The lack of digital equipment as the primary barrier to teleconsultation in a socially deprived French department during the COVID-19 epidemic period

Abstract

Introduction

The digital transition is spreading throughout the healthcare field but is also subject to a digital divide. This study aimed to determine the factors associated with patients’ inability to carry out teleconsultations during the COVID-19 epidemic in a French hospital located in a disadvantaged area close to Paris.

Methodology

This study is a secondary analysis of the SocialCov study, a published monocentric case-control study conducted on patients hospitalized for COVID-19 and control patients hospitalized for another reason. Data regarding teleconsultation, socio-demographic characteristics, and health literacy level were collected using a hetero-administered questionnaire. Factors associated with the inability to conduct a teleconsultation were identified using univariate and multivariate logistic regression.

Results

Among 240 patients,142 (59%) were male, and 105 (44%) were aged >65 years. Overall, 163 (68%) reported their inability to carry out a teleconsultation including 125 (52%) due to the absence of suitable digital equipment. In multivariate analysis, lack of adequate digital equipment was associated with the inability to carry out a teleconsultation (adjusted odds ratio [aOR] = 15.5; 95% CI [6.3, 38.3]). A trend was also observed with age >65 years (aOR = 2.1; 95% CI [0.9, 5.0], p = 0.08) and the presence of a low health literacy (aOR = 2.4; 95% CI [0.9, 5.0], p = 0.08).

Conclusion

In a French socially deprived area, access to technological devices is the primary barrier to conducting teleconsultations during the COVID-19 epidemic. To avoid exacerbating the digital divide, specific solutions must be proposed to reach digitally distant populations, addressing both material and digital literacy aspects.

Keywords

Social deprivation digital literacy digital equipment literacy

Introduction

Digital technology is increasingly integrated into healthcare. The World Health Organization addressed the issue in 2019 by establishing its Digital Health Department.¹ The COVID-19 pandemic has forced people worldwide to stay confined, leading to a significant surge in teleconsultations to minimize travel and comply with lockdown measures.² While numerous studies have explored the acceptability and skills required for this form of consultation, few have combined data on socio-demographic factors, literacy, and patients’ digital technical resources.^3,4 Lack of digital access in healthcare exacerbates social health inequalities.^5,6 In France, Seine-Saint-Denis is the poorest district in the Paris area and has been particularly affected by COVID-19 in terms of mortality.⁷

The study aimed to determine the factors associated with patients’ inability to carry out teleconsultations during the COVID-19 epidemic among hospitalized patients.

Methodology

Study design

This study is an ancillary analysis of the SocialCov study, a single-center case-control study investigating the impact of social deprivation on COVID-19 among patients in Avicenne Hospital.⁸ It was conducted among patients hospitalized between 1 March and 31 October 2020, for COVID-19 (reverse transcriptase polymerase chain reaction [RT-PCR] severe acute respiratory syndrome-coronavirus 2 [SARS-CoV2] positive and/or suggestive lung computed tomography [CT] scan: cases) and control patients hospitalized for other reasons and with a negative RT-PCR for SARS-CoV2. Cases and controls were matched on age (10 years period) and sex. The recruitment of controls according to age and sex was thus adapted every 5 days according to the sex and age of the previously recruited cases. The ancillary study presented was based on data from the SocialCov study but had a different objective, which was to determine the factors associated with the ability to carry out a teleconsultation.

All patients included in the SocialCov study who completed the teleconsultation section were included in this analysis. A written information note was given to each patient and consent was obtained orally when the questionnaire was completed. The study was approved by the hospital's ethics committee with registration number (CLEA-2020-126).

Measures

During hospitalization, after consent and inclusion in the study, clinical study technicians and trained investigators asked patients questions directly and helped them complete the questionnaire (see the Appendix). Regarding teleconsultation, the following information was collected: “Have you already carried out a teleconsultation?”; “If you were offered one, would you feel capable of carrying out a teleconsultation?” and “If you were offered one, would you have the capacity to carry out a teleconsultation (computer, microphone, internet connection, and/or camera available)?” Social deprivation was assessed using the EPICES score, the most widely used validated score in France, with a threshold set at 30.17.⁹ It consists of 11 questions that assess several dimensions of this variable.¹⁰ Literacy was assessed using the single-item literacy screener (SILS) score, a single-question, easy-to-use measure.¹¹ It has been initially used to assess reading ability in general and is now used to identify low health literacy levels among patients. Subjects were asked if they needed help reading medical information, and should answer by: always (lowest health literacy level), often, sometimes, rarely, or never (best health literacy level).

Statistical analysis

Statistical analyses were performed using R studio software, version 2022.12.0. The data were presented in the form of categorical variables and expressed as numbers or percentages. According to the size of the population, the chi-squared test or Fisher's exact test was used to compare qualitative variables (Table 1). Factors associated with the inability to conduct teleconsultations were identified using univariate and multivariate logistic regression models. Variables with significance in univariate analysis (p < 0.05) were included in the multivariate model (Table 2).

Table 1.

Main characteristics of patients according to their ability to carry out a teleconsultation.

	Overall (n = 240)	Ability to carry out a teleconsultation (n = 77)	Inability to carry out a teleconsultation (n = 162)	P value
Hospitalization for COVID-19, n (%)	65 (27)	24 (31)	41 (25)	0.33^a
Male sex, n (%)	142 (59)	47 (61)	95 (58)	0.68^a
Age (years), n (%)				<0.01^b
18–25	9 (3)	4 (5)	5 (3)
26–45	50 (21)	25 (32)	25 (15)
45–65	75 (31)	28 (36)	47 (29)
65	105 (44)	20 (26)	85 (52)
Country of birth, n (%)				0.46^a
France or French overseas territories	108 (45)	37 (49)	71 (43)
Others	131 (55)	39 (51)	92 (56)
Employment status, n (%)				<0.01^a
Employed	65 (27)	31 (40)	34 (20)
Looking for a job	51 (21)	17 (22)	34 (20)
Retired or disabled due to illness	124 (52)	29 (38)	95 (60)
EPICES score, n (%)				<0.01^a
>30.2	176 (75)	47 (63)	129 (81)
Literacy (SILS), n (%)				<0.01^b
Never	153 (66)	91 (86)	62 (57)
Sometimes	16 (7)	15 (1)	1(9)
Rarely	11 (5)	8 (4)	3 (5)
Often	15 (6)	13 (3)	2 (8)
All the times	36 (16)	32 (5)	4 (20)
Numeric equipment, n (%)				<0.01^a
Yes	115 (48)	69 (90)	46 (28)
No	125 (52)	8 (10)	117 (72)

SILS: single-item literacy screener.

^aChi-squared test or ^bFisher's exact test was used to compare qualitative variables.

Table 2.

Factors associated with the inability to carry out a teleconsultation.

Factor	Univariate		Multivariate
	OR (95% CI)	P value	aOR (95% CI)	P value
Covid status	0.7 (0.4,1.3)	0.3	–	–
Female sex	1.1 (0.6, 1.9)	0.7	–	–
Age >65 years	3.1 (1.7, 5.7)	<0.01	2.1 (0.9, 5.0)	0.08
Country of birth	1.2 (0.7, 2.1)	0.5	–	–
Unemployment	2.5 (1.3, 5.3)	<0.01	1.12 (0.5, 2.6)	0.8
EPICES score >30	2.5 (1.3, 4.6)	<0.01	1.24 (0.6, 2.7)	0.6
Literacy (SILS)	5.6 (2.4, 13.1)	<0.01	2.43 (0.9, 5.0)	0.08
Suitable numeric equipment	22.0 (9.8, 49.2)	<0.01	15.5 (6.3, 38.3)	<0.001

SILS: single-item literacy screener; OR: odds ratio; aOR: adjusted OR.

Results

Table 1 displays the socio-demographic characteristics, literacy, and digital equipment in the study population. Among 240 patients (65 cases and 175 controls), 142 (59%) were male, and 105 (44%) were aged >65 years. The EPICES score was >30.2 (the precariousness threshold) for 176 patients (75%). The majority of patients, 131 (55%), were born aboard or in the French overseas territories. In the overall population, 163 (68%) reported their inability to carry out a teleconsultation. On the opposite, 77 (32%) patients reported being capable of conducting a teleconsultation, and 24 (10%) had already done so. For patients hospitalized for COVID-19, 41 (63%) reported that they were unable to perform a teleconsultation, and only 63 (91%) said they had already done so.

There was no significant difference in COVID-19 status. One hundred twenty-five patients (52%) did not have the necessary equipment for teleconsultation. Table 2 presents factors associated with the ability to conduct teleconsultations. In univariate analysis, the factors associated with the inability to conduct teleconsultations were age >65 years (crude odds ratio [cOR] = 3.1; 95% CI [1.7, 5.7], p < 0.001), unemployment (cOR = 2.5; 95% CI [1.3, 5.3], p < 0.001), EPICES score >30.2 (cOR = 2.5; 95% CI [1.3, 4.6], p < 0.001), low literacy level (cOR = 5.6; 95% CI [2.4, 13.1], p < 0.001) and lack of digital equipment (cOR = 21.9; 95% CI [9.8, 49.2], p < 0.001). Sex, country of birth, and COVID-19 status were not. In multivariate analysis, the only remaining associated factor was the lack of digital equipment (adjusted odds ratio [aOR] = 15.5; 95% CI [6.3, 38.3], p < 0.001). A trend was also observed with age >65 years (aOR = 2.1; 95% CI [0.9, 5.0], p = 0.08), and low health literacy level (aOR = 2.4; 95% CI [0.9, 5.0], p = 0.08).

Discussion

A lack of digital equipment was associated with the inability to conduct teleconsultations in both univariate and multivariate analyses, while age over 65 and low health literacy were significantly associated in univariate but only showed a trend in multivariate analysis.

Teleconsultation aims to allow a medical professional to provide a remote consultation to a patient via video transmission. The latest data from the French National Institute of Statistics showed that 91% of households had internet access.¹² In our study, 52% of patients reported a lack of equipment for teleconsultations. The lower figures in our study may be explained by either a lack of digital equipment or incomplete computer equipment (internet access but no camera or microphone on a computer), a population not representative of the French population (as indicated by our results using the EPICES score showing a high level of precariousness), or a possible underreporting due to a lack of knowledge about patients’ equipment. Logically, the absence of equipment appeared as the most crucial factor in multivariate analysis, aligning with literature findings in populations in the United States.¹³ These results are concerning, considering that France is considered a developed country according to the World Bank.¹⁴ Since adjustment for lack of equipment masked the association observed between difficulties in using teleconsultation and the patient's socio-demographic characteristics, we can legitimately assume that they represent mediating factors in the difficulty of using equipment.

Low health literacy level appeared associated with the inability to carry out a teleconsultation in univariate but was only a trend in multivariate analysis, possibly due to insufficient statistical power or overfitting. Since the present study is ancillary to the SocialCov study, which focuses more broadly on the impact of health literacy on COVID-19, the used score assessed health literacy rather than digital literacy.¹⁵ Although digital health literacy is a subset of health literacy, it evaluates different dimensions, highlighting a limitation of our study. The use of a digital literacy score might have revealed the association.

Age over 65 is associated with univariate analysis. These results align with previous studies..¹³ While some studies have shown satisfaction among elderly individuals with telemedicine, it was a specific context during the COVID-19 pandemic.¹⁶ Nevertheless, the authors noted a negative correlation between satisfaction with telemedicine and lower social and educational levels. Thus, intersectionality in digital medicine is a concept to consider because various markers of social vulnerability, whether related to discrimination or not, can overlap and interact.¹⁷

Our study found no differences according to country of birth, as reported for ethnicity.^18,19 The country of birth variable serves as a proxy for migration. A study reported lower digital literacy level scores among migrants with Arabic as their mother language compared to individuals with Swedish as their mother tongue.²⁰ It is worth noting that in this study, questionnaires were translated into Arabic, while in the SocialCov study, an online interpretation service was used for direct questionnaire understanding for allophone patients.

Despite the previously mentioned limitations, our study presents weighted results combining socio-demographic, literacy, and digital equipment data. Its uniqueness lies in the complementarity of these findings, emphasizing the importance of supporting the digital transition for populations remote from digital access. An interesting initiative in Seine-Saint-Denis involves deploying digital advisors to various users of public services.²¹ Inclusive co-participative research on the development of teleconsultation tools could also contribute to reducing these social health inequalities.

Conclusion

Patients’ lack of digital equipment appeared as the primary obstacle to conducting teleconsultations during the COVID-19 epidemic in a population of economically disadvantaged patients hospitalized in France. To avoid deepening social health inequalities and the digital divide, specific solutions need to be proposed for populations distant from digital access, both in terms of computer equipment and digital literacy. Digital health research should more broadly integrate intersectionality concepts.

Footnotes

Acknowledgements

We would like to thank GID (Groupe Infectiologie Digitale) members for their guidance in this research.

Contributorship

JGDB designed the study. JGDB managed the data collection. Data screening and extraction were performed by JGDB and AM. JGDB drafted the first versions of the manuscript. NV, OB, SM, CT, HC, FM, SB, and LD reviewed the final manuscript. All authors read and approved the final manuscript.

Declaration of conflicting interests

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

Ethical approval

The ethics committee of Avicenne Hospital approved this study (REC number: CLEA-2020-126).

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Est Ensemble Organization.

Guarantor

JGDB.

ORCID iDs

Jeanne Goupil de Bouillé

Nicolas Vignier

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