In the United States, disparities in reproductive health outcomes persist between youth living in rural and urban areas. Studies have shown that female adolescents in rural counties demonstrate higher birth rates than adolescents in urban counties (43.3% vs. 32.7%) and higher rates of sexual activity.1 These disparities result, in part, from increased barriers faced by rural adolescents trying to access reproductive healthcare: confidentiality and anonymity concerns, fewer adolescent medicine specialists, transportation challenges, poverty, community disorganization, limited resources, and a lack of accurate and comprehensive sex education.2
A recent study compared awareness and use of family planning services among female adolescents in California at rural and urban program sites. Survey data from 4,614 female adolescents, ages 14-18, was collected before participation in the federally funded California Personal Responsibility Education Program. Young women in rural settings were less aware of where to access reproductive healthcare compared to urban young women (52% vs. 65%), and they were less likely to report using family planning services (18% vs. 27%). Non-Hispanic black women, older women, and those who had experienced sexual intercourse or a prior pregnancy demonstrated significantly higher odds of using family planning services. However, younger female adolescents and Hispanic participants were less likely to report awareness or use of family planning services, demonstrating heightened disparities based on age and race/ethnicity.1
Enter Telemedicine
In July 2015, the American Academy of Pediatrics (AAP) released a policy statement about the use of telemedicine to address disparities in patient access to care, especially between rural and urban populations.3 Telemedicine uses telecommunications technology to deliver health services to patients who live in remote areas and to facilitate information exchange between medical providers and patients, as well as between medical providers. This technology can include video conferencing from the privacy of a patient’s home, avoiding an in-person visit by receiving medical services over the phone or internet, and by using technology in remote areas so a specialist/medical provider can be virtually present in the room.4
Telehealth includes the provision of both clinical care and provider education, while telemedicine only refers to clinical care delivery. Several telehealth programs in the United States use technology to meet identified needs and improve patient access to care.5 For adolescents living in rural areas who otherwise would forgo care because of fear of embarrassment, transportation difficulties, and/or confidentiality concerns, using a web app could alleviate many of these concerns.6
A 2016 prospective cohort study evaluated the use of telehealth to teach reproductive health to 55 female students at two high schools in rural West Virginia, where there are high rates of teen pregnancy. Eight 60-minute sessions were offered over a course of one month, all conducted using high-definition teleconferencing equipment, and delivered by a team of expert faculty, residents, or medical students based out of a “distant” (hub site where provider is located) academic hospital three hours away. Reported HPV vaccination increased from 38% to 70% among all participants, and 91.8% reported telehealth was “very effective” as a teaching tool at the six-month evaluation in terms of acceptability and understandability. Similar sustainable models could be developed to reach adolescents in other rural communities with limited resources and health providers.7
Improve Access for All Teens
Existing barriers to telehealth implementation and sustainability include state and federal policies that restrict medical providers from practicing telemedicine, ongoing costs of technology maintenance, training and technical support costs, and issues with licensure and payment. Advocating for the elimination of telehealth barriers ultimately will extend the reach of and access to quality reproductive healthcare for adolescents in geographically isolated areas.
The AAP recommends providers of educational programming use telemedicine technologies, such as mobile and web apps, as part of education programs for remote members of the medical care team and clinical sites. Another recommendation pertains to ongoing and future research to study the effectiveness of telemedicine in expanding patients’ access to healthcare, reducing healthcare costs, and improving quality of healthcare.
The Standardized Pediatric Research on Outcomes and Utilization of Telehealth Collaborative (SPROUT) is the first program to establish a network of institutions to conduct collaborative research on pediatric telehealth. SPROUT is supported by the AAP’s Section on Telehealth Care and the American Telemedicine Association Pediatric Special Interest Group. (More information is available at: http://bit.ly/2nKCiwo.)
REFERENCES
- Yarger J, Decker MJ, Campa MI, Brindis CD. Rural-urban differences in awareness and use of family planning services among adolescent women in California. J Adolesc Health 2017;60:395-401.
- Garside R, Ayres R, Owen M, et al. Anonymity and confidentiality: Rural teenagers’ concerns when accessing sexual health services. J Fam Plann Reprod Health Care 2002;28:23-26.
- Committee on Pediatric Workforce, Marcin JP, Rimsza ME, Moskowitz WB. The use of telemedicine to address access and physician workforce shortages. Pediatrics 2015;136:202-209.
- Reproductive Health Technologies Project. Building Bridges: Innovation in Telemedicine Use for the Provision of Reproductive Health Care. Available at: http://bit.ly/2nKvb7j. Accessed April 18, 2017.
- North S, Woolford SJ, Yen S, et al. Improving access to care through telehealth: Keys to developing successful telehealth programs for adolescents. Presented at the 2017 Society for Adolescent Health and Medicine Annual Meeting. New Orleans; March 2017.
- Elliott BA, Larson JT. Adolescents in mid-sized and rural communities: Foregone care, perceived barriers, and risk factors. J Adolesc Health 2004; 35:303-309.
- Yoost JL, Starcher RW, King-Mallory RA, et al. The use of telehealth to teach reproductive health to female rural high school students. J Pediatr Adolesc Gynecol 2017;30:193-198.
For adolescents living in rural areas who otherwise would forgo care because of fear of embarrassment, transportation difficulties, and/or confidentiality concerns, using a web app could alleviate many of these concerns.
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