A multi-stakeholder approach is needed to reduce the digital divide and encourage equitable access to telehealth

Abstract

Since the COVID-19 pandemic onset, there has been exponential growth in the uptake of telehealth, globally. However, evidence suggests that people living in lower socioeconomic areas, cultural and linguistically diverse communities, people with disabilities, and with low health literacy are less likely to receive telehealth services. These population groups have disproportionately higher health needs and face additional barriers to healthcare access. Barriers that reduce access to telehealth further exacerbate existing gaps in care delivery. To improve equity of access to telehealth, we need to reduce the digital divide through a multi-stakeholder approach. This article proposes practical steps to reduce the digital divide and encourage equitable access to telehealth. Enabling more equitable access to telehealth requires improvements in digital health literacy, workforce training in clinical telehealth, co-design of new telehealth-enabled models of care, change management, advocacy for culturally appropriate services, and sustainable funding models.

Keywords

COVID-19 pandemic Telehealth strategy stakeholders access equity digital divide consumer policy sustainability models of care

Background

In the right circumstances, telehealth can improve access to health services, reduce travel requirements, and improve responsiveness to care.^{1, 2} According to recent reviews, there is growing evidence supporting the clinical effectiveness and safety of telehealth when compared with conventional methods of service delivery.³ Although the use of telehealth has been reported for decades, its recognition worldwide has become much more prominent due to the 2019 coronavirus (COVID-19) pandemic.⁴ Telehealth is being increasingly integrated into primary care settings and specialist services, such as cardiology,⁵ pulmonology,⁶ and dermatology.⁷ These changes occurred globally and have been supported by increased funding and enhanced flexibility in how health services are remunerated.^8–10 However, the continued growth of telehealth depends on necessary changes in our health system.⁴

The transformation of various service models would not have occurred without changes in health policies (processes),⁹ funding policies (reimbursement),⁸ and communication strategies (training and public awareness). During the early phase of the pandemic, many countries such as the United States, the United Kingdom, and Australia temporarily relaxed funding eligibility requirements, resulting in substantial growth in telehealth uptake.¹¹ Substitution of in-person consultations and reporting of telehealth services (not normally remunerated) contributed to increases in activity.^8,12 However, there are reported concerns about the overall reach of telehealth services and reasons other than technological, which might delay or prohibit access.^10,13,14 In the right circumstances, telehealth can be used to improve access to services to under-resourced communities, but ironically, the equity problem may be further compromised when telehealth is also difficult to access.¹⁵

Telehealth inequity has been reported in the literature^16,17 and we believe there is a need for broad system change to achieve more equitable access to telehealth services. This article proposes a series of practical steps to improve access to telehealth services from a consumer, healthcare practitioner/clinician, health service, policy-maker, and researcher perspective.

The digital divide

The exponential growth in telehealth activity during the COVID-19 pandemic is a promising indication of how our health systems can provide more convenient and patient-centric services – but it should also serve as a warning. According to Watts, “any healthcare development that doesn't rapidly become available to all individuals has the unintended consequence of fuelling health inequality.”¹⁸

The benefits of telehealth are contingent on one's ability to access these services.¹⁰ People living in lower socioeconomic areas, cultural and linguistically diverse communities, people living with disabilities, and people with low health (and/or digital) literacy often experience difficulties accessing telehealth.¹⁵ Irrespective of modality, poor access to health services negatively impacts health outcomes, health-related quality of life, and health-related costs.¹³ Further, those who could benefit from telehealth most, tend to be from more vulnerable population groups and may be more likely to experience difficulties accessing telehealth.¹⁵ Studies have consistently described this phenomenon as the digital divide,¹⁵ representing a threat to equitable access to healthcare and social justice.

The digital divide is a complex construct reflecting the inability to access or benefit from emerging technologies (including telehealth).¹⁵ Access to digital health services (including telehealth) requires (1) the ability to use a technological device (digital literacy) and (2) access to the technical infrastructure required to support telehealth services.² Failure to address these requirements will almost certainly disadvantage certain groups who could benefit from telehealth.¹⁵ Failure to acknowledge the problem and address logistical factors may contribute to the widening gap in health care access.¹⁹

Achieving equitable access to telehealth

Addressing disparities derived from the digital divide is crucial to achieving equitable access to telehealth services.^13,20 Telehealth services are diverse and implemented in multiple settings, making it difficult to overcome the digital divide through linear thinking. As described by Yellowlees,²¹ enabling equitable access to telehealth services should involve more than just investment in telecommunications and communications technology.^14,22 A recent scoping review by Bailey et al.²³ included studies designed to address telehealth access barriers in populations with comorbidities, limited English proficiency, and from ethnically diverse populations. This review supports measures to ensure telehealth best practice including (1) patient-centred design of care, (2) culturally appropriate solutions, (3) trusted relations between care providers, and (4) confidentiality of patient information.²³ Bailey's review also highlights the need to promote policy-level changes to help with the uptake of telehealth services.²³ Specifically, they highlight the relevancy of involving multiple stakeholders to implement effective and culturally competent telehealth solutions addressing equitable access to healthcare.^23,24 Moreover, from a research perspective, it also highlights the need to explore the role of telehealth for underresourced population groups, specifically looking at clinical requirements, preferences, technology requirements, and other enablers which will support access to telehealth services.^24,25

Access to telehealth services can be affected by cultural and language barriers.²⁰ For people who do not speak English, language translation services should be incorporated into telehealth sessions to reduce communication barriers.²⁶ Designing culturally competent telehealth services will improve health outcomes²⁶ and access gaps.¹³ Cultural competence reflects the ability of the health system to provide healthcare, acknowledging the diversity of the population, including social, cultural, spiritual, and linguistic needs.²⁷ For example, Caffery et al.²⁸ reported that telehealth services could facilitate care provision when cultural competence is considered in the service design, particularly among Aboriginal and Torres Strait Islander peoples. The use of participatory design methods (co-design and user engagement) is a potential solution to plan cultural-competent telehealth services,^15,22 since this method has been reported to improve consumers’ satisfaction levels, engagement, and attendance rates.²⁹ However, to improve feasibility, codesign methods should also consider addressing the gaps in digital health literacy among consumers and telehealth practitioners.^29–31

To further achieve equitable access, we should consider providing support to consumers, practitioners, and health services managers and building capacity to design, implement, and access telehealth services.^32,33 This support will require raising awareness about telehealth benefits among consumers and specific training for practitioners to facilitate telehealth integration into routine practice.^4,32,33 In a recent study, Lawrence et al.³¹ discussed the positive impact of an adapted telemedicine-specific training program for medical residents. Their results highlighted how preparedness and confidence in using and recommending telehealth tools for consumers can be improved by capacity building.³¹ However, this study also acknowledged the need to explore how telemedicine-specific training programs can include people with diverse digital literacy.³¹ This means that practitioners’ telehealth training should appropriately consider societal and cultural factors to promote equitable access to telehealth.^31,33

Multiple equity access gaps are derived from the lack of funded telehealth services.^13,20 It seems that changes to telehealth funding arrangements around the world, has resulted in an increase in reported telehealth services^8,10 and some potential efficiencies (due to substitution of in-person services),³⁴ representing an opportunity to expand telehealth use to under-resourced populations.¹ However, multiple telehealth interventions would still benefit from sustained and improved funding policies.⁴ Bradford et al.¹ considered it essential for policy makers, (such as government agencies) to understand how telehealth can be integrated in new models of care, and what the resource implications (and associated costs) were likely to be. This will facilitate the integration of telehealth interventions into clinical practice and promote more equitable access to the health services.^1,4 Developing policies should support sustained funding to maintain telehealth provision,⁴ especially for people who may normally experience difficulties accessing healthcare (including telehealth).

Recommendations

For telehealth opportunities to be fully realised, we must address the obvious barriers experienced by people impacted by the digital divide. This process requires strategies to address multiple factors including acknowledgement that the digital divide exists, and its potential impact on telehealth access; improving the digital literacy of patients (knowledge of and ability to engage in telehealth services); customization of health services with consideration of patient needs; and training of health service staff to ensure that services are designed and implemented in accordance with clinical requirements and patient needs.

The literature supports developing culturally competent models to improve the delivery³⁵ and effectiveness^35,36 to promote equitable access to telehealth interventions. Across multiple studies, codesign, including engaging consumers,³⁷ caregivers, and practitioners, has been reported as key requirements for the planning and implementation of interventions which are culturally appropriate.^28,35,38 This will contribute to improving user experience, telehealth care delivery,²⁸ capacity building,³¹ and health literacy.³⁸

In Table 1, we summarize selected strategies for the various stakeholder groups; including consumers (patient and carers), consumer advocacy groups, health service staff (clinicians), health services (providers), policy-makers/funders, and researchers. We acknowledge that there are other stakeholders not represented in this table (such as industry), who have an important role in improving telehealth systems and capability.

Table 1.

Strategies to reduce the digital divide and increase access to telehealth.

Objective	Activities	Stakeholder/s
Increase consumer knowledge of telehealth	- Develop marketing and communication resources (in multiple languages) to encourage awareness and understanding of telehealth: What is telehealth? Examples of how telehealth can be used How to access telehealth? Telehealth expectations Practical tips for a telehealth consultation	Consumer advocacy groups; Health services; Researchers (teaching)
Ensure early and continuous consumer engagement in the design of telehealth services	- Co-design culturally competent services with consumers that meet consumer health and social needs. - Consider how consumer-reported experience measures can be built into services and how a wide range of consumers can complete these measures. - Offer incentives for consumer engagement to encourage collaboration and development of service models which best align with consumer needs and expectations.	Consumers; Health services; Health service staff; Researchers.
Increase access, use or adoption of technological devices	- Develop device loan schemes to support consumers who would benefit from telehealth interventions but do not have access to appropriate equipment. - Provide culturally appropriate information and services through technologies that fit consumers’ daily lives and consider variations in digital health literacy. - Introduce interactive technologies to promote active engagement and build self-management skills.	Health services; Health service staff; Policy-makers/funders.
Support language translation services to utili ze telehealth	- Invest in targeted translation programs and develop strategies that support delivering health services (including telehealth) to all consumers, irrespective of culture, language, location, and digital health literacy. - Proactively review and develop new service models using translation services in collaboration with all stakeholders, including the consumers.	Health services, Health services staff; Researchers.
Provide staff and consumer training	- Provide clinical telehealth training to all staff, ensuring a clear understanding that telehealth is a routine service made available to patients. Fundamentals of telehealth Practical use of telehealth and communication strategies Discipline-specific telehealth applications, evidence-based examples. Gaps in who is and is not accessing telehealth - Develop an evidence-base for telehealth-enabled services which specifically address the needs of people who experience difficulties accessing healthcare; with a focus on innovative models of care that are sustainable and patient-centric	Health services; Researchers
Ensure processes are in place to reduce inequity – such as access to technology, advocacy, translation services, appropriate education and training, and consumer and staff education.	- Provide clinical telehealth training to all staff, ensuring a clear understanding that telehealth is a routine service made available to patients. Fundamentals of telehealth Practical use of telehealth and communication strategies Discipline-specific telehealth applications, evidence-based examples. - Provide training to all staff to encourage awareness of equity issues. - Implement key performance indicators that demonstrate services’ reach and improvements in access to services for at-risk populations.	Health services; Researchers.
Ensure capacity to meet the health needs of all population groups, including at-risk populations.	- Allocate funding to support the planning and delivery of services to all populations, recognising that additional resources may be required to meet the needs of people who might experience challenges accessing health care. (e.g. translation services, culturally appropriate service guidelines, loan schemes). - Secure funding for projects which address equity of access to all health services (including telehealth); with a focus on: Patient experience Usability and acceptance Clinical effectiveness Cost-effectiveness - Implement strategies which permit low cost (or free) access to telecommunications and/or communications software and hardware (Internet, smartphones, camera etc) for eligible patients.	Health services; Health services staff; Researchers; Policy-makers/funders.
Encourage high-quality telehealth service models integrating cultural competence and equity of access.	- Develop policies and procedures which highlight the importance of promoting fair and equitable access to health services - Apply change management principles supporting the transition to innovative models of care.	Health services; Health services staff; Researchers; Policy-makers/funders.
Advocate for projects which prioriti ze under-resourced populations (e.g. culturally and linguistically diverse, low socio-economic, or low health literacy).	- Carry out research demonstrating existing limitations (opportunities for improvement) in the health sector associated with access to healthcare. - Contribute to the evidence required for policy decisions, such as funding for telehealth and incentives for telehealth uptake.	Researchers; Policy-makers/funders.

Conclusions

For decades, telehealth has been recognised as an effective way of improving equity of access to health services. Although telehealth adoption is rapidly increasing around the world, we need to be mindful that (for a variety of reasons) some people and population groups are unable to access telehealth services. As telehealth is integrated into mainstream practice, it is essential that we support a multistakeholder approach to reduce the digital divide. Actions will address digital health literacy, workforce training in clinical telehealth, codesign of new telehealth-enabled models of care, change management, advocacy for culturally appropriate services, and sustainable funding models which result in more equitable access to health services, including telehealth.

Footnotes

Authors contributions

This piece was conceptualized by ACS. Literature search was conducted by VMGR. Manuscript was drafted by VMGR, EET, JTK and ACS. All authors critically reviewed the manuscript. All authors approved the final manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Heart Foundation of Australia, (grant number 105215, 106081). E.E.T. (105215) and J.T.K. (106081) are funded by fellowships from the National Heart Foundation of Australia.

ORCID iDs

Victor M Gallegos-Rejas

Emma E Thomas

Jaimon T Kelly

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