Special ambulatory gynecologic considerations in the era of coronavirus disease 2019 (COVID-19) and implications for future practice

Evaluation of telemedicine for contraceptive counseling given to pregnant women during the COVID-19 pandemic: A randomized controlled trial

In this study, we aimed to evaluate the impact of telemedicine for contraceptive counseling on knowledge levels and satisfaction with Family Planning Services. We collected data from 77 third-trimester pregnant women using a personal information form, Family Planning Knowledge Questionnaire, and the Satisfaction with Family Planning Services Scale and compared the data using chi-square test, Fisher's exact chi-square test, t-test for independent and dependent groups and Mann-Whitney U analysis. The experimental group participants (n = 37) received two informative video visits for contraceptive counseling, while the women in the control group (n = 40) received routine face-to-face Family Planning Services at their primary health care center. Participants in the experimental group showed a greater increase in knowledge levels and higher satisfaction with Family Planning Services than those in the control group (p < 0.05). In conclusion, we determined that telemedicine for contraceptive counseling is a promising option even beyond the pandemic.

Minimally invasive outpatient hysterectomy for a benign indication: A systematic review

BACKGROUND

Outpatient surgery in gynaecology may offer advantages including cost reduction, patient convenience and hospital bed optimisation without compromising patient safety and satisfaction. With the continual rise in health costs since 2000, outpatient surgery could be a line of action to improve financial resource utilisation and a solution for continuing to treat patients during crises such as the coronavirus disease 2019 pandemic.

OBJECTIVE

This systematic review provides an overview of the literature on minimally invasive outpatient hysterectomy for benign indications.

METHOD

A focused systematic review of the medical literature between 2018 and 2022 on outpatient gynaecological surgery for a benign indication was conducted using the PubMed and Google Scholar search engines. We then narrowed our selection to articles that referred to hysterectomy. Successful same-day discharge (SDD) was defined as the patient's return home on the day of the procedure without an overnight stay.

RESULTS

Fifteen articles that focused on minimally invasive surgery were included in this review. Most of the studies (n = 11) were conducted in the United States. Outpatient surgery had a mean success rate of 60 % and a mean readmission rate of 3 %. The main reasons for SDD failure were patient choice, failed voiding, the need for pain management, nausea or vomiting, or both and the late timing of surgery. SDD was not associated with more complications and readmissions compared with inpatient care. The three main attribute predictors of SDD were young age, early timing of surgery and short total operative time. Patient satisfaction with SDD was high in absolute terms and relative to satisfaction with hospitalisation.

CONCLUSION

Minimally invasive outpatient hysterectomy for a benign indication is feasible and safe but is associated with a notable risk of failure. To increase the success rate of outpatient management, patients must be well selected and surgery pathways must be planned in advance. The implementation of enhanced recovery protocols may help promote outpatient hysterectomy for a benign indication.

The Impact of the COVID-19 Pandemic on the Military Health System's Care of Military Sexual Assault

BACKGROUND

Sexual assault remains a high priority challenge for leaders in the U.S. military. The COVID-19 pandemic further complicated the issue by disrupting work and lifestyles, potentially affecting reporting and care-seeking by victims. To date, there are no studies addressing the impact of changes in access to health services and reporting of sexual assault by active duty service members to inform medical and public health interventions in a post-COVID-19 era and during future public health emergencies.

METHODS

Using the Military Health System Data Repository (MDR), we identified a retrospective open cohort of active duty servicemembers receiving care in the Military Health System (MHS) from fiscal years 2018 to 2021. Through the use of ICD-10 diagnostic codes, all corresponding sexual assault care was identified for the cohort before (October 1, 2017-February 28, 2020; pre-pandemic period) and after (March 1, 2020-September 30, 2021; pandemic period) the institution of COVID-19 pandemic protective measures. Pre-pandemic and pandemic period rates of sexual assault associated encounters per 10,000 total health encounters were calculated by geographic location and compared using Wilcoxon's sign rank test. Multivariate log binomial regression models were performed to estimate associated risk of sexual assault among active duty servicemembers and compared across both periods.

RESULTS

The study identified 47,067,073 encounters for servicemembers in the pre-pandemic period, of which 7,813 (0.016%) were associated with sexual assault. During the pandemic period, 4,377 (0.015%) of 28,926,480 encounters were associated with sexual assault, indicating a 44% reduction in total encounters and a 9% reduction in the proportion of encounters associated with sexual assault. Eighteen installations within the MHS had statistically significant increases in rates of encounters. Most sexual assault encounters occurred in the 20-24 year age, Female, White, Junior Enlisted, Army, and Unmarried categories. During both time-frames, younger age and being female were associated with an increased risk of sexual assault encounters. Race, service branch, and marital status were also associated with the risk of encounters.

CONCLUSION

Contrary to reports indicating a modest increase in the number of sexual assaults reported within the DoD, we found a reduction in the frequency of healthcare encounters associated with sexual assault during the pandemic which may be related to reduced access to care. Men comprised approximately 22% of sexual assault encounters delivered through the MHS although the racial distribution of encounters approximates the estimates of the DoD-published demographic statistics. This study illustrates that COVID-19 measures appear to have reduced access to care for sexual assault within the MHS but did not demonstrably alter the demographics of servicemembers seeking care. These findings suggest that the MHS may require contingency plans for future disruptions to care and public health emergencies.

Timing of Colposcopy and Risk of Cervical Cancer

OBJECTIVE

To quantify the association between time to colposcopy and risk of subsequent cervical cancer.

METHODS

A longitudinal analysis of patients aged 21-79 years with an abnormal cervical cancer test result from health care systems in Texas, Massachusetts, and Washington was performed. The outcome was a cervical cancer diagnosis 12 months or more after the abnormal result. The primary analysis compared receipt of colposcopy within 3 months (91 days or less) with receipt of colposcopy at 3-12 months (92-365 days) and no colposcopy within 12 months of the abnormal test result; post hoc analyses compared colposcopy within 12 months (365 days or less) with no colposcopy within 12 months. Associations were assessed with multivariable Cox proportional hazards regression controlling for age, risk status, result severity, and health care system.

RESULTS

Of 17,541 patients, 53.3% of patients received colposcopy within 3 months, 22.2% received colposcopy in 3-12 months, and 24.6% had no colposcopy within 12 months. One hundred forty-seven patients were diagnosed with cervical cancer within 12 months and removed from subsequent analyses. Sixty-five patients (0.4%) were diagnosed with cervical cancer more than 1 year (366 days or more) after the abnormal Pap or human papillomavirus test result. The risk of cervical cancer detection more than 1 year after the abnormal test result was not different in patients who received colposcopy within 3-12 months (hazard ratio [HR] 1.07, 95% CI 0.54-2.12) and higher among patients with no colposcopy within 12 months (HR 2.34, 95% CI 1.33-4.14) compared with patients who had colposcopy within 3 months. Post hoc analyses showed that the risk of cervical cancer diagnosis was 2.29-fold higher among those without colposcopy within 12 months compared with those who received colposcopy within 12 months (95% CI 1.37-3.83); among patients with high-grade cytology results, the risk of cervical cancer detection among those without colposcopy within 12 months was 3.12-fold higher compared with those who received colposcopy within 12 months (95% CI 1.47-6.70).

CONCLUSION

There was no difference in cervical cancer risk at more than 1 year between patients who received colposcopy within 3 months compared with those who received colposcopy within 3-12 months of an abnormal result. Patients who did not receive colposcopy within 12 months of an abnormal result had a higher risk of subsequent cervical cancer compared with those who received a colposcopy within 12 months.

Contraceptive services in Oregon's state-funded network during the COVID-19 pandemic

OBJECTIVES

To understand how changes to in-person health care during the COVID pandemic impacted contraceptive use in Oregon's state-funded network.

STUDY DESIGN

A retrospective cohort of 245,600 visits (virtual and in-person) among 70,295 women presenting to publicly funded family planning clinics in Oregon between January 2019 and June 2021. Data were abstracted from clinic records and restricted to visits of patients identifying as female, 12-51 years old, not using sterilization as a method. Contraception was grouped by effectiveness Tier (Tier 1: intrauterine device, implants; Tier 2: progestin injectable, pill/patch/ring). Multivariable logistic regression predicted the use of contraception by stage of the COVID pandemic which corresponded to service availability (prepandemic, acute: nonemergency services halted, subacute: restricted services), patient demographics, including insurance type, and clinic and geospatial characteristics.

RESULTS

Overall during the acute stage, people with visits were more likely to leave with a method of contraception odds ratios (OR) 1.39 (95% confidence interval [CI] 1.24-1.57); however, it was significantly less likely to be a Tier 1 method (OR 0.82, 95% CI 0.74-0.91) as compared to prepandemic. This finding was particularly marked in rural areas (OR 0.69 [96% CI 0.58-0.83]) and among the publicly insured (OR 0.87 [95% CI 0.80-0.94]).

CONCLUSIONS

Demand for contraception increased during the acute phase of the COVID pandemic, and shifts in method mix from Tier 1 to Tier 2 methods occurred. Disparities in contraceptive access persisted for those in rural locations or with public insurance.

IMPLICATIONS

Lessons learned from the COVID-19 pandemic are critical to informing our future emergency response. The need for family planning services increased during the public health emergency.

Feasibility and anticipated acceptability of community health worker-facilitated HPV self-sampling for cervical cancer screening around Lake County, Indiana

Background/Objective

In light of calls to engage community health workers (CHWs) in the delivery of cervical cancer screening innovations, this study explores CHW perspectives on i) barriers to cervical cancer screening in a predominantly Hispanic community in Lake County, Indiana, the county with the highest cervical mortality in the state; and ii) the acceptability and feasibility of CHW-facilitated human papillomavirus (HPV) self-sampling as a means of reducing screening disparities.

Methods

In 2021, in-depth interviews were conducted with 15 CHWs employed by Lake County community-based organizations including clinics, schools, and faith-based organizations.

Results

Harnessing CHWs' voices as insiders with knowledge of their communities' health landscape, our analysis identified multilevel barriers to screening that spanned individual, interpersonal, and community levels of the socio-ecological model. CHW-facilitated HPV self-sampling shows promise of mitigating several barriers to cervical cancer screening. Privacy, time saved, and comfort were perceived to be facilitators for acceptability, with concerns about the novelty of this approach and trust in provider (as opposed to CHW) expertise emerging as key barriers. In terms of feasibility, synergies with existing CHW work, and some community members' prior experience with self-sampling were found to be facilitators, while CHW's time limitations and self-efficacy in providing adequate medical support were areas of concern. Considerations for adoption included CHW training, gender concordance, safety, and respect, among others.

Conclusion

This study provides critical insights from CHWs as key stakeholders on a screening model that directly engages them, which can inform implementation to increase screening in medically-underserved communities in the US.

Inter(national) recommendations to face violence against women and girls in COVID-19 pandemic

This article is an integral part of the research "Violence in the context of COVID-19: global challenges and vulnerabilities", which proposes a critical reflection on situations of gender-based violence increased by social distancing protocols, required by the COVID-19 pandemic. Based on a 2020 literature survey, we have analyzed recommendations made by researchers and institutions from different countries around the world, with the aim of systematizing and disseminating strategies to deal with this scenario. The material is organized into two thematic areas, namely: gender policies and intersectoral actions; and strategies to face violence against women and children in the health and social work field. The recommendations are focused on the development of actions by States/governments, service networks and society in general. Part of the recommendations suggest increasing or adapting existing surveillance actions and part of them contribute with creative proposals, guiding promotional and preventive actions at an individual and collective level. The adoption of teleassistance, media campaigns raising awareness that violence is unjustifiable and the development of reporting strategies through signs and codes have been reiterated in the literature.

The role of community healthcare professionals in discussing sexual assault experiences during obstetrics and gynecological healthcare appointments

BACKGROUND

Nearly half of adult women in the US report experiencing sexual assault, with almost one-fifth reporting rape. For many sexual assault survivors, healthcare professionals are the first point of contact and disclosure. This study aimed to understand how healthcare professionals working in community settings perceived their role in discussing sexual violence experiences with women during obstetrical and gynecological healthcare appointments. The secondary purpose was to compare healthcare professionals' perspectives with the patients' to determine how sexual violence conversations should occur in these environments.

METHODS

Data were collected in two phases. Phase 1 consisted of 6 focus groups (Sept-Dec, 2019) with women aged 18-45 (n = 22) living in Indiana who sought community-based or private healthcare for women's reproductive healthcare needs. Phase 2 included 20 key-informant interviews with non-physician healthcare professionals (i.e., NP, RN, CNM, doula, pharmacist, chiropractor) living in Indiana (September 2019-May 2020) who provided community-based women's reproductive healthcare. Focus groups and interviews were audio-recorded, transcribed, and analyzed using thematic analyses. HyperRESEARCH assisted in data management and organization.

RESULTS

There were three resulting themes: (1) healthcare professionals' approaches to screening for a history of sexual violence varied depending on how they ask, what setting they work in, and type of professional asking; (2) healthcare experiences can compound traumatic experiences and create distrust with survivors; and (3) sexual violence impacts patient healthcare experiences through what services they seek, how professionals may interact with them, and what professionals they are willing to utilize.

CONCLUSIONS

Findings offered insight into actionable and practical strategies for enhancing sexual violence screening and discussions in community-based women's reproductive health settings. The findings offer strategies to address barriers and facilitators among community healthcare professionals and the people they serve. Incorporating healthcare professional and patient experiences and preferences for violence-related discussions during obstetrical and gynecological healthcare appointments can assist in violence prevention efforts, improve patient-professional rapport, and yield better health outcomes.

Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Follow-Up Care amidst a Global Pandemic

STUDY OBJECTIVE

To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ² tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes.

RESULTS

Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities.

CONCLUSIONS

Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care.

Perceived Access to Contraception via Telemedicine Among Young Adults: Inequities by Food and Housing Insecurity

BACKGROUND

Telemedicine expanded rapidly during the COVID-19 pandemic, including for contraceptive services. Data are needed to understand whether young people can access telemedicine for contraception, especially in underserved populations.

OBJECTIVE

To compare young people's perceived access to telemedicine visits for contraception during the COVID-19 pandemic by food and housing insecurity.

DESIGN

Supplementary study to a cluster randomized controlled trial in 25 community colleges in California and Texas. Online surveys were administered May 2020 to April 2021. Mixed-effects logistic regression models with random effects for site were used to examine differences in access to contraception through telemedicine by food and housing insecurity status, controlling for key sociodemographic characteristics, including race/ethnicity, non-English primary language, health insurance status, and state of residence, and contraceptive method used.

PARTICIPANTS

1,414 individuals assigned female at birth aged 18-28.

MAIN MEASURES

Survey measures were used to capture how difficult it would be for a participant to have a telemedicine visit (phone or video) for contraception.

KEY RESULTS

Twenty-nine percent of participants were food insecure, and 15% were housing insecure. Nearly a quarter (24%) stated that it would be difficult to have a phone or video visit for contraception. After accounting for sociodemographic factors and type of method used, food insecure (adjusted odds ratio [aOR], 2.17; 95% confidence interval [CI], 1.62-2.91) and housing insecure (aOR, 1.62; 95% CI, 1.13-2.33) participants were significantly more likely to report that it would be difficult to use telemedicine for contraception during the pandemic.

CONCLUSIONS

Underserved patients are those who could benefit most from the expansion of telemedicine services, yet our findings show that young people experiencing basic needs insecurity perceive the greatest difficulty accessing these services for essential reproductive care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03519685.

Context Matters: Assessing the Association Between Area Deprivation and the Severity of Injury and Types of Domestic Violence Victimization Among Women

OBJECTIVES

To analyze the association between social determinants of health (SDOH), as measured by the Area Deprivation Index (ADI), and the severity of injury and types of domestic violence (DV) victimization among women (≥18 years of age) in Milwaukee, Wisconsin.

METHODS

Neighborhood ADI data from the American Community Survey (2014-2018) were merged with Milwaukee Police Department DV data (2013-2017). ADI included multiple SDOH domains (education, employment, income/poverty, and housing quality). Types of DV were classified using an adaptation of the FBI-Uniform Crime Reporting-Hierarchy Rule, including Crimes Against Persons (homicide/negligent manslaughter, sexual assault/rape, and aggravated battery/assault). Chi-square, Anova tests, and logistic regression analyses were performed using Stata v.14.2; p-values ≤ .05 were considered statistically significant.

FINDINGS

Except for aggravated battery/assault (OR: 1.003, 95% CI: 1.001-1.010), there was no statistically significant relationship between neighborhood disadvantage and DV victimization in 21,095 DV incidents between 2013 and 2017. Adjusted model results indicate that with each increase in neighborhood disadvantage (by ADI), there was a 1.003 increase in the likelihood for aggravated battery/assault (OR: 1.003, 95% CI: 1.001-1.005). Severity of DV injury was not significantly associated with ADI (OR: 1.002, 95% CI: 0.999-1.004). However, non-Hispanic Black women were 1.3 times more likely than non-Hispanic Whites to be victims of aggravated battery/assault (OR: 1.321, 95% CI: 1.189-1.469). Hispanic women were more likely than non-Hispanic Whites to sustain a more severe injury (OR: 0.841, 95% CI: 0.732-0.970]).

CONCLUSION

The likelihood of DV-aggravated battery/assault increased with neighborhood deprivation, and significant associations (and highly lopsided prevalence) were found in types of DV victimization by race/ethnicity, with non-Hispanic Black women experiencing higher prevalence than others. This study adds to the body of knowledge by looking at how macro-level neighborhood-SDOH characteristics influence women's exposure to various forms of DV victimization and demonstrated the feasibility of linking law enforcement DV data to SDOH metrics, providing context for law enforcement DV victimizations.

Psychological and Biochemical Effects of an Online Pilates Intervention in Pregnant Women during COVID-19: A Randomized Pilot Study

The purpose of this study was to analyze the effect of real-time online Pilates exercise during COVID-19 on women's body composition, blood lipids, and psychological health after childbirth. The participants were 16 pregnant women (24-28 weeks pregnant) enrolled at the C Women's Culture Center in Seoul, South Korea, classified into online Pilates groups and non-exercise groups (PE, n = 8; CON, n = 8). The online Pilates program was conducted for 8 weeks, twice a week, and 50 min a day using a real-time video chat app. Participants visited the hospital twice for body composition and blood tests. Questionnaires on postpartum depression, sleep disorder, and stress were conducted at 6 weeks and 12 weeks after childbirth. We found a significant difference between groups in body composition. The weight, percentage of body fat, body fat mass, and BMI of the PE group decreased. Blood lipids showed significant differences between the groups in TC, TG, LDL and CRP, while insulin and HDL showed no difference. All blood lipids, insulin, and CRP in the PE group were reduced. There were significant differences between the groups in postpartum depression, sleep disorders, and perceived stress indices performed in the post-test, and the serotonin concentration in the PE group increased. Serotonin levels were significantly correlated with postpartum depression, body fat mass, and body fat rate. Pregnant women's online Pilates in this study was effective at reducing weight and depression in women after childbirth and should be used to promote women's mental health during COVID-19.

Competing health risks associated with the COVID-19 pandemic and early response: A scoping review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Predictors of treatment failure for adenocarcinoma in situ of the uterine cervix: Up to 14 years of recorded follow‑up

The incidence of adenocarcinoma-in-situ (AIS) of the uterine cervix is rising, with invasive adenocarcinoma becoming increasingly common relative to squamous cell carcinoma. The present study reviewed a cohort of 84 patients first-time treated by conization for histologically-confirmed AIS from January 2001 to January 2017, to identify risk factors associated with recurrent/persistent AIS as well as progression to invasive cervical cancer. Nearly 80% of the patients were age 40 or younger at conization. Endocervical and ectocervical margins were deemed clear in 42 of the patients. All but two patients had ≥1 follow-up, with post-conization high-risk human papilloma virus (HPV) results documented in 52 patients. Altogether, 12 histopathologically-confirmed recurrences (14.3%) were detected; two of these patients had microinvasive or invasive carcinoma. In three other patients cytology showed AIS, but without recorded histopathology. Eight patients underwent hysterectomy for incomplete resection very soon after primary conization; they were not included in bivariate or multivariate analyses. Having ≥1 post-follow-up positive HPV finding yielded the highest sensitivity for histologically-confirmed recurrence: 87.5 [95% confidence interval (CI) 47.4-99.7]. Current or historical smoking status provided highest specificity: 94.4 (95% CI 72.7-99.9) and overall accuracy: 88.0 (95% CI 68.8-97.5) for histologically-confirmed recurrence. With multiple logistic regression (MLR), adjusting for age at conization and abnormal follow-up cytology, positive HPV18 was the strongest predictor of histologically-confirmed recurrence (P<0.005). Having ≥2 positive HPV results also predicted recurrence (P<0.02). Any unclear margin yielded an odds ratio 7.21 (95% CI 1.34-38.7) for histologically-confirmed recurrence adjusting for age, but became non-significant when including abnormal cytology in the MLR model. The strong predictive value of HPV, particularly HPV18 and persistent HPV positivity vis-à-vis detected recurrence indicated that regular HPV testing for patients treated for AIS is imperative. In conclusion, furthering a participatory approach, including attention to smoking with encouragement to attend needed long-term follow-up, can better protect these patients at high risk for cervical cancer.

The impact of coronavirus on reproduction: contraceptive access, pregnancy rates, pregnancy delay, and the role of vaccination

It is important to closely examine trends in reproduction during a pandemic because it provides not only the foundation for an improved future response but also crucial insights regarding the disparate impact across different races and socioeconomic classes. The coronavirus disease 2019 pandemic is a prime example of the impact a pandemic can have on a nation’s reproductive health. Contraception and abortion access became more difficult with more barriers to access, likely contributing to increasing unintended pregnancy rates. Underrepresented minorities and vulnerable populations were disproportionately affected by the virus on their reproductive health as well as by the virus itself. As the first ever messenger ribonucleic acid vaccine in conjunction with the lack of inclusion of pregnant and peripartum women in initial studies and conflicting and misinformation on social media, the initial role of the coronavirus disease 2019 vaccine in women of reproductive age was unclear. Further research inclusive of this group of women has led to the consensus by major medical societies to recommend vaccination of women regardless of pregnancy or lactating status.

Examining these topics in depth will lead to the development of strategies that can be employed to mitigate the negative effects on reproductive health during the current pandemic and can also be applied to future strategic plans to prevent similar negative outcomes.

Telehealth for Contraceptive Care During the Initial Months of the COVID-19 Pandemic at Local Health Departments in 2 US States: A Mixed-Methods Approach

OBJECTIVES

This study examined implementation of telehealth for contraceptive care among health departments (HDs) in 2 Southern US states with centralized/largely centralized governance structures during the early phase of the COVID-19 pandemic. Sustaining access to contraceptive care for underserved communities during public health emergencies is critical. Identifying facilitators and barriers to adaptive service provision helps inform state-level decision making and has implications for public health policy and practice, particularly in states with centralized HD governance.

DESIGN

Mixed-methods study including a survey of HD clinic administrators and key informant interviews with clinic- and system-level staff in 2 states conducted in 2020.

SETTING

Health department clinics in 2 Southern US states.

PARTICIPANTS

Clinic administrators (survey) and clinic- and system-level respondents (key informant interviews). Participation in the research was voluntary and de-identified.

MAIN OUTCOME MEASURES

(1) Telehealth implementation for contraceptive care assessed by survey and measured by the percentage of clinics reporting telehealth service provision during the pandemic; and (2) facilitators and barriers to telehealth implementation for contraceptive care assessed by key informant interviews. For survey data, bivariate differences between the states in telehealth implementation for contraceptive care were assessed using χ2 and Fisher exact tests. Interview transcripts were coded, with emphasis on interrater reliability and consensus coding, and analyzed for emerging themes.

RESULTS

A majority of HD clinics in both states (60% in state 1 and 81% in state 2) reported a decrease in contraceptive care patient volume during March-June 2020 compared with the average volume in 2019. More HD clinics in state 1 than in state 2 implemented telehealth for contraceptive services, including contraceptive counseling, initial and refill hormonal contraception, emergency contraception and sexually transmitted infection care, and reported facilitators of telehealth. Medicaid reimbursement was a predominant facilitator of telehealth, whereas lack of implementation policies and procedures and reduced staffing capacity were predominant barriers. Electronic infrastructure and technology also played a role.

CONCLUSIONS

Implementation of telehealth for contraceptive services varied between state HD agencies in the early phase of the pandemic. Medicaid reimbursement policy and directives from HD agency leadership are key to telehealth service provision among HDs in centralized states.

Intimate Partner Violence in the COVID-19 Era: A Health, Psychological, Forensic and Legal Perspective

This commentary aims to provide a multidisciplinary framework on intimate partner violence (IPV) during the COVID-19 pandemic (with a specific focus on the most predominant form of gender-based violence, i.e., male violence towards women), commenting on the multiple negative consequences of the pandemic on gender violence and providing elements of effective practice. We searched literature for reports/studies on the issue of IPV during the COVID-19 pandemic, focusing on health, psychological, forensic, and legal aspects. The combined effects of lockdowns, isolation at home with abusive partners, quarantine, and economic worries/loss of a job could significantly facilitate violence against women and, at the same time, diminish women’s chances to seek for help, with a strong negative impact on their life. The continued offer of clinical, psychological, forensic, and legal services for survivors of violence, despite the modifications to the provision of these services due to the new needs related to the COVID-19 pandemic, appears of utmost importance. All actions to support survivors of IPV are expected to be multidisciplinary, including the involvement of social and/or legal services and health systems, and woman-centred. Implementing these measures in the COVID-19 era appears challenging but is of primary importance.

The Use of Telemedicine in Pediatric and Adolescent Gynecology

STUDY OBJECTIVE

To study the feasibility of virtual visits for ambulatory encounters in pediatric and adolescent gynecology DESIGN: A retrospective review SETTING: Boston Children's Hospital PARTICIPANTS: Patients who were seen virtually through the Division of Gynecology between January 1, 2020 and June 1, 2020 MAIN OUTCOME MEASURE(S): Patient demographics, visit diagnoses, and operational characteristics of the completed visits RESULTS: There were a total of 654 virtual visits for 614 patients. Ninety-one percent (n=558) of patients were in-state, and the median age of patients was 17 years (range 0 - 37 years). The majority were return visits (n=502, 76.8%), 115 (17.6%) were new patient visits, and 32 (4.89%) were post-operative visits. The median virtual visit duration was 12 minutes and 39 seconds (range 5 minutes to over 1 hour). The most common gynecologic diagnoses were dysmenorrhea/endometriosis (n=485, 74.2%), abnormal uterine bleeding (n=225, 34.4%), and pelvic pain (n=82, 12.5%). The percentage of virtual visits which required an in-person follow-up visit within 90 days was low (n=14, 2.1%). Five of these were within 30 days from the initial virtual visit, 6 were within 60 days, and 3 were within 90 days.

CONCLUSION

Telemedicine is a feasible method for expanding access to, and healthcare delivery for, pediatric and adolescent gynecology, with low rates of short interval in-person follow-up required. Virtual visits can be conducted for a range of patients with a variety of gynecologic conditions, upon initial presentation and follow-up.

A Review of Cancer Screening Recommendations during the COVID-19 Pandemic

BACKGROUND

Cancer screening tests are recommended to prevent cancer-associated mortality by detecting precancerous and cancerous lesions in early stages. The COVID-19 pandemic disrupted the utilization of preventive health care services. While there was a rise in the number of cancer screening tests beginning in late 2020, screenings remained 29%-36% lower than in the pre-pandemic era.

OBJECTIVE

The objective of this review article was to assist health care providers in identifying approaches for prioritizing patients and increasing breast, cervical, and colorectal cancer screening during the uncertainty of the COVID-19 pandemic.

METHODS

We used the scoping review framework to identify articles on PubMed and EBSCO databases. A total of 403 articles were identified, and 23 articles were selected for this review. Literature review ranged from January 1st, 2020 to September 30th, 2021.

RESULTS

The articles included two primary categories of recommendations: (1) risk stratification and triage to prioritize screenings and (2) alternative methods to conduct cancer screenings. Risk stratification and triage recommendations focused on prioritizing high-risk patients with an abnormal or suspicious result on the previous screening test, of certain age group and sex, having personal medical or family history of cancers, currently symptomatic, predisposed to hereditary cancers, and cancer-causing mutations. Other recommended strategies included: identifying areas facing most disparities, creating algorithms and using artificial intelligence to create cancer-risk scores, leveraging in-person visits to assess cancer risk, and providing the option of open access screenings where patients can schedule screenings and can be assigned a priority category by health care staff. Some recommended using telemedicine to categorize patients and determine screening-eligibility for patients with new complaints. Several articles noted the importance of implementing preventive measures such as COVID-19 screening prior to the procedures, maintaining hygiene measures, and social distancing in waiting rooms. Alternative screening methods which do not require an in-person clinic visit and can effectively screen patients for cancers included mailing self-collection sampling kits for cervical and colorectal cancers and implementing or expanding mobile screening units.

CONCLUSIONS

Although the COVID-19 pandemic had devastating effects on population health globally, it could be an opportunity to adapt and evolve cancer screening methods. Disruption often creates innovation, and focus on alternative methods for cancer screenings may help reach rural and under-resourced areas after the pandemic has ended.

CLINICALTRIAL

Attitudes and Preferences Regarding Non-Clinic-Based Self-Collection for Sexually Transmitted Infection Testing Among Clinic Attendees in British Columbia, Canada

BACKGROUND

Sexually transmitted infections (STIs) are a global epidemic; although screening programs reduce transmission, barriers, including access and stigma, hinder success. The World Health Organization highlights the ability to maintain health without the direct support of a health care provider as one form of self-care, which can be applied to STI testing. Self-care through non-clinic-based self-collection for STI testing can address barriers while providing comprehensive care. Before implementation of innovative changes to screening approaches, it is important to understand if communities who rely on in-person care will self-collect outside of the clinic setting. This study investigated willingness to use non-clinic-based self-collection for STI testing among STI clinic attendees in British Columbia, Canada.

METHODS

Participants (n = 446) were recruited from STI clinics offering clinic-based self-collection for STI testing and completed a survey assessing self-care attitudes, including willingness to self-collect urine samples, throat swabs, and anogenital swabs outside of the clinic setting. Descriptive statistics, bivariable analyses, and multivariable models were conducted to investigate willingness to use non-clinic-based STI self-collection methods and associated correlates.

RESULTS

This population reported high willingness to use non-clinic-based self-collection methods for STI testing (urine samples, 73%; throat swabs, 67%; anogenital swabs, 65%). Those aged 35 to 54 years compared with 15 to 34 years were more likely to be willing (adjusted odds ratio, 1.87; 95% confidence interval, 1.03-3.50); those identifying as straight/mostly straight compared with gay/lesbian were less likely to be willing (adjusted odds ratio, 0.39; 95% confidence interval, 0.23-0.65).

CONCLUSIONS

Non-clinic-based self-collection for STI testing can address barriers to testing while maintaining quality care. Those currently receiving in-person care find these methods highly acceptable. These findings reinforce that self-collection for STI testing used in British Columbia clinics is acceptable to clients and may be extended to collection performed outside of the clinical setting.

Early Welsh cervical screening programme learning as a consequence of the coronavirus pandemic

BACKGROUND

The coronavirus pandemic has had a profound impact on the cervical screening programme in Wales for the eligible women, sample takers and laboratory and colposcopy services.

AIMS

To explore what changes due the pandemic have adversely affected screening outcomes in Wales and what lessons can be learned to improve cervical screening in Wales and elsewhere.

METHODS

A review of the screening performance in 2020 and the first quarter of 2021 in Wales as well as a comparison with other cervical screening programme responses to the pandemic.

RESULTS

A three-month pause of screening together with a change in a variety of working practices, including social distancing, use of personal protective equipment, use of virtual meetings and home working have been implemented. The combination of a pause to the issue of invitations, plus reduced services in primary and secondary care, together with population lockdown, have contributed to longer waiting times for colposcopy and potentially delayed cancer diagnoses. Some programme changes which were being evaluated prior to the pandemic could be developed now to mitigate the impact of the pandemic such as improved information, increased screening intervals for human papillomavirus-based screening programmes and home working for call and recall staff.

CONCLUSIONS

Despite a considerable short-term interruption to the cervical screening programme, some changes introduced as a result of the coronavirus pandemic could provide key lessons learnt for improvement for cervical cancer prevention services.

Competing Health Risks Associated with the COVID-19 Pandemic and Early Response: A Scoping Review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from January 1st to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints met inclusion criteria, including 8.2% (132/1604) of published studies and 10.2% (21/205) of preprints: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (13/166) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Intimate Partner Violence and Trauma-Informed Care in Pregnancy

Intimate partner violence is defined as any behavior within an intimate relationship that causes physical, psychological, or sexual harm to those in the relationship. Globally, women are disproportionately victims of intimate partner violence. The risk increases during pregnancy, with rates estimated as high as 20% among pregnant persons. Intimate partner violence is associated with adverse perinatal outcomes, including perinatal and maternal death. As pregnancy is a period of frequent interaction with the healthcare system, it is an opportune time to screen and intervene for intimate partner violence. Universal screening at the first prenatal visit and subsequently every trimester is recommended, with either written or verbal validated tools. Pregnant persons experiencing intimate partner violence need nonjudgmental, compassionate, confidential and trauma-informed care. The goal of this review is to outline pregnancy-specific care considerations.

COVID-19's impact on contraception experiences: Exacerbation of structural inequities in women's health

INTRODUCTION

Structural inequities may impact the relationship between COVID-19 and access to contraception.

METHODS

In July 2020 and January 2021, we used social media to survey 2 samples of women of reproductive age who had not been surgically sterilized and were not currently pregnant about their experiences seeking contraception. We explore whether experiences differed for people experiencing social and/or economic disadvantage due to COVID-19, using multivariable logistic regression to control for age, education and income.

RESULTS

In July 2020, 51.5% of respondents who sought contraception (total N = 3064) reported barriers to care compared to 55.3% in January 2021 (total N = 2276). A larger percent (14% in July 2020 and 22% in Jan 2021) reported not using their preferred method of contraception due to COVID-19. Individuals experiencing income loss (OR = 1.61, 95% CI 1.27-2.04 early in the COVID-19 pandemic and OR = 1.58, 1.21-2.06 mid COVID-19 pandemic) and hunger (OR = 1.73, 1.24-2.40 early and OR = 2.02, 1.55-2.64 mid-COVID-19 pandemic) were more likely to report they would be using a different method if not for COVID-19, compared to respondents without income loss or hunger.

CONCLUSIONS

COVID-19 has complicated access to contraception, especially for disadvantaged populations.

IMPLICATIONS

Efforts are needed to ensure access to contraception despite the COVID-19 epidemic, especially for disadvantaged populations.

Cancer management during the COVID-19 pandemic: Choosing between the devil and the deep blue sea

COVID-19 was declared a "Public Health Emergency of International Concern" in March 2020. Since then, drastic measures were implemented to reduce the virus spread. These measures prevented cancer patients from receiving prompt medical care. A delay in testing and treating cancer patients is thought to protect them from serious COVID-19 complications but exposes them at the same time to the risk of disease progression and cancer related mortality. Healthcare providers are therefore facing the dilemma of choosing between two unpleasant scenarios. To shed light upon the matter, we present in this review article, based on an extensive search of the literature, an overview of the delay in the management of cancer patients, possible contributors to this delay and its benefits and risks on cancer patients' health.

Impact of COVID-19 on cervical cancer screening: Challenges and opportunities to improving resilience and reduce disparities

The COVID-19 pandemic has a major impact on a wide range of health outcomes. Disruptions of elective health services related to cervical screening, management of abnormal screening test results, and treatment of precancers, may lead to increases in cervical cancer incidence and exacerbate existing health disparities. Modeling studies suggest that a short delay of cervical screening in subjects with previously negative HPV results has minor effects on cancer outcomes, while delay of management and treatment can lead to larger increases in cervical cancer. Several approaches can mitigate the effects of disruption of cervical screening and management. HPV-based screening has higher accuracy compared to cytology, and a negative HPV result provides longer reassurance against cervical cancer; further, HPV testing can be conducted from self-collected specimens. Self-collection expands the reach of screening to underserved populations who currently do not participate in screening. Self-collection and can also provide alternative screening approaches during the pandemic because testing can be supported by telehealth and specimens collected in the home, substantially reducing patient-provider contact and risk of COVID-19 exposure, and also expanding the reach of catch-up services to address backlogs of screening tests that accumulated during the pandemic. Risk-based management allows prioritizing management of patients at highest risk of cervical cancer while extending screening intervals for those at lowest risk. The pandemic provides important lessons for how to make cervical screening more resilient to disruptions and how to reduce cervical cancer disparities that may be exacerbated due to disruptions of health services.

Perinatal Behavioral Health, the COVID-19 Pandemic, and a Social Determinants of Health Framework

The United States has greater prevalence of mental illness and substance use disorders than other developed countries, and pregnant women are disproportionately affected. The current global COVID-19 pandemic, through the exacerbation of psychological distress, unevenly affects the vulnerable population of pregnant women. Social distancing measures and widespread closures of businesses secondary to COVID-19 are likely to continue for the foreseeable future and to further magnify psychosocial risk factors. We propose the use of a social determinants of health framework to integrate behavioral health considerations into prenatal care and to guide the implementation of universal and comprehensive psychosocial assessment in pregnancy. As the most numerous and well-trusted health care professionals, nurses are ideally positioned to influence program and policy decisions at the community and regional levels and to advocate for the full integration of psychosocial screening and behavioral health into prenatal and postpartum care as core components.

Age, margin status, high-risk human papillomavirus and cytology independently predict recurrent high-grade cervical intraepithelial neoplasia up to 6 years after treatment

The present study aimed to identify the factors that independently contribute to disease recurrence among women first-time treated for high-grade cervical intraepithelial neoplasia (CIN) during 4–6 years of follow-up. Overall, 529 of 530 eligible patients participated; these patients all attended a 1st follow-up appointment ~6 months post-conization, at which time high-risk human-papillomavirus (HPV) testing, liquid-based cytology and colposcopy were performed. Full data on margin excision status, other aspects of initial treatment and comorbidity were obtained. At least one subsequent follow-up was attended by 88% of patients. A total of 22 recurrent cases were detected during follow-up. Detected recurrence was the outcome of focus for multiple logistic regression analysis, with odds ratios (OR) and 95% confidence intervals (CI) computed. Four significant independent risk factors were identified: Age 45 years or above (OR=3.5, 95% CI=1.3–9.9), one or both unclear or uncertain margins (OR=5.3, 95% CI=2.0–14.2), positive HPV at 1st follow-up (OR=5.8, 95% CI=2.0–16.8), and abnormal cytology at 1st follow-up (OR=3.9, 95% CI=1.4–11.0). Bivariate analysis revealed that persistent HPV positivity was associated with recurrence (P<0.01). These findings indicated that incomplete excision of the CIN lesion may warrant more intensive subsequent screening, regardless of early post-conization HPV findings. Although early post-conization positive HPV was a powerful, independent predictor of recurrent high-grade CIN, over one-third of the patients with detected recurrence had a negative early post-conization HPV finding. These patients returned for routine screening, at which time, in most cases, HPV status was positive, thus indicating the need for repeated HPV evaluation. Especially during the on-going pandemic, home vaginal self-sampling is recommended. Particular attention is required for women aged ≥45 years. In addition, although not statistically significant, relevant comorbidities, especially autoimmune conditions, warrant consideration in clinical decision-making. Women who have been treated for high-grade CIN are at risk for recurrent disease and progression to cervical cancer; therefore, they require careful, individualized follow-up to avoid these adverse consequences.

Impact of the COVID-19 pandemic on voluntary terminations of pregnancy in an Italian metropolitan area

PURPOSE

The COVID-19 pandemic and national lockdown from 9 March to 4 May 2020 changed social, familial, and sexual relationships, as well as how citizens interact with the health services. How these profound changes have affected sexuality, contraception and voluntary terminations of pregnancy is still largely undescribed. The main objective of this study was therefore to find out whether the COVID-19 pandemic and ensuing lockdown affected the demand for legal abortion.

MATERIAL AND METHODS

The study period was divided into three phases: the pre-pandemic (January and February 2020); lockdown (March and April); and post-lockdown (May and June). The number and characteristics of women requesting pregnancy termination each month during that time were compared with the stats for the same months in the preceding three years (2017-2019).

RESULTS

Immediately after national lockdown, the number of voluntary abortions markedly declined (-40.45%). The effect was more evident in women below 20 years of age (-66.67%), employed versus unemployed women (-42.71% vs. -21.05), and non-Italian versus Italian citizens (-53.01 vs. -32.85). No difference was found in the mean time from request to execution of the procedure, or in the type of the procedure used.

CONCLUSION(S)

National lockdown reduced the number of unwanted pregnancies, especially in younger women. The Italian health service's response to the demand appears to have been unaffected by the pandemic. However, as the demand for abortion is still high, probably due to unplanned pregnancies among cohabitants within a stable relationship, contraception guidance should be improved among women traditionally deemed low-risk in terms of sexual behaviour.

Impact of COVID-19 Pandemic on the Clinical Activities in Obstetrics and Gynecology: A National Survey in China

Objective: Few studies have quantified the influence of coronavirus disease 2019 (COVID-19) pandemic on medical providers. This is the first national study to investigate the impact of the pandemic on physicians practicing obstetrics and gynecology in China.

Methods: A two-stage, stratified, cluster sampling method was performed based on the city categories (category 1, fewer than 10,000 beds; category 2, 10,000–30,000; and category 3, more than 30,000) and public hospital levels (primary, secondary, and tertiary). Physicians practicing obstetrics and gynecology reported the relevant changes in their general clinical activities and changes in the management of specific diseases or conditions occurring during the periods that they were most strongly affected. These changes were compared by municipal and hospital characteristics.

Results: Questionnaires were collected from a representative sample of 11,806 physicians actively practicing obstetrics and gynecology in 779 hospitals from 157 cities of 31 provinces. Except emergency visits and online consultations, category 3 cities, tertiary hospitals and general hospitals had greater reductions in overall clinical activities than category 1 cities, primary hospitals and specialized hospitals (all adjusted p < 0.05), respectively. The differences also existed in the management of specific diseases and conditions, especially for less urgent conditions, including cervical cancer screening, instructions regarding contraception and miscarriage, and assisted reproduction (all p < 0.05).

Conclusions: During the COVID-19 pandemic, the clinical obstetrics and gynecology activities in China markedly decreased, with significant differences across municipal and hospital characteristics.

Trial Registration: This study was registered with ClinicalTrials.gov on July 27, 2020 (NCT04491201).

Sexual and reproductive health services provided by community pharmacists: a scoping review

OBJECTIVES

Pharmacists are increasingly providing patient-focused services in community pharmacies, including in the area of sexual and reproductive health (SRH). Specific SRH areas have been the focus of research, but a broader perspective is needed to position pharmacists as SRH providers. This review explored research that described and evaluated professional pharmacy services across a broad range of SRH areas.

DESIGN

Scoping review DATA SOURCES: Medline, EMBASE, CINAHL, Web of Science, Scopus and Cochrane Library (January 2007-July 2020).

STUDY SELECTION

Studies reporting on the description and evaluation of professional pharmacy SRH services provided by community pharmacists.

DATA EXTRACTION

Two investigators screened studies for eligibility, and one investigator extracted the data. Data were analysed to primarily describe professional pharmacy services and intervention outcomes.

RESULTS

Forty-one studies were included. The main SRH areas and professional pharmacy services reported were sexually transmitted and bloodborne infections (63%) and screening (39%), respectively. Findings showed that pharmacists' delivery of SRH services was feasible, able to reach vulnerable and high-risk groups, and interventions were highly accepted and valued by users. However, integration into daily workflow, pharmacist remuneration, cost and reimbursement for patients, and policy regulations were some of the barriers identified to implementing SRH services. Studies were primarily in specific areas such as chlamydia screening or hormonal contraception prescribing, while studies in other areas (ie, medical abortion provision, long-acting reversible contraception prescribing and vaccine delivery in pregnant women) were lacking.

CONCLUSION

This scoping review highlights the expansion of pharmacists' roles beyond traditional product-focused services in a number of SRH areas. Given the potential feasibility, users' acceptability and reach, pharmacists are ideally situated to enhance SRH care access. Future research describing implementation and evaluation of professional pharmacy services in all SRH areas is needed to promote access to these services through community pharmacies and position pharmacists as SRH providers worldwide.

COVID-19 Remote Consultation Services and Population in Health Inequity-Concentrating Territories: A Scoping Review

Background: This review aimed to map initiatives for measuring the satisfaction of vulnerable populations with teleconsultation services offered by public and private health care providers in their territories, during the coronavirus disease (COVID-19) pandemic. Systematic studies on the opinions of people most affected by health inequities are limited. Therefore, we included evaluations of teleconsultation-based services offered to socioeconomically disadvantaged and clinically vulnerable populations globally, with a focus on surveillance, treatment, and prevention of COVID-19.

Materials and Methods: This review includes analytical and descriptive observational studies primarily from MEDLINE, EMBASE, SCOPUS, and Web of Science databases, published after the World Health Organization received the first warnings about COVID-19 from Chinese authorities in December, 2019, until December 2020. The search strategy combined aspects of COVID-19, telemedicine, patient satisfaction, and key concepts of vulnerable populations.

Results: We selected 33 studies for full-text reading and 10 for critical appraisal. Two categories emerged from the qualitative analysis: telehealth evaluation and services during COVID-19, and opinions of vulnerable populations. Television and social networks play a crucial role in providing information. Although teleconsultations are practical and cost effective for patients, the majority preferred receiving in-person treatment in primary care clinics.

Conclusions: Listening to the opinions of vulnerable groups and their caregivers is critical both before and during adoption of COVID-19 control measures. Health managers need to monitor the health of and delivery of services to socioeconomically and clinically vulnerable people closely, to improve services, and provide care from a human rights perspective.

Rationale and design of the Prevent Anal Cancer Self-Swab Study: a protocol for a randomised clinical trial of home-based self-collection of cells for anal cancer screening

INTRODUCTION

Squamous cell carcinoma of the anus is a common cancer among sexual minority men, especially HIV-positive sexual minority men; however, there is no evidenced-based national screening protocol for detection of anal precancers. Our objective is to determine compliance with annual anal canal self-sampling or clinician-sampling for human papillomavirus (HPV) DNA.

METHODS AND ANALYSIS

This is a prospective, randomised, two-arm clinical study to evaluate compliance with annual home-based versus clinic-based HPV DNA screening of anal canal exfoliated cells. The setting is primary care community-based clinics. Recruitment is ongoing for 400 HIV-positive and HIV-negative sexual minority men and transgender persons, aged >25 years, English or Spanish speaking, no current use of anticoagulants other than nonsteroidal anti-inflammatory drugs and no prior diagnosis of anal cancer. Participants are randomised to either receive a swab in the mail for home-based collection of an anal canal specimen at 0 and 12 months (arm 1) or attend a clinic for clinician collection of an anal canal specimen at 0 and 12 months (arm 2). Persons will receive clinic-based Digital Anal Rectal Examinations and high-resolution anoscopy-directed biopsy to assess precancerous lesions, stratified by study arm. Anal exfoliated cells collected in the study are assessed for high-risk HPV persistence and host/viral methylation. The primary analysis will use the intention-to-treat principle to compare the proportion of those who comply with 0-month and 12-month sampling in the home-based and clinic-based arms. The a priori hypothesis is that a majority of persons will comply with annual screening with increased compliance among persons in the home-based arm versus clinic-based arm.

ETHICS AND DISSEMINATION

The study has been approved by the Medical College of Wisconsin Human Protections Committee. Results will be disseminated to communities where recruitment occurred and through peer-reviewed literature and conferences.

TRIAL REGISTRATION NUMBER

NCT03489707.

Depression and anxiety in pregnancy during COVID-19: A rapid review and meta-analysis

The study rapidly reviewed and meta-analyzed the worldwide prevalence of depression and anxiety among pregnant women during the COVID-19 pandemic. A systematic search of the literature and meta-analyses were conducted from December 2019 - February 2021 with a total of 46 studies meeting inclusion criteria. Depression was assessed in 37 studies (N = 47,677), with a pooled prevalence of 25.6%. Anxiety was assessed in 34 studies (N = 42,773), with a pooled prevalence of 30.5%; moderation by time showed that prevalence of anxiety was higher in studies conducted later in the pandemic.

The impact of the COVID-19 pandemic on organised cervical cancer screening: The first results of the Slovenian cervical screening programme and registry

BACKGROUND

The COVID-19 pandemic threatens the impact of cervical cancer screening and global cervical cancer elimination goals. As cervical cancer screening programmes were adjusting to the new situation, we evaluated the intensity, quality, and outcomes of cervical cancer screening in Slovenia in the first seven months of the pandemic.

METHODS

Historical observational study on data from a population-based cervical cancer screening registry. Number of cervical cytopathology (screening and follow-up), histopathology (diagnostic procedures, invasive procedures and number of newly diagnosed CIN2+ cases) and HPV test results from the entire Slovenian women population between January 1st and September 30th 2020 were compared to a three-year average of the years 2017-19.

FINDINGS

A two-month screening lock-down between March 12th and May 8th 2020 resulted in an epidemic deficit of screening (-92%), follow-up (-70%), and HPV triage tests (-68%), as well as invasive diagnostic (-47%) and treatment (-15%) of cervical lesions. Time to diagnosis and treatment did not increase; times to laboratory results fluctuated but stayed within standards. Slovenia has entered the second epidemic intending to add as little as possible to the pandemic deficit of screening smears (-23%) and yearly CIN2+ cases (-10%). Women aged 30-39 were most affected, with the highest pandemic deficit of screening smears (-26%) and yearly CIN2+ cases (-19%).

INTERPRETATION

The pandemic has deeply affected all levels of our lives. New vulnerable groups and inequalities have emerged that require recognition and action. To prevent long-term increases in the cervical cancer burden due to the COVID-19 pandemic, it is crucial that organised screening is maintained and monitored in settings where it can be safely and comprehensively provided.

FUNDING

None.

COVID-19 and perinatal intimate partner violence: a cross-sectional survey of pregnant and postpartum individuals in the early stages of the COVID-19 pandemic

OBJECTIVE

The objectives of this study were to: (1) document violent and controlling behaviours within intimate partnerships during the perinatal period; and (2) determine individual, interpersonal and household-level factors influencing the risk of perinatal intimate partner violence (IPV).

DESIGN

Cross-sectional survey.

SETTING

The Ottawa Hospital, Department of Obstetrics and Gynecology, Ottawa, Ontario, Canada.

PARTICIPANTS

Patients who gave birth at The Ottawa Hospital and were >20 days post partum between 17 March and 16 June 2020.

MAIN OUTCOMES AND MEASURES

Perinatal IPV was defined as regular controlling behaviours or act-based forms of emotional/physical/sexual abuse in the 12 months before pregnancy, during pregnancy and/or post partum. Log-binomial multivariable regression models were used to compute adjusted risk ratios (aRRs) and 95% CIs to identify potential risk factors for IPV: maternal age, postpartum depression, parity, increase in partner substance use and household income.

RESULTS

Among 216 participants, the median maternal age was 33 years (IQR: 30-36). In total, 52 (24.07%) reported some form of perinatal IPV, 37 (17.13%) reported regular controlling behaviour and 9 (4.17%) reported both. Household income below the municipal median was the strongest risk factor for perinatal IPV (aRR: 3.24, 95% CI: 1.87 to 5.59). There was no apparent association between maternal age (aRR: 0.99, 95% CI: 0.94 to 1.04), postpartum depression (aRR: 1.03, 95% CI: 1.00 to 1.07), nulliparity (aRR: 1.18, 95% CI: 0.71 to 1.97) or increases in partner substance use (aRR: 0.73, 95% CI: 0.42 to 1.25) with IPV.

CONCLUSION

One in four individuals in this study experienced perinatal IPV. Household income was the strongest risk factor, and surprisingly, many hypothesised risk factors (eg, mental health, partner substance use, etc) were not significantly associated with perinatal IPV in this sample. This highlights the challenges in both measuring IPV and identifying individuals exposed to perinatal IPV during the high stress of the COVID-19 pandemic.

Access to Healthcare during COVID-19

Ensuring access to healthcare is critical to prevent illnesses and deaths from COVID-19 and non-COVID-19 cases in health systems that have deteriorated during the pandemic. This study aims to map the existing literature on healthcare access after the appearance of COVID-19 using an ontological framework. This will help us to formalize, standardize, visualize and assess the barriers to and drivers of access to healthcare, and how to continue working towards a more accessible health system. A total of 131 articles are included and considered for mapping in the framework. The results were also compared to the World Health Organization guidelines on maintaining essential health services to determine the overlapping and nonoverlapping areas. We showed the benefits of using ontology to promote a systematic approach to address healthcare problems of access during COVID-19 or other pandemics and set public policies. This systematic approach will provide feedback to study the existing guidelines to make them more effective, learn about the existing gaps in research, and the relationship between the two of them. These results set the foundation for the discussion of future public health policies and research in relevant areas where we might pay attention.

Restructuring maternal services during the covid-19 pandemic: Early results of a scoping review for non-infected women

INTRODUCTION AND OBJECTIVE

The novel coronavirus outbreak has caused substantial changes in societal norms as well as adjustments in health systems worldwide. To date the impact of these pandemic-related variations has yet to be fully understood also in the field of maternal health for which continuity of care is a proven life-saving preventive measure.

DESIGN

Following the PRISMA guidelines for reviews, a literature search was carried out to assess different approaches that combine quality of maternal care with the imposed social-distancing rules. Nine studies were included in the scoping review.

FINDINGS

Reduction of in-person visits is the preferred overall solution. Yet, fewer consultations can still guarantee essential services and appropriate care through integration with telemedicine. Referral to epidemic-free community centres is an alternative option and new paths need to include the interdisciplinary contribution of medical consultants and IT experts, among others. In this context, delaying access for symptomatic expectant mothers is still debated since it carries the potential risk of untimely detection of pregnancy complications.

KEY CONCLUSIONS

Preliminary experiences provide an overview of the different attempts put in place to reshape health services to contain the pandemic hazards.

IMPLICATIONS FOR PRACTICE

These early prototypes may inspire future innovative health solutions compatible with local resources and specific population preferences and needs.

Impact of the COVID-19 Pandemic on Cancer Diagnoses in General and Specialized Practices in Germany

The aim of this retrospective study was to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on cancer diagnosis in general and specialized practices in Germany. This study included a total of 102,009 patients aged ≥18 years newly diagnosed with cancer in 1660 practices in Germany from January to May 2019 and from January to May 2020. Practices included general, gynecology, ear, nose, and throat (ENT), dermatology, and urology practices. New cancer diagnoses included all types of cancer and corresponded to cancers not previously documented in the database for a given patient. The number of new cancer diagnoses per general practice decreased significantly between March and May 2020 compared with the same period in 2019 (March: -12.0%, April: -27.6%, and May: -23.4%). A similar trend was observed in specialized practices, and this trend was more pronounced in April 2020 (dermatology: -44.4%, gynecology: -32.0%, and ENT: -28.2%). In addition, there was a significant decrease in almost all sex and age groups in April and May 2020 compared with the same period in 2019. Finally, the decrease in the number of new cancer diagnoses was particularly pronounced among cancers of the skin and the respiratory and intrathoracic organs. Together, these data show that the COVID-19 pandemic had a significant negative impact on cancer diagnosis in Germany, highlighting the need for public health measures improving the management of cancer in this country during this ongoing pandemic.

COPING STRATEGIES FOR VIOLENCE AGAINST CHILDREN, ADOLESCENTS AND WOMEN IN THE CONTEXT OF SOCIAL ISOLATION DUE TO COVID-19: SCOPING REVIEW

ABSTRACT Objective: to map the recommendations of the coping strategies for violence against children, adolescents and women in the context of social isolation due to Covid-19. Method: a scoping review according to the Joanna Briggs Institute, through a research strategy carried out in the gray literature by the CAPES Portal and in the following databases: SCIELO, LILACS, PubMed, CINAHL, Web of Science, and Institutional Repository for Information Exchange of the Pan American Health Organization. The analysis of the identified material was carried out by three independent reviewers. The extracted data were analyzed and synthesized in narrative form. Results: of the 526 studies found, 59 were kept for review and their content was summarized in six categories: 1) prevention; 2) identification and intervention; 3) continued care; 4) care for the safety and mental health of the professionals; 5) intersectoriality/interdisciplinarity; and 6) special care for vulnerable populations. Conclusion: the services must guarantee continuous, intersectoral and safe care, especially in the context of mental health, as well as community awareness must be promoted. Health professionals must be sensitive and alert to signs of violence, intervening immediately and connected to the safety network.

An Integrated Approach to Improve Maternal Mental Health and Well-Being During the COVID-19 Crisis

The ongoing COVID-19 pandemic has led to disruption of normal life across the globe, severely affecting the already vulnerable populations such as the pregnant women. Maternal mental health and well-being is a public health priority and the evidence about the impact of COVID-19 on mental health status of pregnant women is gradually emerging. The findings of the recently published studies suggest that increased risk perception about contracting COVID-19, reduced social support, increase in domestic violence, disruption of antenatal care, and economic consequences of COVID-19 mitigation strategies can lead to adverse mental health outcomes in antenatal period. There is a significant increase in antenatal depression and anxiety since the onset of COVID-19 and social determinants of health (e.g., younger age, lower education, lower income) are associated with these poor outcomes. In this paper, we propose an integrated approach to improve the mental health and well-being of pregnant women. Physical activity and/or mind-body interventions like yoga can be practiced as self-care interventions by pregnant women. Despite social distancing being the current norm, efforts should be made to strengthen social support. Evidence-based interventions for perinatal depression should be integrated within the health system and stepped, collaborative care using non-specialist health workers as key human resource be utilized to improve access to mental health services. Use of digital platforms and smartphone enabled delivery of services has huge potential to further improve the access to care. Most importantly, the COVID-19 related policy guidelines should categorically include maternal mental health and well-being as a priority area.

Violence against women during the COVID-19 pandemic: An integrative review

BACKGROUND

During the COVID-19 pandemic, incipient data have revealed an increase in violence against women (VAW).

OBJECTIVE

To analyze the existing scientific literature on strategies and recommendations to respond to VAW during the implementation of social distancing measures in response to the COVID-19 pandemic.

SEARCH STRATEGY

An integrative review was conducted based on articles published between December 2019 and June 2020. Suitable articles were identified from the PubMed, SciELO, and LILACS databases, using relevant terms.

SELECTION CRITERIA

Eligible studies included opinion and primary research articles describing the dynamics of VAW during quarantine and in the context of the restrictive measures taken during the COVID-19 pandemic and proposing recommendations to respond to this issue.

DATA COLLECTION AND ANALYSIS

Data were extracted from eligible publications and qualitative synthesis was used.

MAIN RESULTS

The 38 articles included in the study showed that some factors increasing women's vulnerabilities to violence were exacerbated during the social distancing and lockdown period. Health professionals are essential for screening and responding to VAW during the pandemic.

CONCLUSIONS

Strategies must include integrated actions aiming to prevent and respond to violence during and after the COVID-19 pandemic. These must be designed based on lessons learned from previous public health emergencies.

Sexual activity and contraceptive use during social distancing and self-isolation in the COVID-19 pandemic

OBJECTIVES

The aims of the study were to investigate the effects of social distancing during the COVID-19 pandemic on the use of hormonal contraceptives, their discontinuation and the risk of unplanned pregnancy.

METHODS

The study enrolled 317 women listed in the database of the Department of General Surgery and Medical-Surgical Specialties, University of Catania, Italy, family planning clinic who were known to be using hormonal contraceptives. The women were contacted by telephone and asked whether they would like to participate in the study. If they agreed, they were then emailed a questionnaire about their social behaviour and sexual activity during the pandemic, according to their cohabiting status, i.e., whether they were continuing to use their hormonal contraception and whether they had had an unplanned pregnancy.

RESULTS

The questionnaire was completed by 175 (81.8%) women who were using short-acting reversible contraception (SARC) and by 90 (87.4%) women who were using long-acting reversible contraception (LARC). All married and cohabiting women were continuing to use their contraceptive method. None had had an unplanned pregnancy. On the other hand, 51 (50.5%) non-cohabiting or single women had discontinued their SARC method while social distancing, for non-method-related reasons; however, 47 (46.5%) non-cohabiting or single women had continued their sexual activity, infringing social distancing rules, and 14.9% had had an unplanned pregnancy, for which they had sought a termination.

CONCLUSION

Several non-cohabiting women using SARC had discontinued their contraceptive method during the pandemic but had continued to engage in sexual activity and had had an unplanned pregnancy. Clinicians should counsel women about what they should do in regard to contraception in the event of new, future social distancing measures.