COVID-19-Associated Misinformation Across the South Asian Diaspora: Qualitative Study of WhatsApp Messages.

Background: South Asians, inclusive of individuals originating in India, Pakistan, Maldives, Bangladesh, Sri Lanka, Bhutan, and Nepal, comprise the largest diaspora in the world, with large South Asian communities residing in the Caribbean, Africa, Europe, and elsewhere. There is evidence that South Asian communities have disproportionately experienced COVID-19 infections and mortality. WhatsApp, a free messaging app, is widely used in transnational communication within the South Asian diaspora. Limited studies exist on COVID-19-related misinformation specific to the South Asian community on WhatsApp. Understanding communication on WhatsApp may improve public health messaging to address COVID-19 disparities among South Asian communities worldwide. Objective: We developed the COVID-19-Associated misinfoRmation On Messaging apps (CAROM) study to identify messages containing misinformation about COVID-19 shared via WhatsApp. Methods: We collected messages forwarded globally through WhatsApp from self-identified South Asian community members between March 23 and June 3, 2021. We excluded messages that were in languages other than English, did not contain misinformation, or were not relevant to COVID-19. We deidentified each message and coded them for one or more content categories, media types (eg, video, image, text, web link, or a combination of these elements), and tone (eg, fearful, well intentioned, or pleading). We then performed a qualitative content analysis to arrive at key themes of COVID-19 misinformation. Results: We received 108 messages; 55 messages met the inclusion criteria for the final analytic sample; 32 (58%) contained text, 15 (27%) contained images, and 13 (24%) contained video. Content analysis revealed the following themes: "community transmission" relating to misinformation on how COVID-19 spreads in the community; "prevention" and "treatment," including Ayurvedic and traditional remedies for how to prevent or treat COVID-19 infection; and messaging attempting to sell "products or services" to prevent or cure COVID-19. Messages varied in audience from the general public to South Asians specifically; the latter included messages alluding to South Asian pride and solidarity. Scientific jargon and references to major organizations and leaders in health care were included to provide credibility. Messages with a pleading tone encouraged users to forward them to friends or family. Conclusions: Misinformation in the South Asian community on WhatsApp spreads erroneous ideas regarding disease transmission, prevention, and treatment. Content evoking solidarity, "trustworthy" sources, and encouragement to forward messages may increase the spread of misinformation. Public health outlets and social media companies must actively combat misinformation to address health disparities among the South Asian diaspora during the COVID-19 pandemic and in future public health emergencies.

Centering Health Equity in Telemedicine.

In the wake of the racial injustices laid bare in 2020, on top of centuries of systemic racism, it is clear we need actionable strategies to fundamentally restructure health care systems to achieve racial/ethnic health equity. This paper outlines the pillars of a health equity framework from the Institute for Healthcare Improvement, overlaying a concrete example of telemedicine equity. Telemedicine is a particularly relevant and important topic, given the growing evidence of disparities in uptake by racial/ethnic, linguistic, and socioeconomic groups in the United States during the COVID-19 pandemic, as well as the new standard of care that telemedicine represents post-pandemic. We present approaches for telemedicine equity across the domains of: (1) strategic priorities of a health care organization, (2) structures and processes to advance equity, (3) strategies to address multiple determinants of health, (4) elimination of institutional racism and oppression, and (5) meaningful partnerships with patients and communities.

System-Level Factors Associated With Telephone and Video Visit Use: Survey of Safety-Net Clinicians During the Early Phase of the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic prompted safety-net health care systems to rapidly implement telemedicine services with little prior experience, causing disparities in access to virtual visits. While much attention has been given to patient barriers, less is known regarding system-level factors influencing telephone versus video-visit adoption. As telemedicine remains a preferred service for patients and providers, and reimbursement parity will not continue for audio visits, health systems must evaluate how to support higher-quality video visit access. OBJECTIVE: This study aimed to assess health system-level factors and their impact on telephone and video visit adoption to inform sustainability of telemedicine for ambulatory safety-net sites. METHODS: We conducted a cross-sectional survey among ambulatory care clinicians at a hospital-linked ambulatory clinic network serving a diverse, publicly insured patient population between May 28 and July 14, 2020. We conducted bivariate analyses assessing health care system-level factors associated with (1) high telephone adoption (4 or more visits on average per session); and (2) video visit adoption (at least 1 video visit on average per session). RESULTS: We collected 311 responses from 643 eligible clinicians, yielding a response rate of 48.4%. Clinician respondents (N=311) included 34.7% (n=108) primary or urgent care, 35.1% (n=109) medical, and 7.4% (n=23) surgical specialties. Our sample included 178 (57.2%) high telephone adopters and 81 (26.05%) video adopters. Among high telephone adopters, 72.2% utilized personal devices for telemedicine (vs 59.0% of low telephone adopters, P=.04). Video nonadopters requested more training in technical aspects than adopters (49.6% vs 27.2%, P<.001). Primary or urgent care had the highest proportion of high telephone adoption (84.3%, compared to 50.4% of medical and 37.5% of surgical specialties, P<.001). Medical specialties had the highest proportion of video adoption (39.1%, compared to 14.8% of primary care and 12.5% of surgical specialties, P<.001). CONCLUSIONS: Personal device access and department specialty were major factors associated with high telephone and video visit adoption among safety-net clinicians. Desire for training was associated with lower video visit use. Secure device access, clinician technical trainings, and department-wide assessments are priorities for safety-net systems implementing telemedicine.

The Abrupt Expansion of Ambulatory Telemedicine: Implications for Patient Safety.

The exponential growth of telemedicine in ambulatory care triggered by the COVID-19 public health emergency has undoubtedly impacted the quality of care and patient safety. In particular, the increased adoption of remote care has impacted communication, care teams, and patient engagement, which are key factors that impact patient safety in ambulatory care. In this perspective, we draw on a scoping review of the literature, our own clinical experiences, and conversations with patient safety experts to describe how changes in communication, care teams, and patient engagement have impacted two high priority areas in ambulatory safety: diagnostic errors and medication safety. We then provide recommendations for research funders, researchers, healthcare systems, policy makers, and healthcare payors for how to improve patient safety in telemedicine based on what is currently known as well as next steps for how to advance understanding of the safety implications of telemedicine utilization.

Clinician Experience with Telemedicine at a Safety-net Hospital Network during COVID-19: A Cross-sectional Survey

Objective. The COVID-19 pandemic prompted unprecedented expansion of telemedicine services. We sought to describe clinician experiences providing telemedicine to publiclyinsured, lowincome patients during COVID-19. Methods. Online survey of ambulatory clinicians in an urban safetynet hospital system, conducted May 28, 2020–July 14, 2020. Results. Among 311 participants (response rate 48.3%), 34.7% (n=108/311) practiced in primary/urgent care, 37.0% (n=115/311) medical specialty, and 7.7% (n=24/311) surgical clinics. A large majority (87.8%, 273/311) had conducted telephone visits, 26.0% (81/311) video. Participants reported observing both technical and nontechnical patient barriers. Clinicians reported concerns about the diagnostic safety of telephone (58.9%, 129/219) vs. video (35.3%, 24/68). However, clinician comfort with telemedicine was high for telephone (89.3%, 216/242) and for video (91.0%, 61/67), with many clinicians (92.1%, 220/239 telephone;90.9%, 60/66 video) planning to continue telemedicine after COVID-19. Conclusions. Clinicians in a safetynet health care system report great comfort with and intention to continue telemedicine after the pandemic, despite safety concerns and patient challenges.