Telehealth Expands Contraceptive Access, but Some Youth Just Want Face-to-Face Care
A research review involving telemedicine-delivered contraceptive health services to female adolescents and young adults revealed that youth find these acceptable, but some reported a preference for in-person care.1
“We wanted to get a sense of the dimensions or domains of preferences. We talked with young people to get a sense of what’s important to them,” says Samantha Garbers, PhD, study co-author and associate professor in the department of population and family health at Columbia University. “We were surprised about how little there is in the literature of patients’ perspectives. We had a whole team that screened 160 articles, and [they found] literally three articles.”
Garbers and colleagues looked at studies that included the perspectives of patients and providers. They found a lot of literature about medication abortions prescribed via telemedicine services, and they saw some papers on mobile apps and text messaging.
“But we were interested in telemedicine, synchronous audio/visual communication between the patient and provider,” Garbers explains.
For instance, can patients benefit from a telehealth visit before an in-person visit for a long-acting reversible contraceptive (LARC)?
“Some prior work I’ve done looked at continuation rates of people who initiated copper IUDs in a community health center,” Garbers says. “We found that folks who met with a health educator before insertion of the IUD were more likely to continue with the IUD beyond six months, which is a measure of satisfaction.”
Since heavier periods are a side effect of copper IUDs, it is important to know how to help patients maintain that method of contraception if a little more education and preparation would be beneficial.
“Counseling adolescents or young women about what to expect and how to manage the side effects can increase satisfaction,” she adds. “There is a lot of opportunity to use telehealth. Obviously, a person has to go in person to have a LARC method inserted.”
There are opportunities for patients to meet with health educators and providers ahead of time. “There’s also an opportunity to meet with the patient at a two-week follow-up visit to manage side effects,” Garber says. “This improves care for adolescents.”
Confidentiality, Privacy Are Concerns
Investigators found in the review that internet access is not a major issue. “In the abstract, the benefits of telehealth care are lower cost, no transportation costs, and no physical exam when that’s not needed,” Garber says. “What was very interesting was that both patients and providers brought up concerns around confidentiality and privacy. For patients, it was a concern about confidentiality and what would happen with their information going over the internet — ‘Who will hear this?’”
For providers, the concern was about their young patients having equitable access to private space in the home. A person may have access to the internet but cannot talk privately due to a lack of private space.
“Providers had more specific concerns and equity-focused concern around folks having a private place to talk with a doctor on the screen,” Garbers notes. “For adolescent and young adult patients, it was an abstract issue around privacy and confidentiality.”
Telehealth became more readily available during the COVID-19 pandemic. As Garbers and colleagues note, telemedicine use across all clinical specialties increased more than twentyfold, and in-person clinic visits declined almost 50% in 2020.1 There appeared to be less use of telehealth in school-based health programs.
“There is very little on adolescents’ actual experience, and this was earlier in the pandemic,” Garber says. “We struggled to find research that just looked at adolescents and young women. The fact is that this [telehealth and youth] is not well-studied at all.”
For instance, it could be that for many school-age young people, school-based health centers are both convenient and familiar, so they have less need or desire for telehealth appointments related to reproductive health.
“If the site the patient has an existing relationship with is already very convenient, then telehealth may not represent a lot of value added,” Garber says. “But only three studies looked at the patient’s perspective.”
Some practice recommendations were noted in the research, including:
• Assure confidentiality. The authors of one study advised providers to assure patients that their information is secure and confidential, and to show them security measures when possible.1,2
“Physicians also shared some concerns about confidentiality, especially pediatricians,” Garber says.
• Maintain private areas in a community location. Sometimes, telehealth visits between adolescents and reproductive health providers may take place in a community center or library. If so, these visits should occur in a neutral, multipurpose location to ensure privacy. A nurse or other medical provider should be onsite at the telemedicine location to facilitate the visit and ensure patient comfort.1,2
“Younger people were concerned because sometimes telehealth is provided in a community setting, like getting contraception in a mobile van,” Garber says. “They worry that someone will see them get into the van.”
One recommendation was to place “Free flu shots” signage on the van instead of advertising sexually transmitted infection services or contraception services, she adds.
• Show provider’s background setting. To improve participant comfort with telemedicine, the provider’s background and setting should be visible in the video call. Also, provider credentials should be made clear to patients.1,2
“Make sure the background where the doctor is does not have a disembodied head on a plain background,” Garber says.
• Focus on relationship-centered care. Providers should frame contraception as a holistic part of a person’s overall health, including the benefits in preventing cancer, heart disease, and more. They can offset the impersonal nature of telemedicine by ensuring they are perceived as understanding and down to earth and by avoiding judgment.1-3
• Address privacy concerns. Providers can help patients with privacy concerns by asking yes/no questions, requesting that patients use headphones, and using the Zoom chat feature instead of speaking out loud. Also, patients can upload photos to their electronic health record rather than conducting exams via webcam.1,4
Providers also need to know their states’ laws regarding medical appointments with minors and whether they need guardian permission or consent. For teens who can meet with a reproductive health provider, a virtual option may solve their problem with transportation. They could download an app and have a secure virtual session.
“If they have access to private space and a device, it can be a great fit,” Garber adds.
REFERENCES
- Diaz MF, Colleen G, Gruver R, et al. Providing contraceptive health services to adolescents and young adults by telemedicine: A scoping review of patient and provider perspectives. J Pediatr Adolesc Gynecol 2022;S1083-3188(22)00219-4.
- Sundstrom B, DeMaria AL, Ferrara M, et al. “The closer, the better:” The role of telehealth in increasing contraceptive access among women in rural South Carolina. Matern Child Health J 2019;23:1196-1205.
- Sundstrom B, DeMaria AL, Ferrara M, et al. “People are struggling in this area:” A qualitative study of women’s perspectives of telehealth in rural South Carolina. Women Health 2020;60:352-365.
- Barney A, Buckelew S, Mesheriakova V, Raymond-Flesch M. The COVID-19 pandemic and rapid implementation of adolescent and young adult telemedicine: Challenges and opportunities for innovation. J Adolesc Health 2020;67:164-171.
A research review involving telemedicine-delivered contraceptive health services to female adolescents and young adults revealed that youth find these acceptable, but some reported a preference for in-person care.
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