Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians

Abstract

Purpose

We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic.

Methods

Data were from the DocStyles online panel survey administered September–November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence “at any point during the COVID-19 pandemic”, and examined differences by physician specialty and adolescent patient volume.

Results

Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%–37% depending on the strategy) did not.

Discussion

Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Implications and Contributions.

This analysis is among the few to examine the impact of the COVID-19 pandemic in 2021 on sexual and reproductive health (SRH) services. Although findings indicate reductions in SRH service delivery challenges among physicians who serve adolescents, some clinical practices may need support to ensure adolescent access to SRH care.

Access to quality sexual and reproductive health (SRH) services is an important aspect of adolescent health and reproductive autonomy. When the COVID-19 pandemic began in 2020, concerns were raised about potential negative consequences for adolescent SRH services, such as clinic closures and foregone care to minimize SARS-CoV-2 exposure [1,2]. Subsequent data from 2020 found declines in SRH visits [[2], [3], [4], [5], [6], [7]] and disruption of SRH services that involve in-person appointments (e.g., intrauterine device [IUD] and implant placement/removal, clinic-based sexually transmitted infection [STI] screening) relative to before the pandemic [[8], [9], [10]], including among adolescents and young adults specifically [2,4,6,9]. However, these challenges have also spurred implementation of alternative service delivery strategies, including telehealth for SRH services [[9], [10], [11], [12]], aligning with practice recommendations for reproductive health care during the pandemic [13].

Our prior research contributed to the evidence regarding the initial impact of the COVID-19 pandemic on adolescent SRH services in the United States using data from the Fall 2020 administration of DocStyles, an online panel survey of US providers [9]. Among primary care physicians whose practices provided SRH services to adolescents just before the pandemic, about half (51%) reported disruptions in long-acting reversible contraception (LARC, i.e., IUDs and implants) services, and 36% reported disruptions to clinic-based STI testing at any point during the first 6 months of the pandemic. Additionally, physicians indicated that their practices experienced reductions in walk-in hours (38%), weekend/evening hours (31%), and adolescents seeking care (43%) in the month prior to completing the Fall 2020 survey. The majority of physicians (61%) reported their practices had provided contraception via telehealth at any point during the pandemic up until survey completion, of which nearly half (46%) were newly initiated telehealth services [9].

Most of the published data on COVID-19 and SRH services in the United States, in general and for adolescents specifically, were collected in 2020 and included the initial months of the pandemic when many clinics were closed for SRH services deemed not essential [[3], [4], [5],7,9,10,[14], [15], [16], [17], [18]]. As the context of the pandemic has evolved (e.g., vaccine availability, new variants, and changing restrictions), less is known about if or how it continues to impact SRH services, although what is known underscores the importance of ongoing monitoring [19,20]. The Guttmacher Survey of Reproductive Health Experiences fielded in May 2020 and July–August 2021 among women aged 18–49 years found improved access to SRH services comparing 2021 and 2020 estimates yet nearly one in five respondents reported challenges with access in 2021 [20].

We collected additional data on COVID-19 and SRH services as part of the Fall 2021 DocStyles survey. Using data from physicians whose practices provided SRH services to adolescents just before the pandemic, we examined prevalence of service delivery challenges and use of strategies initiated during the pandemic to support access to services in the Fall 2021. We also examined differences by physician specialty and adolescent patient volume to better understand which practices continued to experience service delivery challenges and which have sustained strategies to support access.

Methods

Data source

Data were from the Fall 2021 DocStyles provider survey administered September 14–November 10, 2021. DocStyles is a nonprobability-based online panel survey administered by Porter Novelli (http://styles.porternovelli.com). US health care providers are recruited from Sermo's global medical panel (http://www.sermo.com) of 350,000 providers until quotas of 1,000 general primary care physicians (i.e., family practitioners and internists) and 250 for various provider types (e.g., nurse practitioners) and physician specialties (e.g., obstetricians/gynecologists, pediatricians) are reached. Eligibility requirements included practicing for at least 3 years and actively seeing patients in the United States. Depending on the number of questions asked, respondents received an honorarium ranging between $26 and $68. Items of interest for this analysis were fielded with general primary care physicians, pediatricians, and obstetricians/gynecologists, and survey response rates for each group were 65%, 66%, and 62%, respectively. Porter Novelli provided internal documentation indicating that gender, age, and region of the DocStyles samples of primary care physicians and obstetricians/gynecologists were largely similar to those included in the American Medical Association Masterfile; gender and race/ethnicity of the DocStyles sample of pediatricians were fairly similar to those participating in the American Academy of Pediatrics Periodic Survey [21]. Because Porter Novelli provides only deidentified data as part of their licensing agreement, the Centers for Disease Control and Prevention determined that institutional review board review was not required.

Measures

Survey questions were designed to assess three time periods: “at any point during the COVID-19 pandemic” (i.e., at any point during the COVID-19 pandemic up until survey completion in the Fall 2021; referred to as: at any point during the pandemic), “in the past month” (i.e., in the month prior to when respondents completed the survey in the Fall 2021; referred to as: in the month prior to survey completion), and “just before the COVID-19 pandemic” (referred to as: just before the pandemic) (Supplemental File 1). The latter time period was assessed to identify pandemic-related service delivery challenges and strategies to support access initiated during the pandemic. For this analysis, we examine measures specifically relevant to adolescents (e.g., walk-in and weekend/evening hours considered to be youth-friendly practices [22]).

Service delivery challenges

Physicians were asked whether their practice experienced certain issues delivering family planning and STI services to patients (not specifically adolescents) and could select one or multiple responses from a list that included: IUD or implant placement services limited; IUD or implant removal services limited; walk-in hours reduced; weekend/evening hours reduced; and fewer adolescents seeking care. We combined responses to the two items about LARC services so that if physicians indicated IUD or implant placement or removal services were limited, then LARC services were considered limited. Given that maintaining access to LARC removals is particularly important for reproductive autonomy, we examined limited LARC removal services separately as well.

In addition to limited services, we also calculated discontinuation of services using another question that asked physicians what services their practice provided at any point during the pandemic. Respondents who provided IUD or implant placement or removal just before the pandemic but indicated neither IUD nor implant placement or removal services were provided any point during the pandemic were considered to have discontinued LARC services since the pandemic began. Again, we also examined discontinuation of LARC removal services separately. Respondents who provided clinic-based STI testing just before but not at any point during the pandemic were considered to have discontinued clinic-based STI testing since the pandemic began.

Strategies to support access

As for strategies used to support access to SRH services, the questions about services provided during each time period included the following response options: telehealth for contraception initiation; telehealth for contraception continuation; and telehealth for STI services. We created a single item for telehealth for contraception initiation or continuation. Separate questions asked physicians to select all the strategies their practice had used at each time period from a list that included the following: renewed contraception prescriptions without requiring an office visit; provided or prescribed a year's worth of oral contraceptives; and provided or prescribed emergency contraceptive pills in advance of need. In addition to examining each strategy independently, we calculated the proportion who did not use any strategy, both at any point during the pandemic and in the month prior to survey completion. We also calculated the median number of strategies used during each time period.

Analyses

The analytic sample included family practitioners, internists, pediatricians, and obstetricians/gynecologists whose main work setting was outpatient and whose practice provided family planning or STI services to at least one adolescent patient (defined as male and female patients aged 15–19 years, to align with our prior study [9] and focus on an older population of adolescents more likely to be sexually active and in need of SRH services) per week just before the COVID-19 pandemic (n = 948). Analyses of each service delivery indicator (with the exception of fewer adolescents seeking care) were limited to physicians who reported the respective service delivery indicator was available just before the pandemic. Analyses of strategies to support access were limited to physicians who did not use each respective strategy just before the pandemic given our interest in what has occurred among those who initiated these strategies during the pandemic.

For both service delivery challenges and strategies to support access, we calculated proportions for each variable of interest at any point during the pandemic and in the month prior to survey completion and used McNemar's test to examine significant (p < .05) changes in the estimates between time periods. For use of strategies to support access, we also calculated the proportion reporting use of the strategy in the month prior to survey completion among those who had used the strategy at any point during the pandemic (i.e., initiated). We used chi-square statistics (or Fisher's exact test when cell counts were <5) to examine differences in the proportion reporting service delivery challenges and use of strategies in the month prior to survey completion (among those who initiated each strategy during the pandemic) by physician specialty and average weekly adolescent patient volume for SRH services. The latter was categorized for these analyses based on tertiles (1–4 patients, 5–10 patients, >10 patients). Findings were stratified by these variables in order to better understand the impact of COVID-19 for adolescent patients specifically.

There were some discrepancies in participant responses by time period. Specifically, a few respondents (ranging from 1.8% to 5.3% of the overall analytic sample, depending on the indicator) answered affirmatively to an item about the month prior to survey completion but negatively to the corresponding item regarding at any point during the pandemic. We explored two approaches to handling these discrepancies: (1) recoded responses to the item assessing at any point during the pandemic to the affirmative and (2) treated respondents with this discrepancy as missing. Since the findings were similar between these approaches and we wanted to retain as many respondents as possible, we used the recoded responses for the final analyses.

Results

Sample characteristics

About one-fifth (21.6%) of respondents were internists, 37.8% were family practitioners, 18.3% were pediatricians, and 22.4% were obstetricians/gynecologists (Table 1 ). The majority of physicians were male (60.2%) and non-Hispanic White (62.6%). Most worked primarily in a group practice (81.2%), and most practices were in an urban or a suburban setting (88.5%). Median weekly adolescent patient volume just before the pandemic was 20 patients for any service and eight patients for SRH services.

Table 1.

Sample characteristics of physicians, DocStyles Online Panel Survey, Fall 2021^a (n = 948)

Sample characteristics	% (n) or median (IQR)b
Physician characteristics
Physician specialty
Family practitioner	37.8 (358)
Internist	21.6 (205)
Pediatrician	18.3 (173)
Obstetrician/gynecologist	22.4 (212)
Age, years	49.5 (18)
Gender
Male	60.2 (571)
Female	39.7 (376)
Other	0.1 (1)
Race/ethnicity
White, non-Hispanic	62.6 (593)
Black, non-Hispanic	2.9 (27)
Hispanic	5.5 (52)
Other, non-Hispanicc	29.1 (276)
Number of years practicing	18 (14)
Clinical practice characteristics
Primary work setting
Individual outpatient practice	18.8 (178)
Group outpatient practice	81.2 (770)
Census region
South	33.1 (314)
Northeast	21.2 (201)
Midwest	21.7 (206)
West	24.0 (227)
Urbanicity
Urban	34.6 (328)
Suburban	53.9 (511)
Rural	11.5 (109)
Approximate household income of majority of patients
<$25,000	5.4 (51)
$25,000–$49,999	24.0 (227)
$50,000–$99,999	41.9 (397)
$100,000–$249,999	18.5 (175)
≥$250,000	10.3 (98)
Average weekly adolescent patient volume for any reason just before the COVID-19 pandemic	20 (23)
Average weekly adolescent patient volume for SRH services just before the COVID-19 pandemic	8 (17)

IQR = interquartile range; SRH = sexual and reproductive health services.

^aSurvey was fielded September 14, 2021–November 10, 2021. Analytic sample includes family practitioners, internists, pediatricians, and obstetricians/gynecologists who work primarily in an outpatient practice setting and who provided SRH services (family planning or STI services) to at least one adolescent patient (male or female 15–19 years) per week just before the COVID-19 pandemic began.

^bMedian (IQR) reported for age, number of years practicing, and patient volume indicators; % (n) reported for all other variables.

^cIncludes multi-racial.

Service delivery challenges

Comparing physicians' reports of service delivery challenges occurring at any point during the COVID-19 pandemic up until survey completion in the Fall 2021 and in the month prior to the survey completion (Table 2 ), fewer physicians reported their practices experienced limited LARC placement or removal services (33.0% vs. 11.0%), limited LARC removal services (28.9% vs. 6.6%; data not shown), or limited clinic-based STI testing (22.0% vs. 7.9%) as well as reductions in walk-in hours (56.7% vs. 28.2%), weekend/evening hours (54.6% vs. 26.7%), and adolescents seeking care (59.0% vs. 30.4%). As for discontinuation of services, among physicians whose practices provided LARC placement or removal services just before the pandemic, 4.3% indicated that these services had not been provided at any point during the pandemic. Among those who reported that LARC removal services were provided just before the pandemic, 4.0% reported LARC removals had not been provided at any point during the pandemic. Finally, among physicians whose practices provided clinic-based STI testing just before the pandemic, 2.7% reported that this service was not provided at any point during the pandemic (data not shown).

Table 2.

Service delivery challenges reported by physicians during the COVID-19 pandemic, DocStyles Online Panel Survey, Fall 2021

Service delivery challenges	At any point during the pandemic % (n)a	In the month prior to survey completion % (n)b
IUD or implant placement or removal services limitedc	33.0 (147)	11.0 (49)
Clinic-based STI testing limitedd	22.0 (179)	7.9 (64)
Walk-in hours reducede	56.7 (304)	28.2 (151)
Weekend/evening hours reducedf	54.6 (227)	26.7 (111)
Fewer adolescents seeking careg	59.0 (559)	30.4 (288)

Boldface indicates p < .05 based on McNemar's test comparing the proportion experiencing the issue at any point during the COVID-19 pandemic and in the month prior to survey completion.

IUD = intrauterine device; SRH = sexual and reproductive health; STI = sexually transmitted infection.

^aAt any point during the COVID-19 pandemic up until survey completion in Fall 2021.

^bSurvey was fielded September 14, 2021–November 10, 2021.

^cAmong physicians who reported IUD or implant services were provided just before the COVID-19 pandemic (n = 445).

^dAmong physicians who reported clinic-based STI testing was provided just before the COVID-19 pandemic (n = 813).

^eAmong physicians who reported walk-in hours were available just before the COVID-19 pandemic (n = 536).

^fAmong physicians who reported weekend/evening hours were available just before the COVID-19 pandemic (n = 416).

^gAmong physicians overall (n = 948).

There were some differences in the proportion of physicians reporting service delivery challenges in their practice in the month prior to survey completion by physician specialty and adolescent patient volume for SRH services (Table 3 ). About one-quarter (26.0%) of internists reported that LARC services were limited in their practice in the month prior to survey completion, as compared with 13.7% of family practitioners, 9.5% of pediatricians, and 5.3% of obstetricians/gynecologists. A similar pattern was seen for limited clinic-based STI testing: 17.1% of internists reported this challenge in their practice whereas 9.3% of family practitioners, 2.7% of pediatricians, and 2.5% of obstetricians/gynecologists did so. The lowest proportion reporting fewer adolescents seeking care in their practice was among obstetricians/gynecologists (20.3%); about one-third of pediatricians (35.8%), family practitioners (33.0%), and internists (31.7%) reported this challenge. Reductions in walk-in and weekend/evening hours varied by adolescent patient volume; the highest prevalence of reductions were among physicians whose practices had >10 adolescent patients per week for SRH services (37.7% for walk-in hours and 33.3% for weekend/evening hours).

Table 3.

Service delivery challenges reported by physicians in the month prior to survey completion^a by physician specialty and adolescent patient volume, DocStyles Online Panel Survey, Fall 2021

Characteristic	LARC services limited % (n/Nb)	Clinic-based STI testing limited % (n/Nc)	Walk-in hours reduced % (n/Nd)	Weekend/evening hours reduced % (n/Ne)	Fewer adolescents seeking care % (n/Nf)
Physician specialty
Family practitioner	13.7 (23/168)	9.3 (29/312)	29.8 (68/228)	30.1 (50/166)	33.0 (118/358)
Internist	26.0 (13/50)	17.1 (26/152)	32.0 (39/122)	25.7 (18/70)	31.7 (65/205)
Pediatrician	9.5 (2/21)	2.7 (4/148)	27.2 (28/103)	21.9 (26/119)	35.8 (62/173)
Obstetrician/Gynecologist	5.3 (11/206)	2.5 (5/201)	19.3 (16/83)	27.9 (17/61)	20.3 (43/212)
Average weekly adolescent patientvolume for SRH services just beforetheCOVID-19pandemic
1–4 patients	8.5 (8/94)	7.3 (16/219)	22.1 (29/131)	19.4 (21/108)	32.2 (87/270)
5–10 patients	11.4 (19/167)	6.5 (20/306)	23.4 (50/214)	25.5 (41/161)	27.0 (98/363)
>10 patients	12.0 (22/184)	9.7 (28/288)	37.7 (72/191)	33.3 (49/147)	32.7 (103/315)

LARC = long-acting reversible contraception; SRH = sexual and reproductive health; STI = sexually transmitted infection.

Boldface indicates p < .05 based on chi-square or Fisher's exact test (in cases were n < 5 for any cell) comparing distribution of each service delivery issue by physician specialty and adolescent patient volume.

^aSurvey was fielded September 14, 2021–November 10, 2021.

^bNumber of physicians who reported LARC was provided just before the COVID-19 pandemic by physician specialty or adolescent patient volume for SRH services.

^cNumber of physicians who reported clinic-based STI testing was provided just before the COVID-19 pandemic by physician specialty or adolescent patient volume for SRH services.

^dNumber of physicians who reported walk-in hours were available just before the COVID-19 pandemic by physician specialty or adolescent patient volume for SRH services.

^eNumber of physicians who reported weekend/evening hours were available just before the COVID-19 pandemic by physician specialty or adolescent patient volume for SRH services.

^fNumber of physicians by physician specialty or adolescent patient volume for SRH services.

Strategies to support access

For each strategy to support access that we examined among physicians whose practices did not use the strategy just before the pandemic, the proportion using the strategy in the month prior to survey completion was lower compared with the proportion who had used the strategy at any point during the pandemic (i.e., those who initiated the strategy during the pandemic) (Table 4 ). While most practices that initiated a given strategy used that strategy in the month prior to survey completion, some practices—ranging from 21.9% for telehealth for contraception to 36.8% for providing or prescribing emergency contraceptive pills in advance of need—did not (data not shown). About one in 10 physicians reported not using any of the strategies examined at any point during the pandemic (7.3%) and in the month prior to survey completion (10.4%). The median number of strategies used at each time period was three (data not shown).

Table 4.

Use of strategies to support access to SRH services during the COVID-19 pandemic among physicians whose practice did not use the strategy just before the pandemic, DocStyles Online Panel Survey, Fall 2021

Strategies to support access	At any point during the pandemica (i.e., initiated) % (n)	In the month prior to survey completionb % (n)
Contraceptive services
Telehealth for contraceptive initiation or continuationc	51.5 (301)	40.2 (235)
Renewed contraception prescriptions without requiring an office visitd	46.5 (141)	33.7 (102)
Provided or prescribed a year's worth of oral contraceptivese	20.9 (69)	13.6 (45)
Provided or prescribed emergency contraceptive pills in advance of needf	13.4 (76)	8.5 (48)
STIservices
Telehealth for STI servicesg	31.4 (227)	23.8 (172)

SRH = sexual and reproductive health; STI = sexually transmitted infection.

Boldface indicates p < .05 based on McNemar's test comparing the proportion reporting use at any point during the COVID-19 pandemic and in the month prior to survey completion.

^aAt any point during the COVID-19 pandemic up until survey completion in Fall 2021.

^bSurvey was fielded September 14, 2021–November 10, 2021.

^cAmong physicians who did not provide telehealth for contraceptive initiation or continuation just before the COVID-19 pandemic (n = 585).

^dAmong physicians who did not renew contraception prescriptions without requiring an office visit just before the COVID-19 pandemic (n = 303).

^eAmong physicians who did not provide or prescribe a year's worth of oral contraceptives just before the COVID-19 pandemic (n = 331).

^fAmong physicians who did not provide or prescribe emergency contraceptive pills in advance of need just before the COVID-19 pandemic (n = 567).

^gAmong physicians who did not provide for telehealth for STI services just before the COVID-19 pandemic (n = 722).

Among physicians whose practice initiated a strategy at any point during the pandemic, the only differences in use of strategies in the month prior to survey completion by physician specialty were for renewing contraception prescriptions without requiring an office visit and telehealth for STI services (Table 5 ). About four-fifths of family practitioners (80.7%) and internists (81.2%) and three-fifths of pediatricians (59.1%) and obstetricians/gynecologists (56.7%) reported renewing contraception prescriptions without requiring an office visit. A similar pattern was seen for telehealth for STI services. There were no differences by adolescent patient volume for SRH services.

Table 5.

Use of strategies in the month prior to survey completion^a among physicians whose practice initiated the strategy during the pandemic^b by physician specialty and adolescent patient volume, DocStyles Online Panel Survey, Fall 2021

Characteristic	Telehealth for contraception % (n/Nc)	Renewed contraception prescriptions without requiring an office visit % (n/Nd)	Provided or prescribed a year's worth of oral contraceptives % (n/Ne)	Provided or prescribed emergency contraceptive pills in advance of need % (n/Nf)	Telehealth for STI services % (n/Ng)
Overall	78. 1 (235/301)	72.3 (102/141)	65.2 (45/69)	63.2 (48/76)	75.8 (172/227)
Physician specialty
Family practitioner	80.0 (84/105)	80.7 (46/57)	69.2 (18/26)	65.9 (27/41)	81.4 (70/86)
Internist	90.9 (40/44)	81.2 (26/32)	57.9 (11/19)	54.6 (6/11)	86.0 (43/50)
Pediatrician	72.4 (42/58)	59.1 (13/22)	58.3 (7/12)	60.0 (6/10)	63.6 (28/44)
Obstetrician/gynecologist	73.4 (69/94)	56.7 (17/30)	75.0 (9/12)	64.3 (9/14)	66.0 (31/47)
Average weekly adolescent patient volume for SRH services just before the COVID-19 pandemic
1–4 patients	72.8 (59/81)	70.6 (24/34)	75.0 (9/12)	57.1 (8/14)	70.9 (39/55)
5–10 patients	79.6 (90/113)	70.9 (39/55)	48.2 (13/27)	70.8 (17/24)	73.4 (58/79)
>10 patients	80.4 (86/107)	75.0 (39/52)	76.7 (23/30)	60.5 (23/38)	80.7 (75/93)

SRH = sexual and reproductive health; STI = sexually transmitted infection.

Boldface indicates p < .05 based on chi-squared or Fisher's exact test (in cases where n < 5 for any cell) comparing distribution of use of the access strategy by physician specialty and adolescent patient volume.

^aSurvey was fielded September 14, 2021–November 10, 2021.

^bDefined as physicians who reported the strategy was not used just before the COVID-19 pandemic but was used at any point during the pandemic.

^cNumber of physicians whose practice initiated telehealth for contraception by physician specialty or adolescent patient volume for SRH services.

^dNumber of physicians whose practice initiated renewing contraception prescriptions without requiring an office visit by physician specialty or adolescent patient volume for SRH services.

^eNumber of physicians whose practice initiated providing or prescribing a year's worth of oral contraceptives by physician specialty or adolescent patient volume for SRH services.

^fNumber of physicians whose practice initiated providing or prescribing emergency contraceptive pills in advance of need by physician specialty or adolescent patient volume for SRH services.

^gNumber of physicians whose practice initiated telehealth for STI services by specialty or adolescent patient volume for SRH services.

Discussion

Findings from this analysis of physicians whose practices provided SRH services to adolescent patients just before the pandemic indicate that fewer practices were experiencing service delivery challenges in the Fall 2021 compared with any point during the COVID-19 pandemic up until survey completion. However, challenges continued for some practices. About one in 10 physicians overall indicated that LARC services and clinic-based STI testing were limited in the month prior to completing the survey in the Fall 2021; about one-quarter reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care during that same time period. Such findings suggest that pandemic-related challenges persisted for some physicians. Reports of limited LARC and STI testing services were 26% and 17% for each respective service among internists and 5% and 2% for each respective service among obstetricians/gynecologists. Such findings may reflect competing priorities that internal medicine practices face, including provision of COVID-19 related services, as well as differences in patient populations and services sought. Reductions in adolescent care-seeking also varied by physician specialty, with about one-third of family practitioners (33%), internists (32%), and pediatricians (36%) reporting this as an issue for their practice whereas 20% of obstetricians/gynecologists reported this issue in their practice. Because reductions in walk-in and weekend/evening hours were more prevalent among physicians who reported higher adolescent patient volume for SRH services at their practice, these challenges may have particularly impacted adolescent patients' access to SRH care. Persistent challenges with access and service availability could have contributed to the reductions in adolescent care-seeking observed in the Fall 2021, although factors related to patient demand (e.g., less need for services due to decreased sexual activity) may also have been involved.

Our findings that suggest overall improvements but some persistent service delivery challenges align with data reported by women of reproductive age in the Guttmacher survey implemented in May 2020 and July–August 2021 [20]. Another repeated cross-sectional study that surveyed women of reproductive age in July 2020 and January 2021 found that for some measures of access to contraception, challenges seemed more pronounced in early 2021 [19]. Increased availability of COVID-19 vaccination since early 2021 may have contributed to the improvements observed in the Guttmacher survey and our analysis. Of note, both prior studies examined differences in service delivery challenges by patient race/ethnicity and socioeconomic status and found that challenges with access disproportionately affected racial/ethnic minorities and individuals of low socioeconomic status [19,20]. Our study provides a complementary perspective, reporting data from physicians instead of patients and examining salient physician/clinic characteristics to identify where particular supports for access are needed.

Most practices that initiated strategies to support access to SRH services during the pandemic were using them in the month prior to survey completion. However, about one-quarter to one-third (depending on the specific strategy) did not, indicating there may be challenges sustaining these service delivery approaches. Based on these findings, along with data from the Guttmacher survey suggesting that telehealth is helping to address pandemic-related gaps in contraceptive services [20], efforts that can reduce discontinuation of innovative strategies to support SRH access, including telehealth, may prove helpful. It is unclear why a higher percentage of general primary care physicians were renewing prescriptions without an office visit and using telehealth for STI services. Perhaps these physicians perceived a greater need to sustain these strategies given that our data suggest clinic-based service delivery challenges are more pronounced, at least for internists, or it is possible that pediatricians are less comfortable diverging from the standard practice.

Future qualitative research may be particularly helpful in understanding why some practices that initiated these strategies during the pandemic may no longer be using them even as the pandemic continues. As constraints on in-person visits have eased, use of more innovative service delivery strategies may no longer seem necessary. Patient and provider preference for more traditional interactions may also underpin discontinuation of the strategies we examined. However, a small, web-based survey of US family planning providers found that most patients had positive experiences with telehealth for contraceptive counseling [23], and three-quarters of patients (>18 years) from a large academic medical center receiving contraceptive counseling via telehealth strongly agreed that these types of visits should be maintained after the pandemic [16]. Policy and systems-level barriers to innovative service delivery strategies are also important to consider. For example, early in the pandemic, temporary legal and reimbursement changes were implemented to facilitate telehealth (e.g., allowing clinicians to practice across state lines, mandating insurance coverage) [24], yet some of those flexibilities are no longer in place [25].

This study has several measurement issues that limit the conclusions we can draw in relation to our research objectives. Although the analytic sample is limited to physicians whose practices provided SRH care to adolescent patients just before the pandemic and we consider differences by adolescent patient volume for SRH services, few of the measures are specific to adolescents. Thus, we cannot be certain that limited services or use of strategies to support access directly affected adolescent patients. The terminology of “just before the COVID-19 pandemic” and “at any point during the COVID-19 pandemic” was intentionally broad, but respondents may have varying interpretations of these time periods. Additionally, the two time periods assessed during the pandemic were overlapping, and we do not know how consistent service delivery challenges or use of strategies to support access have been during the pandemic. We also do not know whether findings suggesting use of strategies to support access was not sustained reflect actual discontinuation of the strategy or limited patient demand. Finally, physicians were asked to report on their entire practice so the validity of responses for those who worked primarily in group practices is unclear, and we do not know the number of unique practices represented.

The study sample has limitations as well. Internet-based panels have sampling constraints [26], and the DocStyles sample is not probability-based. Therefore, statistical inferences should be interpreted with caution, and findings are not representative of all U.S. physicians or the specialties we examined.

As the pandemic continues and prevention measures are adjusted in response to changing COVID-19 community levels [27], researchers, clinicians, and public health practitioners can monitor the impact on SRH services, including among adolescents specifically. Such monitoring may be especially important during periods when COVID-19 cases are increasing given the potential negative impact on delivery and receipt of SRH services. While findings from this analysis suggest reductions in SRH service delivery challenges among physicians who serve adolescent patients, some physicians reported service delivery challenges with in-person care in the Fall 2021 Assessing reasons for any disruption as part of future quantitative and qualitative data collection could help inform intervention efforts, including implementation of alternative service delivery strategies like those examined in this study. Use of innovative service delivery strategies may help support access, yet our findings suggest that some clinical practices may need support sustaining these strategies. Institutionalizing innovative approaches could serve to not only minimize disruptions in SRH care for adolescents during the COVID-19 pandemic but expand access going forward.