‘I didn’t want to visit a doctor unless it was extremely necessary’: perspectives on delaying access to sexual and reproductive health care during the COVID-19 pandemic in Australia from an online survey

Keywords: COVID-19, health services: accessibility, primary health care, reproductive health services.

The COVID-19 pandemic prompted a series of restrictions in Australia throughout 2020. As was the case in many countries, lockdowns were one of the strategies introduced to reduce the risk of transmission of COVID-19. Australian restrictions began on 29 March 2020, when the federal government announced limitations on gatherings and instructed Australians to only leave home for essential activities (Prime Minister of Australia 2020). Although exact rules varied by state, all of Australia experienced some form of lockdown from late March to mid-May 2020. Later in the year, further outbreaks resulted in local area and statewide lockdowns for varying durations, the longest being the 112-day Victorian lockdown from July to October 2020. Alongside restrictions, many healthcare services that provide sexual and reproductive health (SRH) care modified their service delivery. Australian national health insurance (Medicare)-funded telehealth services were expanded to allow GPs and other providers to deliver telephone or virtual consultations (Hunt and Kidd 2020), and walk-in services for asymptomatic patients were removed from some sexual health clinics (Chow et al. 2021). However, during all lockdown periods, essential health services in all states and territories were permitted to continue operating. Decisions about changes to service delivery were made at a clinic level.

Reduced patient attendances were reported by some services, including metropolitan sexual health clinics (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) 2020; Chow et al. 2021). Although declines may have been due, in part, to reduced accessibility, concerns were raised that the ‘stay at home’ public health messaging had resulted in Australians avoiding seeking care. This messaging, along with the suspension of non-urgent elective surgeries (Australian Institute of Health and Welfare (AIHW) 2021b) and implementation of ‘COVID-safe’ practices in clinics (e.g. asking patients to wait outdoors before appointments; Australian Medical Association 2020), may have inadvertently discouraged patients from accessing care. In response to these concerns, various bodies, including the Royal Australian College of General Practitioners (RACGP) and primary health networks (PHNs), launched campaigns encouraging people not to neglect their health and to continue to access services when needed (RACGP 2020; North Western Melbourne PHN 2021).

Throughout 2020, we conducted a series of online cross-sectional surveys of people’s SRH experiences during COVID-19. Several free-text questions were included to collect contextual information about experiences, including the impact of COVID-19 on health-seeking behaviours. Including free-text questions when conducting quantitative surveys can yield rich and valuable qualitative data (Rich et al. 2013). In this paper, we explore the SRH issues for which young Australians delayed seeking care and the rationale behind decisions to delay accessing care.

We distributed four online surveys throughout 2020 to explore the impact of COVID-19 on Australians’ SRH. The surveys were developed by members of the Sexual Health Unit at The University of Melbourne, and were distributed using Qualtrics Survey Software (Qualtrics, Provo, UT, USA) Participants were recruited online via paid Facebook and Instagram advertisements targeting people living in Australia who were ≥18 years of age. Members of the research team also distributed the survey via email and Twitter to personal and professional networks.

People living in any state or territory within Australia were eligible to participate provided they were aged ≥18 years. Upon clicking the survey link, participants were provided with a plain language statement, with information about the study, researchers and data security and storage. Respondents were informed that participation was voluntary and that the survey would take approximately 30 minutes to complete. Prior to commencing the survey, respondents were asked whether they consented to participating, as well as two eligibility questions (country of residence and age). Individuals who declined to consent, indicated that they were living outside of Australia or were <18 years of age were ineligible and exited from the survey. Participants did not review their answers, although they could use a ‘back’ button to amend responses. Respondents could complete each survey only once; cookies were used to assign a unique user identifier to each client computer to prevent multiple submissions. However, individuals could participate in multiple waves of the survey and were invited to provide an email address if they wished to be informed about future surveys. Email addresses were removed from the dataset at regular intervals and stored separately from the dataset in a secure folder. We asked participants for the name of their first pet and street, allowing us to create a unique participant code to identify repeat responders (Lim et al. 2011). No incentives were provided to participants.

Survey 1 included a free-text question asking whether respondents had experienced difficulty accessing healthcare services. During analysis of Survey 1 data (Coombe et al. 2020), we identified several responses to this question suggesting that rather than experiencing difficulty, some individuals were deciding to delay accessing care. We therefore included a specific question in subsequent surveys to address this (‘Since the start of the COVID-19 pandemic, have you delayed or put-off seeking sexual and reproductive healthcare because of the pandemic?’). This was a closed question (yes/no), and those who responded ‘yes’ were invited to elaborate on their response (‘If yes, please tell us about it below’). This paper involves an analysis of the responses to this free-text question from Survey 2 (S2), open from 11 to 29 June 2020, and Survey 3 (S3), open from 13 to 31 August 2020. We only explored responses from young people (18–29 years old) in this study because their sexual health needs and experiences of accessing care may differ from those of older adults (Department of Health 2018). Any responses from participants aged ≥30 years were removed from the dataset before analysis for this paper. S2 had a completion rate of 55.1%, whereas that of S3 was 59.0%.

All comments were imported into NVivo qualitative software (QSR International, Cambridge, MA, USA). To explore the data, one researcher (HB) undertook a conventional content analysis using an inductive approach (Hsieh and Shannon 2005). Data from the two surveys were analysed concurrently. After reading and re-reading the dataset, initial coding of data commenced. After all comments had been coded, one researcher (HB) examined all data within each code, combining some and splitting others into subcategories. Because we were specifically interested in decisions to delay seeking care, a total of 16 comments indicating that participants were unable to access care due to factors beyond their control (e.g. cancellation of an appointment by a health professional) were excluded from the analysis. Fourteen participants completed both surveys and responded to the free-text question on both occasions. These comments were read together and considered as a single comment.

This study received ethics approval from The University of Melbourne Human Research Ethics Committee (ID 2056693). This research was undertaken with the informed consent of participants.

Overall, 1058 young people completed at least one survey and answered questions about access to healthcare services (S2, n = 463; S3, n = 511; S2 and S3, n = 84). Of these, 827 (78.3%) were female, 208 (19.7%) were male and 21 (2.0%) were gender diverse. Respondents had a median age of 22 years (interquartile range (IQR) 20–25 years) and over half (57.3%) were university educated.

Of the 1058 survey completers, 262 (24.8%; 13.0% of men and 27.6% of women) reported that at some point during the pandemic they had delayed seeking care for an SRH-related reason. Most of these respondents (228/262 (87.0%); 92.6% of men and 86.4% of women) provided a free-text response in at least one survey, resulting in a total of 242 comments (S2, n = 105; S3, n = 137) included in this analysis. Participants who provided a comment were predominantly female (86.4%) with a median age of 23 years (IQR 20–26 years).

Two overarching categories were identified from free-text data. The first category consisted of descriptions of the SRH issues that respondents had decided to delay seeking care for, whereas the second consisted of reasons why respondents delayed seeking care. Both categories contain several themes, described below.

Survey respondents provided a range of reasons for which they would have consulted a healthcare provider in usual circumstances but decided not to due to COVID-19. These largely fell into one of three themes, namely delaying routine check-ups and screening, delaying contraceptive care and delaying care despite feeling unwell or concerned, as outlined below.

Many comments revealed that individuals postponed accessing routine check-ups and screenings. Several women said that they were due for a cervical screening test. Others talked about missing sexual health check-ups, or routine testing for sexually transmissible infections (STIs):

I have avoided getting a cervical screening test and a sexual health check-up [Female, 25 years, S3].

I usually get tested every month. I have definitely missed a few appointments because I don’t want to go to clinics [Male, 23 years, S3].

Many respondents also said they had decided to delay accessing care related to their contraception. This included accessing contraception for the first time, changing contraceptive method, filling prescriptions and the insertion, removal or check-ups for long-acting reversible contraception (LARC):

I was meant to go to the GP to get oral contraceptive pills so that me and my boyfriend could have sex but that has been put off because of the pandemic [Female, 22 years, S3].

Cancelled my first follow-up appointment with family planning for check-up of my Mirena [intrauterine device] insertion [Female, 28 years, S3].

Have avoided seeing a doctor about trying a different contraceptive method other than the pill [Female, 20 years, S2].

Several respondents commented that, despite feeling unwell or having unaddressed or unresolved issues, they had delayed accessing care. Issues described included abnormal bleeding, pain, issues with contraception and low libido. Some respondents delayed investigations for issues including endometriosis and polycystic ovary syndrome:

My period is out of whack and I know I should go see someone to get blood tests and things [Female, 23 years, S3].

I have put off going to the doctors to check my contraceptive implant (Implanon) as it has flared up and is bruised and itchy [Female, 21 years, S3].

A few individuals explained they were managing issues by taking pain medication, trying alternative treatments or simply coping with pain and discomfort:

I have avoided following up with the hospital referral I have, to investigate why I have been having pain during intercourse. Because of COVID I feel like it wouldn’t be sensible to go into hospital, so I’ve been pursuing other treatments like psychological and [relaxation] techniques [Female, 25 years, S2].

Some respondents did not refer specifically to symptoms, but instead disclosed that they had reason to be concerned about potential infection with an STI:

After engaging in unprotected sexual activity in a threesome with my boyfriend and another friend (who has a known history of STIs, but currently clean, and has multiple other sexual partners), did not go for STI screening even though I had some anxiety about it [Female, 19 years, S2].

Many respondents provided comments explaining why they had decided not to access SRH care. The comments largely fell under four themes, namely concerns about contracting COVID-19, a perception that there was a reduced need for care, uncertainty about accessing care during lockdown restrictions and low motivation or anxiety related to accessing SRH care, as outlined below.

Most commonly, reluctance to access services was related to fears of contacting COVID-19. Healthcare settings were perceived to be particularly high risk and, for some, the need to use public transport or travel to busy areas or COVID-19 ‘hotspots’ was also a barrier to seeking care:

I want to get a blood test to confirm pregnancy but worry about my and baby’s health if I [go] to [the doctors] where sick people are [Female, 18 years, S2].

I put off my Pap smear [cervical screening] [be]cause I didn’t want to go to the doctors and risk getting sick or being exposed to sickness [Female, 26 years, S3].

Several respondents appeared to have weighed up the risks and benefits, deciding that their issue was not a priority. For some, this related to their personal or household vulnerability to COVID-19-related complications (e.g. if they or a family member was immunocompromised). Others discussed seeking care for some issues but not others, suggesting that although some concerns were prioritised and considered worth the risk, others were not:

I put off many pregnancy GP check-ups and hospital visits due to fear of COVID. I did not put off any procedures, tests, ultrasounds, or vaccinations [Female, 29 years, S3].

Several respondents reported delaying seeking SRH care because they felt there was reduced need. Typically, this was due to individuals reducing risky sexual activity or not being sexually active due to COVID-19:

Delayed my quarterly STI and HIV tests that I usually get along with my prep [PrEP: pre-exposure prophylaxis] prescription. I’m not having sex frequently so it doesn’t feel worthwhile [Male, 21 years, S3].

I have avoided presenting for STI screening. I would usually go every 3 months and at the commencement of any new partner or client [sex worker]. I have not been tested since before the pandemic was declared however I have reduced my exposure to STIs through reducing contacts [Female, 26 years, S3].

Others said that in usual circumstances they would have accessed STI testing, but because they had minimal concerns or no symptoms, there was a lack of urgency to get tested:

I have put off getting an updated STI check. I am 99% certain I don’t have one. Nor does he. However I usually get one after every new partner. I haven’t done that yet with my new partner due to COVID-19 [Female, 25 years, S3].

Although most comments about reduced need for care were related to STI testing, some respondents said they did not need to access contraception or care for sexual dysfunction issues due to a decrease in sexual activity.

Several comments suggested some people were uncertain about what constitutes ‘essential’ and necessary care, and whether care for SRH issues would be considered a valid reason to leave home during lockdown. Some comments indicated that there was a perception among some people that only an emergency would warrant a visit to a healthcare service:

I have been feeling pain for many months and kept postponing getting it checked as I didn’t want to visit a doctor unless it was extremely necessary [Female, 24 years, S3].

Irregular and painful periods, plus excessive/unusual looking blood flow have been concerning me since last year, but my family is currently wary of going to any medical centres unless it’s urgent or an ‘emergency’ [Female, 18 years, S3].

A few respondents said they had initially thought they were not allowed to seek care for their sexual health, but later (after realising this was permissible) had sought care:

I delayed getting an STI test until last week, when I realised [I] was allowed to go out to access any kind of health care [Female, 28 years, S3].

I delayed getting my cervical screening and enquiring about getting a [Mirena] because I thought that these wouldn’t be urgent enough to warrant a doctor’s visit under Melbourne’s current lockdown restrictions. However when I spoke with my GP she said that these services were still available, and so I did end up getting my cervical screening [Female, 25 years, S3].

Several respondents discussed experiencing a lack of motivation to seek care. Some said they felt ‘lazy’ or had become accustomed to staying at home. Others directly talked about mental health issues, particularly anxiety that made seeking care for SRH issues challenging:

I had been having symptoms since March, even after a course of antibiotics, but I waited for several months to return to my GP because my mental health was very low and it was hard to motivate myself to go [Trans Man, 27 years, S3].

A few respondents said that accessing SRH care would make them feel anxious in usual circumstances, and the pandemic had exacerbated those feelings. A small number of participants also said they felt anxious when making telephone calls, and had therefore avoided seeking care that required a telehealth consultation with their clinician:

I’ve always avoided going to health professions for anxiety related reasons and the pandemic has made that infinitely worse so I avoided it altogether [Non-Binary/Trans Masculine, 21 years, S3].

When I first realised I’d need to fill up my script you had to do so by contacting the doctor over the phone which made me put off doing it as I have anxiety and find talking on the phone very difficult [Female, 20 years, S3].

Finally, a few respondents divulged feelings of shame and irresponsibility due to needing to access care. These individuals worried about judgement from clinicians towards them for continuing to have sex with casual partners during lockdowns:

Early in 2020 I was due for a regular STI test but felt ashamed to go because I knew I wasn’t supposed to be engaging in intimate relations with multiple people and therefore shouldn’t need an STI test. I did go but I felt bad [Female, 23 years, S3].

Despite public health messaging encouraging individuals to continue to seek care for non-COVID-19 health issues, many young Australians within our study avoided seeking care for various aspects of their SRH; one-quarter of young people surveyed in June and August 2020 delayed accessing care during the pandemic. Although the remaining three-quarters did not report delaying access to care, it should be noted that we are unable to determine how many of these respondents accessed care, and how many did not need to access care. Those who avoided accessing care most commonly described delaying contraceptive care, STI testing and cervical cancer screening.

Reluctance to attend services due to fears of contracting COVID-19 has been reported in Australia, as well other countries (Continuity of Care Collaboration 2020; Findling et al. 2020; Lazzerini et al. 2020) and this was the most common reason why our respondents delayed accessing care. Although telehealth has the potential to circumvent these concerns, and may have been used by other survey respondents, this did not appear to be considered an option by many of the respondents who reported delaying care. Using telehealth for SRH-related reasons may be acceptable to some, and Family Planning services in Australia received generally positive feedback from telehealth patients (Cheng et al. 2021). However, security and patient privacy may be a barrier for others (Barney et al. 2020). Some comments from our survey also suggest that, for some, anxiety related to making telephone calls may be a barrier to using telehealth. Online STI test kits or requests may also have provided some people with the option to access care without the need to attend a service. These online resources are available for some individuals in Australia (e.g. TESTme (https://testme.org.au/) in Victoria and 13 HEALTH Webtest (https://www.qld.gov.au/health/staying-healthy/sexual-health/chlamydia-test) in Queensland), although eligibility is dependent on location and level of risk. We did not receive any responses suggesting that young people considered or used an online STI testing service, although it is possible that further promotion and expansion of eligibility of these resources may have improved access to testing for some, and should be a consideration in the future.

Many comments also suggested that SRH was not prioritised during COVID-19. Several respondents said they did not need to access STI testing or contraceptive care due to changes to their sexual activity. A reduction in sexual activity was reported by over half the respondents in Survey 1 (Coombe et al. 2020), and other research has also reported a decline in casual sex among some populations throughout the pandemic (Reyniers et al. 2021). However, some comments disclosed engagement in high-risk sexual behaviours, including sex with multiple and/or casual partners. These behaviours increase a person’s risk of STI, which, when left untreated, can have serious adverse consequences, especially for women of reproductive age (Australian Sexual Health Alliance 2018). Young people who consider themselves at risk of an STI should be encouraged to continue to access care, with an understanding that it is an important health concern and a valid reason to leave home during lockdown.

Cervical screening was also considered to be a low priority for some respondents. Although the AIHW reported a large drop in cervical screening tests in 2020 compared with 2019, this was expected regardless of COVID-19 due to changes made to the national cervical screening program (NCSP; AIHW 2021a) Importantly, the NCSP continued throughout 2020. However, our findings indicate that some Australians felt that cervical screening was non-essential.

Confusion about whether accessing services for SRH care is allowable during lockdowns does not appear to be unique to young Australians; a Scottish study also identified uncertainty about accessing services during lockdowns (Lewis et al. 2021). However, of particular concern is our finding that some individuals delayed presenting to services despite feeling worried about their health and/or experiencing symptoms, with several perceiving their issue not to be an ‘emergency’ or a valid reason to access care. Some described experiencing pain and abnormal bleeding, two symptoms that can be a sign of serious issues and should be assessed as quickly as possible. Although few in number, some respondents also described avoiding accessing pregnancy care. Early access to antenatal care and confirmation of pregnancy is important, particularly for individuals unsure about continuing with a pregnancy. Other women discussed having issues with their contraception. Side effects of hormonal contraceptives, as well as concerns about potential failure of contraceptive methods, can have negative effects on young women’s physical and mental health (Dixon et al. 2014), and it is essential that women feel able to access contraceptive care during periods of lockdown, especially those experiencing negative side effects.

Finally, it should be considered that seeking SRH care remains a stigmatising and anxiety-inducing experience for many young people, especially members of the LGBTQI+ community. A small number of comments alluded to pre-existing fears and anxiety about accessing care, and it is notable that several of these comments were from non-binary and transgender individuals. This is not surprising considering that this population is significantly more likely to experience discrimination from healthcare providers (Ayhan et al. 2020).

The limitations of our study should be considered when interpreting findings. We relied on a convenience sample and, across all surveys, most respondents were female and Victorian respondents were over-represented. We may not have sufficiently captured the experiences of different population groups, including culturally and linguistically diverse populations, nor across different areas of Australia. However, our online survey allowed for wide reach, and was cost-effective, resulting in a reasonable sample size.

Australians must feel able to access services for reasons relating to their SRH. Young Australians in particular are in need of quality, accessible and affordable SRH services, including screening services for STIs and contraceptive care, and should be encouraged to continue to seek care when they feel it is necessary.

The data that support this study cannot be publicly shared due to ethical or privacy reasons.

The authors report no conflicts of interest.

JSH is supported by a National Health and Medical Research Council Fellowship (1136117). This research did not receive any specific funding.