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Cantor A, Nelson HD, Pappas M, et al. Effectiveness of Telehealth for Women’s Preventive Services [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2022 Jun. (Comparative Effectiveness Review, No. 256.)

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Effectiveness of Telehealth for Women’s Preventive Services [Internet].

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Results

Results of Literature Search

A total of 5,704 references from electronic database searches and reference lists were reviewed. After dual review of titles and abstracts, 320 papers were selected for full-text review, of which 304 articles were excluded. Sixteen studies were included across all Key Questions: eight randomized controlled trials (RCTs), one nonrandomized trial, and seven observational studies (Figure 2). Results are arranged by Key Question (KQ), then by outcome, and are summarized below, followed by tables in the accompanying text.

Characteristics of included studies are detailed in Appendix B. A list of included studies can be found in Appendix C and excluded studies with reason for exclusion are in Appendix D. Data abstraction of study characteristics and results, quality assessment for all included studies, and details for grading SOE are available in Appendixes E, F, and G, respectively. Appendix references are available in Appendix H.

Figure 2 is the literature flow diagram depicting the search and selection of articles for the review. The diagram shows that 5,704 citations were identified through literature database searches. 320 articles were reviewed at the full-text level after excluding 5,384 abstracts. From the 320 full-text articles reviewed, 304 were excluded from this review for the following reasons: ineligible population (11), ineligible intervention (202), ineligible comparison (11), ineligible outcome (22), ineligible country (9), ineligible study design (16), ineligible publication type (24), outdated systematic review (5), and contextual information only (4). After excluding these studies, 16 studies were included that provide evidence for the Key Questions, 7 for Key Question 1 and 9 for Key Question 2.

Figure 2

Literature flow diagram. *Other sources include reference lists of relevant articles, studies, and systematic reviews, suggestions from reviewers, etc. Abbreviations: KQ = Key Question

Key Question 1

Women’s Reproductive Health Services

Key Question 1a.

What is the evidence of effectiveness of telehealth as a strategy for delivery of healthcare services for reproductive health?

Key Question 1b.

What are patient preferences and patient choice in the context of telehealth utilization?

Key Question 1c.

What is the effectiveness of patient engagement strategies for telehealth?

Key Question 1d.

What is the impact of COVID-19 on the effectiveness of telehealth and patient engagement?

Key Question 1e.

What are the barriers to and facilitators of telehealth for women’s reproductive health in low-resource settings and populations?

Key Question 1f.

What are the harms of telehealth for women’s reproductive health?

Key Points

  • Evidence of effectiveness of telehealth interventions for contraceptive care was low for contraceptive use at 6 months, low for sexually transmitted infection (STI) and pregnancy rates, and insufficient for abortion rates compared with in-person visits alone. There were no studies of family planning or STI counseling.
  • Telephone counseling when used as a supplement to in-person contraceptive care probably results in similar rates of contraceptive use at 6 months (2 RCTs) and may have similar STI and pregnancy rates (1 RCT each).
  • Cross-sectional surveys of primary care clinicians suggest that telehealth visits for contraceptive care increased during the COVID-19 pandemic.
  • In cross-sectional surveys, the majority of patients and clinicians surveyed reported that telehealth visits for contraceptive care were satisfying and effective.
  • No studies reported on patient engagement strategies (KQ 1c) or harms of telehealth interventions (KQ 1f) for reproductive health services.

Description of Included Studies

Two RCTs of 1,724 women and adolescents, five non-RCTs contributed to evidence on the effect of telehealth interventions on contraceptive care (Table 2).56,57 No studies addressed family planning (e.g., birth spacing, preconception planning) or STI counseling. Both RCTs met criteria for moderate risk of bias (Appendix F).56,57 Populations ranged from 569 to 1,155 participants in reproductive health clinics56 or abortion clinics.57 Mean ages ranged from 16 to 27 years with the majority of participants identifying as non-White in both studies (62 to 75%). Neither study specifically reported being conducted in rural settings. Interventions with effects on contraceptive use included telephone-based support or counseling. Studies involved telephone counseling supplementation to clinic visits in young women and adolescents56 or structured telephone support57 for women seeking postabortion care. Comparisons included limited supplies of contraception plus in-person counseling56 or general advice for followup care as needed.57 Both studies reported contraceptive use as the primary outcome; secondary outcomes included self-reported pregnancy and STI rates,56 and subsequent abortion.57 One trial was conducted in the United States.56 and another in the United Kingdom (U.K.).57 Each of the interventions used different approaches for contraceptive care. Overall strength of evidence (SOE) was low for impact on contraceptive use, low for STI and pregnancy rates, and insufficient for impact on abortion rates (Appendix G). Detailed study characteristics and results can be found in Appendix E.

Five cross-sectional studies meeting inclusion criteria assessed the impact of the COVID-19 pandemic on the effectiveness of telehealth and patient engagement for conditions related to women’s reproductive health; all studies were of contraceptive care interventions and did not evaluate STI counseling or family planning (Table 2).58–62 Surveyed populations included primary care and family planning clinicians, as well as women seeking reproductive care, and ranged in size from 86 to 3,142 participants. Three studies of clinicians examined delivery of telehealth visits for contraception before and during the pandemic, but data were collected at a single timepoint. Studies evaluated the types of contraceptive services provided. Two studies examined patients’ use and acceptability of telehealth services for contraception during the pandemic. All five studies were conducted in the United States. Assessment of the risk of bias was low59 to moderate58,60–62 (Appendix F). Details of studies reporting patient-centered outcomes can be found in Appendix E.

Detailed Synthesis

KQ 1a. Effectiveness of Telehealth for Reproductive Health Services

Two RCTs evaluated telephone-based contraceptive support to supplement to usual care. An RCT evaluated two interventions on the effectiveness of behavioral counseling on oral contraceptive (OC) adherence in the United States (n=1,155); and compared standard care (S) with clinic visits (C) or clinic plus phone visits (C+P).56 Participants were 16 to 24 years old; low income (80%); White (25%), Black (19%), and Hispanic (54%); and the majority self-identified as single or never married (78%). Those receiving standard care received a 4-month supply of OCs, 24 condoms, and a followup appointment at the initial visit, while those in the clinic intervention also received individual educational and behavioral counseling at the initial visit; those in the phone-enhanced intervention also received weekly phone contact with a counselor until they started OCs, followed by monthly calls for 6 months. Outcomes assessed via phone interviews at 3, 6, and 12 months included contraceptive use, reported as continuation of OC. Secondary outcomes included self-reported pregnancy and STI rates. There were no significant differences in OC continuation after 12 months (C+P: 20% [76/384] vs. C: 18% [69/383] vs. S: 20% [77/388]; p=0.77), based on intention-to-treat analyses. Pregnancy (hazard ratio [HR] [95% confidence interval {CI}]: 1.07 [0.72 to 1.59] vs. 1.00 vs. 1.39 [0.95 to 2.03], p=0.22) and STI rates (13 [3.4%] vs. 18 [4.6%] vs. 12 [3.1%]; p=0.50) did not differ between study groups.

A multicenter RCT of contraceptive care following elective abortion in the U.K. evaluated the effectiveness of structured, specialist contraceptive support via telephone at 2 to 4 weeks postabortion compared with general advice to followup with a general practitioner.57 Mean age of participants was 27 years; 65 percent were non-White. The primary outcomes were effective contraceptive use at 6 months postabortion and long-acting reversible contraceptive (LARC) use measured via self-report. There was no statistically significant difference between the telephone intervention and controls for the use of effective contraception methods at 6 months (62% [88/142] vs. 54% [80/148]; mean difference [MD] 8%; 95% CI, −3.4 to 19.2) or LARC at 6 months (42% [60/142] vs. 32% [48/148]; MD 10%; 95% CI, −1.3 to 20.9). There was a statistically significant difference in the proportion of women changing from no method or non-LARC method to a LARC method at 6 months (50%) compared with controls (31%; p=0.004). There were no significant differences between groups for the secondary outcome of subsequent abortion at 1 year (10% [26/270] vs. 10% [28/281]; p=0.10). Limitations included significant loss to followup, as well as lack of blinding and high participant attrition. Applicability was low given the limited population and narrow clinical setting of those enrolled.

In summary, we judged there to be no difference in contraceptive use (two RCTs, low SOE) STI and pregnancy rates (one RCT, low SOE) for telehealth interventions used to supplement usual care compared with usual care alone, but evidence was insufficient for abortion rates (single smaller RCT).

KQ 1b. Patient Preferences and Patient Choice for Telehealth Utilization

One study assessed patient preferences in the context of telehealth utilization for contraceptive care61 and one study assessed utilization of telehealth services.58 Among patients who received care at a single-family planning clinic in New York City, 86 percent reported being “very satisfied” with their visit and 63 percent reported that the visit completely met their needs. Most of those surveyed agreed that telehealth visits should continue after the pandemic (72%) and half preferred telehealth to in-person care (50%). Though very limited in scope and generalizability, this study supports patient acceptability of telehealth for contraceptive care.

One cross-sectional study examined racial and ethnic differences in utilization of telehealth services at 10 family planning clinics located in Arkansas, Kansas, Missouri, and Oklahoma during the early pandemic (April to July 2020).58 Based on a review of electronic health records from this period, 40 percent of a total of 3,142 sexual and reproductive health visits were conducted using telehealth. During this specific time period there were differences in the number of visits conducted via telehealth based on participant race or ethnicity. Among Black participants 31.6 percent of visits were conducted using telehealth, 29.2 percent of visits were among individuals reporting multiple races, and 41.2 percent of visits were among White participants. Visits among Black patients were less prevalent for telehealth visits compared with in-person visits (19.3% vs. 27.7%; p<0.001), with similar patterns among those reporting multiple races (2.5% vs. 4.0%; p<0.05). Visits by White patients were more prevalent among telehealth visits (61.3% vs. 58.3%; p<0.05), as were visits by Asian/Native American/Hawaiian patients (4.0% vs. 2.9%, p<0.05) and those with unknown race/ethnicity (12.9% vs. 7.1%; p<0.001). There was no significant difference for patients identifying as Latinx (8.6% vs. 8.8%). Findings were limited by a narrow selection of family planning clinics in a single geographic region and did not describe the scope of family planning services; however, the majority of visits were for contraception (64%). Study authors did not further elucidate reasons for observed differences in telehealth visits between groups.

KQ 1d. Impact of COVID-19 on the Effectiveness of Telehealth and Patient Engagement

Patient Preferences and Patient Engagement

One cross-sectional survey evaluated use and acceptability of telehealth services from a patient perspective.61 Patients who received contraceptive services via telehealth (n=86) at a family planning clinic affiliated with a large academic health center in New York between April and June 2020 were surveyed.61 There were 169 patients who had an eligible telehealth visit during this period based on their need for contraceptive counseling (e.g., initiate contraception, problems with current method, desire to change or discontinue methods). Of these, 86 (51%) responded to the quantitative survey and 23 participated in a qualitative, in-depth interview. Patients represented different demographic characteristics (12% White, 33% Black, 56% Hispanic), levels of education (33% high school or less), marital status (43% married/partnered), employment status (41% employed full time, 26% employed part time), and the majority (76%) reported never having prior difficulty accessing contraceptive care in the past 5 years. Patient visits primarily took place over the phone (93%) and the remainder (7%) took place via video. Most participants (94%) used smartphones for the visits. Among participating patients, 86 percent reported being “very satisfied” with their visit and 63 percent reported that the visit completely met their needs. The majority indicated that they were not concerned about privacy (67%), though 25 percent reported being somewhat or very concerned about privacy. Interviews revealed that many privacy concerns were regarded as minor and were frequently from non-private home environments where conversations could be overheard. Most patients (72%) agreed that telehealth visits should continue after the pandemic and 50 percent preferred telehealth to in-person care. This study was limited by small sample size from a single, specialty-focused academic health center and had a low response rate, but demonstrated that telehealth was an acceptable mode of delivering and implementing contraceptive care.

Clinician Preferences and Utilization

Three cross-sectional surveys of primary care clinicians suggest an increase in provision of telehealth visits for contraceptive care during the COVID-19 pandemic and high levels (86%) of clinician and patient satisfaction when using telehealth.

A cross-sectional study described results of a survey aimed to evaluate clinician preferences and experiences with rapid expansion of telemedicine for contraceptive counseling in response to the COVID-19 pandemic.60 The survey was given to 754 family planning clinicians and was completed by 172 (34% response rate). Participating clinicians had a mean age of 39.9 years, were primarily female (92.9%) and White (68.6%), were physicians in residency training or fellowship (39.7% and 34.6%, respectively), in mostly academic settings (75.6%) and had practice locations across the U.S. Of responders, 54.3 percent reported that they “sometimes or often” used telehealth for contraceptive care prior to the pandemic and 30.8 percent reported they “sometimes or often” used telehealth for contraceptive care during the past 2 months of the pandemic. Of those who responded, 156 reported providing telehealth services during the COVID-19 pandemic. The majority (79.5%) of clinicians strongly agreed that telehealth visits are an “effective way to provide contraceptive counseling” and 84 percent strongly agreed that the “role of telehealth for contraceptive counseling should be expanded even after the pandemic.”

A cross-sectional study surveyed 791 U.S. primary care physicians who delivered sexual and reproductive healthcare to adolescents prior to the pandemic.59 Data came from the national DocStyles survey of U.S. physicians. Physician specialties included internal medicine (46.0%), family medicine (31.2%), and pediatrics (22.8%). Surveys were completed between September and October, 2020 and compared pre- and during pandemic timeframes. Survey response rates were 69 percent and 76 percent for physicians in internal medicine or family medicine and pediatrics, respectively. Participants were predominantly male (64.8%), non-Hispanic White (59.7%), represented all regions of the United States, had a median age of 47 years, and a median of 16 years in practice. For contraceptive care, 60.7 percent reported that they used telehealth for contraceptive initiation or continuation during the pandemic, compared with 35.2 percent prior to the pandemic. For STI services, 43.5 percent utilized telehealth during the pandemic compared with 21.7 percent prior. Among physicians who delivered these services, 27.3 percent reported confidentiality concerns about the delivery of sexual and reproductive healthcare via telehealth, though the specific nature of these concerns were not described.

A cross-sectional survey of U.S. physicians (n=1,063) from the Web-based 2020 DocStyles survey compared changes in the provision of family planning-related clinical services before and during the COVID-19 pandemic.62 The online survey included primary care physicians (63%), obstetrician-gynecologists (23%), and pediatricians (15%), with nine additional questions specifically evaluating family planning service delivery during the pandemic. Participants represented all U.S. regions, were predominantly male (61.5%), mostly non-Hispanic White (62%), had practiced medicine for more than 10 years (76%), were in a suburban setting (74.6%), and were over 45 years of age (60%). Prior to the pandemic, 27.6 percent reported providing contraceptive initiation by telehealth and 29.4 percent reported managing contraceptive continuation by telehealth. During the pandemic, these proportions increased to 55.8 and 60.1 percent, respectively. Based on physician reporting, there were statistically significant differences in the proportion of those providing LARC placement (41.2% [438] vs. 36.3% [386]; p<0.05) and removal (45.1% [479] vs. 40.1% [426]; p<0.05) before versus during the pandemic and an increase in the use of telehealth for contraceptive initiation (27.6% [293] vs. 55.8% [593]; p<0.05), continuation (29.4% [313] vs. 60.1% [639], p<0.05), or renewal (54.9% [584] vs. 62.2% [661]; p<0.05) during the same period.

These studies demonstrate strong clinician acceptability among primary care and family planning providers. Limitations include low overall survey response rates and the potential for recall bias regarding specific services delivered and delivery timing. Studies also lacked precision in the definitions of contraceptive and STI services as well as timeframes for the periods pre- and during-pandemic.

KQ 1e. Barriers and Facilitators of Telehealth for Women’s Reproductive Health Services in Low Resource Settings

One study examined racial and ethnic differences in the uptake of telehealth services at 10 nonprofit family planning clinics located in Arkansas, Kansas, Missouri, and Oklahoma during the early pandemic (April to July, 2020).58 This study (described above) suggests that there are barriers to participation in telehealth for contraceptive care based on demographic groups. Reasons for between-racial group differences were not explored. Another study conducted in a clinic serving the poorest area of New York City also identified privacy concerns as a potential barrier, though notably, participants reporting these concerns still participated in a telehealth visit.61 Physicians also reported a number of barriers to providing family planning services via telehealth during the COVID-19 pandemic, including: technical challenges (45.8%), confidentiality concerns (21.8%), billing concerns (32.7%), and patient discomfort (31.2%). Compared with a pre-pandemic assessment of telehealth barriers (31.7%, 17.0%, 23.1%, and 21.9%, respectively), the proportion of physicians reporting each of these barriers increased (p<0.05 for each).

In both studies, surveyed patients included only those who participated in telehealth care, so characteristics of nonparticipants (who may have been most impacted by barriers) were not described. Appendix Table E-6 provides a summary of the barriers and facilitators for telehealth interventions identified for this report.

Table 2. Main findings by outcomes category of studies of telehealth for reproductive health.

Table 2

Main findings by outcomes category of studies of telehealth for reproductive health.

Key Question 2

Interpersonal Violence

Key Question 2a.

What is the evidence of effectiveness of telehealth as a strategy for screening and interventions for interpersonal violence (IPV)?

Key Question 2b.

What are patient preferences and patient choice in the context of telehealth utilization?

Key Question 2c.

What is the effectiveness of patient engagement strategies for telehealth?

Key Question 2d.

What is the impact of COVID-19 on the effectiveness of telehealth and patient engagement?

Key Question 2e.

What are the barriers to and facilitators of telehealth for screening and interventions for IPV in low-resource settings and populations?

Key Question 2f.

What are the harms of telehealth for screening and interventions for IPV?

Key Points

  • Evidence of effectiveness of IPV telehealth interventions was low for several outcomes including repeat IPV, symptoms of depression, post-traumatic stress disorder (PTSD), fear of partners, or experiences of coercive control.
  • Evidence of effectiveness was low for IPV telehealth interventions for improving scores of self-efficacy and low for increasing safety behaviors.
  • Evidence for harms of telehealth interventions was insufficient.
  • Use of a mobile app for IPV screening in pregnant women increased during the COVID-19 pandemic compared with pre-COVID utilization rates.
  • Internet access and digital literacy were reported barriers to use of Web-based meeting platforms for telehealth visits among English-speaking immigrant IPV survivors.
  • No trials evaluated patient preferences and choices or patient engagement strategies using telehealth interventions for IPV (KQ 2b, KQ 2c).
  • Feeling anxious or upset while engaging with an online IPV intervention tool was similar for both intervention and control groups in the only trial evaluating potential harms.

Description of Included Studies

Six RCTs12,18,19,63–65 and a nonrandomized trial66 of 2,663 women evaluated the effectiveness of telehealth methods for IPV interventions. One before-after study67 and one cross-sectional study68 described the impact of COVID-19 on the effectiveness of telehealth for IPV (Table 3). One RCT met criteria for low risk of bias12 and five for moderate risk of bias;18,19,63–65 one nonrandomized trial met criteria for moderate risk of bias (Appendix F).66 No trials evaluated patient preferences and choices or patient engagement strategies using telehealth interventions for IPV, and one trial of interventions also evaluated harms.63

Trials were conducted in the United States,18,64–66 Australia,12,19 and Canada,63 and enrolled women with positive responses to IPV screening questions or recent IPV experiences. Trials enrolled between 150 to 720 women from academic medical centers,18,63 family planning clinics,65 a district attorney’s office,66 probation programs,64 and through online recruitment.12,19 Participants were generally age 18 years and older.

The before-after study67 evaluated utilization of a mobile pregnancy app; the other cross-sectional study68 used qualitative data to evaluate virtual (online) platforms for IPV services among immigrant women and providers to identify changes in IPV services and strategies to ensure safety, as well as identify barriers and facilitators to using virtual platforms. Based on modified risk of bias assessments, one study met criteria for moderate risk of bias67 and the other for high risk of bias.68 Both studies were conducted in the United States, one in an academic health center and the other in domestic violence organizations; sample sizes ranged from 62 to 959 participants.

Detailed Synthesis

KQ 2a. Effectiveness of Telehealth for Interpersonal Violence Screening and Interventions

Six RCTs of IPV interventions showed no differences between women randomized to telehealth interventions versus comparison or usual care in repeat IPV, depressive symptoms, PTSD scores, fear of partner, coercive control, measures of self-efficacy, and safety behaviors (low SOE). Evidence for harms of telehealth interventions was insufficient.

Repeat IPV

Two of the six RCTs of IPV interventions evaluated repeat IPV, measured by the Severity of Violence Against Women Scale (SVAWS).18,19 Both trials evaluated similar versions of a tailored, interactive online safety tool versus a static version, adapted for different populations. A RCT of 720 Spanish or English-speaking women from four regions in the United States randomized women to a tailored, interactive online safety and health intervention (Internet Resource for Intervention and Safety, IRIS) versus a static, non-tailored version of the tool.18 Nearly 40 percent of the study population was non-White and 10 percent reported female partners. Both groups reported a significant decrease in three SVAWS subscales for psychological abuse (baseline vs. 12 months: intervention, 47.72 vs. 37.85; p<0.001; control, 45.62 vs 35.43; p<0.001), physical abuse (baseline vs. 12 months: intervention, 41.83 vs. 33.83; p<0.001; control, 40.08 vs 31.65; p<0.001), and sexual abuse (baseline vs. 12 months: intervention, 10.94 vs. 8.98; p<0.001; control, 10.51 vs. 8.73; p<0.001). Less abuse occurred over time for both groups, with no differences between groups.

An RCT of 412 women in Australia19 also evaluated a tailored, interactive, online safety intervention (iSafe) versus a static, non-tailored version. The study population included 27 percent who identified as indigenous (Maori). Both groups demonstrated reduced IPV exposure over time, measured by the SVAWS, with no difference between groups at 12 months (adjusted estimate, −2.47; 95% CI, −7.95 to 3.02). A sub-analysis of indigenous women demonstrated a significant effect of the intervention on IPV based on the SVAWS at 6 months (adjusted intervention estimate, −14.19; 95% CI, −24 to −4.37) and 12 months (adjusted intervention estimate −12.44; 95% CI, −23.35 to −1.54) compared with non-indigenous women.

Depression and Post-Traumatic Stress Disorder

Of the Six RCTs of IPV interventions, five evaluated depressive symptoms and two RCTs also evaluated PTSD.18,19,63 All RCTs used versions of the Center for Epidemiologic Studies Depression Scale (CES-D) to evaluate depressive symptoms, although trials did not indicate whether participants met clinical thresholds for depression based on CES-D scores.

An RCT of 306 women screening positive for IPV in family planning clinics in the United States evaluated an IPV intervention consisting of in-person motivational interviews and three subsequent telephone sessions over 4 months compared with a control intervention involving referrals to community-based resources.65 Depressive symptoms, measured by CES-D scores, improved (declined) for both groups from baseline to 6 months (intervention, 15.7 vs. 11.7, p<0.001; control, 14.3 vs. 11.8, p<0.0001). In an adjusted analysis, improvements in scores were greater for the intervention versus control group (adjusted mean change [standard error {SE}], −4.2 [0.6] vs. −2.6 [0.6]; p=0.07). Limitations for this study were that the comparison did not isolate the telehealth component to determine its effect and that the referral (comparison group) was vaguely defined.

Four trials12,18,19,63 evaluated similar versions of a tailored, interactive online safety tool versus a static version, adapted for different populations of women with a history of IPV, and reported similar outcomes. An RCT of 720 women, described above, in the IRIS trial evaluated depressive symptoms measured by the CES-D, from baseline at 6 and 12-month followup.18 Depression scores improved for both groups over time (baseline vs. 12-months: intervention, 37.00 vs. 26.82, p<0.001; control, 38.73 vs. 26.73; p<0.001), with no difference between groups. Results were similar for PTSD symptoms, measured by the PTSD checklist, Civilian Version (PCL-C), a second primary outcome of the trial (baseline vs. 12-months; intervention, 19.06 vs. 15.83, p<0.001; control, 19.53 vs. 16.06, p<0.001).

An RCT of 462 Canadian women with recent IPV evaluated depressive symptoms, measured by the revised CES-D (CESD-R), from baseline over 3, 6, and 12-month followups for women randomized to a tailored, interactive online safety and health intervention (iCAN Plan 4 Safety), an adapted version of IRIS, or a static non-tailored version of the tool (comparison).63 In the tailored version, women received individualized responses and an action plan based on their responses to questions. Depression scores improved for both groups over time (baseline vs. 12-months: tailored, 40.62 vs. 27.95, p<0.001; non-tailored, 39.15 vs. 29.83; p<0.001), and did not differ between groups. Results were similar for PTSD symptoms, also measured by the PCL-C, a second primary outcome of the trial (baseline vs. 12-months: tailored, 53.00 vs. 43.29, p<0.001; non-tailored, 51.69 vs. 44.45; p<0.001; tailored vs. non-tailored, p=0.269).

In an RCT of 422 women receiving community supervision for substance use in Australia who experienced IPV or fear of a partner in the previous 6 months, interactive computer modules (I-DECIDE) were compared with a static website containing brief information about IPV and a standard emergency safety plan (comparison).12 The computer modules addressed healthy relationships, safety, and priorities. Based on responses, women completed an action planning or motivational interviewing module, and an individualized action plan was developed. Depression scores (CESD-R) improved for both groups from baseline to 12-month followup and did not differ between groups (intervention, 30.6 vs. 21.9; control, 32.5 vs. 21.5; p=0.163).

Another RCT of 412 women in Australia,19 also described above, evaluated depressive systems measured by the CESD-R, at 6 and 12 months. Depression scores improved for both groups over time, with no difference between groups (adjusted intervention estimate, −0.98; 95% CI, −4.89 to 2.94). A sub-group analysis of primary outcomes by ethnicity compared depression scores for indigenous women compared to non-indigenous women and found statistically significant differences in depression scores at 3 months (adjusted intervention effect −8.7; 95% CI, −15.9 to −1.6), but not at 6 or 12 months.

In summary, we judged there to be no difference between groups in depression scores (5 RCTs with similar or slightly improved measures, low SOE) and no difference in groups for PTSD scores (2 RCTs, low SOE).

Interpersonal Violence–Related Outcomes

In an RCT, experiences of coercive control, measured by the Women’s Experiences with Battering (WEB) scale, improved (scores declined) from baseline to 12 months for women randomized to either a tailored interactive online safety and health intervention (iCAN Plan 4 Safety) or a static non-tailored version of the tool (comparison) (tailored, 50.15 vs. 39.62, p<0.001; non-tailored, 49.93 vs. 40.94; p<0.001).63 Results did not differ between groups (p=0.645). A second RCT18 used the WEB scale to measure experiences of coercive control and reported improvement (lower scores) for both groups over time, but no difference between groups. In another RCT of 422 women, the level of fear of a perpetrator, measured by responses on a visual analogue scale, similarly improved (decreased) from baseline to 12 months for women randomized to interactive computer modules (I-DECIDE) or a static website containing brief information about IPV and a standard emergency safety plan.12

In summary, results of the telehealth studies that evaluated interactive online tools indicated improvements in IPV-related measures for both intervention and control groups without significant differences between groups (low SOE).

Self-Efficacy

Three RCTs evaluated self-efficacy as an outcome measure.12,64,65 Self-efficacy scores, measured by the Generalized Self-Efficacy Scale, improved (increased) from baseline to 12 months for both groups in an RCT of 422 women evaluating interactive computer modules (I-DECIDE) compared with a static website containing brief information about IPV and a standard emergency safety plan (comparison).12 However, in this RCT, scores increased more in the control group (intervention, 27.0 vs. 27.8; control, 26.3 vs. 29.0; p=0.0023).

An RCT of 191 women receiving community supervision for prior substance use in the United States evaluated self-efficacy scores from baseline over 3-months followup for women randomized to computerized versus in-person services (comparison).64 These included IPV education, screening, and risk assessment; safety planning; identification of social support; goal setting; and identification of service needs and referrals. A printout of services selected with referrals and action plans were provided to both groups. Results indicated improved (increased) self-efficacy scores, measured by the Domestic Violence Self-Efficacy Scale (DVSE), for both groups (computerized, 20.29 vs. 22.18, p<0.001; in-person, 20.93 vs. 22.85); improvements in scores did not differ between groups (0.36; −2.20 to 2.91). The clinical significance of the 2–point mean increase in scores is unclear.

Self-efficacy scores, measured by the DVSE, also improved from baseline to 6-months followup for both groups in a RCT of 306 women comparing in-person motivational interviews and three subsequent telephone sessions with referrals to community-based resources (comparison) (intervention, 75.9 vs. 82.1, p=0.0002; control, 76.6 vs. 80.7, p=0.0087).65 In an adjusted analysis, improvements in scores did not differ between intervention versus control groups (adjusted mean change [standard error], 6.1 [1.6] vs. 3.7 [1.5]; p=0.255). In summary, we judged there to be no difference between groups in self-efficacy scores (three RCTs with similar or slightly improved measures, low SOE).

Safety Behaviors

Four trials evaluated efforts to adapt safety behaviors as outcome measures.12,18,64,66 A nonrandomized trial of 150 women with protection orders against an intimate partner in the United States evaluated an intervention consisting of six telephone calls over 8 weeks to discuss safety-promoting behaviors compared with usual care.66 Outcomes were measured using the Safety-Promoting Behavior Checklist that included 15 behaviors, such as removing weapons, hiding keys and money, and asking neighbors to call police if violence begins. Women in the intervention group averaged two new safety behaviors over the 18-month followup period (F4,144=5.45, p<0.001), which was significantly higher than the control group (difference, F4,144=2.81; p=0.028).

The proportion of women receiving IPV services over the previous 90 days increased from baseline over 3-months for women randomized to either computerized or in-person services (comparison) in an RCT64 of 191 women receiving community supervision for substance use in the United States (computerized, 8.3% vs. 19.4%, p<0.05; in-person, 4.0% vs. 16.2%, p<0.05); changes did not differ between groups (0.51; 0.07 to 3.92).

In an Australian RCT, the number of helpful behaviors for safety and wellbeing undertaken increased from baseline to 12 months for women randomized to interactive computer modules (I-DECIDE) or a static website containing brief information about IPV and a standard emergency safety plan.12 Each group adopted a mean of 4.2 actions over time, with no difference between groups. In a U.S. RCT18 of a similar interactive, online tool, there was an increase of safety behaviors from baseline to 6 to 12 months for women randomized to an interactive computer module (IRIS) versus a static website, with no difference between groups.

In summary, we judged there to be no difference between groups in safety behaviors scores (4 RCTs with similar or slightly improved measures, low SOE)

Harms of Interventions

One trial reported potential harms of an online IPV intervention using a scoring system based on a 5-point scale.63 There was a similar number of the study population that reported that “working through the online tool made me anxious or upset” (tailored, 29.3% vs. non-tailored, 24.9%). However, there was no difference in potential harms between the tailored intervention and control group (mean [standard deviation] 3.22 [1.25] vs. 3.33 [1.21], p=0.380). No other studies evaluated harms of telehealth interventions for IPV, therefore we judged the evidence to be insufficient to make a conclusion.

KQ 2d. Impact of COVID-19

Two studies evaluated the impact of telehealth strategies to evaluate IPV screening frequency or access to services during the COVID-19 pandemic using a mobile app, phone, or video conference.

A before-after study of 950 women evaluated the use of self-screening tool for IPV as part of an optional module in a prenatal care app.67 The population included pregnant women (80% white) attending an academic health center and compared patients who used the mobile app and completed the IPV screening module during COVID-19 stay-at-home order (March 23 to May 15, 2020) with patients who used the mobile app before the COVID-19 pandemic. Using a quality improvement pilot evaluation strategy, outcomes assessed included a comparison of IPV screening frequencies and IPV incidence rates during these two time periods. The mobile app provides resources to users (e.g., local shelter), analyzes user information to predict pregnancy adverse effects, and assesses patients’ psychosocial risks. The IPV screening module includes two questions from the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System measures of physical violence and forced sexual acts, and 10 questions from the WEB scale to quantify psychological abuse. Study results demonstrated an increased use of an IPV screening mobile app during COVID-19 stay-at-home order compared with pre-pandemic use, from 67 percent (368/552) to 85 percent (347/407) (95% CI, 17% to 28%; p<0.001), but reported similar levels of physical violence, sexual violence, and psychological abuse before and during the stay-at-home order (p=0.56).

In a cross-sectional study,68 qualitative interviews were conducted with IPV survivors (n=45) and 17 providers who serve them to assess the barriers to accessing IPV services using a virtual platform during the COVID-19 pandemic. Participants included English-speaking immigrant IPV survivors from several U.S. regions (i.e., Massachusetts, New Jersey, Texas, Illinois, Maryland, Virginia, and Washington D.C.) and care providers. Interviews were conducted over the phone or via video conference to evaluate the effect of the COVID-19 pandemic on their relationship, accessibility of IPV services, and identification of other pertinent needs or safety concerns. Participants reported challenges with accessing a virtual platform (i.e., lack of internet access, digital illiteracy) and preference for face-to-face interactions, as it allowed survivors to leave their homes. Providers reported strengthening their Web-based platforms to tailor safety plans using code words to indicate that help is needed and hand signals during video conferences to mitigate risk while using video and telephone visits, and using telephone applications and text messaging to check-in with survivors.

Major limitations of studies include low power to detect change in IPV incidence.67,68

Table 3. Main findings by outcome category of studies of telehealth for interpersonal violence.

Table 3

Main findings by outcome category of studies of telehealth for interpersonal violence.

Contextual Question

What guidelines, recommendations, or best practices have been developed for the design and use of telehealth and virtual health technologies for women for any clinical conditions, including patient preferences, patient choice, patient engagement, and implementation in low-resource settings?

In response to the COVID-19 pandemic there was a rapid shift in clinical care to provide clinical services using telehealth platforms. Slowly, guidance emerged in response to the need to support stay-at-home orders while continuing to provide clinical care, including preventive services. Initially, the move to telehealth was reactive and guided by available resources. As the pandemic progressed, data emerged about delays in screening,69 increased incidence of advanced disease,70–72 and increasing disparities in preventive care.73 This resulted in best practices to promote the effective and equitable delivery of healthcare.74–79 Although there are no formal guidelines for telehealth delivery of preventive services, guidance by leading professional organizations for the use of telehealth services can be found in Table 4. None of the guidance specifically addresses low-resource settings.

As the pandemic has continued, formal guidelines from the Centers for Medicare & Medicaid Services and others on the healthcare system side have emerged as a response to billing and reimbursement needs, in addition to efforts to optimize patient health and safety, and to help guide clinicians.80–83 While screening guidelines have not changed in response to the pandemic,84,85 methods for facilitating appropriate and timely screening have been revised to reflect the changing healthcare needs,76 in particular for those at higher risk for healthcare disparities, including those with limited resources due to geography, socioeconomic status, or local resources.

Table 4. Professional guidance for the use of telehealth.

Table 4

Professional guidance for the use of telehealth.

Family Planning Services

Many organizations, including the American College of Obstetricians and Gynecologists (ACOG), American Academy of Family Physicians (AAFP), World Health Organization (WHO), International Federation of Gynaecology and Obstetrics (FIGO), and Women’s Preventive Services Initiative (WPSI), among others,87 have recommended that access to family planning services should be available via telehealth, especially during the COVID-19 pandemic.74,78 Notably, some of these services were offered via telehealth prior to the pandemic and were effective and acceptable to both patients and clinicians.8 These services have continued to remain feasible, safe and acceptable for patients throughout the pandemic.88

Contraception

Several groups, including those who support the use of telehealth for family planning services,87 have recommended reducing barriers to contraceptive access during the COVID-19 pandemic through a variety of mechanisms. These include performing new patient contraceptive visits via telehealth, prescribing multi-month contraception at reduced or no cost, providing counseling about postponing removal of LARC, prioritizing in-person contraceptive visits to placement of LARC while performing pre-procedural counseling via telehealth, training and offering self-administered injectable contraception, and utilizing pharmacist prescribed contraception.89

Sexually Transmitted Infection Counseling

No organizations provide specific guidance or recommendations for STI counseling via telehealth. Recommendations by the CDC suggest reducing barriers to STI testing by increasing access to self-collected STI screening, when appropriate. The CDC and AAP recommend that in-person STI management be reserved for symptomatic patients who have a risk for developing complications, while low-risk STI screening and uncomplicated symptom management be performed via telehealth.90,91

Interpersonal Violence

A proposed option to facilitate routine screening for IPV during the COVID-19 pandemic is to include telehealth via technology-enabled interventions, which has been shown to be preferred by IPV survivors in other contexts.37,92 Organizations such as the National Network to End Domestic Violence, the National Coalition Against Domestic Violence, the National Domestic Violence Hotline, the Sexual Violence Research Initiative, and the Center for Court Innovation have emphasized the importance of continued screening via telehealth visits with clinicians using trauma informed approaches.37,92 While telehealth may offer many benefits and can provide IPV screening that might otherwise not be available under stay-home orders, organizations have recommended that digital tools should be used to augment screening rather than replace it entirely.37,92 More research is needed to identify how digital screening tools and telehealth IPV screening could negatively impact underserved patients. It is recommended that providers who serve immigrant communities be trained to be culturally sensitive when addressing the issue of IPV, and to be able to provide local resources specifically for immigrant patients.68 Prior to the pandemic, online resources allowed for effective screening, and this remains a promising tool in order to improve access to care and promote patient safety given the ongoing pandemic. Screening for IPV during the COVID-19 pandemic has presented many challenges.