By Raquel Boso Perez, David Reid and Kirstin Mitchell
Access to sexual and reproductive health (SRH) services are imperative, even during pandemics such as COVID-19, when physical distancing measures are deemed necessary. We set up the Natsal-COVID study to understand the impact of service reduction and reconfiguration in Britain in response to COVID-19. Findings from the first Natsal-COVID survey included that in the early months of the pandemic one in 10 participants reported unsuccessful attempts to access SRH services (Dema et al., 2021). We wanted to understand people’s experiences in greater depth, so we followed up with 14 women and six men who reported unmet SRH needs in the survey. We summarise our interview findings under four themes:
- Hesitation and self-censorship
Participants frequently discussed hesitation to use services and down-played their needs relative to others, particularly people with COVID-19. Sources of hesitation included feeling like sexual health was less of a priority for service providers, fear of contracting COVID-19 through clinic attendance, concern about burdening an already pressured health system, and fear of healthcare providers’ disapproval for being sexually active when contact between households was restricted. For some participants, hesitation led to inaction. Among those who did seek help, many exhausted other alternatives (such as investigating private healthcare access) or waited until their health needs worsened before recontacting service providers.
- Attempting to access SRH services
Participants found that accessing a service took longer or proved harder than before the pandemic. Many SRH services were closed or on pause. Participants had to navigate inconsistent information, sudden changes to service delivery, new layers of triage, and added gatekeeping. The increased need for forward planning was a barrier, particularly those with children or caring responsibilities. Those requiring multiple healthcare interactions (e.g., STI treatment or antenatal services) experienced less difficulty once in the system but access to in-person care was difficult. Some ‘hit a brick wall’ while others described getting stuck in bureaucratic and technological circles that delayed or prevented their healthcare access. Even with tenacity, not all participants were able to overcome barriers.
- Experiences within SRH services
Twelve participants eventually attended (in-person or remotely) the service they required. Some lacked privacy at home to discuss their SRH needs during remote consultations or were expected to disclose sensitive information in settings that did not feel private (e.g., queuing outside the GP). Additionally, participants navigating phone appointments talked about the difficulty of not knowing when a clinician would call and the challenges of restarting the process if a call was missed. The substitution of in-person appointments with telephone or video consultations felt less supportive for those particularly concerned about their health. Remote consultations were difficult for people with some accessibility needs, such as those with hearing difficulties. Some noted positive changes, such as staff making extra efforts to be friendly and reassuring. However, many reported that remote consultations detracted from their ability to ask questions or have spontaneous discussions. For some, challenges were compounded by having to attend appointments alone without anyone to offer support, ask questions or help remember information on their behalf. This concern was most prominent for those navigating fertility or antenatal/maternity services.
- Attitudes toward the continuation of telemedicine
Many viewed the ongoing implementation of telemedicine as potentially adding quality, if used to complement in-person services. Telemedicine could allow people to save time and money normally spent on childcare or travel. Many appreciated being able to discuss sensitive health needs at home, a familiar and non-clinical environment. Telephone appointments lessened perceived concerns about the stigma of accessing SRH services. However, others worried that telemedicine would make it harder to get in touch with clinicians or increase the number of consultations needed to diagnose or treat their health needs. Additionally, telemedicine felt less suited to those with certain accessibility needs and requirements for privacy.
In summary, participants faced barriers to access due to changing regulations regarding healthcare access, inconsistencies between and within services, the pausing of various services, and difficulties navigating remote healthcare. As the pandemic eases, demand for services may increase due to a backlog of delayed help-seeking and the possibility of increased compensatory risk behaviours.
Additionally, our findings highlighted a mixed picture concerning the acceptability and suitability of telemedicine, arguably one of the most significant adaptations to healthcare during the pandemic. Its ongoing deployment will require careful implementation to minimise barriers to access and enhance patient convenience. Our data supports the introduction of choice over appointment types (i.e., in-person, over-the-phone or video appointments) to meet patients’ varying needs and preferences.
Dema E, Gibbs J, Clifton S, et al. Initial impacts of COVID-19 on sexual and reproductive health service use and unmet need in Britain: findings from a large, quasi-representative survey (Natsal-COVID). SSRN 2021.
Bosó Pérez R, Reid D, Maxwell KJ, et al. Access to and quality of sexual and reproductive health services in Britain during the early stages of the COVID-19 pandemic: a qualitative interview study of patient experiences. BMJ Sexual & Reproductive Health Published Online First: 20 April 2022. doi: 10.1136/bmjsrh-2021-201413
Raquel Boso Perez is a PhD researcher at the MRC/CSO Social and Public Health Sciences Unit at the University of Glasgow. Her research interests focus on how sex, sexuality and intimate relationships impact on people’s health and wellbeing.
David Reid is a researcher at the NIHR Health Protection Research Unit in Blood Borne viruses and STIs at University College London. His current research involves identifying the sexual health, wellbeing, and service needs of those most affected by sexually transmitted infections.
Kirstin Mitchell is Professor of Social Science and Public Health and leads the Relationships and Health programme at the MRC/CSO Social and Public Health Sciences Unit, University of Glasgow. Her main research interests are sexual health and wellbeing; and developing and evaluating complex interventions.