Access to and quality of sexual and reproductive health services in Britain during the early stages of the COVID-19 pandemic: a qualitative interview study of patient experiences

Understanding sexual health service access for gay, bisexual and other men who have sex with men in Ireland during the COVID-19 crisis: Findings from the EMERGE survey

BACKGROUND

In the Republic of Ireland, the COVID-19 crisis led to sexual health service closures while clinical staff were redeployed to the pandemic response. Gay, bisexual and other men who have sex with men (gbMSM) face pre-existing sexual health inequalities which may have been exacerbated. The aim of this study is to understand sexual health service accessibility for gbMSM in Ireland during the COVID-19 crisis.

METHODS

EMERGE recruited 980 gbMSM in Ireland (June-July 2021) to an anonymous online survey investigating well-being and service access through geo-location sexual networking apps (Grindr/Growlr), social media (Facebook/Instagram/Twitter) and collaborators. We fit multiple regression models reporting odds ratios (ORs) to understand how demographic and behavioural characteristics (age, sexual orientation, HIV testing history/status, region of residence, region of birth and education) were associated with ability to access services.

RESULTS

Of the respondents, 410 gbMSM accessed sexual health services with some or no difficulty and 176 attempted but were unable to access services during the COVID-19 crisis. A further 382 gbMSM did not attempt to access services and were excluded from this sample and analysis. Baseline: mean age 35.4 years, 88% gay, 83% previously tested for HIV, 69% Dublin-based, 71% born in Ireland and 74% with high level of education. In multiple regression, gbMSM aged 56+ years (aOR = 0.38, 95%CI:0.16, 0.88), not previously tested for HIV (aOR = 0.46, 95%CI:0.23, 0.93) and with medium and low education (aOR = 0.55 95%CI:0.35, 0.85) had lowest odds of successfully accessing services. GbMSM with HIV were most likely to be able to access services successfully (aOR = 2.68 95%CI:1.83, 6.08). Most disrupted services were: STI testing, HIV testing and PrEP.

CONCLUSIONS

Service access difficulties were found to largely map onto pre-existing sexual health inequalities for gbMSM. Future service development efforts should prioritise (re)engaging older gbMSM, those who have not previously tested for HIV and those without high levels of education.

When one door closes: a qualitative exploration of women's experiences of access to sexual and reproductive health services during the COVID-19 lockdown in Nigeria

BACKGROUND

COVID-19 pandemic widely disrupted health services provision, especially during the lockdown period, with females disproportionately affected. Very little is known about alternative healthcare sources used by women when access to conventional health services became challenging. This study examined the experiences of women and adolescent girls regarding access to sexual and reproductive health (SRH) services during the COVID-19 lockdown in Nigeria and their choices of alternative healthcare sources.

METHODS

The study sites were two northern states, two southern states, and the Federal Capital Territory. Qualitative data were obtained through 10 focus group discussion sessions held with married adolescents, unmarried adolescents, and older women of reproductive age. The data were transcribed verbatim and analysed using a thematic approach and with the aid of Atlas ti software.

RESULTS

Women reported that access to family planning services was the most affected SRH services during the COVID-19 lockdown. Several barriers to accessing SRH services during COVID-19 lockdown were reported, including restriction of vehicular movement, harassment by law enforcement officers, fear of contracting COVID-19 from health facilities, and fear of undergoing compulsory COVID-19 tests when seeking care in health facilities. In the face of constrained access to SRH services in public sector facilities during the COVID-19 lockdown, women sought care from several alternative sources, mostly locally available and informal services, including medicine vendors, traditional birth attendants, and neighbours with some health experience. Women also widely engaged in self-medication, using both orthodox drugs and non-orthodox preparations like herbs. The lockdown negatively impacted on women's SRH, with increased incidence of sexual- and gender-based violence, unplanned pregnancy resulting from lack of access to contraceptives, and early marriage involving adolescents with unplanned pregnancies.

CONCLUSION

COVID-19 negatively impacted access to SRH services and forced women to utilise mostly informal service outlets and home remedies as alternatives to conventional health services. There is a need to ensure the continuity of essential SRH services during future lockdowns occasioned by disease outbreaks. Also, community systems strengthening that ensures effective community-based health services, empowered community resource persons, and health-literate populations are imperative for overcoming barriers to healthcare access during future lockdowns.

Contraception prescribing in England during the COVID-19 pandemic

BACKGROUND

National lockdowns in England due to COVID-19 resulted in rapid shifts in healthcare provision, including in primary care where most contraceptive prescriptions are issued. This study aimed to investigate contraception prescribing trends in primary care during the pandemic and the impact of socioeconomic deprivation.

METHODS

Prescribing data were accessed from the English Prescribing Dataset for the first year of the COVID-19 pandemic (1 March 2020-28 February 2021) and the year prior (1 March 2019-29 February 2020). Data were analysed by geographical region (London, Midlands and East of England, North of England, South of England) and contraceptive type (progestogen-only pill (POP), combined oral contraception (COC), emergency hormonal contraception (EHC) and contraceptive injections). Differences in prescribing rates were calculated using Poisson regression. Pearson correlation coefficients were calculated for the Index of Multiple Deprivation (IMD) scores for each Clinical Commissioning Group (CCG) in the North East and North Cumbria (NENC).

RESULTS

Contraception prescribing rates decreased overall during the COVID-19 pandemic in England (Poisson regression coefficient (β)=-0.035), with a statistically significant (p<0.01) decrease in all four regions. Prescriptions decreased for COC (β=-0.978), contraceptive injections (β=-0.161) and EHC (β=-0.2005), while POP (β=0.050) prescribing rates increased. There was a weak positive correlation between IMD and prescribing rates in NENC (p>0.05).

CONCLUSIONS

Contraception provision was impacted by COVID-19 with an overall decrease in prescribing rates. The deprivation results suggest that this may not be a significant contributing factor to this decrease. Further research is recommended to better understand these changes, and to ensure that services respond appropriately to population needs.

Understanding the impact of COVID-19 on women's access to and experiences of contraceptive services in England: a qualitative study

BACKGROUND

The COVID-19 pandemic response prompted rapid changes to how contraceptive services were delivered in England. Our aim was to examine women's experiences of accessing contraceptive services since March 2020 and to understand any inequalities of access.

METHODS

We conducted telephone interviews with 31 women aged 17-54 years who had accessed contraceptive services in England since March 2020. The sample was skewed to include participants with lower educational attainment and higher deprivation. Interview transcripts were thematically analysed using inductive and deductive approaches.

RESULTS

Few differences were found regarding educational attainment. Participants using contraceptive injections (all living in areas in the most deprived quintile) reported the greatest access challenges. Some switched method or stopped using contraception as a result. More general barriers reported by participants included service closures, unclear booking processes, and lack of appointment availability. Many participants welcomed the flexibility and convenience of remote contraceptive services. However, telephone appointments posed challenges for those at school or living with parents, and some described them as rushed and inconducive to asking questions or raising concerns. Those accessing contraception for the first time or nearing menopause felt they were unable to access sufficient support and guidance during the pandemic. Some participants voiced concerns around the lasting effects of COVID-19 on appointment availability and inadequate service delivery.

CONCLUSIONS

Women's experiences of accessing contraceptive services in England since March 2020 are diverse. While remote services were suitable for some, COVID-19 restrictions unequally impacted women depending on their method of contraception and life stage.

Contraceptive use and pregnancy planning in Britain during the first year of the COVID-19 pandemic: findings from a large, quasi-representative survey (Natsal-COVID)

BACKGROUND

Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic.

METHODS

Natsal-COVID Wave 2 surveyed 6658 adults aged 18-59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness.

RESULTS

Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. 29.3% (26.9%-31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%-20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) scored as 'unplanned'; less planning was associated with younger age, lower social grade and unemployment.

CONCLUSIONS

Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data

OBJECTIVES

To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain.

METHODS

6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties.

RESULTS

In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions.

CONCLUSIONS

Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID)

OBJECTIVES

To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic.

METHODS

British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors.

RESULTS

In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers.

CONCLUSIONS

Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.