Background

In 2016, the Health Resources and Services Administration (HRSA) partnered with the American College of Obstetrics and Gynecology (ACOG) under a cooperative agreement to support the Women’s Preventive Services Initiative (WPSI) to update and develop evidence-based guidelines for women’s preventive healthcare services. Currently, the services informed by the WPSI recommendations are covered for most women without cost sharing under the Affordable Care Act (ACA)¹ resulting in a range of preventive services available to women, including contraception, counseling for sexually transmitted infections (STI), and screening for interpersonal violence (IPV), among others. Implementation of these services is guided by health equity to ensure “quality preventive healthcare for women at every stage of life.”² Evaluating approaches to care that are inclusive, accessible, and sustainable are important to optimize women’s health and reduce disparities. Effective approaches must appeal to both patients and clinicians. As such, care models that include shared decision-making to elicit patient preferences are critical, as they can improve efficacy, patient and clinician satisfaction, and help reduce health disparities.³ Telehealth is one promising approach to meet these needs. However, coverage, reimbursement, and regulation of telehealth services have been slow to evolve.^4,5

Traditionally, preventive services for women are either integrated into well woman visits^6,7 focusing on screening and prevention, or offered opportunistically in the context of managing health conditions. Recent research has found that telehealth may improve some obstetric and gynecologic outcomes⁸ and may be effective for contraceptive care.^9–11 “Telehealth” has been described to include services that utilize information and telecommunications technology in healthcare delivery for a specific patient involving a clinician across distance or time, such as remote real-time clinical visits and remote monitoring. Virtual health technologies are considered part of telehealth services, and may include mobile health applications (apps) or devices that collect patient-generated health data and interventions provided over the internet, such as screening questionnaires and education, but may not be bidirectional. Telehealth for family planning, contraceptive services, and safety decision aids for survivors of IPV^12–14 show promise as a way to make these services more inclusive, accessible, and cost-effective. Telehealth services have been offered for contraception¹⁵ to facilitate access for more geographically distant patients.¹⁶ Telehealth for IPV services^17–19 have demonstrated acceptability and feasibility for violence prevention and decision support for those in abusive relationships. Specific definitions for telehealth interventions were considered as part of the scoping process for this review.

Telehealth may improve access for underserved populations and those facing barriers to care.²⁰ However, use of telehealth could also widen disparities due to the differences in internet access and digital literacy; equity considerations including age, accessibility barriers, and language barriers.^20–24 Other issues such as system factors, including access to care or provider shortages, and social determinants of health including transportation barriers, food insecurity, and trauma could also affect how and whether populations at risk for disparities access care using telehealth. Bias and structural racism²⁵ further exacerbate health disparities.²⁶ Given this context, questions remain about how to best promote access and equity while streamlining healthcare delivery for populations²⁷ with unacceptable, ongoing disparities in health outcomes.^28,29 Updating the approach to preventive services and reproductive healthcare to include telehealth for remote counseling or monitoring may present opportunities to close the gap on these disparities.³⁰ Yet, research has not definitively addressed whether telehealth increases access to care nor whether it results in similar or better outcomes compared with in-person care for reproductive health (including family planning, contraception, and STI counseling) and IPV in women.

The coronavirus (COVID-19) pandemic led to rapid adoption of telehealth as a strategy to provide health services while reducing the risk of coronavirus exposure.^30–33 The pandemic has also highlighted existing health disparities and placed a spotlight on a concerning rise in the incidence of IPV against women and girls as a direct result of COVID-19 mitigation measures, such as stay-at-home orders.^34–38 Intervention efforts for IPV must consider limitations in accessing the usual channels of support, particularly as many women have been unable to leave abusive or unstable environments due to stay-at-home orders and increasing hardship, likely resulting in increased rates of IPV,^39–41 and creating new barriers to reporting. Data from a recent survey highlight the impact of the pandemic on the way that women use and access care.⁴² Compared with men, more women have skipped preventive health services (26% vs. 38%), with differences based on income and overall health, and a disproportionate impact on women of color. Contraceptive access has also been impacted by the pandemic, with more women in younger age groups (18 to 25 years) reporting a delay or inability to access contraception. In the same survey, there were notable increases in the use of telehealth for both men and women, with high overall satisfaction in telehealth use amongst those surveyed.

The Coronavirus Aid, Relief, and Economic Security Act⁴³ provided federal funding to increase telehealth access and provide infrastructure to increase capability and capacity for services for women including provision of family planning.⁴⁴ More recently, additional funding through the American Rescue Plan to enhance funding for Title X has been added to expand telehealth services for comprehensive family planning and related preventive health services.⁴⁵ However, questions remain about whether some services can, or should, continue to occur remotely after the pandemic, given issues of patient perceptions, preferences, and barriers to virtual versus in-person care. Changes in regulatory and payment policies that supported the increases in telehealth during the pandemic may inform patient and clinician preferences. Furthermore, it is also important to identify the disadvantages telehealth may pose in effectively delivering preventive services to specific underserved populations.

Purpose of the Review

This systematic review identifies and synthesizes current research on the use of telehealth for a subset of preventive health services and conditions included in the WPSI guidelines, specifically women’s reproductive health (including family planning, contraception, and STI counseling), and IPV services to inform HRSA program planning and identify research gaps. These services are particularly amenable to telehealth interventions and may have been affected by limited in-person care early in the pandemic. A comprehensive understanding of the current context (Contextual Question), effectiveness (Key Question [KQ] 1a and 2a), patient preferences and engagement (KQ 1b, c and 2b, c), and implementation of telehealth in the context of COVID-19 (KQ 1d and 2d) was the foundation for the review. In addition, barriers to and facilitators of the use of telehealth in geographically isolated and underserved settings and populations (KQ 1e and 2e), and evidence about the impact of COVID-19 on the use of telehealth and virtual health for these services, were included. Harms (KQ 1f and 2f) were also addressed.

Evidence on the impact of COVID-19 on the use of telehealth is particularly relevant.⁴⁶ Considerations for the equitable future use of telehealth as a supplement or replacement for some in-person care needs to consider patient-centered outcomes including patient preferences, content of services and frequency of visits, status of technology, and potential harms. Importantly, this review aims to address the decisional dilemma facing policymakers and practice leaders about the uncertainty regarding the effectiveness of telehealth for delivering specific preventive services and how to best mobilize telehealth to address women’s healthcare needs, particularly for those who are geographically isolated or in underserved settings or populations. This review explicitly evaluates outcomes for populations adversely affected by disparities due to socioeconomic disadvantage, racial or ethnic minority status, rural location, or other factors as defined by the National Institute on Minority Health and Health Disparities.⁴⁷

Scope and Key Questions

The review is defined by six sub-questions that address two overarching preventive health services, the first focusing on evidence about women’s reproductive health and the second focusing on interpersonal violence as they relate to telehealth interventions. A Contextual Question was also requested to help inform the report. Contextual Questions are not reviewed using systematic review methodology. The Key Questions, Contextual Question, and analytic framework (Figure 1) are below.

Analytic Framework

Figure 1

Analytic framework. Abbreviations: COVID-19= coronavirus disease-2019; IPV=interpersonal violence; KQ=Key Questions * Outcomes vary by preventive service and are specified in Appendix Table A-2.