Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review

Background The COVID-19 health crisis has disproportionately impacted populations who have been historically marginalized in health care and public health, including low-income and racial and ethnic minority groups. Members of marginalized communities experience undue barriers to accessing health care through virtual care technologies, which have become the primary mode of ambulatory health care delivery during the COVID-19 pandemic. Insights generated during the COVID-19 pandemic can inform strategies to promote health equity in virtual care now and in the future. Objective The aim of this study is to generate insights arising from literature that was published in direct response to the widespread use of virtual care during the COVID-19 pandemic, and had a primary focus on providing recommendations for promoting health equity in the delivery of virtual care. Methods We conducted a narrative review of literature on health equity and virtual care during the COVID-19 pandemic published in 2020, describing strategies that have been proposed in the literature at three levels: (1) policy and government, (2) organizations and health systems, and (3) communities and patients. Results We highlight three strategies for promoting health equity through virtual care that have been underaddressed in this literature: (1) simplifying complex interfaces and workflows, (2) using supportive intermediaries, and (3) creating mechanisms through which marginalized community members can provide immediate input into the planning and delivery of virtual care. Conclusions We conclude by outlining three areas of work that are required to ensure that virtual care is employed in ways that are equity enhancing in a post–COVID-19 reality.


Background
The COVID-19 health crisis has disproportionately impacted populations who have been historically marginalized in health care and public health, including low-income and racial and ethnic minority groups [1]. In the state of Louisiana in the United States, Black patients made up 59% of deaths related to COVID-19 in the early months of the pandemic despite representing only 33% of the state's population [1]. These disparities in COVID-19 outcomes between Black Americans and White Americans can be observed at a population-wide level [2], and Hispanic and Indigenous American communities have also been disproportionately affected by COVID-19 [3,4]. In the United Kingdom, communities with higher concentrations We make two primary contributions in this paper. Our first contribution is to summarize literature published in 2020 that is explicitly focused on recommending strategies to promote health equity in the delivery of virtual care in the context of the COVID-19 pandemic. We produce a synthesis of these recommendations and organize them according to the three levels at which they are most relevant: (1) policy and government, (2) organization and health system, and (3) community and patient. Our second contribution is to specifically highlight three strategies arising from this literature that are immediately practical and often neglected in the implementation of virtual care initiatives. We conclude by outlining what we view as the central considerations on which governments and health system leaders will need to focus to ensure virtual care is equitable in a sustainable way after COVID-19. We start by reviewing the concept of the digital divide and its links with virtual care in the context of COVID-19.

The Digital Divide
The concept of the digital divide has been widely discussed in the social science literature; this work outlines three "levels" of the divide that are central to understanding the relationships between social inequalities and information technologies [17].
Although originally used narrowly to refer to the gap between those who had access to technologies and those who did not (the "first-level divide"), the concept of the digital divide has evolved to include disparities in technology literacy (the "second-level divide") and disparities in outcomes (the "third-level divide") related to technology use [18]. Specifically, the second-level divide refers to the fact that although some individuals might have access to the internet and digital devices, they might not have the skills and knowledge necessary to use these technologies effectively. The third-level divide indicates that even where some individuals might have sufficient knowledge of how to use the technologies, they might not be able to convert their use of technologies into outcomes that improve their lives. The growing presence of information and communication technologies in health care over the past several years has led to growing attention to the implications of the digital divide for access to, and outcomes of, health care services involving such technologies [19,20].
Reviews of the digital divide in health care have illustrated some important considerations about the role of technologies in either increasing or decreasing disparities in health and health care. Weiss et al (2019) [16] explained that understanding the impact of a health-related technology on health disparities is context-dependent, and requires close attention to particular groups of users and their pathways of access and use. In addition, insights are accumulating regarding strategies to enhance access to, and use of, technologies for health care. A 2017 review of the literature outlined strategies related to increasing access, universal technology design, cultural sensitivity, and efforts to promote participation among underserved groups, all of which are promoted as strategies to reduce technology-related health disparities [19]. We now turn to reviewing applications of this body of knowledge to the COVID-19 pandemic that have been published since the onset of the pandemic in early 2020.

Methods
We completed a narrative review of literature published in 2020 focused on recommendations for the promotion of health equity in the delivery of virtual care as a result of the COVID-19 pandemic. Drawing on methodological guidance for narrative literature reviews related to clarity of focus and transparency of search strategy [21,22], our review focused explicitly on literature that was published in direct response to the widespread use of virtual care during the COVID-19 pandemic, and had a primary focus on providing recommendations for promoting health equity in the delivery of virtual care. Fit with these two criteria formed the inclusion criteria. We did not assess articles for quality, and included all those articles that met the two inclusion criteria. Informed by recent discussions of quality in narrative reviews [21], we provide a detailed representation of our search strategy in Table 1. Search string: ("healthcare disparities" OR "health disparities" OR "health equity") AND ("virtual care" OR "digital health" OR "telemedicine" OR "telehealth") • Total included papers: 5 Forward and backward reference searching Total included papers: 2 Identify highly relevant papers cited by included papers • Identify highly relevant papers that cite included papers We selected for inclusion only those publications that met the above two criteria, and extracted information on the following: (1) the framing of the paper, (2) the challenges each paper identified in relation to health equity and virtual care, and (3) the recommendations provided to promote health equity through virtual care. We then classified recommendations according to three levels of intervention: (1) policy and government, (2) organization and health system, and (3) community and patient. We use the findings from this literature search to highlight three important practical strategies that require attention and are at high risk of being overlooked, and then comment on strategies to make equitable virtual care sustainable following the COVID-19 pandemic.

Overview
Our database search strategy yielded a total of 93 articles. A total of 80 articles were excluded for reasons of lack of fit with inclusion criteria, and two additional articles were identified from forward and backward reference searching. The result of the screening and supplementary reference search was a final sample of 15 included articles. Table 2 summarizes the included articles addressing virtual care and health equity during the COVID-19 pandemic, and Table 3 summarizes the findings from each included article according to the following three levels: (1) policy and government, (2) organization and health system, and (3) community and patient.

Recommended Strategies to Promote Health Equity
At the level of policy and government, recommendations have focused on strategies for health policy makers and health care funders to enable access both to the infrastructure required for patients to participate in virtual care (ie, inclusive design standards, broadband internet, and digital devices) and the availability of virtual care services to entire populations (eg, by appropriately reimbursing virtual care) [13,15,23,25,[30][31][32][33]. In addition, policy-focused recommendations have emphasized the clarity of public health messaging about COVID-19 and related restrictions, and the role of digital technologies in enhancing the accuracy and reach of such messaging [24,29].
Recommendations at the level of health care organizations and health systems have been more varied. These have included encouragement to develop quality improvement activities focused on underserved or marginalized communities [12,18,27], educational initiatives for providers and leaders [12,23,29,33], and the collection of metrics that provide insight into equity-related outcomes [12]. Specific advice to clinicians has included strategies such as carefully planning a mix of in-person and virtual visits for clients especially at risk of poor health outcomes during the pandemic [25], and using telephone-based visits (over video visits) when a patient has access to a telephone but not a device that would enable a video visit [25,26,28,29].
At the level of communities and patients, recommendations focused on both the engagement of community members in service development and strategies to enhance digital literacy [13,25,26,29,30]. Specific approaches advocated include developing partnerships with community-based organizations and using inclusive design strategies that involve diverse users in the design of the technology [13,25]. Efforts to enhance digital literacy through particular educational programs during the pandemic were also common across the contributions we reviewed, including for example programs offered through local libraries [12,15].
Together, these recommendations provide a multilevel approach to ensuring that the widespread use of virtual care during the pandemic does not exacerbate disparities in access to care and health outcomes. In the next section of this paper, we outline three strategies that received relatively little attention in the reviewed literature We emphasize these three in particular because they are practically implementable by local health systems and have high potential for impact. Furthermore, these strategies are critical to the sustenance of equitable virtual care beyond the COVID-19 pandemic.

Discussion
In this discussion section, we describe three specific strategies to promote health equity in the delivery of virtual care programs, and then outline three lines of action at the level of health system strategy to ensure these approaches are sustainable in the longer term.

Simplify User Interfaces and Clinical Workflow
The first strategy that we highlight pertains to simplifying interfaces and workflows associated with accessing and using virtual care. Mounting evidence suggests that when innovations such as digital technologies increase the complexity of health care processes, they are more likely to widen existing health disparities [16]. This is because patients with less education, lower income, and a higher burden of negative social determinants of health (eg, food insecurity, precarious employment, etc) are less able to effectively integrate such innovations into their everyday lives or usual care [16]. This point is especially important given the ongoing financial and social challenges faced by marginalized communities during the COVID-19 crisis, which are likely to persist well beyond the end of the pandemic.
One reason for the elevated challenge of accessing and using complex virtual care technologies for marginalized patient groups relates to the technological infrastructure itself. For example, some technologies have high internet bandwidth requirements or are compatible with only a subset of expensive personal devices (eg, some video visit platforms do not run on Android devices). Virtual care strategies that work with simpler technology requirements are more likely to be accessible to people living with lower income, and are therefore more likely to be equity enhancing [16]. Such "upstream" strategies also have the potential to persist long term since they do not require agency on the part of providers or patients to maintain.
Additionally, significant digital literacy skills are necessary to benefit from virtual care technologies; marginalized groups with less technical experience, such as older adults and those of lower socioeconomic status, are less likely to have these skills [19,20]. Accordingly, virtual care platforms with usability challenges, high literacy demands, and complex workflows are more likely to benefit more advantaged users [16,20]. Thus, it is crucial that the design and delivery of technology-enabled services aim to minimize such barriers. This can be done by means such as using sequential rather than hierarchical navigation through the virtual care platform, an approach that reduces the cognitive burden associated with navigating through a computer interface by simplifying the information and number of choices presented to the user at any given time (ie, one choice at a time rather than a list of choices presented in a hierarchy). A second strategy is to reduce context switching, which occurs when the particular task in which the user is engaged (eg, booking a visit) is interrupted to perform a second task (eg, installing new software or opening a second program). More generally, following design guidelines for lower literacy populations (such as the guidelines produced by the United Nations Educational, Scientific and Cultural Organization [UNESCO] on designing inclusive digital solutions and developing digital skills [34]) will enhance the usability of any virtual care technology for all users. Where clinicians and organizations retain a degree of control over the content of virtual care technologies (more likely with larger health systems and organizations), these design-based solutions offer important strategies to promote health equity in the context of virtual care technologies.

Use Supportive Intermediaries to Help Patients Engage With Virtual Care
In the context of the pandemic, many patients have been forced to engage with virtual care for the first time. In some sites, such as Federally Qualified Health Centers (FQHC) in the United States and other community-based services internationally, the infrastructure for virtual care might not have existed prior to COVID-19. This means that patients might not have had much opportunity to develop the skills required to engage with technology for their health care, especially among those facing other major financial-or health-related challenges. Moreover, first virtual care visits are not optimal environments for learning, fostering the patient-provider relationship, or managing chronic medical conditions as patients and providers are likely to have more urgent priorities related to addressing acute illnesses [35]. Additionally, reflective of the time pressure facing health care providers and staff, the last author's (TV) experience with studying telehealth implementation in an FQHC shows that when challenges emerge during video visits, the immediate reaction is to switch to telephone calls. This results in far more telehealth visits being implemented via telephone than intended.
To address these challenges, we emphasize the strategy of integrating supportive intermediaries or liaisons within virtual care programs to assist new virtual care users in navigating visits. Human-computer interaction and sociology researchers have explored the use of intermediaries to bridge difficulties in access to and use of technologies among people with limited digital access and skills [36,37]. These intermediaries ideally serve as "warm experts," people with relatively advanced knowledge of technologies who are made readily available to support peoples' use of technology in their daily lives [38]. These supportive intermediaries might be identified in a number of ways. For larger organizations with staff that can be redeployed, team members can be trained in navigating a particular technology and provide intermediation to patients remotely. This model has been employed at the hospital (Women's College Hospital) that is the primary affiliation of the first author (JS) during the COVID-19 pandemic, wherein research staff have been redeployed to support patients as they connect virtually with their health care providers. A second option arises from the suggestion of Gray et al (2020) [25] to enlist the support of community health workers where such workers are active in local communities. Community health workers can engage community members who are seeking out health care and provide direct support to patients as they engage with their care providers virtually. Additional strategies that can be pursued to identify and support intermediaries include hiring new staff to take on the intermediary role in permanent positions to assist beyond the pandemic for the long-term sustainability of health equity, building partnerships with community-based organizations, and collaborating with public libraries or patient advocacy groups to establish intermediary support programs. The creation of new staff roles and partnerships represents an infrastructure that has the potential to remain in place after the COVID-19 pandemic.

Engage Members of Marginalized Communities in Planning and Evaluating Virtual Care
As with any health care innovation, virtual care programs risk overlooking the cultural, linguistic, and economic realities of marginalized communities [16,39]. In these cases, the virtual care program is far less likely to be taken up by marginalized patients, which also increases the risk of worsening health disparities. This point was addressed in many of the papers we reviewed, which advocated for the inclusion of marginalized communities in technology design, virtual care program design, training of health care providers, leadership of virtual care programs, and governance of data arising from such programs [12,15,23,25]. In the remainder of this section, we specify these recommendations by focusing on two practical strategies in particular: establishing a community advisory committee, and evaluating the service from the perspective of marginalized groups.
One practical strategy to engage members of marginalized communities in virtual care program delivery is to establish a community advisory committee that represents the views of marginalized patients. Collaborating with trusted partners who are prominent members of particular racial/ethnic or geographic communities could promote meaningful input into the development and improvement of the virtual care program [39]. Methods derived from community-based participatory research can help to ensure meaningful engagement of marginalized communities. Such engagement and input could have the additional benefit of providing a clearer understanding of the impacts of the social determinants of health during the pandemic, clarifying where interventions that look beyond the individual patient to the entire community are needed. Such input can thereby help health care providers and organizations to better understand the shifting needs of their patient populations and enhance their planning in both short-term and long-term time frames.
Evaluation that addresses the needs of underserved communities requires the identification of measures that matter most to members of these groups. This could also be accomplished through receipt of valuable input from key stakeholders, including patients or a community advisory board [12]. Measures should assess both objective features (such as dropped calls or total time spent interacting with patients) and subjective features of virtual care programs (such as satisfaction with and trust in health care providers). This information can be used to inform future quality improvements to the programs to better serve these diverse patient populations, especially in times of crisis when resources are scarce.

Sustainability of Equitable Virtual Care at the Health System Level
Based on the insights generated through our review of literature, we propose three important lines of action to promote health equity in the delivery of virtual care on a large scale and in a sustainable way beyond the pandemic. First, governments and policy makers will need to navigate the demand for investments in infrastructure related to broadband internet access and the availability of digital devices for those who do not have access. The literature reviewed in our paper calls for programs that make devices available to patients who need them to actively engage with virtual care, which constitutes a unique expense for health systems with unique considerations for implementation. Balancing investments in internet access and the availability of digital devices with the clear need for additional investments in public health and the upstream determinants of health will be a central challenge for governments in the years ahead.
Second, health systems and stakeholder groups will need to specify clinical processes and develop effective training for the clinical skills that underpin the equitable delivery of virtual care. This will also require investment in educational programs and curriculum change to enable health care providers to employ virtual care in equitable ways.
Third and finally, health systems will need to invest in developing organizational capacity in health equity as a long-term priority. Where organizations do not already have knowledge of how to deliver equitable care in general, they cannot be expected to deliver virtual care in equitable ways. The development of educational programs such as those focused on anti-racism and anti-oppression initiatives will contribute to enhancing the health equity knowledge and capacity of health care organizations overall. Doing so will build an important foundation for incorporating a stronger focus on health equity into virtual care initiatives well into the future.

Conclusion
The literature on strategies to promote health equity in virtual care programs in the context of COVID-19 presents a strong and comprehensive vision for the ways in which multiple stakeholders can work together to prevent worsening health disparities during the pandemic. However, to ensure that virtual care is employed in ways that are equity enhancing in a post-COVID-19 reality, further work is required. Health system leaders, clinicians, and the research community will need to more deeply engage with the literature summarized in this paper, and shift attention to the practical implementation of these strategies in the longer term.