Telehealth for sexual and reproductive health issues: a qualitative study of experiences of accessing care during COVID-19

Keywords: Australasia, COVID-19, general practice, health services, pandemic, patients-views, primary care, survey.

Medicare, the health insurance system underpinning free healthcare in Australia, introduced free telehealth items from March 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic, enabling patients to access healthcare via telephone/internet.¹ These changes were introduced to promote continuous care for patients while limiting movement to reduce COVID-19 transmission.² Telehealth uptake was substantial. By April 2020, over one-third of consultations in general practice were conducted via telehealth, compared with 1% in 2019.³ Many sexual health clinics also used telehealth to offer counselling services, take sexual histories, and/or provide initial telephone consultations, followed by face-to-face consultations when necessary.⁴

The Royal Australian College of General Practitioners (RACGP) released a guide to support general practitioners (GPs) to provide virtual consultations.⁵ It was recommended that telehealth services be provided only for patients for whom it was safe and clinically appropriate, but there was little advice on sexual and reproductive health (SRH) management, including screening for sexually transmissible infections (STIs) and cervical cancer.

In the Family Planning setting, recent research found telehealth to be generally considered as convenient, efficient, and accessible to patients.⁶ Our research further explored Australians’ experiences of using telehealth to discuss SRH-related issues with a range of healthcare providers during 2020. It aimed to investigate barriers and facilitators to using telehealth from the patient perspective, and to explore the acceptability to patients of providing ongoing SRH telehealth services.

Throughout 2020, we conducted four repeated online cross-sectional surveys using Qualtrics Survey Software (Qualtrics, Provo, UT, USA) to explore the impact of COVID-19 on the SRH of people aged ≥18 years and living in Australia. Recruitment to the surveys has been described elsewhere.^7,8 Briefly, surveys were advertised on social media (Facebook and Instagram) and via researcher networks. Participation was voluntary, and no incentives were provided. This study received approval from the University of Melbourne Human Research Ethics Committee (ID: 2056693).

This paper reports on data from Surveys 3 (13–31 August 2020) and 4 (24 November−18 December 2020), which included questions about accessing healthcare via telehealth (Fig. 1). Consent and demographic details were also collected. During Survey 3, respondents from the state of Victoria were under lockdown orders (including a stay-at-home order, nightly curfew, and travel restrictions), while respondents from all other states were under minimal restrictions. No respondents to Survey 4 were in lockdown.

Fig. 1.  Questions asked in Surveys 3 and 4 relating to access to telehealth services.

Four questions relating to telehealth use are in Fig. 1, including a free-text question asking respondents about their experience of accessing care (QIII). The inclusion of free-text questions within quantitative surveys can yield valuable qualitative data.⁹ Responses to the free-text question were imported into NVivo qualitative software (QSR International, Cambridge, MA) to assist with analysis. There was a total of 92 comments from 86 people (six respondents completed both surveys). Fourteen comments were excluded as they referred exclusively to face-to-face services or non-SRH issues, leaving 78 comments from 72 people for analysis. Conventional content analysis was conducted whereby one researcher (HB) read through the data, coded all comments, and then examined all data within each code, combining some codes.¹⁰

Overall, 1070 people completed surveys and answered questions about accessing healthcare services. Across both surveys, 114 respondents (10.7%) accessed a service via telehealth for an SRH reason within the previous 4 weeks. Demographics of respondents who accessed healthcare via telehealth are in Table 1. Most respondents (87/114; 76.3%) who accessed a telehealth service were satisfied with their experience (‘extremely’ [37/114; 32.5%]; ‘somewhat’ [50/114; 43.9%]).

Table 1.  Demographics of survey participants.

Three themes relating to experiences using telehealth were identified and are outlined below, with illustrative quotes in Table 2.

Table 2.  Themes and illustrative quotes.

Accessing SRH care via telehealth was convenient and quick for many. Some described benefits of having a consultation from home, including the ability to create a safe space, and being able to continue working up until an appointment. Several found it straight-forward to access services, despite COVID-19-related changes. Some respondents described how they would request the type of appointment (i.e. telehealth or face-to-face) they wanted, and some found it easier to access their preferred clinician using telehealth.

However, services were not universally accessible. Some reported long wait times, and others were unable to speak with a preferred clinician. A few also struggled to navigate changes to services, needing to advocate for themselves before being allowed a face-to-face consultation. One respondent also described the frustration and additional cost of having two consultations (telehealth followed by face-to-face). Technical issues, including poor internet connection, reduced telehealth accessibility for a few respondents. Further logistical issues for some individuals related to accessing prescriptions, pathology requests, and test results.

Respondents spoke with clinicians about a broad range of SRH issues via telehealth, including contraception prescriptions, receiving/discussing test results, and organising referrals and face-to-face appointments. Many respondents said their consultation/s met their needs. Telehealth was seen as particularly appropriate for uncomplicated or ongoing issues including repeat prescriptions, common complaints such as urinary tract infections, and routine STI testing.

However, telehealth was not appropriate for all SRH issues. Several respondents described complaints that had been inadequately addressed. For example, one respondent was unable to show a lactation consultant her breastfeeding problem, and others described being unable to have long-acting reversible contraception removed (these respondents were advised to wait rather than book a face-to-face appointment). Other issues were difficult to manage via telehealth for privacy and confidentiality reasons, highlighting that discussing SRH issues can be challenging for those who lack privacy at home.

Respondents discussed connecting with clinicians via telehealth. Several said that telehealth felt ‘weird’ or ‘strange’, and different from face-to-face appointments. Some had trouble making a connection via telehealth with their clinician. Poor internet connection led to difficult and fractured conversations for some. However, even without technical issues, some found it difficult to connect with clinicians due to lack of eye contact, being unable to tell whether their clinician was listening to them, and difficulty in focusing. Having rapport with clinicians was mentioned by some as an enabler to a successful appointment, suggesting telehealth consultations may be improved when there is a previously established relationship.

Of the 114 survey respondents who reported accessing SRH care via telehealth within the past 4 weeks, most were satisfied with care received. Our qualitative analysis revealed that many appreciated the convenience and accessibility of telehealth, particularly for minor, straightforward SRH issues. Our findings are consistent with other research finding telehealth to be an acceptable and convenient means of accessing SRH care, with the potential to circumvent traditional barriers to accessing care.^6,11 The rapid expansion of telehealth services due to COVID-19 has been recognised to have the potential to positively impact young people in particular, who are more likely to encounter barriers to accessing healthcare (e.g. lack of confidentiality and transport, and stigma).^12,13

However, not all respondents in our study reported a positive experience of receiving care via telehealth. Several had difficulty accessing telehealth services (although this may reflect difficulty accessing any services during the first year of the pandemic), and a few expressed frustration that telehealth was their only option, preferring face-to-face care. Reluctance and difficulty engaging with telehealth services for various health issues has been reported by Australian women elsewhere, highlighting that telehealth may not be suitable for all situations.¹⁴ Research conducted at a adolescent clinic in the US also highlights that telehealth is unsuitable for all SRH issues, particularly where physical examinations are concerned.¹³ Confidentiality also remains a key barrier for some using telehealth, especially younger patients. Several respondents highlighted this. In the US, one-quarter of physicians surveyed who provided telehealth for SRH issues reported confidentiality concerns.¹⁵ Others have also identified privacy as a key issue when utilising telehealth, particularly for adolescents.¹³

Our third and final theme revealed that connection and communication with clinicians (on both a technical and interpersonal level) was important to respondents. Technical issues arising in some telehealth consultations can be a barrier to successful communication. This connection appeared to go beyond technology, and some respondents reported difficulty connecting and communicating with clinicians due to being unable to read body language. An existing, ongoing relationship facilitated connection for some.

There are several limitations to our study to consider when interpreting results. Our convenience sample was self-selected and is therefore not representative of the general population. Women, Victorians, and young people were over-represented, and it is likely that we have little representation of some culturally and linguistically diverse populations, some of whom may experience further communication barriers with healthcare providers. Further, the survey items included in this analysis were included within a larger survey exploring many aspects of SRH. To minimise the burden on respondents, we did not ask for detail about the process of the teleconsultation, or the issues that participants were seeking care for, meaning we cannot explore whether there are certain issues that lend themselves better to telehealth.

Accessing SRH care via telehealth can be acceptable and convenient for many, and can provide a valuable alternative in specific situations. Being able to engage and communicate with clinicians, not only on a technical level, but also on an interpersonal, emotional level, is important for patients.

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

JSH is a Joint Editor of Sexual Health, but was blinded from the peer review process for this paper. All other 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.