primary Care Access and Equity in a Post‐COVID Era

Policy Points

• Telehealth has many potential advantages during an infectious disease outbreak such as the COVID‐19 pandemic, and the COVID‐19 pandemic has accelerated the shift to telehealth as a prominent care delivery mode.
• Not all health care providers and patients are equally ready to take part in the telehealth revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.
• Without proactive efforts to address both patient‐ and provider‐related digital barriers associated with socioeconomic status, the wide‐scale implementation of telehealth amid COVID‐19 may reinforce disparities in health access in already marginalized and underserved communities.
• To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.

ContextThe COVID‐19 pandemic has catalyzed fundamental shifts across the US health care delivery system, including a rapid transition to telehealth. Telehealth has many potential advantages, including maintaining critical access to care while keeping both patients and providers safe from unnecessary exposure to the coronavirus. However, not all health care providers and patients are equally ready to take part in this digital revolution, which raises concerns for health equity during and after the COVID‐19 pandemic.MethodsThe study analyzed data about small primary care practices’ telehealth use and barriers to telehealth use collected from rapid‐response surveys administered by the New York City Department of Health and Mental Hygiene''s Bureau of Equitable Health Systems and New York University from mid‐April through mid‐June 2020 as part of the city''s efforts to understand how primary care practices were responding to the COVID‐19 pandemic following New York State''s stay‐at‐home order on March 22. We focused on small primary care practices because they represent 40% of primary care providers and are disproportionately located in low‐income, minority or immigrant areas that were more severely impacted by COVID‐19. To examine whether telehealth use and barriers differed based on the socioeconomic characteristics of the communities served by these practices, we used the Centers for Disease Control and Prevention Social Vulnerability Index (SVI) to stratify respondents as being in high‐SVI or low‐SVI areas. We then characterized respondents’ telehealth use and barriers to adoption by using means and proportions with 95% confidence intervals. In addition to a primary analysis using pooled data across the five waves of the survey, we performed sensitivity analyses using data from respondents who only took one survey, first wave only, and the last two waves only.FindingsWhile all providers rapidly shifted to telehealth, there were differences based on community characteristics in both the primary mode of telehealth used and the types of barriers experienced by providers. Providers in high‐SVI areas were almost twice as likely as providers in low‐SVI areas to use telephones as their primary telehealth modality (41.7% vs 23.8%; P <.001). The opposite was true for video, which was used as the primary telehealth modality by 18.7% of providers in high‐SVI areas and 33.7% of providers in low‐SVI areas (P <0.001). Providers in high‐SVI areas also faced more patient‐related barriers and fewer provider‐related barriers than those in low‐SVI areas.ConclusionsBetween April and June 2020, telehealth became a prominent mode of primary care delivery in New York City. However, the transition to telehealth did not unfold in the same manner across communities. To ensure greater telehealth equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them.     

Varieties of health services utilization by underserved Mexican American women

Varieties of health services utilization by medically underserved patients were examined in 250 Mexican American women attending a primary care clinic in San Diego, California. Less than half (48.4 percent) of these medically underserved women had obtained clinical preventive services conforming to recommended guidelines, 34.4 percent reported having obtained an annual physical examination in the past year, and 66.0 percent reported visiting a doctor only when they were sick. Lack of any form of health insurance, including Medi-Cal, was associated with underutilization of primary care services to a greater degree than the other variables examined. However, other factors such as full-time employment, low education, dissatisfaction with primary care delivery, and cultural preference for traditional ethnomedical alternative forms of health care, constitute important barriers to utilization of primary care services. Efforts to provide health care to the medically underserved must take these barriers into consideration if they are to be successful.     

Contraception access and use among US servicewomen during deployment

BackgroundApproximately 12% of active duty US servicewomen have an unintended pregnancy each year; however, little is known about contraception use during deployment.Study DesignFrom April to November 2010, we conducted an online survey with a convenience sample of 281 servicewomen who had been deployed overseas to assess access to and use of contraception for deployment.ResultsSixty-three percent of respondents used birth control for part or all of their last deployment. Although military health insurance covers most contraceptive methods, one third reported that they were unable to access a method they might want for deployment, and 59% did not speak with a military provider about contraceptive options prior to deployment. Certain methods were reportedly discouraged or not available for some women, including intrauterine devices and sterilization, and 41% of women requiring refills found them difficult to obtain.ConclusionsGiven the high prevalence of unintended pregnancy among servicewomen, efforts should focus on improving contraceptive counseling prior to deployment and ensuring refill access during deployment, as well as expanding access to long-acting reversible methods.     

Health care access of poverty-level older adults in subsidized public housing.

OBJECTIVE. To assess the health status, access and use of health care and unmet health care needs of poverty-level residents of the Seattle Housing Authority over the age of 62. METHODS. An in-person interview survey of a quota sample of community residents. RESULTS. About half of SHA residents reported problems accessing care and sixteen percent reported being denied care. Multivariate analysis showed that encountering barriers of health care use were associated with having insufficient funds for monthly living expenses and lack of transportation. Over 90% of the population knew where to seek health care, so knowledge about sources of care did not appear to be a barrier. SHA residents met or exceeded national goals for completion of six out of nine recommended exams and procedures. SHA residents had unmet needs for services not covered by Medicare or provided by visiting nurse services. CONCLUSIONS. The results suggest that SHA residents know how to access medical care, and that visiting nurse services may be remarkably effective in meeting some medical care needs of SHA residents. It appears access to care by residents of subsidized housing could be improved by addressing transportation and financial barriers, and by providing more services to residents on site.     

“Does this Look Infected to You?” Social Network Predictors of Dental Help-Seeking Among Mexican Immigrants

Compared to U.S. born Latinos, Mexican immigrants (MAs) have diminished health care access and face substantial barriers to accessing needed dental health services. However, little research has examined how MAs social networks shape their use of dental health services. Using data from 332 Mexican immigrants to the Midwest, this research examines the significance of individual and egocentric network characteristics on two measures of dental health service utilization. Findings reveal that network size, network dental service utilization, and the frequency with which MAs discuss acute problems with network ties, positively correspond to use of oral health services. Conversely, embeddedness in networks where ties hassle egos about dental issues and have low levels of dental health knowledge correspond to lower odds of using these services. This research is among the first to use ego network data and methods to examine the ways network characteristics shape oral health behaviors among this underserved population.     

Older lesbian and gay adults’ perceptions of barriers and facilitators to accessing health and aged care services in Australia

Older lesbian and gay people can face considerable marginalisation, which may affect their perceptions and experiences of accessing health and aged care services. To inform strategies promoting accessibility, this study aimed to investigate perceived barriers and facilitators to health and aged care service access among older lesbian and gay adults. A sample of 752 cisgender lesbian women and gay men aged 60 years and older living in Australia responded to questions on a broad range of potential barriers and facilitators to service access. Several barriers and facilitators were commonly reported, with some differences between the women and the men. LGBTI inclusiveness was among commonly reported concerns. A majority of participants reported a lack of LGBTI-inclusive service providers and professionals as a barrier. A majority also reported a perceived lack of professionals adequately trained and competent to work with LGBTI individuals, with significantly more women than men indicating this as a barrier. Almost all participants indicated LGBTI-inclusive mainstream services as a facilitator for access. In all, inclusiveness appears to be a key issue for service access among older lesbian and gay people, which may need to be further addressed by service providers and policy makers for improving service accessibility.     

Identification of targets for improving access to care in persons with long term physical disabilities

BackgroundPeople with long-term physical disability (LTPD) continue to experience difficulties in accessing health care despite the focus of highlighting disparities in the last two decades.ObjectivesTo describe health care utilization, accommodations and barriers experienced while accessing health care, and reasons why individuals delay or skip health care among people with LTPD.MethodsThe current study was a part of a larger longitudinal survey administered to individuals with physical disability associated with one of four long-term conditions (MS; SCI; PPS; MD). Measures included demographics, health care utilization, barriers to health care, and reasons for delaying or skipping medical care from the sixth wave of data from 2015 to 2016.ResultsRoughly 90% of all participants (N = 1159) saw at least one medical provider within 12 months. The most encountered barrier participants reported experiencing within that time was an office that did not have a safe transfer device to move them to an exam table (69%). Participants’ physical function, quality of life, status of living with a spouse, diagnostic condition, and sex (male) were significantly associated with endorsing a barrier in accessing health care. The inability to afford out of pocket expenses was the highest reported reason for delaying health care.ConclusionsPeople with LTPD access a variety of health care, including rehabilitation services, and continue to experience barriers when doing so. While understanding barriers individuals experience when accessing health care is important, it is equally important to document the type of care they delay or skip due to barriers.     

Mental Health Service Utilization among Students and Staff in 18 Months Following Dawson College Shooting

ObjectivesThe aim of this study was to investigate service utilization by students and staff in the 18 months following the September 13, 2006, shooting at Dawson College, Montreal, as well as the determinants of this utilization within the context of Canada''s publicly managed healthcare system.MethodsA sample of 948 from among the college''s 10,091 students and staff agreed to complete an adapted computer or web-based standardized questionnaire drawn from the Statistics Canada 2002 Canadian Community Health Survey cycle 1.2 on mental health and well-being.ResultsIn the 18 months following the shooting, there was a greater incidence and prevalence not only of PTSD, but also of other anxiety disorders, depression, and substance abuse. Staff and students were as likely to consult a health professional when presenting a mental or substance use disorder, with females more likely to do so than males. Results also indicated that there was relatively high internet use for mental health reasons by students and staff (14% overall).ConclusionsFollowing a major crisis event causing potential mass trauma, even in a society characterized by easy access to public, school and health services and when the population involved is generally well educated, the acceptability of consulting health professionals for mental health or substance use problems represents a barrier. However, safe internet access is one way male and female students and staff can access information and support and it may be useful to further exploit the possibilities afforded by web-based interviews in anonymous environments.