Introduction
As of 2018, 19 million women do not have access to birth control prescriptions in the United States (Pietrangelo, 2018). These women live in areas known as “contraceptive deserts,” where women do not have reasonable access to a medical facility where they can receive a doctor’s prescription for birth control. Barriers that women in contraceptive deserts face include a lack of insurance or funding for a doctor’s visit and a lack of transportation or time to get to a doctor’s office (Power to Decide, 2019). The effects of the COVID-19 pandemic further contribute to the challenges of obtaining hormonal contraceptives. Face-to-face visits with the obstetrician-gynecologist (OB-GYN) are limited as well as many women have lost their jobs and their insurance plans used to afford these visits and contraceptives (Lindberg et al., 2020).
However, a new online phenomenon, mail-order birth control, gains attention by reducing these obstacles. Mail-order birth control is a form of telemedicine that allows physicians to examine patients and provide treatments and prescriptions online (Zuniga et al., 2020). The service allows women to order their birth control via the Internet and have it sent directly to their home or pharmacy. What remains unexplored, however, is whether and the degree to which psychological factors motivate women to use mail-order birth control services.
With the theoretical framework of the theory of planned behavior (TPB), this study identifies women’s attitudes and norms toward mail-order birth control, and the barriers they face when considering purchasing it. We also address how the adoption of telemedicine and mail-order birth control can help increase access to hormonal contraceptives. An online survey and supplemental interviews were conducted from twelve midwestern and three southern states of the United States. The study suggests a way to promote women’s sexual health and access to birth control.
Literature Review
Birth Control and Health Disparity
Since oral contraceptives for women were legalized in the United States in 1960, American women have been given the greater power to plan their families and to actively participate in the American economy (Richards, 2016). Hormonal contraceptives have helped women better plan and space out their pregnancies and have had a positive effect on women’s lives and health outcomes by reducing poverty and abortion rates. Hormonal contraceptive pills have been one of the two most used contraceptive methods since 1982 (Guttmacher Institute, 2020). With a small amount of man-made estrogen and progestin hormones, hormonal contraceptive pills inhibit the body’s natural cyclical hormones to prevent pregnancy (Todd, 2020).
While birth control has become more widely accessible to women, some still face obstacles when trying to obtain a prescription. According to the National Survey of Family Growth, approximately sixty-five percent of all women of reproductive age (15-49) in the US use some form of contraception between 2015 and 2017 (Daniels & Abma, 2018; Kavannaugh & Jerman, 2018). However, unintended pregnancies still represent about 45 percent of all pregnancies (Finer & Zolna, 2016). Such statistics indicate that many American women still lack proper access to birth control prescriptions (Pietrangelo, 2018). Most of these women need publicly subsidized birth control or live in “contraceptive deserts.” Contraceptive deserts are predominantly rural areas that do not sustain a variety of health centers offering the full range of birth control methods. Women in these areas may have little to no reasonable access to medical facilities due to the lack of transportation, time, convenience, proximity, insurance, or money (Power to Decide, 2019).
The traditional way for a patient to obtain a prescription for birth control is to find a nearby medical facility, make sure their insurance is accepted, schedule an appointment, and meet with the doctor in person. Many women, however, cannot complete this process due to a number of barriers. Women living in isolated communities, for example, face barriers such as not having a regular doctor or clinic, being unable to take time off from school or work, lacking time or transportation to get to the office, or being unable to make it to inconvenient clinic hours (Zuniga et al., 2020).
Current efforts to reduce the barriers posed by contraceptive deserts, such as selling oral contraceptives over the counter, are in the works. However, the Food and Drug Administration’s (FDA) approval process for this could take years. Thus, it is necessary to find another feasible way to reduce the health disparity among already existing practices. Telemedicine is regarded as one of the solutions (Zuniga et al., 2020).
Telemedicine
Telemedicine refers to a remote clinical service that delivers healthcare from a distance, which oftentimes involves clinical treatments (Flodgren et al., 2015; O'Hara, Johnston & Browne, 2020). Telemedicine service allows patients to use email, video conference, text chat, and audio calls to access communication with clinicians and patient portal technologies (Jiang & Street, 2017). It has become an increasingly common mode of healthcare delivery in various health fields such as dermatology, neurology, and even intensive care (Kahn, 2015).
Telemedicine helps close gaps of limited healthcare access and high demands for treatments. (Hatcher-Martin et al., 2020). In a national survey among all the US emergency departments open in 2016, forty-eight percent of emergency departments reported they received telemedicine services (Zachrison et al., 2020). The COVID-19 pandemic further increases telemedicine use due to the stay-at-home restrictions limiting access to face-to-face care. Patients are encouraged to use online health services and patient portal technologies to communicate with clinicians (Lindberg et al., 2020).
There are financial benefits to using telemedicine as it has the potential to expand access to high-quality healthcare by reducing the costs of running a medical facility (Kahn, 2015). It can also reduce individuals’ healthcare costs and improve patient health outcomes by offering access to a wider range of medical specialties such as urgent care, cardiovascular care, and neurological care online (Flodgren et al., 2015). In addition, telemedicine makes healthcare and health services more convenient for patients and physicians. Primary care physicians can use it to treat patients such as nursing home residents or disabled patients who have difficulty visiting clinics (Kahn, 2015). It is especially beneficial for those who live in isolated communities by helping these individuals obtain medical help more efficiently and at a reduced cost (Singh, Roy & Goyal, 2016).
Telemedicine and Mail-Order Birth Control
The past few years have seen the rise of telemedicine websites that allow women to receive birth control prescriptions online (Zuniga et al., 2020). Especially in 2020, COVID-19 made rapid and large impacts on women’s sexual health and birth control use. Women had to delay or cancel their OB/GYN appointments. This disruption of face-to-face care results in continued barriers to obtaining birth control leading to negative health, social and economic consequences. Economic challenges include losing their job and insurance which help pay for birth control prescriptions. Due to the pandemic, more women have reported increased worry than previously over their ability to afford and obtain their birth control (Lindberg et al., 2020). However, telemedicine allows for alternate means for these women to maintain access to birth control during the pandemic (Lindberg et al., 2020).
As of February 2018, nine US-based platforms prescribe birth control online, including HeyDoctor and Lemonaid (Zuniga et al., 2020). These sites accept insurance, and/or have low out-of-pocket costs. Women can log onto these websites and fill out a questionnaire about their health and medical history. The questionnaire is then reviewed by an online doctor who prescribes a hormonal contraceptive that is sent directly to the patient’s home or pharmacy in a discreet package.
Mail-order birth control sites have broken down many of the barriers that women in contraceptive deserts face. However, people remain hesitant to adopt the services. A significant barrier to their adoption is user acceptance of the method. Cranen and her colleague (2011) conducted an experiment of a pre- and post-test of users’ perceptions of telemedicine websites. Among participants with no prior experience with telemedicine, many had reservations about the idea but had a positive perception after experimenting with the service. A brief trial of telemedicine services may thus reduce the risk and uncertainty of adopting the new method, impact patients’ perceptions of it in a positive way (Cranen et al, 2011; Ranganathan & Balaji, 2020), and eventually increase acceptance of this new form of healthcare. Patients’ prior experience of and comfort with telemedicine services can, therefore, be related to women’s acceptance of mail-order birth control. Based on the literature, the following hypotheses are proposed:
H1: Women’s perceived comfort level of telemedicine will be positively associated with their intention to purchase birth control online.
H2: Women’s prior experience of telemedicine will be positively associated with their intention to purchase birth control online.
Just like other telemedicine, mail-order birth control services have generated concerns regarding privacy, health information security relating to the Health Insurance Portability and Accountability Act (HIPPA), and less personalized care (Jiang & Street, 2017). Perhaps, the biggest concern in using mail-order birth control is safety. For example, women with high blood pressure should not be prescribed certain hormonal contraceptives. Since patients are reviewed and submit their medical history online, it is challenging to screen them for such medical conditions (Zuniga et al., 2020).
Despite the concerns, the service seems to grow (Zuniga et al., 2020). However, the factors that motivate or prevent women from purchasing birth control online are not fully addressed. There is still a lack of existing literature evaluating the comparisons of patient satisfaction outcomes between telemedicine and face-to-face care in general (i.e. Hatcher-Martin et al., 2020). Understanding such motivations and concerns is crucial to finding the best way to promote telemedicine services for women’s health. We thus propose two research questions:
RQ1: What are the current attitudes of women toward purchasing birth control online?
RQ2: What are the concerns that women face when it comes to purchasing birth control online?
Theory of Planned Behavior and Mail-Order Birth Control
Along with exploring attitudes and concerns of using mail-order birth control, the current study applies the theory of planned behavior (TPB) to explain the psychological decision-making process of purchasing birth control online. The theory of planned behavior (Ajzen, 1985) has helped us understand the determinants of health practices. The theory is often used to determine what leads people to certain health behaviors (Fishbein & Ajzen, 2010). Thus, it offers the best key to understanding why women may choose to use mail-order birth control. The key components of the TPB, the background factors, attitudes, norms, and barriers involved in purchasing birth control online, are observed.
Regarding background factors, Fishbein and Ajzen (2010) note that situational and socio-demographic variables must be taken into consideration to behaviors. These factors influence humans’ beliefs and values in the world, which lead to forming one’s attitudes, perceived norms, and behavioral control. In the case of mail-order birth control, age, education level or competency of internet use could shape women’s belief toward the idea of purchasing birth control online.
Attitude refers to an emotional entity that one has toward behavior in terms of favorability (Fishbein, 2008), and it has immediate influence over human behavior (e.g. McMillan & Conner, 2003). Attitude is formed with situational factors, geographical factors, beliefs, and values. For example, a woman’s culture or situational upbringing may influence her attitudes toward the use of birth control pills. These factors may also form her attitude toward purchasing mail-order birth control. Thus, we propose the following hypothesis.
H3: Women’s attitude toward (a) birth control and (b) mail-order birth control will be positively associated with their intention to purchase birth control online.
Second, the TPB framework demonstrates that an individual’s adoption of a new behavior or system is influenced by norms - social pressures (e.g. McMillan & Conner, 2003; Paudyal et al., 2014; Seth et al., 2019). Purchasing birth control online could involve uncertainty. Therefore, approvals from her social environment (e.g. doctors, family, and friends, etc.) could function as an assurance to perceive the new method to be normal and acceptable. TPB typically provides three different types of norms that affect a behavioral intention (Fishbein, 2008): subjective, injunctive, and descriptive norm. Subjective norms refer to the degree to which one wants to behave like their peers. Injunctive norms refer to the perception that one believes those who are important to the individual would approve of their behaviors. Descriptive norms refer to the extent that one perceives others would behave in a given situation. These norm types can help determine how women want to be similar to and approved by their peers in terms of the adoption of mail-order birth control. Thus, we introduce the following hypothesis.
H4: Women’s (a) subjective norms, (b) injunctive norms, and (c) descriptive norms vis à vis mail-order birth control will be positively associated with their intention to purchase birth control online.
Lastly, barriers are addressed as the third component of TPB. Arguably, addressing barriers illustrate perceived behavioral control indirectly. Perceived behavioral control refers to an individual’s perception of his/her ability to perform a given behavior, and it is mostly affected by resource or environmental constraints (Fishbein, 2008). For example, Tseng et al. (2017) notes on their smoking cessation behavior research that perceived behavior control can be reinforced by persuading smokers that they can overcome cessation barriers. Regarding birth control purchase, many barriers discourage women to access birth control. Women may face situational barriers (i.e., lack of transportation or scheduling difficulties), financial barriers (i.e., insurance coverage or pill price, etc.), or geographical barriers (i.e., distance to the doctor’s office). Those barriers indeed could turn into motivating factors for women to switch to use mail-order birth control. Therefore, we developed the following hypothesis.
H5: Women’s (a) perceived barriers to visiting a doctor’s office, (b) financial barriers (insurance coverage of birth control), and (c) geographical barriers (distance to doctor’s office) will be positively associated with their intention to purchase birth control online.
Methods
Online Survey
We conducted an online survey through Qualtrics and Amazon’s Mechanical Turk (MTurk) online panel to recruit research participants. We provided participants with informed consent forms at the beginning of the survey and offered them small incentives as compensation through the MTurk system at the end of the survey. Participants spent 10.78 minutes on average completing the survey.
Sampling Procedure
The survey targeted women aged 18 to 44 because this is regarded as the average reproductive age for women (Guttmacher Institute, 2020). We chose all twelve states in the Midwest (North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri, Wisconsin, Illinois, Michigan, Indiana, and Ohio) and three in the South (Alabama, Texas, and North Carolina). The Midwest is identified as a contraception desert regarding the number of clinics providing birth control (Power to Decide, 2019). Alabama has reportedly the lowest number of such clinics among all southern states. Over 300,000 women in Alabama are in need of birth control, however, only 17 clinics offer it (Power to Decide, 2019). Texas was selected for the study because it is often cited as an example of a contraception desert by the mass media (McClurg & Lopez, 2018). It is the largest state in the South in terms of territory and population and has a moderate number of health clinics across its territory: 401 clinics for 1,700,000 plus women who need contraception. Some counties have multiple clinics, some a few, and some none at all (Power to Decide, 2019). Lastly, North Carolina was chosen due to the disparity in healthcare access between its rural and urban areas (Power to Decide, 2019).
Sample
A total of 603 participants were recruited in February and March of 2020, of whom 177 (29.4%) reside in Texas, 113 in North Carolina (18.7%), 36 in Alabama (6%), and 337 in the twelve Midwestern states (55.9%). Women at the age of 18 to 44 were invited to the survey. Their median age range was 30-34 years old, while their median income fell in the $50,000 - $74,999 range. The average education level was a four-year college degree (SD= .92). 72.4% (n=435) of the sample identified themselves as Caucasian.
Supplemental Interviews
We conducted five phone interviews as a supplement. An optional question in the survey asked them to leave their contact information for a follow-up interview in which they could share their story and experience. Phone interviews were conducted and audio recorded with the participants’ consent. Semi-structured open-ended questions were asked regarding the interviewees’ current living situations, the barriers they face when trying to obtain birth control, their knowledge and use of contraceptives, their attitudes toward mail-order birth control, and their attitude, knowledge, and use of telemedicine. A $20 Amazon gift card was mailed to each interviewee after the interview. Interviewees spent about 25 minutes on average completing the interviews.
Measures
A total of 603 participants were recruited in February and March of 2020, of whom 177 Purchase intention of mail-order birth control. The purchase intention consists of a single item on a 7-point Likert scale: I would use an online birth control service in the next three months: M = 4.19, SD= 2.03, α = not applicable (n/a).
Perceived comfort level of using telemedicine. Three 7-point scale statements were used to measure perceived comfort level of using telemedicine tools: I would feel comfortable receiving medical treatment from an online doctor via (a) phone call, (b) text chat, and (c) video chat (M=4.80, SD=1.49; α= .855).
The scope of telemedicine experience. This was calculated as the sum of three dichotomous items, as follows: Within the last 12 months, (a) I have used online websites to receive medical treatment or prescriptions, (b) I have sent or received a text message from a doctor or other healthcare professional, (c) I have shared health information from either an electronic monitoring device or smartphone with a health professional: 0= no 1= yes, a summation of the scope ranges from 0 to 3, M=1.32, SD=1.08, α = n/a.
Attitude toward birth control. We adopted six 7-point scale items from Terry and O’Leary (1995) and edited the wording according to the purposes of our study: Taking hormonal contraceptives would be (a) bad - good, (b) unpleasant - pleasant, (c) inconvenient - convenient, (d) not reliable - reliable (e) not affordable - affordable, and (f) uncomfortable - comfortable: M= 4.98, SD=1.35, α= .871.
Attitude toward mail-order birth control. The statements about the attitude toward birth control were reused, but the options asked respondents about their attitudes toward mail-order birth control: M=5.61, SD=1.26, α= .892.
Subjective, injunctive & descriptive norm toward mail-order birth control. Each of the three statements was used to measure the subjective norm, injunctive norm and descriptive norm respectively on a 7-point Likert scale (Ajzen, 2006): When it comes to matters of purchasing birth control online, I want to be like my friends (subjective norm: M=3.38, SD=1.77, α= n/a), most people who are important to me (my doctors, parents, friends, significant other) would approve of me purchasing birth control online (injunctive norm: M=5.18, SD=1.58, α= n/a), and most people like me would purchase birth control online (descriptive norm: M=5.20, SD=1.56, α= n/a).
Perceived barrier to visiting the doctor’s office to get a birth control prescription. Three 7-point Likert scale statements were used with reversed coding: (a) I have time to get to a doctor’s office when needed, (b) My doctor’s office is open when I am available, (c) I can manage my schedule when I need to visit a doctor’s office, ranging from 1 (strongly disagree) to 7 (strongly agree). Later, the score was reversed to have higher scores indicate the larger perceived barriers (M=1.88; SD=1.39; α=.903).
Barrier: insurance coverage. One dichotomous item asked whether the respondent had insurance that covers birth control: 0= covered (n=434, 72%), 1 = not covered (n=169, 28%).
Barrier: distance to doctor’s office. One dichotomous item asked whether the respondent lived within 15 miles of her doctor’s office: 0= within 15 miles (n=552, 91.5%), 1 = more than 15 miles (n=44, 7.4%).
Covariables. Controlling variables were listed as follows: self-rated overall internet skill, prior experience using mail-order birth control, age, education, and income. The overall internet skill was measured with a single Likert scale item, ranging from 1= poor to 7= excellent (M=6.39, SD=.856). Prior experience of mail-order birth control was measured with a dichotomous item asking whether the respondent had used mail-order birth control in the past 12 months: 0=no, 1=yes (n=98, 16.3%). Descriptive statistics results concerning age, education, and income status were reported in the sample section above.
Advantages and disadvantages of using mail-order birth control. Our research team asked three open-ended questions to address what the survey participants would think about advantages, disadvantages and concerns with mail-order birth control as follows: What do you see as the advantages of prescribing your birth control online for a year? What do you see as the disadvantages of prescribing your birth control online for a year? And, what else comes to your mind when you think of prescribing your birth control online for a year?
Results
A hierarchical regression analysis was used to test the hypotheses. Participants’ age, education, internet skills, and prior experience with mail-order birth control were controlled in the regression analysis. H1 addresses how the perceived comfort level of telemedicine is associated with the intention to purchase birth control online. As seen in Table 1, women’s positive perception of telecommunication tools is associated with their intention to purchase birth control online (β=.360, p< .001). H2 addresses how the prior experience with telemedicine services affects the intention to purchase mail-order birth control. The regression analysis shows that the scope of telemedicine experience has a positive impact on the intention to purchase (β=.143, p<.01). In summary, perceived comfort level and prior trials of telemedicine services determine women’s interest to purchase mail-order birth control.
H3a and H3b examine the impact of women’s attitude toward birth control and mail-order birth control on their intention to purchase mail-order birth control. Both attitudes (βAttitude toward birth control=.234, p<.001; βAttitude toward mail-order birth control=.370, p<.001) are positively associated with the intention to purchase. H4s address the impacts of perceived norms on the intention to purchase. All three norms - subjective (β=.234, p<.001), injunctive (β=.189, p<.001), and descriptive (β =.154, p<.01) - are positively associated with the intention to purchase mail-order birth control. H5s address the relationship between women’s perceived barriers to accessing health care services and their intention to purchase mail-order birth control. The hierarchical regression analysis showed that when women find visiting a doctor’s office inconvenient, they are more likely to show intent to purchase birth control online (β =.083, p<.05). However, insurance coverage (β=.025, p= n.s.) and distance to a doctor’s office (β=-.029, p= n.s.) do not affect women’s intention to purchase birth control. Therefore, the data confirmed only H5a, and rejected H5b and H5c.
RQ1 explores women’s attitudes toward mail-order birth control. Two open-ended questions investigate the advantages and disadvantages of using mail-order birth control. The results reveal interesting findings (Table 2). In particular, one aspect of the service is perceived as both an advantage and a disadvantage. For example, 464 respondents admit that mail-order birth control would be convenient (n=464; 82.6%) and that they would enjoy it because they would not need to visit a doctor’s office to renew their birth control prescription (n=73; 13%). One interviewee describes her situation as follows:
[Interviewee #5] Yeah. You know the normal stuff: work, kids. Trying to schedule everything and everything going on… when you're going into a doctor, it's hard because a lot of the times, my son is the one that's homeschooled. So I can't take them back in the room with me. So then I have to have him sit in the waiting room, and I have to make sure he's entertained. And I have to ask the receptionist, can you keep an eye on him because he's a little too young? It's very inconvenient.
However, the disadvantage, according to respondents, is not having a consultation with a doctor (n=92; 18.3%), which they feel would be the downside of the telemedicine service. Similarly, although women perceive the mail-order birth control as more affordable than the pills prescribed by a doctor (n=74; 13.2%), many of them point to insurance coverage, the upfront cost of the order, and shipping as the disadvantages of mail-order birth control. The new online service would protect women’s privacy from doctors and pharmacists (n=49; 8.7%). However, respondents also express concern about health information security in an online environment and see this as a disadvantage (n=16; 3.1%). In summary, women’s attitude toward mail-order birth control is complex. The new telemedicine service offers women opportunities but also comes with risks.
Regarding the concerns that women would have with the use of mail-order birth control (RQ2), most respondents mention financial issues, such as the price of the products and insurance coverage (n=107; 32.6%). To some extent, this contradicts the H5b test result. However, it is conceivable that financial elements such as insurance support and out-of-pocket costs play a key role in encouraging women to try the new telemedicine service. Reliability (n=78; 23.8%) and trustworthiness of telemedicine services and product safety (n=31; 9.5%) are among the main barriers. Another noticeable barrier is disapproval from family or peers (n=38; 11.6%). Although using birth control is a highly personal matter, respondents care about the approval of their reference groups, which is consistent with what the theory of planned behavior concludes about decision-making processes and human behavior. The interviewees’ reactions nonetheless reveal subtle differences:
[Interviewee #2] I doubt they would ever know but I don't think they'd mind if I did. Since they know my work schedule and I'm driving all the time, this thing here in this thing here, you get a lot of stuff mailed. They would understand.
[Interviewee #3] I think my friends would be fine with it. I don't know about my family. I probably wouldn't tell them.
[Interviewee #5] Actually, their opinion doesn't matter. Yeah I mean not to be rude but yeah. I wouldn't even listen to my sisters. Something like that comes down to the couple.
Discussion
The current study advances our understanding of mail-order birth control and women’s attitudes and norms when obtaining a prescription for hormonal contraceptives online. The theory of planned behavior framework provides a clear picture of attitudes, norms, barriers, and comfort levels related to the use of birth control and ordering it online. This study demonstrates several implications on women’s access to birth control online.
First, telemedicine plays a large role in the study as does understanding women’s perceived comfort levels when communicating with doctors online. Our study finds that women who have previously used telemedicine services or who feel comfortable talking to doctors online are more likely to purchase birth control online. This finding indicates that prior experience matters when it comes to comfort levels and likeliness to order from online doctors. According to the diffusion of innovation theory (Rogers, 2003), the adoption of a new idea or behavior in a social system is a process whereby some people are more apt to adopt the innovation than others. Telemedicine is a relatively new idea of healthcare services, and diffusion of the idea is initiated by a few innovators. Early adopters embrace change opportunities and feel comfortable adopting new services. Thus, experiences of telemedicine services that such early adopters embrace can reduce uncertainty and risks on the patients' end and fosters her confidence in telemedicine (i.e. Cranen et al, 2011; Ranganathan & Balaji, 2020).
However, certain states do not allow doctors to prescribe hormonal contraception without a face-to-face visit. Fischer (2020) reported that at least five states have restrictions on telemedicine, which makes it difficult for women to receive a prescription for their birth control. During the COVID-19 pandemic, some state regulations are altering health policies and insurance plans to better cover patients’ telemedicine and birth control needs (Rafie, 2020). It would encourage more women to try telemedicine services and such experiences would change women’s perception toward telemedicine and mail-order birth control. Future studies need to address the adoption process of new healthcare services.
Second, we found women seek some levels of social approval to adopt a new healthcare method. Our quantitative data shows that the variables of attitudes and norms in the Theory of Planned Behavior confirm women’s intentions to use mail-order birth control. In particular, women’s subjective, injunctive, and descriptive norms all have an impact on their decisions (H4). However, the interviewees contradict the survey findings as many of them claim that their friends and family have little influence over their birth control decisions. They communicate about birth control use and types strictly with their face-to-face doctors. Such a discrepancy may indicate the complexity of the human decision-making process. As social beings, women may want approval from their peers regarding their decisions about birth control although they feel their decision is ultimately a personal matter. When adopting a new behavior, peer approval may serve as a safeguard that reduces risks and uncertainty. Therefore, health communicators or marketers, especially in pharmaceutical business for mail-order birth control services could help women make informed decisions by providing reliable customer reviews or building online communities.
Third, our survey finds that women with perceived barriers to visiting doctors’ offices, such as scheduling difficulties, indicate greater intention to use mail-order birth control (H5a). However, financial (H5b) and geographical (H5c) barriers appear to be not statistically significant for intentions. This contradicts the findings of the verbatim data presented in Table 2. The interviewees, all women living in rural areas, were vocal about the fact that financial and geographical barriers play a significant role in their ability to obtain a birth control prescription. The barriers lead them to express greater intention to purchase hormonal birth control online.
Such contradicting results are possibly caused by measurement issues. For financial barriers, we simply asked if the survey respondents have insurance and if it covers birth control without specifying to what extent their insurance covers contraceptives, how much out-of-pocket funds are used to pay for contraceptives, or to what extent their co-pay or time spent traveling to a doctor’s office is burdensome. Regarding geographical barriers, our survey asked if the respondents live within 15 miles near a medical facility that is open around their schedule. Public transportation availability, car ownership, or types of doctor’s office was not asked in the questionnaire. The measurement issue would have caused insignificant results. Future studies need to use more sophisticated measures in the survey design. Nonetheless, our results demonstrate that women deal with many challenges when obtaining a prescription for hormonal contraceptives.
Lastly, we should not ignore that many women showed concerns about the adverse effects of birth control pills (Table 2). Discussing this or switching means of birth control may be harder when communicating with online doctors. Mail-order birth control sellers provide online doctors, and purchases are made through consultation with online doctors. Some respondents, however, misunderstood that they can purchase hormonal birth control online without a doctor’s approval. Future studies need to address how thoroughly and accurately mail-order birth control providers display information regarding their drugs, the purchase procedure of birth control, and the availability of doctors online. Otherwise, women may be exposed to the detrimental side effects of improperly prescribed hormonal birth control pills (Riski et al., 2019).
Limitations and Suggestions for Future Studies
Several limitations are worthy of consideration for future research. First, the sample turned out to consist of slightly over 70% Caucasian women although we anticipated a higher Hispanic rate in Texas. This turnout may be due to the locations selected, such as the Midwest. Future research may want to consider recruiting a more diversified ethnic mix of respondents.
Second, the quality of interactions between women and their online or offline doctors goes beyond the scope of the study. Women with chronic health conditions may influence their trust level in physicians and intention to use telemedicine services. Future studies need to explore the reliability of online doctors on mail-order birth control websites. In the meantime, the role of telemarketers in facilitating communication and trust between patients and online doctors needs to be addressed to advance telemedicine services.
Lastly, different state health policies and insurance plans have been altered to better suit patients’ online care since COVID-19. Policy experts are identifying ways to express women’s sexual and reproductive health as essential health care by protecting and expanding access to health insurance coverage (Lindberg et al., 2020). Future studies need to examine how these alterations change women’s perceptions of mail-order birth control and telemedicine services. All these studies will mark new steps towards improving confidence in access to birth control and promoting women’s health.
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