Health equity related challenges and experiences during the rapid implementation of virtual care during COVID-19: a multiple case study.

BACKGROUND: Virtual care quickly became of crucial importance to health systems around the world during the COVID-19 pandemic. Despite the potential of virtual care to enhance access for some communities, the scale and pace at which services were virtualized did not leave many organizations with sufficient time and resources to ensure optimal and equitable delivery of care for everyone. The objective of this paper is to outline the experiences of health care organizations rapidly implementing virtual care during the first wave of the COVID-19 pandemic and examine whether and how health equity was considered. METHODS: We used an exploratory, multiple case study approach involving four health and social service organizations providing virtual care services to structurally marginalized communities in the province of Ontario, Canada. We conducted semi-structured qualitative interviews with providers, managers, and patients to understand the challenges experienced by organizations and the strategies put in place to support health equity during the rapid virtualization of care. Thirty-eight interviews were thematically analyzed using rapid analytic techniques. RESULTS: Organizations experienced challenges related to infrastructure availability, digital health literacy, culturally appropriate approaches, capacity for health equity, and virtual care suitability. Strategies to support health equity included the provision of blended models of care, creation of volunteer and staff support teams, participation in community engagement and outreach, and securement of infrastructure for clients. We put our findings into the context of an existing framework conceptualizing access to health care and expand on what this means for equitable access to virtual care for structurally marginalized communities. CONCLUSION: This paper highlights the need to pay greater attention to the role of health equity in virtual care delivery and situate that conversation around existing inequitable structures in the health care system that are perpetuated when delivering care virtually. An equitable and sustainable approach to virtual care delivery will require applying an intersectionality lens on the strategies and solutions needed to address existing inequities in the system.

Challenges and Strategies for Promoting Health Equity in Virtual Care: Protocol for a Scoping Review of Reviews.

BACKGROUND: The rapid virtualization of health services during the COVID-19 pandemic has drawn increasing attention to the impact of virtual care technologies on health equity. In some circumstances, virtual care initiatives have been shown to increase health disparities, as individuals from underserved communities are less likely to benefit from such initiatives. OBJECTIVE: The purpose of this paper is to describe a protocol for a scoping review of reviews that aims to map review-level evidence that describes challenges and strategies for promoting effective engagement with virtual care technologies among underserved communities. METHODS: Our methodology was adapted from seminal scoping review guidelines provided by Arksey and O'Malley, Levac at al, Colquhoun et al, and the Joanna Briggs Institute. Our search strategy was developed for the following databases: MEDLINE (on Ovid), EMBASE (on Ovid), CINAHL (on EBSCO), Scopus, and Epistemonikos. Supplementary searches will include the use of Google Scholar and reference tracking. Each citation will be independently screened by 2 researchers at the title and abstract level, and full-text screening will be performed in accordance with our eligibility criteria. The eligibility criteria focused on the inclusion of methods-driven reviews (ie, systematic reviews, scoping reviews, meta-analyses, realist reviews, and critical interpretative syntheses) to enhance rigor and quality. Other inclusion criteria included a focus on virtual care services that facilitate bidirectional patient-provider communication (ie, video, telephone, and asynchronous messaging visits) for underserved populations (ie, those who experience social disadvantage due to race, age, income, and other factors related to the social determinants of health). RESULTS: This scoping review of reviews will provide a broad overview of identified challenges associated with the accessibility of virtual health care services among underserved communities. In addition, strategies for improving the access to, uptake of, and engagement with virtual care technologies among underserved communities will be identified. The knowledge synthesized from this review will aid in developing and implementing virtual services that acknowledge the unique needs of populations who experience barriers to care and disproportionately worse health outcomes. The results will also inform gaps in current research. CONCLUSIONS: The rapid shift toward virtual health services has highlighted the urgent need to critically examine the intersection of virtual care and health equity. Although technology-driven innovations in health care generally aim to improve access, quality, and health outcomes, it is also possible for these innovations to produce intervention-generated inequities. Assessing current review-level evidence on the key challenges and strategies for improving the application of virtual care in underserved communities is imperative for ensuring that virtual care benefits all populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/22847.