Acceptability of Gynecologic e-Health Modalities by Hispanic/Latina Women of Reproductive Age.

The online questionnaire was completed by 351 Hispanic/Latina women residing in Puerto Rico (91.1%) and the USA (8.9%). Although participants from other countries completed the online questionnaire, we only included data from women of reproductive age who were born in Puerto Rico, living either in Puerto Rico or the USA, in the analysis. Only 12 participants (3.4%) chose to answer the English version of the questionnaire. The study participants were an average of 30.9 years old (range: 21 to 50 years). Most were highly educated with 43.0% (n=150) having completed at least a bachelor’s degree, and were single (n=165, 47.0%). Half of the participants (n=178, 50.9%) worked full-time; 44.6% (n=156) were students. The majority (n=230, 69.7%) earned less than $30,000, and 41.2% (n=136) earned less than $15,000 per year. Many participants (n=259, 73.8%) had private health insurance ( Table 1 ). All participants owned smartphones, and almost all (n=345, 98.3%) reported intermediate to advanced technological expertise. Most (n=293, 83.4%) used the internet most of the time or regularly ( Table 1 ). Almost 40% of participants sought gynecologic care at least once a year (n=129, 37.8%), and 65.6% (n=229) had a preferred gynecologist ( Table 2 ). The top reasons for gynecologic consultation were PAP testing (n=262, 69.1%), family planning (n=114, 30.1%), breast exam (n=113, 29.8%), and dysmenorrhea (n=81, 21.4%). The most common diagnoses included endometriosis (n=23, 43.4%) and PCOS (n=10, 18.9%) ( Figure 1A ). The top non-gynecologic conditions reported were Neurocognitive (n= 134) and Endocrine (n=32) ( Figure 1B ). Only 11.3% (n=43) have had a laparoscopy or laparotomy, and 3.4% (n=13) had a hysterectomy. Almost 40% of study participants (n=136, 38.9%) had been pregnant, with an average of 1.9 pregnancies (SD=1.0), and one-quarter reported miscarriages (n=34, 25.0%). Only 1 in 10 (n=22; 10.3%) had tried getting pregnant without success ( Table 2 ). Almost 60% of participants (n=208, 59.8%) sought medical attention during the pandemic: 50.5% from Gynecology (n=105), 42.8% from Primary Care (n=89), and 27.5% from Mental Health (Psychologist and Psychiatrist) (n=57). Problems obtaining medical attention during the pandemic were reported by 20.7% (n=73), including office hour limitations (n=40, 54.8%), difficulties contacting the doctor (n=29, 39.7%), conflicts with work schedule (n=28, 38.4%), and fearing exposure to COVID-19 (n=27, 37.0%) ( Table 3 ). Eight out of 10 study participants (n=280; 82.4%) had not been offered the option of telemedicine by their gynecologist during the COVID-19 pandemic, thus 17.6% (n=60) were offered the option. However, 90% (n=316, 90.5%) were willing to have telemedicine consults; 62% (n=196) agreed with “ I would feel very comfortable seeing my gynecologist. ” ( Table 4 ). Advantages of consulting a gynecologist via telemedicine included reducing exposures to COVID-19 (n=335, 88.4%), less waiting time in medical offices (n=294, 77.6%), and flexibility in getting appointments (n=224, 59.1%). Many found value in getting electronic prescriptions (n=207, 54.6%) and receiving quick responses to questions and concerns (n=178, 47.0%). Regarding barriers or limitations of telemedicine consults, over one-third of participants (n=123, 32.5%) thought that health insurance did not cover the cost, and one fourth (n=96, 25.3%) had privacy concerns. Of those who would not agree to telemedicine consults (n=33, 9.5%), 87.9% (n=29) expressed preferring face-to-face communications, and 36.4% (n=12) had privacy issues. 64% of study participants (n=224, 63.8%) currently use menstrual cycle tracking mobile apps. The principal reasons to use tracking apps were to estimate menstruation days (n=206, 85.1%), to track ovulation (n=112, 46.3%), and to monitor symptoms (n=63, 26.0%). The most used period trackers were Flo (n=60, 27.1%), Period Tracker (n=47, 21.3%), and My Calendar (n=28, 12.7%) ( Table 5 ). Among the most useful functions of menstrual cycle tracking mobile apps were the calendar (n=212, 87.6%), reminders (n=142, 58.7%), and monitoring of fertile days (n=142, 58.7%) or symptoms (n=108, 44.6%). Many disliked paying for advanced options (n=100, 44.6%) but few were bothered by receiving too many notifications (n=25, 11.2%). One-third forgot to use it (n=67, 29.9%); only 8.5% (n=19) expressed privacy concerns. ( Table 5 ) A high proportion of participants (n=310, 89.6%) reported willingness to try new menstrual cycle/symptom tracking mobile apps. The most common reasons included the generation of shareable reports (n=229, 60.4%), and having access to telemedicine consultations with gynecologists (n=220, 58.0%). Other motivations were access to consultations with wellness coaches (n=130, 34.3%) and support groups (n=95, 25.1%). However, it is notable that over half of the participants (n=183, 54.2%) would refuse to pay a fee for access to a mobile app even if they give access to private gynecologic consultations. Out of the 45.8% (n=164) willing to pay, 57.6% (n=86) said they would prefer to pay per consult, followed by 17.4% (n=30) opting for an annual fee. Multiple correlation analyses were performed to understand factors that were associated with the acceptability of telemedicine for gynecological consultations and willingness to use menstrual cycle tracking apps. Participants who were more willing to accept telemedicine gynecologic consultations were of higher education (p=0.007, OR=2.74) and had advanced technological expertise (p=0.033, OR=2.01) ( Table 6 ). Participants who were more willing to try a new mobile app to track their menstrual cycle and gynecologic symptoms were young women (29 years or less) (OR=2.5, p=0.004), students (OR=1.9, p=0.047), of a lower income (OR=2.2, p=0.014), and currently using a menstrual period tracking app (OR=9.15, p<0.000). However, women with a preferred gynecologist (OR=0.39, p=0.011) were less likely to try a gynecologic health application ( Table 7 ).

This study protocols, recruitment strategies and survey were approved by the Institutional Review Board of the Ponce Health Sciences University (IRB Approval #2007042526). This cross-sectional study used an anonymous survey disseminated online to collect quantitative data regarding perceptions on e-Health strategies modalities for gynecologic care. Participants, premenopausal adult (21 to 50 years old) women, were recruited through social media of women’s health organizations and WhatsApp group invitations. An electronic link to an anonymous questionnaire was created using the REDCap platform to ensure response confidentiality [ 22 ]. The survey was distributed in Spanish and English from August 2020 to January 2021. The study team developed a new 37-question survey to capture self-reported data on demographics (e.g., age, education, social status, insurance type, technological expertise), gynecologic and obstetric traits (e.g., menstrual cycle characteristics, parity, miscarriages), clinical history (e.g., gynecologic and non-gynecologic diagnoses), access to health care during the pandemic, acceptability of using telemedicine to facilitate access to gynecologic care and usability of mobile apps to monitor menstrual cycle and symptoms. Questions regarding acceptability of telemedicine included: Would you agree to have a telemedicine consultation with your gynecologist? If yes, why? Which of the following do you consider to be limitations or barriers regarding telemedicine consultation with your gynecologist? Which of the following do you consider to be advantages of consulting your gynecologist via telemedicine? Questions regarding mobile app usability included: Do you currently use any menstrual cycle monitoring application? What functions do/would you find useful in a menstrual cycle tracking app? What don’t you like about a menstrual cycle tracking app? Descriptive statistics (mean, range, standard deviation) were used to analyze continuous variables such as age and number of pregnancies. Frequency and percentages were used for non-continuous variables such as country of birth, education, technological expertise, and clinical and gynecological data. Univariate statistics (Chi-square (χ2) or Fisher’s exact test) were applied for assessing the likelihood of accepting e-Health modalities by categorical variables including age (29 or younger/30 or more), annual income ($30,000 or less/more than $30,000), education (up to College/Graduate), technological expertise (low-moderate/advanced), student status (Yes/No), health insurance type (public/private), having a gynecologic diagnosis (Yes/No), and having a preferred gynecologist (Yes/No). Statistical significance was established at p < 0.05, confidence intervals at 95%. All analyses were conducted with SPSSv28 (IBM).

e-Health modalities, including telemedicine and mobile apps, have a great potential of providing timely access to clinical consultation during natural disasters and public health emergencies. Knowledge of the facilitators and barriers to adopting gynecologic e-Health tools across populations is essential for implementing these modalities in an ethnically/culturally relevant fashion, with the long-term objective of decreasing diagnostic delays and improve reproductive health globally. While it is generally recognized that e-Health modalities are broadly and universally acceptable as an alternative to face-to-face sessions, even in the context of underserved populations [ 23 , 24 ], there may be differences in adoption rates among different racial/ethnic and sociodemographic groups. e-Health utilization is low among Hispanic people, primarily due to issues of trust and literacy [ 25 , 26 ]; however, there are limited data regarding acceptability, facilitators, and barriers to adopting these resources for gynecologic and reproductive health care, specifically in Hispanic/Latina women. We designed this study to tackle this gap in the literature, focusing on Puerto Rican women, a representative Hispanic/Latina population. Despite study limitations including selection bias, as participants were recruited online, our study generated significant contributions to the e-Health scientific literature. According to the American College of Obstetricians and Gynecologists (ACOG) recommendations, well-woman visits are critical for providing preventive and screening services, including but not limited to, reproductive health care. Our cohort reported the same rates of annual gynecologic consults (40%) as shown for the US [ 27 ]. These relatively low rates of gynecological care-seeking behavior could be due to changes in the cervical cancer screening guidelines and the increasing use of longer-acting reversible contraceptive methods [ 28 , 29 ]. The principal reasons for a gynecologic visit within our sample were PAP testing, family planning, and breast examination, as expected for the age range. Other investigators on women’s health have found that preventive health care is the main reason for consult, followed by pregnancy guidance/post-natal care and health complaints [ 30 ]. The prevalence of gynecologic conditions was not increased compared to other cohorts (endometriosis 6.6%, PCOS 2.8%, uterine fibroids 2.0% v.s. 6–10%, 3–10%, 5.7–9.6%, respectively) [ 31 – 34 ]. Regarding the obstetrics profile of our cohort, less than half had ever been pregnant, with a mean of 1.9 births, in accordance with fertility rate data for the US and Puerto Rico (1.7 and 1.3 live births per woman, respectively [ 35 ]. Our results indicate that this study cohort is representative of the reproductive aged population of women in Puerto Rico. The COVID-19 pandemic forcefully deprioritized in-person primary and secondary levels of care, endangering worldwide health. Social distancing measures and the fear of infection enhanced the adaptation of telemedicine as an alternative means of care to mitigate health needs [ 36 ]. Gynecologists did not offer telemedicine consultations to most of our study participants during the pandemic, although most would be comfortable with this option. Half of the participants sought gynecological consultations during the pandemic, demonstrating the high need for these services during emergencies. We conclude that there are opportunities to increase the uptake of telemedicine services for Hispanic/Latina women of reproductive age. According to the WHO, female health is disproportionately affected during emergencies due to societal norms and caregiver roles. Interrupting sexual and reproductive health services disempowers and exposes women to avoidable health risks [ 14 ]. Hence, using alternatives to the traditional model of care during health emergencies is critical to preserve gynecologic and reproductive health. Higher education and advanced technological expertise correlated with acceptance of telemedicine for gynecological consults. Based in this result, we conclude that more efforts must be put in place to train and engage less educated and technologically savvy women with e-Health tools. Perceived barriers to telemedicine in this cohort included a preference for face-to-face interactions, misconceptions regarding health insurance coverage, and privacy concerns. Our results highlight the need for more patient education regarding health insurance coverage, confidentiality assurances, and the convenience of telemedicine (e.g., not waiting in offices or scheduling appointments outside work hours). Alternatives such as a combination of in-person and telemedicine consultations shown to be highly acceptable for obstetric care could be offered [ 37 ]. There are ample opportunities for practitioners to become advocates of e-Health adoption, particularly in low-resource settings and rural areas with less access to gynecologists, as a secure, convenient tool for obtaining access to care in pandemic and non-pandemic situations [ 36 ]. Just over half of our participants reported current use of menstrual cycle tracking mobile apps to monitor menstruation, ovulation, and gynecologic symptoms, even though most period trackers are in English. They sought user-friendly apps that could generate shareable custom reports and allowed access to telemedicine gynecological consultations. Being younger than 29 y/o, a student, already using a period tracker, and having a lower income were all significantly associated with gynecologic mobile app acceptability. The high levels of acceptability of gynecologic mobile apps shown by this study highlight their untapped potential for solving access to care issues for Spanish-speaking Hispanic/Latina women, particularly for younger demographics that are more familiar with these technologies. Developers must note that mobile app adoption and engagement depend on much more than being user-friendly; they must also provide clinical reports and direct links to consultations as this study uncovered [ 19 , 20 ]. Our study participants were relatively young (average of 31 years old), highly educated, and either working or studying. Many were students, which may explain the low average personal income reported. This demographic also agrees with the high levels of technological expertise, smartphone ownership, and internet usage frequency observed. Interestingly, being technologically savvy did not depend on socioeconomic status in this young population. While acceptability rates for e-Health technologies in our study population were high, there may be barriers to their successful implementation, including local infrastructure and technology gaps [ 38 ]. In Puerto Rico, there is high adoption of mobile technologies. In 2020, 78% of the population was estimated to access the internet from their mobile device [ 39 ]. There were 2.44 million internet users (84% penetration), 2.10 million social media users (72% penetration), and 3.1 million mobile connections (106% of the total population)[ 40 ]. Thus, our results may not be generalizable to other populations that are older or with lower levels of accessibility to smartphones and technological infrastructure. To ensure improved e-Health equity, policy changes should address barriers faced overwhelmingly by marginalized patient populations and those who serve them. In conclusion, this study shows that gynecologic e-Health modalities are highly acceptable for Hispanic/Latina women of reproductive age. We also identified opportunities for increasing the adoption of these tools to facilitate access to gynecologic care, especially for young, lower-income Hispanic/Latina women during pandemic and non-pandemic contexts. While the study was conducted in Puerto Rican women, its results can be impactful for other Hispanic/Latina women in other world regions, including Latin America, North America and Spain. In the long-term, we expect that these data will promote research on the efficacy of e-Health approaches to mitigate the effects of public health emergencies on the health and wellbeing of women of reproductive age globally.

The COVID-19 pandemic impaired access to healthcare due to a sense of fear and uncertainty, resulting in worsened symptomatology and increased psychosocial stress and anxiety globally [ 1 – 4 ]. The health effects of this pandemic extend beyond those infected to patients with chronic conditions known to be triggered by psychosocial stressors [ 5 ]. Not only this is seen under the COVID-19 pandemic; natural emergencies worldwide—hurricanes, earthquakes, forest fires, floods, severe snowstorms—contribute to exacerbating barriers to accessing medical care. Women are being disproportionally affected by these scenarios due to unbalanced societal structures (larger burden of household duties, child and elderly care, and partner-associated distress), limiting their capacity to seek medical and psychological health care [ 6 , 7 ]. The Kaiser Family Foundation’s (KFF) National 2020 Women’s Health Survey showed that more women skipped preventative health services during the COVID-19 pandemic than men [ 8 , 9 ]. A larger share of women compared to men reported being unable to get an appointment (30% vs. 20%) and considered that pandemic-related stress affected their mental health (51% vs. 34%). Moreover, among women reporting poor to fair general health, 46% skipped routine screening health services, and 32% missed a recommended treatment or test during the COVID-19 pandemic. Of those who reported lack of access to healthcare, 27% indicated that their underlying medical conditions worsened during the pandemic. Strategies to solve these limitations have thus become a public health priority as resulting detriments in physical and mental health continue to be documented in women across the globe [ 10 ]. Negative outcomes experienced by women during the COVID-19 pandemic include delayed or lack of access to gynecological and reproductive healthcare, leading to increased anxiety and symptom worsening [ 11 , 12 ]. Worryingly, the impact of the COVID-19 pandemic is amplified in populations that historically have been medically underserved. Half of uninsured women have visited an Ob/Gyn specialist over the past three years, and 33% of women reported having experienced delays or cancellations in sexual and reproductive health services, with the highest proportion being Hispanic/Latina women (45%)[ 11 ]. These results support the need for implementing electronic health (e-Health) strategies to alleviate long-term detrimental effects of pandemics and other natural events on reproductive health of populations with documented health disparities, as recommended by World Health Organization (WHO) and gynecological professional associations [ 13 , 14 ]. Telemedicine or mobile phone-delivered interventions are secure and cost-effective compared to standard care while being flexible, scalable, and accessible [ 15 , 16 ]. e-Health modalities applied to gynecology primarily aim to support prenatal care, clinical follow-ups, and management of symptoms in real-time by facilitating direct patient support [ 17 , 18 ]. However, there is no published evidence for the acceptability and efficacy of gynecological health digital modalities in Hispanic/Latina women. While telemedicine usage increased dramatically in women during the COVID-19 pandemic (from 13% to 38%)[ 8 , 9 ], there are many factors (age, insurance, education, language, access to technology) that modify technology adoption rates. Likewise, mobile app use and engagement would depend on multiple factors including being user-friendly, amenable to individuals with various health literacy levels, and providing valuable resources, such as custom reporting or direct links to consultations [ 19 , 20 ]. Broad implementation of e-Health is necessary to ensure health equity and solve disparities in access to care in populations that are already marginalized and medically underserved [ 21 ]. Given that the COVID-19 pandemic caused a substantial impact on healthcare access for women worldwide [ 7 ], our study aimed to assess i) the acceptability of telemedicine for gynecologic consults, ii) the usability of mobile apps to track menstrual cycle and symptoms, and iii) the factors that are associated with the acceptability and usability of e-Health modalities in Hispanic/Latina women of reproductive age. These findings will inform health policy decisions related to public health emergencies that cause access to care limitations disproportionally affecting the already underserved Hispanic/Latina population.