The report is a product of the VA/HSR Evidence Synthesis Program.

Telehealth Services Designed for Women

Telehealth encompasses a variety of technologies and approaches to connect individual patients to healthcare resources with the goal of improving personalization, efficiency, access to care, and secure sharing of health information. Within the VA healthcare system, telehealth and advanced health information technology has long been an area of innovation, i.e., mobile health applications, clinical videoconferencing between patient and care providers, and home self-monitoring with data transmission via phone lines. Telehealth may be a good fit for addressing the needs of women Veterans because alternate forms of healthcare communication are already in use by this population. Compared with men, women Veterans are more likely to contact their healthcare team by telephone (63% vs 55%), and women also use other forms of telehealth (i.e., video conferencing, home telehealth, and store and forward) at similar rates as men.

Investigators with VA's Evidence-based Synthesis Program site located in Durham, NC, conducted an evidence map that characterizes the quantity, distribution, and characteristics of evidence that assesses the effectiveness of telehealth services designed specifically for women. Using MEDLINE® (via PubMed®) and Embase® to find relevant articles and systematic reviews published between inception and December 29, 2016, investigators identified 5,305 citations. From these, they identified 209 primary reports and 2 systematic reviews addressing telehealth interventions for women, including: 81 primary studies and 1 systematic review related to maternal health, 56 to prevention, 43 to disease management, 11 to family planning, 7 to identifying and managing women at high risk for breast cancer, 6 to mental health, and 5 studies and 1 systematic review related to intimate partner violence.

Summary of Findings
The evidence maps in this report serve as a broad visualization of the field of telehealth interventions designed specifically for women. For example, see Figure 13 for "Study Characteristics by Focused Area of Research" and Figure 14 for "Intervention Components by Focused Area of Research." When looking across these areas, most identified studies had small samples (n <250). For studies that provided race and ethnic study composition (n = 114), most studies included populations that were predominantly white (68%). Age distributions in this literature tracked with population distributions of women potentially affected by the identified health issues. Most studies were conducted in high-income countries, recruited from outpatient settings, and were limited in duration (e.g., <12 weeks). Across all areas of research, telephone was the dominant telehealth modality used and typically facilitated communication between patients and healthcare team members. Interventions were mostly supported by diverse credentialed and non-credentialed positions (i.e., registered nurses, behavioral health specialists, health educators, peer/lay healthcare workers). Three studies recruited participants from an active military base or the Veteran population.

The following are highlighted key findings under each of the seven focused areas of research.

Maternal Health

• Maternal health was the largest focused area within the women's telehealth literature with 7 subcategories including prenatal care (n = 21), lactation (n = 16), postpartum (n = 9), peripartum mental health (n = 14), smoking cessation (n = 8), weight management (n = 8), and gestational diabetes (n = 5).
• Most maternal health studies had 500 or fewer participants, were conducted in high-income countries, and used telephone as the telehealth modality.
• There was a wide variety of interventionist types, the most common being registered nurses, midwives, and peer or lay health workers.

Prevention

• The largest sub-category in this area was devoted to increasing physical activity.
• The most common intervention length was 25-52 weeks, and telephone was the dominant telehealth modality.
• For the studies that delineated a primary outcome, all were at the patient level.

Disease Management

• The vast majority of studies were mainly conducted in countries categorized as high income by the World Bank.
• The largest proportion of studies had fewer than 1,000 participants, and most studies were conducted with middle-aged women.
• The most common mode of telehealth delivery was telephone, and in one-third of studies the interventionist was a nurse.
• The majority of studies focused on patient-level outcomes, the most common of which were quality of life or clinical symptoms.

Family Planning

• Six of the 11 studies in this area addressed contraception use, two addressed post-abortion care, two focused on issues related to assisted reproductive technology, and one study addressed fertility and pregnancy among cancer survivors.
• Four studies had more than 1,000 participants, and half of those were conducted in high-income countries as defined by the World Bank.
• Most studies used telephone as a central telehealth modality.
• All but one study used telehealth to communicate between the healthcare team and the patient, but the actual credentials of the interventionist varied across studies.

High-Risk Breast Cancer Assessment

• All seven studies were synchronous, telephone-based, featured telehealth as the central intervention modality, and were designed for information flow from a provider to a patient.
• Most studies compared telephone-based genetic counseling with in-person counseling, while one study focused on promoting healthy behaviors, and one study provided social support to women known to carry genetic mutations that put them at high risk for breast cancer.
• Studies were conducted among high-income countries.

Mental Health

• In addition to the 14 studies identified in the maternal health section that focused on post-partum depression and parenting anxiety, 6 more studies were identified that focused on mental health generally. All of these studies included synchronous telephone communication and addressed anxiety, PTSD, and/or depression.
• One study examining treatment of PTSD via telemedicine recruited both Veteran and civilian women through a VA and community setting.

Intimate Partner Violence

• All studies were telephone-based studies that targeted reproductive age women and were relatively short in length (all 24 weeks or less).
• All outcomes measured across these five studies were patient level with no measures of provider- or system-level outcomes.

Gaps in the Literature
Beyond maternal healthcare, a relatively small number of telehealth studies were identified that addressed other gender-specific needs of women Veterans, i.e., family planning, intimate partner violence, homelessness, pain management, and high-risk breast cancer assessment. Further, beyond postpartum depression, few studies used telehealth interventions to address the mental health needs of women. Investigators also found relatively few studies among older women, and studies conducted with racially or ethnically diverse populations. Telephone was the most commonly studied telehealth modality, while newer approaches (i.e., mobile health technologies) were underrepresented. This gap underscores the need to study how best to use evolving technology that can address the needs of women. There is also a need for research on the extent to which telehealth improves provider and system outcomes related to provider satisfaction and retention and patient access to care.

While very few telehealth studies were based within VA, the nature of VA as a large and diverse health care system that has been a national leader in developing and implementing telehealth modalities creates many opportunities to pursue multisite trials to address some of the gaps in the body of literature described in this report.

FUTURE RESEARCH
Findings highlight some notable gaps in the literature, including the need for more exploration in the areas of mental health, pain management, intimate partner violence, and family planning. Investigators also note the need to explore the testing of alternative telehealth modalities such as texting and videoconferencing — and the need to test these strategies in more diverse populations of women. Key to VA, investigators also note the need to implement studies that assess the impact of telehealth on provider- and system-level outcomes.

Reference
Goldstein KM, Gierisch JM, Zullig LL, Alishahi A, Brearly T, Dedert EA, Raitz G, Sata SS, Whited JD, Bosworth HB, McDuffie J, Williams JW Jr. Telehealth Services Designed for Women: An Evidence Map. VA ESP Project #09-010; 2017.

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