Maine is a rural state. Women — particularly those with opioid use disorder — sometimes encounter barriers to reproductive healthcare services, including screening for sexually transmitted infections (STIs).
- Telehealth is a good option for contraceptive and other reproductive health services for women who choose not to enter a family planning clinic because of transportation barriers or stigma from their substance use.
- Outreach educators met women with opioid use disorder through partnerships with community organizations, including programs that serve women affected by domestic violence, substance use treatment, needle exchange, and behavioral health.
- Women could receive HIV/STI counseling, testing, and contraceptive care through telehealth. Outreach educators help them access telehealth providers and give them condoms and STI test kits.
A Maine family planning clinic launched a program to reach women who experience barriers to reproductive healthcare, counseling, and testing for sexually transmitted infections (STIs). The program focused on outreach, sending an educator to various locations and providing an educational session for women who are especially vulnerable, including those who use opioids.
Three out of five people in Maine live in rural areas. Accessing healthcare is challenging because it involves considerable travel time and related costs. Also, 64,000 Maine women of reproductive age live in a contraceptive desert.1
These factors suggest that a telehealth option for contraceptive and reproductive health services would be a potential solution to overcoming access barriers. The pilot program offered the women, who attended the outreach sessions, access to HIV counseling and testing, STI testing, and contraceptive or pregnancy testing and counseling.
“The program was pre-pandemic, but we altered it since the pandemic,” says Leah Coplon, CNM, MPH, program director of Maine Family Planning “This was designed before telehealth was all the rage to have a way to connect patients with clinical services. Outreach coordinators would go and do sessions and connect people to a nurse practitioner.”
After the COVID-19 pandemic hit, the sites no longer allowed outreach coordinators to visit. Before the pandemic, outreach coordinators spoke to recovery groups about hepatitis C and HIV. They gave out gonorrhea and chlamydia testing kits that women could use and drop off or send in to obtain results, Coplon says.
The family planning clinic partnered with community organizations that serve women with opioid use disorder (OUD). These included programs for domestic violence, harm reduction, intensive outpatient, OUD treatment, needle exchange, and behavioral health organizations.
“Some sites wanted a more formal discussion, and they put aside some time for that,” she adds. “We tried to cater these discussions to the site.” Their goal was to be adaptable and not just present a PowerPoint lecture.
Research has shown that telehealth for HIV/STI prevention and care can work well, through digital innovations and text messages. These can improve adherence with treatment, says Terri-Ann Thompson, PhD, senior associate with Ibis Reproductive Health in Cambridge, MA.
“We looked at a hybrid model of both in-person and telehealth to reach this hard-to-reach population — women with opioid use disorders,” Thompson says. “We were trying to think about ways to bring services to a population that is hard to reach because of stigma and other factors that prevent them from going into a clinic to access services.”
Women with OUD are at high risk for STIs, but they often do not visit family planning or other healthcare clinics, she adds. It also is important to bring interventions that involve telehealth to states that are more rural, such as Maine.
Patients Fear Stigma
Outreach coordinators visited some of Maine Family Planning’s 18 clinics across Maine. Even when the targeted population of women lived fairly close to one of these clinics, they were not visiting them because of stigma around their opioid use, Coplon says. When the pandemic hit, no one visited the clinic for weeks.
“Many of these sites were reinvented in a virtual way, so they would do a virtual recovery group and our outreach educators would show up at the beginning of the virtual group meeting and then link people to telehealth services,” Coplon explains. “The outreach educators were able to answer questions about STI screening and HIV and help clients with scheduling visits.”
Some of their experiences suggested the effort to reach women who otherwise would have been difficult to help was working.
“One of our outreach educators, once the pandemic hit, was moved into a clinic role as a medical assistant to help her with her hours,” Coplon says. “She said, ‘I’d see so many clients I saw in other places, and I’d see them at the clinic, and they would be asked if they used substances, and they would say no.’”
The outreach educator knew they had OUD, but the women did not feel comfortable sharing their drug use with family planning clinic staff, despite the staff’s open and nonjudgmental approach with patients, she says.
Stigma and fear of judgment are so important in these women’s minds that they were willing to miss out on optimal care to protect their privacy. But they did feel comfortable with the outreach educators because of the nature of that intervention and how it was a collaboration with community organizations the women trusted, such as substance use support groups.
“Embedding an outreach educator in those sites actually made a huge difference,” Coplon says.
The study authors found interactions between clients and outreach educators could lead to more services for the women. The program, adjusted for the pandemic, connected outreach coordinators with family planning clinic staff, as well as with patients. Through telehealth, family planning clinical staff provided preventive reproductive health services, including HIV/STI counseling, testing, and contraceptive care.1
“While not every individual went ahead to request STI testing, the interaction led to many seeking condoms, as well as many asking sexual and reproductive health questions,” Thompson says. “There’s something to be said here about having increased access to information, whether for program directors or for individuals getting services for themselves.”
Telehealth Means Greater Access
The revised program is to provide robust telehealth and remote care, including HIV testing and STI testing. “As much as possible, we’re trying to promote telehealth for everybody and simultaneously work on larger issues like broadband,” Coplon says. “We don’t want to prevent anyone from accessing services.”
The goal was to encourage family planning clinics to leverage telemedicine technologies, including training, services, and support, to other providers in terms of STI prevention services. “As folks are more dispersed, people are getting lots of care in different kinds of settings,” Thompson says. “The more we can make information widespread for providers, the better off we’ll be.” With reproductive health services, telecommunication technology can help increase the spread of information, she says.
There are some issues with telehealth that family planning clinicians need to keep in mind, Coplon notes. For instance, at the start of each telehealth call, the provider introduces the patient to each person in the room, even if the person cannot be seen on the video call.
“We make sure they understand that nothing is recorded, and there is no lasting documentation about the visit,” Coplon says. “They sign a consent specifically related to telehealth.”
When patients discuss STIs and abortion services, they may not want their family members to hear them speak on the telehealth call. Clinicians will ask the patients for a code word they can give when their family member walks into the room and they want the talk to shift to something that appears to be non-healthcare-related, she explains.
The study authors’ findings that telehealth can benefit women with OUD suggest that an expansion of telehealth services to additional populations would be practical and helpful. “The pandemic has shown us that many parts of sexual and reproductive health services can be provided outside the clinic setting,” Thompson says. “Counseling, screening, prescriptions, and follow-up care are not out of reach of individuals because they can’t make it to a clinic.”
Adding more telehealth to family planning services in the post-pandemic environment will extend the clinic and reduce the need for patients to travel. It will save patients the time and cost of finding child care and transportation, reducing barriers to care.
“There are ways to bring parts of the service to individuals using technology. That’s a really important lesson, especially as we think about sustaining access to care during a public health crisis,” Thompson says.
However, the benefits of telehealth do not mean that clinics should ignore potential disparities and barriers to this service.
“Telehealth is not a silver bullet,” Thompson says. “I think about younger people who, if they are in spaces that don’t allow for privacy, where patients can receive services safely, then telehealth is challenged and there still is a barrier.”
- Thompson TA, Ahrens KA, Coplon L. Virtually possible: Using telehealth to bring reproductive health care to women with opioid use disorder in rural Maine. Mhealth 2020;6:41.