‘ Without support CALD patients will be left behind ’: A mixed-methods exploration of culturally and linguistically diverse (CALD) client perspectives of telehealth and those of their healthcare providers

Abstract

Introduction

The rapid adoption of telehealth during the global pandemic has the potential to widen disparities for culturally and linguistically diverse (CALD) consumers. We explored the perspectives and experiences of CALD consumers accessing telehealth during the global pandemic and those of their healthcare providers.

Methods

A multistakeholder mixed-methods study involving two parallel samples comprising consumer–participants (n = 56) and healthcare provider–participants (n = 81). Multicultural consumer–participants, recruited from consecutive referrals to Health Language Services for telehealth support, were assisted to complete two surveys (before and after their clinical telehealth appointment) in their preferred language. A purposive sample of consumer–participants was interviewed to understand their perceived barriers and enablers of successful telehealth consultations. Simultaneously, all healthcare providers within the local health district were eligible to participate in an online survey if they had provided telehealth care to a consumer during the recruitment period. Closed-ended responses were descriptively summarised, while open-ended responses and interview transcripts were analysed thematically.

Results

Despite 86% of consumer–participants inexperienced with telehealth, 80% achieved a successful appointment with a healthcare provider. Consumer perceptions were shaped by cultural and diagnostic concepts of legitimacy, in the context of known accessibility and technology literacy challenges. Healthcare provider perspectives were less favourable towards telehealth, with equity of healthcare delivery a major concern.

Discussion

Our findings highlight unintended consequences arising from a rapid transition to telehealth. Adopting collaborative approaches to the design and implementation of telehealth is imperative to mitigate health inequities faced by CALD communities and maximise their opportunity to realise potential health benefits associated with telehealth.

Keywords

Telehealth culturally and linguistically diverse consumer perspective healthcare provider perspective equity

Introduction

The COVID-19 pandemic has accelerated the adoption of telehealth across Australia and internationally, necessitated by the need to minimise the risk of virus exposure to health consumers and their carers.¹ Although evidence suggests telehealth is a safe and valid means of attending to consumers’ health needs,^2,3 the speed and universality within which it has been adopted in the last two years may have unintended consequences.^4–6 Without adequate consumer engagement and attention to the vulnerabilities of specific communities, such as those from culturally and linguistically diverse (CALD) backgrounds, the rapid transition to telehealth has the potential to widen healthcare disparities.^5,7–9

Extensive research has investigated consumer perspectives of telehealth and emphasised the importance of understanding the perspectives of potential users, and factors that influence their decisions to use digital technologies.^10,11 This is particularly important for CALD communities, who are known to experience intersectional disadvantages arising from socioeconomic, health literacy and language challenges.^5,12 Recent evidence suggests that CALD consumers are less likely than the wider population to have utilised or experienced a successful telehealth consultation during the pandemic.^13–15 Importantly, optimal strategies for enhancing telehealth experiences by CALD communities are largely unknown, although engagement of cultural healthcare workers and the adoption of culturally sensitive practices by services have been recommended.^9,16–18 It is important to understand the perspectives and experiences of consumers from CALD backgrounds towards telehealth if effective service models are to be developed and sustained beyond the current pandemic. The paucity of research exploring CALD perspectives of telehealth and those of their healthcare providers (HCPs) has, therefore, provided an opportunity to address an important evidence gap.

This study was situated in a local health district in South Western Sydney that provides approximately 1 million scheduled consultations a year^19,20 to a highly multicultural population with more than half the population born overseas and 10% with limited English proficiency.^19,21 In 2020, the COVID-19 pandemic necessitated a rapid adoption of virtual models of care,²² creating a natural opportunity to document the experiences of CALD consumer and their HCPs. Thus, using a mixed-methods design, our study sought to 1) explore the perspectives of a CALD sample of consumers towards telehealth before and after their clinical telehealth consultation; 2) identify barriers and enablers towards successful telehealth adoption by CALD consumers; and 3) document the perspectives of HCPs providing telehealth for CALD consumers during the COVID-19 pandemic.

Methods

Study design and participants

A prospective multi-stakeholder convergent mixed-methods design involving two parallel surveys of CALD consumers and HCPs (phase one) and in-depth semi-structured interviews with CALD consumers (phase two) exploring their experiences using telehealth. A constructivist–interpretative epistemological position framed the qualitative and interpretive elements,²³ while a merging approach was used in the analysis phase as the datasets were synthesised.²⁴

Consumer–participants were identified from consecutive referrals to the district Multicultural Health Service for telehealth connection support between March and December 2021. Participants were eligible for inclusion if they were aged ≥ 18 years, self-identified as belonging to a CALD community and spoke Arabic, Assyrian, Vietnamese or Spanish, and were able to give verbal consent in their preferred language. HCP–participants were recruited via a district-wide survey link, snowball sampling and clinician-referrals to the district Multicultural Health Service. HCP–participants were eligible for inclusion if they worked in SWSLHD and had provided telehealth services to a CALD client within the study recruitment period. HCP consent was implied by the completion and submission of the survey online. SWSLHD Human Research Ethics Committee provided ethical approval for this study (2020/ETH02637).

Phase 1: Survey data collection

Two customised separate surveys (consumer and HCP survey) were created by the research team with questions derived from previous research^17,25–27 (Appendix 1). The consumer survey comprised a pre-appointment component, to capture prior experience with telehealth and perceived barriers (Appendix 1A), and a post-appointment component (Appendix 1B) that explored items adapted from Mooi et al.²⁵ In the post-assessment survey, telehealth appointments were coded as successful (achievement of a video connection between a patient and HCP) or unsuccessful (inability to achieve a video link, resolve technology issues or the participant abandoning the process). Open-ended questions explored challenges encountered by unsuccessful participants, while successful participants were asked about their experiences using telehealth according to four topic areas (consultation quality, interaction with the HCP, acceptability and future presence and overall satisfaction) on a five-point Likert scale with anchors from strongly agree to strongly disagree.²⁵ The survey designed by Mooi et al.²⁵ was selected because it had been specifically designed to capture responses from a specific cultural group (Indigenous communities), by a researcher either via phone or videoconference and was readily adaptable to the target communities. Consumer–participant surveys were piloted with multicultural consumer volunteers, revised and administered by a multicultural health officer over the phone or virtually.

The healthcare provider survey was adapted from the survey published by Cottrell et al.²⁸ and contained three parts outlined in Figure 1 and Appendix 1C. This previously established survey was selected because it aligned with our intention to capture HCPs’ knowledge, confidence, acceptance and satisfaction towards telehealth.²⁸ Although formal validation studies have not been performed on this survey, it was derived from qualitative research findings,²⁹ grounded in theoretical constructs that underpin the use of technology in the workplace³⁰ and was reported as easy to complete in our pilot testing with a sample of five healthcare providers. All healthcare provider surveys were completed online via REDcap.^31,32

Figure 1.

Study outline.

Phase 2: Semi-structured interviews

A purposive sampling technique,³³ comprising those who were successful and unsuccessful and a range of sociodemographic characteristics, identified consumer survey respondents who may provide diverse perspectives on their telehealth experience. Semi-structured individual interviews were conducted with consenting consumer–participants between June and November 2020 in the participant's preferred language by an experienced and trained multicultural health officer (PG, TN and HL) or a clinician–researcher (BB) utilising an interpreter. A semi-structured interview guide was developed based on existing literature,^34,35 piloted and refined (Appendix 2). Interviews were conducted via phone or virtually, audio-recorded, translated and transcribed in English for analysis.

Data analysis

As the number of healthcare providers and CALD communities utilising telehealth for health consults in SWSLHD was unknown on commencement an a-priori sample size calculation was not performed. Rather, we sought to maximise the potential to reach CALD consumers by recruiting from SWSLHD language support services. The sample size for the qualitative phase was guided by concurrent data collection and analysis that informed the point at which sufficient depth of information had been obtained from the interviews, and a sample adequate for theoretical sufficiency was achieved.³⁶

Data collected from the consumer–participants and HCPs were analysed separately. Descriptive statistics were used to summarise the data. Responses to free-text questions contained in both consumer- and HCP–participant surveys underwent qualitative content analysis,³⁷ with double coding performed by a team of four researchers (BB, GS, TT and PG). Responses were independently read and coded to yield a list of topics and patterns of ideas inductively generated. Codes were then organised into categories and combined with similar ideas to form the most prominent and recurring themes. The analysis was discussed with all members of the research team so that different perspectives could be considered, and personal biases or preconceptions reflected during the analysis.

Interview transcripts were analysed separately using reflexive inductive thematic analysis.^38,39 All transcripts were read and analysed using line-by-line open coding by two authors independently. The analysis team was led by the first author (BB), a clinical research fellow experienced in qualitative analysis and members of the multicultural team (GS, PG and TN). Initially, open coding was conducted manually by the team and subsequently imported into the NVivo 12 software package⁴⁰ for further data management. From there, all codes were evaluated and reorganised, and connections between codes were identified to develop initial themes. Themes were reviewed and refined using an iterative process across the team until the team was satisfied; and the primary overarching ideas were well-formulated.

Merging of the quantitative and qualitative data sources was conducted using side-by-side comparisons to explore the alignment of quantitative appraisals of consumer–participant experiences with the personal perceptions interpreted from the content and thematic analyses.⁴¹ These components were then integrated in the discussion to allow the comparison and communication of congruent and divergent interpretations.

Results

Consumer–participant characteristics

Figure 1 outlines participant progression through the study, including those consenting (n = 56), and participating in an interview (n = 19). The characteristics of participants included in the survey, and qualitative sub-cohort, are displayed in Table 1. Consumer–participants were predominantly middle-aged, receiving healthcare for a metabolic (32%) or physical condition (63%), with greater representation of consumer–participants from Arabic (46%) and Vietnamese (30%) cultural backgrounds. Despite 86% of consumer–participants reporting no prior experience with telehealth, 80% experienced a successful telehealth appointment with a healthcare provider. Unsuccessful appointments were attributed to technology incompatibility (n = 3), technology unfamiliarity (n = 3), inability to troubleshoot connection issues (n = 3) and an inability to achieve a video connection (n = 2).

Table 1.

Consumer–participant characteristics.

	Overall sample(n = 56)	Nested qualitative sample(n = 19)	Language sub-groups (n = 56)
	Overall sample(n = 56)	Nested qualitative sample(n = 19)	Arabic(n = 26)	Assyrian(n = 9)	Vietnamese(n = 17)	Spanish(n = 4)
Age (years), M (SD)	49 (13.5)	52 (13.7)	48 (9.2)	43 (17.4)	50 (14.2)	68 (12)
Gender, (n) Male: Female	20:36	7:12	13:13	2:7	4:13	1:3
Clinic attending, n (%)
Pain Ccinic	31 (55)	11	20	1	6	4
Diabetes/Dietetics	18 (32)	5	1	8	9	0
Physiotherapy	4 (7)	2	3	0	1	0
Lymphoedema	2 (4)	1	1	0	1	0
Neuropsychology	1 (2)	0	1	0	0	0
Used telehealth before, n (%)	8 (14%)	3	6	1	1	0
Technology available, n (%)
Smartphone	48 (85.5)	18	23	7	15	3
Tablet	1 (2)	0	0	1	0	0
Laptop/Computer	6 (10.5)	1	3	1	1	1
Unsure	1 (2)	0	0	0	1	0
Internet access, n (%)
In-home NBN/broadband	22 (39)	6	11	0	10	1
Mobile data	28 (50)	11	15	6	5	2
Unsure or no access	6 (11)	2	0	3	2	1
Success connecting, n (%)	45 (80)	14	23	6	13	0
Utilised connection resources provided, n (%)	20 (36)	7	11	1	8	0
Written resources	19 (34)	7	10	1	8	0
Video resources	7 (12.5)	3	5	1	1	0
Requested verbal connection support, n (%)	43 (77)	12	16	7	16	4

n: Number of participants; M: mean; SD: standard deviation.

Consumer–participant perceptions before and after a telehealth appointment

All participants were asked to reflect on their perceptions of telehealth and the degree to which they felt confident and supported using telehealth before a trial connection was conducted, and after their appointment with their HCP. Thematic content analysis revealed mixed perceptions of telehealth prior to commencement and was characterised by two key themes: ‘Legitimacy of Telehealth’ and ‘Technology Literacy’ (Table 2).

Table 2.

Themes characterising consumer–participant perceptions of telehealth before and after their appointment.

Theme	Description	Supporting quotes
Legitimacy of telehealth	Some perceived telehealth as a legitimate alternative to conventional care, especially in the context of a global pandemic. Legitimacy varied across cultural groups with over half Vietnamese participants endorsing telehealth as an alternative, while less than a quarter Arabic and no Spanish or Assyrian regarded it as appropriate. Legitimacy concerns focused on care equivalency and the nature of the complaint. Physical complaints were more likely to be perceived as unsuitable for telehealth.	‘it is not convenient to travel around, so telehealth is a good way for a health appointment’ (V13, 45 years) Vietnamese: ‘as long as I am clearly explained about my health condition and treatment and advices of how to take care of my health, than I am fine’ (V11, 27 years). ‘I really need to see someone face to face for my problem’ (S2, 56 years). ‘how they are going to treat me properly if they cannot see me?’ (A5, 56 years).
Technology Literacy	Experience with technology in other aspects of life, independent of age, underpinned willingness, and confidence to engage with telehealth. Experience, language, quality of resources and perceived health status underpinned hesitancy amongst inexperienced participants. Confidence and trust in the HCP motivated some inexperienced participants to try, while social support attenuated technology literacy challenges.	‘I don’t think it will be difficult, I use my phone for lots of things so I think I will be able to do this no problem’ (AR11, 44 years) ‘‘I am often utilising apps on my phone… I do not have any difficulties’ (V6, 62 years) it is hard to follow and I have no knowledge of this’ (AR21, 62 years) ‘I will also be worried due to language barrier, or internet may not work well on my appointment time’ (Vietnamese 3, 70 years) ‘my memory is a problem so even if you tell me, I may forget about it’ (S1, 78 years). ‘they are trying very hard to help us during this time’ (AR3, 46 years) ‘I cannot do this by myself… Even I don’t use my phone, I don’t know what to do, but my daughter lives with me and can help me, if you explain to her’ (AR5, 56 years).
Therapeutic Interpersonal Connectivity	Telehealth was considered by critics as deficient in allowing participants to establish therapeutic connectivity with their HCPs. ‘Touch’, ‘body language’ and ‘natural’ settings were considered important missing elements. Participants felt trust and rapport were difficult to establish without a face-to-face meeting.	‘they can not see you properly on the telehealth. Like some time you may not be able to explain the problem but then they can touch or feel the problem’ (AR11, 44 years) ‘I feel more confident and natural when meeting them’ (V15, 50 years). ‘I didn’t even see the person first and so it is hard to tell them things when you don’t see them first. So I didn’t, I don’t feel I could be completely honest with them’ (AR5, 56 years).
Self-efficacy	There was a continuum of self-efficacy related to engaging with telehealth ranging from those hamstrung by perceived compounding challenges to those who approached challenges with psychological flexibility.	Overwhelmed by compounding health challenges: ‘I am very scared… my knees and my back are getting worse and no-one is helping me… nothing is working, I don’t know what to do’ S1, 78 years) ‘I really need to see someone face to face for my problem. I don’t think I can do the telehealth; it is too much for me with my problems’ (S2, 56 years). Psychological flexibility and willingness: ‘If I use it more often, then I get used to it’ (V16, 53 years)

Note: Letter and number correspond to the language subgroup and participant number.

V: Vietnamese; AR: Arabic; A: Assyrian, S: Spanish; HCP: healthcare provider.

Importantly, cultural background and social support, such as the presence of a younger family member, appeared to influence perceptions around the value of telehealth (Table 2). Before the telehealth connection less than half the participants rated themselves as optimally supported and confident (42% and 47%, respectively; Figure 2).

Figure 2.

Consumer participants ratings of support and confidence before and after a telehealth consult.

Following the pre-appointment survey, all participants were offered support by a multicultural health officer to familiarise themselves with the technology and trial a connection prior to their clinical telehealth appointment. Despite translated written instructions and in-language videos provided to participants, only 36% accessed these resources. Rather, 77% requested verbal guidance from a multicultural health officer as their preferred form of support. Following the trial attempt, eight participants (14%) declined continuing to a telehealth appointment with their healthcare provider, with difficulties connecting, feeling overwhelmed (‘the stress is not good for me’, Spanish 2, 56 years) and a lack of confidence (‘I am not confident to do this at all. I don’t want to do it now’, Vietnamese 17, 62 years) cited as explanations.

Following the telehealth appointment, participant confidence and feelings of support shifted towards a more positive orientation with 61% considering themselves optimally supported and 52% optimally confident. Figure 3 displays key responses to five broad areas that required participants to rate their experience. Overall, participant responses were favourable towards telehealth, with over 85% more confident using telehealth following their consultation, 90% feeling they could establish sufficient rapport with their HCP and three-quarters satisfied with the care they received via telehealth. Although 76% would consider using telehealth for future appointments, 80% reported a preference for an in-person appointment before a telehealth appointment is trialled in future. Importantly, a health language interpreter was utilised in 96% of these consultations (70% via video; 30 via audio only). Content analysis of open-ended participant responses identified themes of ‘Therapeutic interpersonal connectivity’ and ‘Self-efficacy’ as characterising those who were critical versus receptive to telehealth following their health appointment (Table 2).

Figure 3.

Consumer provider–participant survey results.

Consumer–participant reflections on barriers and enablers for the use of telehealth

The in-depth interviews provided the opportunity to explore key barriers and enablers to using telehealth from those who were successful (n = 13) and those who were unsuccessful (n = 6). Four key themes were understood from the analysis of participant experiences, defined as ‘life complexity’, ‘accessibility’, ‘the role of the pandemic’ and ‘experiences consolidating or challenging preconceptions’.

‘Life complexity’ was an important element that influenced a person's perceived success with telehealth, and their future intentions towards its use. This encompassed competing demands, perceived psychological health, comorbid conditions/impairments and economic pressures with supporting quotes outlined in Table 3. Importantly, self-efficacy appeared to influence the degree to which a person felt they had the capability to overcome challenges with those who did not successfully connect communicating a perceived lack of control over their circumstances (‘it is the situation, what can I do?’; Spanish 3, 79 years, unsuccessful).

Table 3.

Consumer–participant and HCP themes related to barriers and enablers to telehealth.

Participant	Category	Theme	Supporting quote
Consumer	Barrier	Life complexity	Competing demands: ‘I have a son who is disabled, so he doesn’t let me finish my, or be fully focused on an interview’ (AR19, 56 years, successful). Perceived psychological health: ‘I don’t like to do things that make me nervous. Like now, even giving you my email, I get nervous trying to find this and to read it and it make me like panic’ (S2, 56 years, unsuccessful) Comorbid conditions/impairments: ‘I was not able to watch some movements or read some on-screen words. I have ordered eyeglasses, but it will take time’ (AR10, 47 years, successful) Economic pressures: ‘I can't do it because I just, I got to pay so much already, just for the electricity now…it is nearly $300 just for myself…and it is too much’ (S1, 78 years, unsuccessful)
Consumer	Barrier & Enabler	Accessibility	Financial accessibility problems: ‘Many people cannot afford to buy devices to use’ (V2, 60 years, successful) Functionality of technology ‘my house is really in the bottom and the back, so it's really bad position for the reception, so sometimes the internet is really bad’ (AR11, 44 years, successful) Outdated resources: ‘I do have a computer on loan, but that is a bit old’ (S2, 56 years, unsuccessful) Practical support: ‘she [daughter] has to tell me how to use it. She takes me through the program so now I can use it myself’ (A7, successful) Familiarity with complimentary applications: ‘my wife is on Microsoft teams and my daughter used some Zoom.’ (AR11, 44 years, successful)
Consumer	Barrier & Enabler	Pandemic Influence	Appreciation: ‘the situation make us chose the different way to solve the problem… so that's a good choice from [hospital] to figure it out, some different way to help us out, like while at home. So yes, this is good’ (AR11, 44 years, successful). Safety and convenience: ‘it is safer to avoid the current virus’ (Arabic 5, 56 years, successful) and ‘I prefer to stay at home, because I have a health condition. I can’t take the risk’ (AR1, 43 years, successful) Reluctant motivator: ‘For now, because of Covid-19 and for the current situation we cannot go out for meetings and visiting hospital…if its possible to go and visit them it would be better….they do not know what my conditions are’ (A7, 40 years, successful) Barrier: ‘It is because I don’t know you…Because of the virus I have not seen you. So, because of that I am not – I don’t know how much I can open up with you if I see your faces [on the video]’ (A3, 33 years, unsuccessful)
Consumer	Barrier & Enabler	Experiences consolidating or challenging preconceptions	Consolidated positive perceptions of telehealth: ‘it was very clear. They were very professional, and it was nice I could see them as well’ (V18, 54 years, successful). ‘I learned how to treat headache, leg pain, also some exercises help strengthen the bones…now I acquired some experience [with telehealth], so whatever they recommend, I will do’ (AR1, 43 years successful). Challenged negative perceptions: ‘…now if I had to go to the hospital, I may just not go, especially that I don’t like to go out a lot’ (AR5, 56 years, successful) ‘I won’t say no to something anymore, after I tried the online physiotherapy, I changed my mind’ (AR1, 43 years, successful). Consolidated negative perceptions: ‘As for the session, this was not much except a bit of talk. And I was offered follow up but it is not at a suitable time for me. I am not happy’ (AR24, 45 years, successful). ‘I prefer to go to the hospital. When I went before, it was better’ (V18, 54 years, successful). ‘I prefer to go and see them. If my blood sugar remains like this, what will they tell me on the video? Have done all that I was advised with’ (A7, 40 years, successful).
HCP	Barrier	Inefficiency	Connectivity issues: ‘the patient I was treating spent half of the assessment linking into telehealth so was not efficient in assessment or treatment’ (P57) Reliability and validity of modified assessments: ‘I cannot adequately assess patients and do a physical examination’ (P74).
HCP	Barrier	Equity	Disadvantaged caused by inadequate technological resources ‘a smart phone as their device of choice is inadequate for effective health’ and ‘high quality internet is also a challenge’ (P64) Disadvantage caused by suboptimal communication: ‘CALD patients need face to face interpreters to build trust and rapport. Even with using phone interpreters it is difficult as reception is not good in hospital even using a work mobile. There is always connectivity issues. Patients are almost always Elderly cannot hear properly when using technology or do not engage’ (P28).

Note: Letter and number corresponds to the language subgroup and participant number.

V: Vietnamese; AR: Arabic; A: Assyrian, S: Spanish; HCP: healthcare provider.

‘Accessibility’: The availability of resources and the functionality of technology were important accessibility considerations for participants. Participants highlighted if you ‘lack the facilities as I mentioned, that's the obstacle’ (Vietnamese 6, 62 years, successful). Participants encountered issues with outdated devices hindering the effective use of telehealth applications, financial barriers and poor internet connectivity, with many relying on mobile data alone (Table 3, Supporting Quotes). Even amongst participants who had access, there were concerns regarding the performance of their technology with many highlighting issues encountered such as ‘I was disconnected from the video conference because the internet was slow and breakdown’ (Vietnamese 12, 44 years, successful). Two factors emerged as important for overcoming accessibility challenges. The first was the widespread societal adoption of virtual communication platforms such as ‘zoom’ and ‘teams’ that reduced apprehension associated with the sudden introduction of telehealth, while the second was the presence of practical support from a household member (Table 3).

‘The role of the pandemic’: The contextual circumstances of the global COVID-19 pandemic played both an enabling factor and a barrier to the successful use of telehealth. Overwhelmingly, participants agreed to trial telehealth because of the impact of government-mandated lockdown and health facility restrictions, with participants emphasising ‘only during these bad situations of Covid-19, it is helpful’ (Assyrian 5, 69 years, successful). In this context, the pandemic was considered a primary motivator for attempting an appointment in the first place, many of whom would otherwise not have considered it ‘I am not satisfied [to continue], it is just because of the covid epidemic right now I can’t see the doctor. If the epidemic ends later, I still want to see the doctor in person’ (Vietnamese 2, 60 years, successful). In some circumstances, the pandemic was also considered a psychological barrier to the successful use of telehealth with one participant reflecting ‘maybe if life will be back to normal, yes, I can do video call therapy, but now, after being in lockdown for all these months, I am fed up’ (Arabic 6, successful).

‘Experiences consolidating or challenging preconceptions’

This theme was characterised by the degree to which the experience of the telehealth appointment with the healthcare provider aligned with expectations and either consolidated or challenged preconceptions of the value of telehealth. Positive preconceptions of telehealth, predominantly amongst those with high self-efficacy and/or technology literacy (Table 2), were consolidated by the relatively easy and positive experience of connecting to their HCP. Where participants’ expectations were hesitant regarding telehealth, the experience with their HCP and the extent to which their concerns were addressed determined if their preconceptions were consolidated or changed. For example, if a participant was sceptical of the value of telehealth prior to the appointment (‘I didn’t want to do it at first’) and subsequently experienced a satisfactory outcome where ‘I really benefited from them and my health condition improved’ then their preconceived ideas were sufficiently challenged. In contrast, if the health consult was not perceived as a satisfactory response to their health complaint, then telehealth was regarded as a suboptimal alternative, and face-to-face alternatives were preferred (Table 3).

Healthcare provider attitudes towards and experiences with telehealth for CALD patients

Eighty-one HCP–participants from a variety of clinical professions and clinical areas responded to the survey online with valid responses. The characteristics of HCP–participants are displayed in Table 4. Eighty-eight percent of HCP–participants had not used telehealth prior to its adoption as a response to the global pandemic and over half were using telehealth for more than 50% of their clinical caseload. Importantly, HCP–participants reported using telehealth for CALD patients less often, with only 37% of participants using it for 50% of their clinical caseload with CALD patients. This is despite restrictions imposed on health services at the time of the survey limiting face-to-face appointments for all but the most urgent cases.

Table 4.

HCP–participant characteristics.


Clinical Role/Profession, n (%)	Sample(n = 81)
Physiotherapists	21 (26)
Medical specialists	15 (18)
Occupational therapists	10 (13)
Social workers	6 (7)
Dieticians	4 (5)
Nurse	3 (4)
Psychologist	2 (3)
Genetic counsellors	2 (2)
Other	18 (22)
Clinical area, n
Pain clinic	7
Diabetes/Dietetics	7
Physiotherapy	14
Occupational therapy	9
Cardiac services	3
Brain injury unit	5
Speech pathology	8
Social work	6
Lymphoedema clinic	3
Genetics clinics	5
Mental health	2
Cancer services	2
Aged care	2
Other	8
Used telehealth before, n (%)	10 (12.3)
Telehealth adopted as pandemic response, n (%)	71 (87.7)
Current use of telehealth (overall), n (%)
Majority of clinical time (≥80%)	28 (34.6)
Large proportion of clinical time (≥50; <80%)	17 (21)
Often (≥20; <50% of clinical time)	14 (17.3)
Infrequent (<20% of clinical time)	17 (25)
First appointment with telehealth	5 (6.2)
Use of telehealth with CALD patients, n (%)
Majority of clinical time (≥80%)	16 (19.8)
Large proportion of clinical time (≥50; <80%)	14 (17.3)
Often (≥20; <50% of clinical time)	18 (22.2)
Infrequent (<20% of clinical time)	27 (33.3)
First appointment with telehealth	6 (7.4)
Intent to use beyond pandemic restrictions, n (%)
Yes	21 (25.9)
No	27 (33.3)
Unsure	33 (40.7)

n: Number of participants; HCP: healthcare provider.

Other: Individual representation from Disability Services, Drug Health, Emergency Department, Hands Clinic, Renal Clinic, Antenatal Clinic, Immunology, and Respiratory Clinic.

Figure 4 displays HCP responses to survey items across four broad categories (overall impressions, quality and familiarity of resources, comparability with face-to-face and satisfaction with care). HCP–participant responses were mixed towards telehealth, with some considering it appropriate given the contextual circumstances of the Covid-19 pandemic and others expressing reservations about the clinical outcomes that can be achieved via telehealth (30%). Although just over half felt they were able to competently assess and/or treat CALD clients using telehealth, less were satisfied with the clinical outcomes achieved (44%) or the level of service they could provide to CALD patients (36%). In comparison to in-person appointments, HCPs perceived telehealth to be an inferior alternative overall (86%), which was time inefficient (42%), difficulty for CALD patients to follow clinical instructions (49%), and not able to achieve equivalent outcomes (60%). Combined, these perceptions of telehealth may explain the lower rates of telehealth adoption for CALD consumers compared to the wider population (Table 4).

Figure 4.

Healthcare provider–participant survey results.

Content analysis of HCP-opened responses about their experiences using telehealth with CALD clients demonstrated consistent repetition of two interrelated themes: ‘Inefficiency’, or the added time burden of supporting a patient to connect and/or conduct a modified assessment/treatment; and ‘Equity’ characterised by the delivery of care they deemed as of poorer quality because a patient did not have the technology, languages skills or health literacy to adequately engage in a telehealth appointment (Table 3).

Discussion

This mixed-methods study documents consumer and HCP perspectives on telehealth during a time of rapid and widespread adoption across the health system. Our findings highlight factors that influence consumer receptivity towards, and successful engagement with telehealth. These included perceived legitimacy, the therapeutic experience and known challenges with technology, accessibility and self-efficacy. Although consumer–participants were generally receptive towards telehealth, HCPs overwhelmingly communicated concerns about the universal adoption of telehealth and potential unintended consequences of amplifying health inequity. The combined perspectives are critical to consider in the future design of models of telehealth, as services and policymakers shift towards identifying opportunities for sustained utilisation.

Unintended consequences of access to care inequity and quality concerns are known to accompany a rapid transition to new technologies such as telehealth.^8,12,42 Consistent with previous research involving patients from low socioeconomic backgrounds, our findings highlighted multiple sources of vulnerability owing to the absence of optimal resources,^43–45 such as 86% of our sample relying on their mobile phone, and challenges with the speed of internet connectivity. Several US studies have documented that ethnic minorities and those with limited English proficiency had lower odds of completing telemedicine consultations successfully during the global pandemic.^13–15 Combined, these data suggest CALD communities can be disproportionately impacted by sudden changes in healthcare delivery. Future policy work and research should be focused towards addressing accessibility and resource disparities,⁵ potentially via the use of device loan schemes or broadening the availability of community WiFi networks,⁹ so the benefits of telehealth can be more equitably realised.

From a HCP perspective, known challenges in adapting clinical care to a virtual medium emerged. Consistent with a Cochrane review of health workers’ experiences using mobile health technologies,⁴⁶ a need for training, technical support and user-friendly interfaces was communicated. Interestingly, this was communicated despite the local health district providing a range of resources (written and audio-visual), formal training (webinar and online modules) and personnel support services to HCPs alongside their transition to telehealth. As such, specificity of training and resources may be needed, adapted for different professions and catering to the needs of those with diverse digital literacy.⁹ Alongside usability concerns, HCPs expressed concern that telehealth was accentuating healthcare disparities for CALD consumers, independent of accessibility. Even within technologically successful encounters, HCPs perceived their ability to deliver effective healthcare was constrained by the added complexities of cross-cultural encounters which they perceived to be accentuated by telehealth. As such, only a quarter of HCP participants intended to continue utilising telehealth beyond the pandemic response. For the benefits of telehealth to be realised beyond emergency response, models of care need to be revised and HCPs supported to experience the value of telehealth.^47,48 Understanding the specific contexts within which healthcare is delivered, co-designing telehealth models around acceptable changes to HCPs workflow and equipping the future workforce with the necessary skills to effectively engage with telehealth will support the integration of telehealth as ‘business as usual’.^47,48

An important message arising from both consumer and healthcare provider responses was the impact on the therapeutic relationship. Despite 90% of consumers rating the telehealth consultation as sufficient for establishing rapport, open-ended responses were less favourable. Telehealth was perceived by consumers and HCPs as an interruption to aspects of non-verbal communication and information exchange considered important for building trust and a working therapeutic relationship. The importance of non-verbal communication has been well documented and is especially important in cross-cultural encounters.^49,50 Although the use of accredited health language interpreters, as occurred for 96% of participants in this study, can enhance the accuracy of communication,⁵¹ they alone do not bridge cross-cultural communication gaps.⁵² As such, deliberate and targeted attention towards developing HCP screen etiquette skills to maximise their ‘tele-presence’, as has been recommended by previous research,^42,53,54 may be necessary to implement if models of telehealth are to be sustained beyond the current pandemic.

Alongside strategies to optimise HCP competence using telehealth, approaches that enhance digital literacy and address cultural misconceptions about telehealth are warranted. In our study, support provided by a multicultural health worker was an important element underpinning consumers’ confidence in attempting a telehealth consultation. Importantly, despite the availability of translated written and audio-visual resources, CALD consumers overwhelmingly preferred verbal guidance by an intermediary with whom they could relate or trust (77%). Perhaps this is not surprising given the documented benefit of multicultural community health workers or navigators for overcoming health literacy challenges amongst cultures with strong verbal and community traditions.^18,55,56 As such, future implementation models should consider strategies beyond translated materials and language support alone. Rather, the co-design of a multifaceted suite of options readily tailored to the preferences of users with diverse language, digital literacy and technology needs is warranted.⁹ Solutions could include support from bilingual community members, experienced in telehealth use, who can simultaneously address cultural misconceptions while also facilitating service navigation.¹⁸ Finally, embedding routine data collection that allows for evaluation of the consumer experience and highlights gaps in telehealth provision would allow services to be responsive to changing community needs and address any telehealth inequities as they arise.

Although our study reported on the experiences of diverse patients accessing telehealth, it should be interpreted in the context of its limitations. As our study was conducted alongside the rapid transition to telehealth, the heightened societal stress and mixed messaging around the pandemic may have influenced patients’ and HCP attitudes towards healthcare generally and may not be solely reflective of their experience with virtual care. Second, the population of consumer participants sampled only included those referred for health language support, and as such may not capture the experiences of those consumers from CALD backgrounds who may be more proficient in technology or those who did not seek healthcare during this time. Lastly, our sample was underpowered to adequately explore the breadth of health contexts and conditions for which telehealth was considered by CALD patients as an appropriate medium of healthcare delivery. Future research should consider exploring the influence specific diagnoses have on CALD patients’ preferences towards telehealth.

Conclusion

This study highlights opportunities for telehealth to be sustained as a future model of healthcare delivery for consumers from CALD backgrounds. Importantly, our findings caution against universal adoption of telehealth, with the potential to amplify healthcare disparities amongst vulnerable communities if not adequately tailored to their contexts. Rather, attention to critical factors underpinning consumer and HCP receptivity towards and success with telehealth described should be considered.

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X231154943 - Supplemental material for ‘Without support CALD patients will be left behind’: A mixed-methods exploration of culturally and linguistically diverse (CALD) client perspectives of telehealth and those of their healthcare providers

Supplemental material, sj-docx-1-jtt-10.1177_1357633X231154943 for ‘Without support CALD patients will be left behind’: A mixed-methods exploration of culturally and linguistically diverse (CALD) client perspectives of telehealth and those of their healthcare providers by Bernadette Brady, Golsa Saberi, Yvonne Santalucia, Paul Gorgees, Tran Thao Nguyen, Hien Le, and Balwinder Sidhu in Journal of Telemedicine and Telecare

Footnotes

Acknowledgements

The authors would like to acknowledge and thank the entire team at SWSLHD Health Language and Multicultural Health Services who supported this project and facilitated engagement of CALD communities. We would especially like to acknowledge the contribution of Tran Thao Nguyen, co-author who sadly passed away in 2022.

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: The first author is supported by a clinical research fellowship from the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE).

ORCID iD

Bernadette Brady

Supplemental material

Supplemental material for this article is available online.

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