Navigating the digital divide: A systematic review of eHealth literacy in underserved populations in the United States

"Addressing barriers to digital health readiness among a Latino population"

Objective

There are many potential barriers to an individual's readiness and ability to use telehealth, including technology access, trust and knowledge. This qualitative study was a partnership between Jefferson and Esperanza Health Center (EHC), focused on addressing barriers to digital readiness among the Latino population served by EHC.

Methods

We conducted semi-structured interviews with Latino patients to assess their experiences with technology and willingness to learn more about technology for healthcare. Interviews were transcribed, coded, and analyzed using a content analysis approach.

Results

We completed 28 interviews. Most interviews (n = 23, 82 %) were conducted in Spanish. Barriers to using health technology included forgetting passwords, platforms not being available in multiple languages, and lacking digital skills.

Conclusion

Participants identified a need and interest in receiving support to develop technological skills needed to access health information and engage in digital health services. Future work is needed to develop patient-centered interventions to support the digital health readiness needs of underserved populations.

Innovation

Healthcare systems and community health organizations can partner to build the capacity of community members to identify barriers in digital health use. These partnerships have the potential to empower communities to create culturally sensitive interventions that aim to increase digital health literacy.

Turning to digital: Examining the relationship between offline healthcare barriers and U.S. older adults' emotional well-being via online patient-provider communication and perceived quality of care (2017-2020)

Purpose

To examine the association between offline healthcare barriers and emotional well-being and assess the mediation roles of online patient-provider communication (OPPC) and perceived quality of care. This study also investigates the trends in offline healthcare barriers, OPPC, perceived quality of care, and emotional well-being over four years among the old population in the U.S.

Methods

Data from the Health Information National Trends Survey (HINTS) 5 Cycles 1, 2, and 4 were used. Mediation analysis and comparison analysis were employed.

Results

The results indicated an increment in OPPC and a decline in patient's perceived quality of care between 2017 and 2020. Across the three years, offline healthcare barriers were consistently negatively associated with emotional well-being, and perceived quality of care remained a mediator in such a relationship. Moreover, the serial mediating roles of OPPC and perceived quality of care between offline healthcare barriers and emotional well-being turned from statistically non-significant (2017) to significant (2018, 2020).

Conclusion

Our results witness the growing adoption of OPPC among older adults and the evolution of OPPC as a complementary communication modality. The findings can support interventions to augment OPPC utilization and enhance the perception of quality care of older adults, contributing to their increased emotional well-being.

Analysis of high-risk human papillomavirus infections and cervical intraepithelial neoplasia: factors influencing awareness among women of childbearing age in southwest China

BACKGROUND

High-risk Human Papillomavirus (HPV) infections are a leading cause of cervical diseases among Han Chinese women of reproductive age. Despite studies like Mai et al. (2021) addressing HPV prevalence in Southern China, awareness remains low, especially in Southwest China. Our study addresses this gap.

OBJECTIVE

This hospital-based, retrospective study analyzes the prevalence of high-risk HPV and its association with cervical intraepithelial neoplasia (CIN) among Han Chinese women of reproductive age in Southwest China.

METHODS

Data were collected from 724 women undergoing routine health exams from December 2022 to April 2023. A total of 102 women with high-risk HPV infections were identified. A survey assessed HPV awareness, CIN incidence, and socio-demographic factors influencing awareness.

RESULTS

Of the 724 women, 102 (14.1%) were diagnosed with high-risk HPV, with HPV-16 being the most common subtype (22.5%). Awareness was significantly lower among unmarried women (OR: 6.632, p = 0.047), those with high school education or less (OR: 20.571, p = 0.003), and rural residents (OR: 19.483, p = 0.020). HPV-16 was detected in 54.55% of women with high-grade CIN.

CONCLUSION

There is an urgent need for targeted education and HPV vaccination in Southwest China, particularly for women with lower education, rural residents, and older individuals. Subtype-specific strategies are essential for preventing and managing CIN.

Shared decision-making in underserved populations with multiple sclerosis: A systematic review

BACKGROUND

The concept of shared decision-making (SDM) is valuable to ensure patients receive individualized care. SDM occurs when healthcare providers engage patients in making personal healthcare decisions that could contribute to better long-term outcomes. With the ever-increasing landscape of treatment options available, SDM can be challenging but valuable for patients. Patients from underserved populations are potentially less likely to engage in SDM, impacting their long-term care. This systematic literature review aimed to explore SDM in these patient populations.

METHODS

Relevant articles were retrieved from PubMed using key search terms, without any restriction on publication date. All searches and data retrieval were conducted between May 25, 2022, and August 17, 2022, and abstracts were reviewed by two independent reviewers. A thematic analysis was used to present the data.

RESULTS

All search terms yielded 418 articles; 89 were included (33 involving patients with multiple sclerosis [MS]). Reported mean percentage of patients with MS (including from underserved populations) who preferred SDM was 52 % (range: 37.5-71.5; n = 4). Differences in racial/ethnic assimilation of information communicated by clinicians were reported, impacted by the lower literacy level and certain cultural health beliefs in groups of underserved populations. Primary care clinicians play a key role in providing information to patients in underserved populations.

CONCLUSIONS

There is a clear benefit for SDM for patients with MS, and without it, patients report dissatisfaction, decisional regret, and lack of confidence in the medical system. However, there are several challenges, including the need for further examination of social determinants of health, for underserved patient populations which still need to be addressed.

Determinants to Tele-Mental Health Services Utilization Among California Adults: Do Immigration-Related Variables Matter?

To investigate the relationship of predisposing, enabling, need, and immigration-related factors to tele-mental health services utilization among California adults, we conducted a secondary analysis of two waves of the California Health Interview Survey (CHIS) collected between 2015 and 2018 (N = 78,345). A series of logistic regression models were conducted to examine correlates and predictors to tele-mental health services use. Approximately 1.3% reported the use of tele-mental health services. Overall, health insurance status, severe psychological distress, perceived need for mental health services, and identifying as Asian, remained strong predictors for tele-mental health service use. When accounting for all factors, we found that being a non-citizen was associated with lower odds of tele-mental health service use (AOR = 0.47, CI = 0.26, 0.87, p < 0.05). These findings suggest that citizenship, resources to access, and perceived need for mental health care collectively are the most significant factors driving the use of tele-mental health services. There is a need to address inequitable access to tele-mental health services among immigrants who do not qualify for healthcare coverage due to citizenship status.

Patient satisfaction and digital health in primary health care: a scoping review protocol

Introduction

Using digital health in primary health care (PHC) contributes to reducing costs and travel time, achieving global development goals, improving access, quality and longitudinality of care, and managing health crises. Its evaluation must go beyond the technical-operational aspects to include patient satisfaction, a key element in assessing the quality of care.

Objective

To identify and map patient satisfaction (expectations, desires, cultural values) about the adoption of digital health strategies and assess their impact on the quality of care in PHC.

Methods

The review will follow the recommendations proposed by the Joanna's Briggs Institute (JBI) manual, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) and the methodology proposed by Arksey and O'Malley and Levac et al. and will be conducted in nine stages. The search will be conducted in health studies databases (MEDLINE via PubMed, EMBASE, CINAHL, Web of Science, and BVS), gray literature, and preprint repositories (Google Scholar and MedRxiv). Two reviewers will select the studies, and the third will analyze possible conflicts. The inclusion criteria comprise studies that have been made available in their entirety, whether they are primary studies or short communications, as well as the following materials extracted from the gray literature: preprints, manuals, government documents, books, guidelines, theses and dissertations. Exclusion criteria include literature reviews, abstracts, books, conference archives, letters to the editor, duplicates and opinion articles. Data will be analyzed by content analysis and inferential statistics. This protocol is registered on the Open Science Framework (OSF) under DOI 10.17605/OSF.IO/PUJDB.

Results

The study aims to understand aspects related to the expectations, desires, and cultural values of patients from different countries, as well as the strengths and critical nodes of the use of digital health on the quality of care in PHC.

Understanding patient perspectives on digital therapeutics and its platform for insomnia: insights from focused group interviews

BACKGROUND

Digital therapeutics (DTx) is a treatment option that uses computer software to provide evidence-based interventions for medical disorders. DTx platforms are digital services that facilitate interactions among stakeholders of DTx treatment within a standardized structure. However, there is still a lack of overall awareness regarding the effectiveness and usage of DTx and DTx platforms. This study aimed to investigate insomnia patients' recognition, thoughts, feelings, and demands for conventional treatments versus DTx for insomnia.

METHODS

Nine participants, aged 19-50 years, who had experience with professional medical interventions for insomnia, were recruited through purposive sampling. Two online focus group interviews, each lasting 1.5 h, were conducted. The interview questions focused on difficulties encountered during conventional treatment, inadequate recognition of DTx, and concerns and demands regarding DTx and its platform. The data were analyzed using thematic analysis.

RESULTS

The participants reported subjective difficulties associated with receiving conventional treatment, including concerns about drug side effects and dependence, social stigma, and lack of perceived necessity for treatment. They expressed concerns about DTx, such as cost-effectiveness, evidence on efficacy, and concerns about breach of personal information. Additionally, their demands included convenience of use, reduction in social stigma related to the use of DTx, compatibility of DTx with other healthcare systems, and enhanced communication with healthcare providers when using DTx platforms.

CONCLUSIONS

The focus group highlighted the need for increased awareness, demonstrated efficacy, cost-effectiveness, cybersecurity measures, and accessibility of insomnia DTx and its platforms. Tailored approaches considering patient characteristics are crucial for widespread adoption of insomnia DTx and its platforms.

Digital Health Literacy and Its Association With Sociodemographic Characteristics, Health Resource Use, and Health Outcomes: Rapid Review

BACKGROUND

Digital health literacy has emerged as a critical skill set to navigate the digital age.

OBJECTIVE

This review sought to broadly summarize the literature on associations between digital health literacy and (1) sociodemographic characteristics, (2) health resource use, and (3) health outcomes in the general population, patient groups, or parent or caregiver groups.

METHODS

A rapid review of literature published between January 2016 and May 2022 was conducted through a search of 4 web-based databases. Articles were included on the basis of the following keywords: "measured digital health literacy," "digital literacy," "ehealth literacy," "e-health literacy," "electronic health literacy," or "internet health literacy" in adult populations; participants were from countries where English was the primary language; studies had to be cross-sectional, longitudinal, prospective, or retrospective, and published in English.

RESULTS

Thirty-six articles met the inclusion criteria. Evidence on the associations between digital health literacy and sociodemographic characteristics varied (27/36, 75% included studies), with higher education (16/21, 76.2% studies that examined the association) and younger age (12/21, 57.1% studies) tending to predict higher digital health literacy; however, other studies found no associations. No differences between genders were found across the majority of studies. Evidence across ethnic groups was too limited to draw conclusions; some studies showed that those from racial and ethnic minority groups had higher digital health literacy than White individuals, while other studies showed no associations. Higher digital health literacy was associated with digital health resource use in the majority of studies (20/36, 55.6%) that examined this relationship. In addition, higher digital health literacy was also associated with health outcomes across 3 areas (psychosocial outcomes; chronic disease and health management behaviors; and physical outcomes) across 17 included studies (17/36, 47.2%) that explored these relationships. However, not all studies on the relationship among digital health literacy and health resource use and health outcomes were in the expected direction.

CONCLUSIONS

The review presents mixed results regarding the relationship between digital health literacy and sociodemographic characteristics, although studies broadly found that increased digital health literacy was positively associated with improved health outcomes and behaviors. Further investigations of digital health literacy on chronic disease outcomes are needed, particularly across diverse groups. Empowering individuals with the skills to critically access and appraise reliable health information on digital platforms and devices is critical, given emerging evidence that suggests that those with low digital health literacy seek health information from unreliable sources. Identifying cost-effective strategies to rapidly assess and enhance digital health literacy capacities across community settings thus warrants continued investigation.

"I Don't Believe in Age; I Believe in Staying Enthusiastic": An Exploratory Qualitative Study into Recruitment Strategies Stimulating Middle-Aged and Older Adults to Join Physical Activity Interventions

Many middle-aged and older adults (MAOAs) do not engage in sufficient physical activity (PA), despite its well-documented benefits for healthy aging. Existing PA interventions often fail to reach or engage the target population effectively. This study investigates MAOAs' preferences for recruitment strategies to optimize the reach and uptake of PA interventions, thereby enhancing their impact on healthy aging and public health. Qualitative interviews were conducted with 39 MAOA participants (69% female, mean age = 69.46, SD = 7.07), guided by McGuire's Theory on Persuasive Communication. Factors related to the source, message content, channel, receiver characteristics and target behavior of recruitment strategies were analyzed. Our findings suggest a preference for trustworthy sources (e.g., healthcare professionals over commercial entities) and positive, non-ageist messaging. MAOAs vary in their channel preferences but emphasize the importance of personalization. Despite heterogeneity, MAOAs commonly perceive themselves as sufficiently active, indicating a need for improved knowledge on what constitutes sufficient PA, as well as easy enrollment or trying out interventions. Tailoring recruitment strategies to diverse MAOA segments based on age seems crucial for effective engagement. Future research could explore quantitative research into how communication factors relate to various target population characteristics.

Getting the most out of remote care: Co-developing a Toolkit to improve the delivery of remote kidney care appointments for underserved groups

BACKGROUND

Telephone and video appointments are still common post-pandemic, with an estimated 25%-50% of kidney appointments in the United Kingdom still conducted remotely. This is important as remote consultations may exacerbate pre-existing inequalities in those from underserved groups. Those from underserved groups are often not represented in health research and include those with learning disability, mental health needs, hearing/sight problems, young/older people, those from ethnic minority groups.

OBJECTIVES

The aim was to develop a Toolkit to improve the quality of remote kidney care appointments for people from different underserved groups.

DESIGN

A parallel mixed methods approach with semistructured interviews/focus groups and survey. We also conducted workshops to develop and validate the Toolkit.

PARTICIPANTS

Seventy-five renal staff members completed the survey and 21 patients participated in the interviews and focus groups. Patients (n = 11) and staff (n = 10) took part in the Toolkit development workshop, and patients (n = 13) took part in the Toolkit validation workshop.

RESULTS

Four themes from interviews/focus groups suggested areas in which remote appointments could be improved. Themes were quality of appointment, patient empowerment, patient-practitioner relationship and unique needs for underserved groups. Staff reported difficulty building rapport, confidentiality issues, confidence about diagnosis/advice given, technical difficulties and shared decision making.

CONCLUSION

This study is the first to explore experiences of remote appointments among both staff and those from underserved groups living with kidney disease in the United Kingdom. While remote appointments can be beneficial, our findings indicate that remote consultations need optimisation to meet the needs of patients. The project findings informed the development of a Toolkit which will be widely promoted and accessible in the United Kingdom during 2024.

Evaluating the feasibility and acceptability of home-based urinalysis for albumin-creatinine ratio with smartphone technology: A quality improvement project

BACKGROUND

Despite albumin-creatinine ratio (urine) testing being recommended for detection of chronic kidney disease among adults with diabetes, testing rates are suboptimal.

AIM

We implemented and evaluated a quality improvement project in an inner-city diabetes population in London, UK to assess the feasibility and acceptability of implementing novel home-based urinalysis using smartphone technology.

METHODS

After eligible patients were identified and consented, testing kits were sent to the patient's home. Test results and patient feedback were collected through the smartphone application. Focus group discussions were conducted to evaluate primary care staff perspectives on uptake and delivery of the service.

RESULTS

In total 2370 patients agreed to take part. Of these, 1244 completed the test (61% of those eligible) and of these, 465 (37%) had clinically significant albuminuria. 98% of patients found the test easy or very easy to use. Staff in primary care found the service to be beneficial for patients, and reported ease of set up and minimal administrative processes. Concerns regarding barriers among patients with lower digital literacy and non-English speakers were raised although these concerns were not substantiated.

CONCLUSION

Home-based albumin-creatinine ratio urine testing may improve the testing rates of people with diabetes at higher risk of chronic kidney disease. This is important post-pandemic, as healthcare services are trying to return to pre-pandemic levels of care. The study also found that the use of smartphone technology in an underserved (deprived) community is feasible, despite reservations about levels of digital literacy and possible language barriers. Further evaluation of effectiveness and costs is required.

Needs, expectations, facilitators, and barriers among insurance physicians related to the use of eHealth in their work: results of a survey

PURPOSE

To determine needs, expectations, facilitators, and barriers of insurance physicians (IPs) for using eHealth in their work. Also, we investigated differences between age groups.

MATERIALS AND METHODS

All insurance physicians employed at the Dutch Social Security Institute (SSI) received an online anonymous survey in July 2020.

RESULTS

Three hundred and fifteen IPs (31%) responded. According to these IPs, the most important need for using eHealth was to collect medical information more effectively and efficiently (71%).Main facilitators were that eHealth could make IPs' work more effectively and efficiently (61%) and more future-proof (60%). Main barriers were losing human interaction (54%) and security issues (51%). Younger IPs saw more options for using eHealth, compared to older IPs.

CONCLUSIONS

The majority of IPs (in particular younger IPs) had a positive view towards using eHealth in their daily work. Nevertheless, differences in needs, expectations, facilitators and barriers between the age groups should be taken into account for the successful development and implementation of interventions using eHealth in insurance medicine.

Use of telemedicine to obtain contraception among young adults: Inequities by health insurance

OBJECTIVES

The objective of this study was to describe the use of telemedicine for contraception in a sample of young adults and examine differences by health insurance coverage.

STUDY DESIGN

We analyzed survey data collected from May 2020 to July 2022 from individuals at risk of pregnancy aged 18 to 29 recruited at 29 community colleges in California and Texas. We used multivariable mixed-effects logistic regression models with random effects for site and individual to compare the use of telemedicine to obtain contraception by insurance status, sociodemographic characteristics, and state.

RESULTS

Our analytic sample included 6465 observations from 1630 individuals. Participants reported using a contraceptive method obtained through telemedicine in just 6% of observations. Uninsured participants were significantly less likely than those privately insured to use contraception obtained through telemedicine (adjusted odds ratio [aOR], 0.54; 95% confidence interval [CI], 0.31-0.97), as were participants who did not know their insurance status (aOR, 0.54; 95% CI, 0.29-0.99). Texas participants were less likely to use contraception obtained via telemedicine than those in California (aOR, 0.42; CI: 0.25-0.69).

CONCLUSIONS

Few young people in this study obtained contraception through telemedicine, and insurance was crucial for access in both states.

IMPLICATIONS

Although telemedicine holds promise for increasing contraceptive access, we found that few young adults were using it, particularly among the uninsured. Efforts are needed to improve young adults' access to telemedicine for contraception and address insurance disparities.

Smart device interest, perceived usefulness, and preferences in rural Alabama seniors

Limited data exist on the preferences for smart home devices in rural Americans. We examined the interest, usefulness, and pleasantness of various smart home interfaces and determined whether they differed by ethnicity, rurality, age, and gender. A total of 118 older adults living in the rural Deep South completed a survey instrument that assessed interest in various smart home applications and was queried about the perceived usefulness and perceived ease of use of screen, voice, and robot interfaces in 7 distinct scenarios. Personality data was collected via the Big Five Inventory. Technology readiness was measured using a technological readiness instrument. Participants were primarily female (81%), rural (76%), African American (69%), and aged 65-74 years old (51%). Participants were recruited from a total of 5 cities in West Alabama within the Black Belt. Data was collected before COVID-19 (July 2018 through July 2019).

Recruitment strategies for reaching adults aged 50 years and older with low socioeconomic status for participation in online physical activity interventions

Background

Generally, the health condition of those with higher socioeconomic status (SES) is better compared to those with lower SES. The application of appropriate strategies to reach low SES populations with electronic health (eHealth) interventions is thus of major importance to reduce health inequalities. eHealth-studies providing detailed information on recruitment strategies are scarce, despite the fact that this information is crucial for comparable research and implementation.

Objective

To provide insight into the reach, sample characteristics and costs of three pre-planned strategies for recruiting adults aged 50 years and older with low SES for participation in an online physical activity intervention, as part of a field study.

Methods

Recruitment took place via (1) invitation letters via a municipality, (2) gyms and (3) social media advertisements, aiming to include 400 participants. Additional procedures were followed to reach specifically the low SES group. Response rates, sociodemographic characteristics and costs per strategy were assessed.

Results

The highest response was shown for the municipality approach (N = 281), followed by social media (N = 71) and gyms (N = 45). Ten participants were recruited via family/friends. The most low-educated participants were reached via the municipality (N = 128) followed by social media (N = 9), gyms (N = 8) and family/friends (N = 5). Recruitment costs were with €2,142.37 the highest for the municipality compared to €96.81 for social media and no costs for gyms.

Conclusions

Recruitment via invitation letters through a municipality has the highest potential for reaching low SES participants of the three applied strategies, although the higher recruitment costs need to be taken into account.

Construction of the Digital Health Equity-Focused Implementation Research Conceptual Model - Bridging the Divide Between Equity-focused Digital Health and Implementation Research

Digital health implementations and investments continue to expand. As the reliance on digital health increases, it is imperative to implement technologies with inclusive and accessible approaches. A conceptual model can be used to guide equity-focused digital health implementations to improve suitability and uptake in diverse populations. The objective of this study is expand an implementation model with recommendations on the equitable implementation of new digital health technologies. The Digital Health Equity-Focused Implementation Research (DH-EquIR) conceptual model was developed based on a rigorous review of digital health implementation and health equity literature. The Equity-Focused Implementation Research for Health Programs (EquIR) model was used as a starting point and merged with digital equity and digital health implementation models. Existing theoretical frameworks and models were appraised as well as individual equity-sensitive implementation studies. Patient and program-related concepts related to digital equity, digital health implementation, and assessment of social/digital determinants of health were included. Sixty-two articles were analyzed to inform the adaption of the EquIR model for digital health. These articles included digital health equity models and frameworks, digital health implementation models and frameworks, research articles, guidelines, and concept analyses. Concepts were organized into EquIR conceptual groupings, including population health status, planning the program, designing the program, implementing the program, and equity-focused implementation outcomes. The adapted DH-EquIR conceptual model diagram was created as well as detailed tables displaying related equity concepts, evidence gaps in source articles, and analysis of existing equity-related models and tools. The DH-EquIR model serves to guide digital health developers and implementation specialists to promote the inclusion of health-equity planning in every phase of implementation. In addition, it can assist researchers and product developers to avoid repeating the mistakes that have led to inequities in the implementation of digital health across populations.

Internet-based eHealth technology for emotional well-being among the older adults with a family cancer history: full mediation effects of health information self-efficacy and cancer fatalism

BACKGROUND

Older adults with a family cancer history (FCH) face an increased cancer risk, which may adversely impact their emotional well-being. Internet-based eHealth technologies (IETs) provide a potential solution to this challenge. This study examines the influence of using IETs on the emotional well-being of older adults with FCH. It also delves into the mediating pathways through health information self-efficacy and cancer fatalism.

METHODS

This study conducted a mediation analysis using data from the Health Information National Trends Survey (HINTS 6) collected from March 2022 to November 2022, focusing on older adults with FCH who had previously searched for cancer-related information (N = 1,280).

RESULTS

In the mediation model, no positive direct associations between IETs usage and emotional well-being were found. Only health information self-efficacy and cancer fatalism were found to mediate the relationship between IETs usage and emotional well-being serially (β = 0.007, 95% CI [0.003, 0.012]).

CONCLUSIONS

The findings inform health information professionals and healthcare practitioners on enhancing the impact of IETs usage on individual health information self-efficacy, which mitigates cancer fatalism, contributing to better emotional well-being in the digital era.

Rehabilitation interventions delivered via telehealth to support self-management of rheumatic and musculoskeletal diseases: A scoping review protocol

BACKGROUND

Telerehabilitation is a term to describe rehabilitation services delivered via information and communication technology. Such services are an increasingly important component for the management of rheumatic and musculoskeletal diseases (RMDs). Telerehabilitation has the potential to expand the long-term self-management options for individuals with RMDs, improve symptoms, and relieve pressures on health care services. Yet, little is known about the variety of interventions implemented, and how they are being evaluated. Thus, this scoping review aims to identify and describe existing rehabilitation interventions delivered via telehealth for RMDs. Specifically, we aim to identify and summarize the key components of rehabilitation, the technology used, the level of health care professional interaction, and how the effectiveness of interventions is evaluated.

METHODS

We will conduct this review following the latest JBI scoping review methodology and the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). The 'Population-Concept-Context (PCC)' framework will be used, whereby the 'Population' is RMDs (≥18 years); the 'Concept' is rehabilitation; and the 'Context' is telehealth. Developed in collaboration with a subject Librarian, refined PCC key terms will be utilized to search (from 2011-2021) three electronic databases (i.e., Embase, Scopus, Web of Science) for articles published in English. Search results will be exported to the citation management software (EndNote), duplicates removed, and eligibility criteria applied to title/abstract and full-text review. Relevant information pertaining to the PCC framework will be extracted. Data will be summarized qualitatively, and if appropriate, quantitatively via frequency counts of the components comprising the 'Concept' and 'Context' categories of the PCC framework.

DISCUSSION

Findings from the proposed scoping review will identify how telehealth is currently used in the delivery of rehabilitation interventions for RMDs. The findings will develop our understanding of such interventions and provide a platform from which to inform future research directions.

Patients' Experiences With Digitalization in the Health Care System: Qualitative Interview Study

BACKGROUND

The digitalization of public and health sectors worldwide is fundamentally changing health systems. With the implementation of digital health services in health institutions, a focus on digital health literacy and the use of digital health services have become more evident. In Denmark, public institutions use digital tools for different purposes, aiming to create a universal public digital sector for everyone. However, this digitalization risks reducing equity in health and further marginalizing citizens who are disadvantaged. Therefore, more knowledge is needed regarding patients' digital practices and experiences with digital health services.

OBJECTIVE

This study aims to examine digital practices and experiences with public digital health services and digital tools from the perspective of patients in the neurology field and address the following research questions: (1) How do patients use digital services and digital tools? (2) How do they experience them?

METHODS

We used a qualitative design with a hermeneutic approach. We conducted 31 semistructured interviews with patients who were hospitalized or formerly hospitalized at the department of neurology in a hospital in Denmark. The interviews were audio recorded and subsequently transcribed. The text from each transcribed interview was analyzed using manifest content analysis.

RESULTS

The analysis provided insights into 4 different categories regarding digital practices and experiences of using digital tools and services in health care systems: social resources as a digital lifeline, possessing the necessary capabilities, big feelings as facilitators or barriers, and life without digital tools. Our findings show that digital tools were experienced differently, and specific conditions were important for the possibility of engaging in digital practices, including having access to social resources; possessing physical, cognitive, and communicative capabilities; and feeling motivated, secure, and comfortable. These prerequisites were necessary for participants to have positive experiences using digital tools in the health care system. Those who did not have these prerequisites experienced challenges and, in some cases, felt left out.

CONCLUSIONS

Experiences with digital practices and digital health services are complex and multifaceted. Engagement in digital practices for the examined population requires access to continuous assistance from their social network. If patients do not meet requirements, digital health services can be experienced as exclusionary and a source of concern. Physical, cognitive, and communicative difficulties might make it impossible to use digital tools or create more challenges. To ensure that digitalization does not create inequities in health, it is necessary for developers and institutions to be aware of the differences in digital health literacy, focus on simplifying communication with patients and next of kin, and find flexible solutions for citizens who are disadvantaged.

Barriers and facilitators to pediatric telehealth use in English- and Spanish-speaking families: A qualitative study

BACKGROUND

With the rapid increase in telehealth use during the COVID-19 pandemic, concerns have been raised about the potential for exacerbating existing healthcare disparities in marginalized populations. While eliminating barriers such as transportation and time constraints, telehealth may introduce barriers related to technology access. With little known about the patient experience accessing telehealth during the COVID-19 pandemic, this study seeks to understand the barriers and facilitators to telehealth use as well as interventions that may address them.

METHODS

We conducted qualitative interviews with parents of pediatric patients of a primary care clinic in a diverse community during the study period of March-May 2021. The interviews explored barriers and facilitators to telehealth during the COVID-19 pandemic. Interviews were balanced across language (Spanish and English) as well as across visit type (in-person vs. telehealth). Recruitment, collection of demographic information, and interviews were conducted by telephone. The conversations were recorded and transcribed. Once thematic saturation was achieved, the data were analyzed using a modified grounded theory approach.

RESULTS

Of the 33 participants, 17 (52%) spoke English and 16 (48%) spoke Spanish. A total of 17 (52%) had experienced a telehealth encounter as their first visit during the study period while 16 (48%) had an in-person visit. Five themes were identified: (1) a recognition of differences in technological knowledge and access, (2) situational preferences for telehealth versus in-person visits, (3) avoidance of COVID-19 exposure, (4) convenience, and (5) change over time. English-speaking patients expressed greater ease with and a preference for telehealth, while Spanish-speaking participants expressed more technological difficulty with telehealth and a preference for in-person visits. Suggested interventions included informational tutorials such as videos before the visit, technical support, and providing families with technological devices.

CONCLUSION

In this study, we examined patient and family perspectives on pediatric telehealth during the COVID-19 pandemic. Implementation of the suggested interventions to address barriers to telehealth use is essential to prevent further exacerbation of health disparities already experienced by marginalized populations.

Thematic Analysis of Alzheimer's Medication Management Discussion in a Non-Moderated Online Forum

BACKGROUND

Managing medications for Alzheimer's disease and related dementias is challenging for caregivers. Information about caregivers' strategies to manage these challenges is needed to inform intervention development.

OBJECTIVE

This study aimed to understand caregivers' medication management experiences by analyzing online community discussions.

METHODS

Posts were extracted from the ALZConnected® Forum using keywords "medication" and "drug" via web scraping. The researchers applied thematic analysis.

RESULTS

Four major themes emerged: (1) role transition of medication management responsibilities, (2) caregivers' uncertainty about medication purpose and values, (3) conflicts between the care recipients and caregivers, and (4) difficulty accessing and affording medications.

CONCLUSIONS

The experiences shared on a non-moderated, unstructured online forum indicate that medication management is challenging and overwhelming for caregivers of people living with Alzheimer's disease and related dementias. Since this is a progressive disease with various stages and changing needs, caregivers' strategies vary and are often limited by available resources and support. Health care providers should offer training and support for caregivers to navigate the transfer of medication management responsibilities and changing care needs as the disease progresses.

Digital Literacy and Associated Factors in Older Adults Living in Urban South Korea: A Qualitative Study

This study aimed to explore digital literacy among community-dwelling older adults in urban South Korea. A semistructured interview guide was developed using the Digital Competence ( 2.0 framework, which emphasizes the competencies for full digital participation in five categories: information and data literacy, communication and collaboration, content creation, safety, and problem-solving. The data were analyzed using combined inductive and deductive content analysis. Inductive analysis identified three main categories: perceived ability to use digital technology, responses to digital technology, and contextual factors. In the results of deductive analysis, participants reported varying abilities in using digital technologies for information and data literacy, communication or collaboration, and problem-solving. However, their abilities were limited in handling the safety or security of digital technology and lacked in creating digital content. Responses to digital technology contain subcategories of perception (positive or negative) and behavior (trying or avoidance). Regarding contextual factors, aging-related physical and cognitive changes were identified as barriers to digital literacy. The influence of families or peers was viewed as both a facilitator and a barrier. Our participants recognized the importance of using digital devices to keep up with the trend of digitalization, but their digital literacy was mostly limited to relatively simple levels.

Development of the Digital Inclusion Questionnaire (DIQUEST) in Parkinson's Disease

BACKGROUND

No tool is currently able to measure digital inclusion in clinical populations suitable for telemedicine. We developed the "Digital Inclusion Questionnaire" (DIQUEST) to estimate access and skills in Parkinson's Disease (PD) patients and verified its properties with a pilot study.

METHODS

Thirty PD patients completed the initial version of the DIQUEST along with the Mobile Device Proficiency Questionnaire (MDPQ) and a practical computer task. A Principal Components Analysis (PCA) was conducted to define the DIQUEST factor structure and remove less informative items. We used Cronbach's α to measure internal reliability and Spearman's correlation test to determine the convergent and predictive validity with the MDPQ and the practical task, respectively.

RESULTS

The final version of the DIQUEST consisted of 20 items clustering in five components: "advanced skills," "navigation skills," "basic skills/knowledge," "physical access," and "economical access." All components showed high reliability (α > 0.75) as did the entire questionnaire (α = 0.94). Correlation analysis demonstrated high convergent (rho: 0.911; p<0.001) and predictive (rho: 0.807; p<0.001) validity.

CONCLUSIONS

We have here presented the development of the DIQUEST as a screening tool to assess the level of digital inclusion, particularly addressing the access and skills domains. Future studies are needed for its validation beyond PD.

Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Disparities in resource utilisation by families of children with cardiac conditions

OBJECTIVES

There are limited data documenting sources of medical information that families use to learn about paediatric cardiac conditions. Our study aims to characterise these resources and to identify any disparities in resource utilisation. We hypothesise there are significant variations in the resources utilised by families from different educational and socio-economic backgrounds.

METHODS

A survey evaluating what resources families use (websites, healthcare professionals, social media, etc.) to better understand paediatric cardiac conditions was administered to caretakers and paediatric patients at Morgan Stanley Children's Hospital. Patients with a prior diagnosis of CHD, cardiac arrhythmia, and/or heart failure were included. Caretakers' levels of education (fewer than 16 years vs. 16 years or more) and patients' medical insurance types (public vs. private) were compared with regard to the utilisation of resources.

RESULTS

Surveys completed by 137 (91%) caretakers and 27 (90%) patients were analysed. Websites were utilised by 72% of caretakers and 56% of patients. Both private insurance and higher education were associated with greater reported utilisation of websites, healthcare professionals, and personal networks (by insurance p = 0.009, p = 0.001, p = 0.006; by education p = 0.022, p < 0.001, p = 0.018). They were also more likely to report use of electronic devices (such as a computer) compared to those with public medical insurance and fewer than 16 years of education (p < 0.001, p < 0.001, respectively).

CONCLUSION

Both levels of education and insurance status are associated with the utilisation of informative resources and digital devices by families seeking to learn more about cardiac conditions in children.

Digital health in perinatal care: Exploring usage, attitudes, and needs among Swiss women in urban and rural settings

Background

Switzerland's healthcare system is known for its quality but faces challenges such as slow digitalization and fragmentation, especially in perinatal care. This study investigates Swiss women's use, needs, and attitudes in respect of digital health tools during pregnancy and postpartum, focusing on any differences between rural and urban populations.

Methods

A web-based cross-sectional survey targeted pregnant women and those who had given birth in the last 12 months. Participants were recruited through social media, and the data were analyzed using principal component analysis and multivariable regressions to explore factors affecting the use of digital tools and attitudes toward eHealth.

Results

A total of 1160 participants completed the survey. Healthcare professionals (92%) and private networks (77%) were the primary sources of information. Women expressed a strong preference for app features such as data access (73%), prescription management (73%), and scheduling appointments with healthcare professionals (71%). However, they also raised concerns about the impersonal nature of digital healthcare interactions (71%). Overall, rural women had more negative attitudes toward online health information seeking, which can be attributed to differences in education levels.

Conclusion

The findings indicate that while Swiss women in the perinatal period do utilize digital tools, they focus more on nonmedical topics such as tracking physiological development. The study underscores the importance of adapting digital health solutions to the specific needs of women in the perinatal period. Emphasis should be placed on developing applications that are not only informative but also empower women on their healthcare journey while ensuring data privacy and supporting personal interactions with healthcare providers.

Psychometric validation of the Chinese digital health literacy instrument among Chinese older adults who have internet use experience

INTRODUCTION

In this digital age, the Internet has become a major source of health information, and electronic health (eHealth) literacy becomes increasingly important for older individuals to properly use the extensive eHealth resources for self-care. A valid and reliable tool for assessing older people's eHealth literacy would help healthcare workers identify those disadvantaged groups in digital health and provide relevant health education.

OBJECTIVES

This study aimed to evaluate the psychometric properties of the Chinese version of DHLI in assessing eHealth literacy among older adults in China.

METHODS

A web-based, cross-sectional study was conducted among 277 Chinese older adults from September to November 2021. Two weeks after the first completion, 62 of them answered the C-DHLI again. The reliability (e.g. internal consistency and test-retest reliability), factorial structure and validity (i.e. content validity and convergent validity) of the C-DHLI were evaluated based on the survey data.

RESULTS

The results demonstrated good internal consistency (Cronbach's alpha: 0.94) and test-retest reliability (total intraclass correlation coefficient [ICC]: 0.94) of the C-DHLI. Principal component analysis revealed that the 18 items of C-DHLI loaded on three factors, accounting for 74.69% of the total variance; CFA supported its three-factor structure with good model fits. Convergent validity was examined by the significant associations between C-DHLI and C-eHEALS (r = 0.61), health literacy (r = 0.56), and whether having used the Internet for health information (ρ = 0.43) (ps <.001). A cut-off score of 45 was recommended for determining higher and lower literacy using the C-DHLI, with the area under curve of 0.82 (95% CI = 0.77-0.88).

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

The C-DHLI showed good psychometric performance in assessing eHealth literacy among Chinese older adults. The findings can support healthcare professionals to effectively measure eHealth literacy among older adults and conduct tailored eHealth interventions or training.

Impact of China's digital economy development on the health of middle-aged and older people: an air pollution-based perspective

China has shown good momentum on the road of digital economy development, however, it is also rapidly entering an aging society. Exploring the health effects of the digital economy is of positive significance for realizing healthy aging in China. This paper focuses on the relationship between the digital economy and the health of middle-aged and older people using microdata from the China Health and Retirement Longitudinal Study (CHARLS) 2011-2018 and macrodata from Chinese cities. The study found that the digital economy showed a significant inverted U-shaped relationship on the health of middle-aged and older people. The results of subgroup regressions indicated heterogeneity in this effect across gender, education level, urban/rural and region. Individual health in female, highly educated, and urban groups is more closely related to the digital economy. Middle-aged and old groups in the western region are better able to enjoy the dividends of the digital economy, while middle-aged and old groups in the eastern region are more negatively affected by the digital economy. In the lead-up to the development of the digital economy, individual health can be promoted by narrowing the urban-rural income gap and increasing basic medical resources, while in the later stage of the development of the digital economy, it manifests itself in inhibiting the level of individual health by widening the urban-rural income gap and lowering the level of basic medical resources. In addition, air pollution exhibits a positive moderating effect between the digital economy and individual health, suggesting that air pollution reinforces the impact of the digital economy on health. Expansive analyses indicate that the digital economy has a negative impact on physiological health.

Effectiveness of Interventions to Improve Digital Health Literacy in Forced Migrant Populations: Protocol for a Mixed Methods Systematic Review

BACKGROUND

Digital health literacy is considered a health determinant that can influence improved health and well-being, health equity, and the reduction of social health inequalities. Therefore, it serves as an asset for individuals to promote their health. However, low digital health literacy is a major problem among forced migrant populations. They do not always have the capacity and skills to access digital health resources and use them appropriately. To our knowledge, no studies are currently available to examine effective interventions for improving digital health literacy among forced migrant populations.

OBJECTIVE

This paper presents the protocol for a systematic review that aims to assess the effectiveness of digital health literacy interventions among forced migrant populations. With this review, our objectives are as follows: (1) identify interventions designed to improve digital health literacy among forced migrant populations, including interventions aimed at creating enabling conditions or environments that cater to the needs and expectations of forced migrants limited by low levels of digital health literacy, with the goal of facilitating their access to and use of eHealth resources; (2) define the categories and describe the characteristics of these interventions, which are designed to enhance the abilities of forced migrants or adapt digital health services to meet the needs and expectations of forced migrant populations.

METHODS

A mixed methods systematic review will be conducted according to the PRISMA-P (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) checklist. The research will be conducted in an iterative process among the different authors. With the help of a medical information specialist, a specific search strategy will be formulated for the 6 most relevant databases (ie, MEDLINE, Embase, CINAHL, Web of Science, Academic Search Premier, PsycINFO, and the Google Scholar search engine). A literature search covering studies published between 2000 and 2022 has already been conducted. Two reviewers then proceeded, individually and independently, to conduct a double selection of titles, abstracts, and then full texts. Data extraction will be conducted by a reviewer and validated by a senior researcher. We will use the narrative synthesis method (ie, structured narrative summaries of key themes) to present a comprehensive picture of effective digital health literacy interventions among forced migrant populations and the success factors of these interventions.

RESULTS

The search strategy and literature search were completed in December 2022. A total of 1232 articles were identified. The first selection was completed in July 2023. The second selection is still in progress. The publication of the systematic review is scheduled for December 2023.

CONCLUSIONS

This mixed methods systematic review will provide comprehensive knowledge on effective interventions for digital literacy among forced migrant populations. The evidence generated will further inform stakeholders and aid decision makers in promoting equitable access to and use of digital health resources for forced migrant populations and the general population in host countries.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50798.

Identifying benefits and concerns with using digital health services during COVID-19: Evidence from a hospital-based patient survey

Despite large-scale adoption during COVID-19, patient perceptions on the benefits and potential risks with receiving care through digital technologies have remained largely unexplored. A quantitative content analysis of responses to a questionnaire (N = 6766) conducted at a multi-site acute trust in London (UK), was adopted to identify commonly reported benefits and concerns. Patients reported a range of promising benefits beyond immediate usage during COVID-19, including ease of access; support for disease and care management; improved timeliness of access and treatment; and better prioritisation of healthcare resources. However, in addition to known risks such as data security and inequity in access, our findings also illuminate some less studied concerns, including perceptions of compromised safety; negative impacts on patient-clinician relationships; and difficulties in interpreting health information provided through electronic health records and mHealth apps. Implications for future research and practice are discussed.

Seeking Health in a Digital World: Exploring Immigrant Parents' Quest for Child Health Information-A Scoping Review

During pregnancy and early parenthood, parents' strong interest in pediatric health information presents a valuable opportunity to positively impact long-term health-seeking behavior and overall child health. In line with the increasing prevalence of digital transformation, a scoping review was conducted to explore two key aspects: (1) information seeking and use of digital health information among immigrant parents, and (2) associated reasons and factors. The literature search covered the period until July 2022, using Web of Science, MEDLINE, and CINAHL Complete databases. Out of 625 articles, 12 were included, comprising six qualitative, five quantitative studies, and one review. The majority of studies focused on immigrants in North America, primarily from Latin America and Asia. The studies varied in topics and methodologies, making it challenging to draw general conclusions. Nevertheless, while most immigrant parents rely on digital information on child health, they often prefer human sources such as family, friends, or healthcare providers. Trustworthiness and accessibility emerged as critical criteria for health resources. Two focus group discussions, derived from the results of the review, confirmed these findings for migrant mothers in Switzerland.

Data-Driven and Technology-Enabled Trial Innovations Toward Decentralization of Clinical Trials: Opportunities and Considerations

Traditional trial designs have well-recognized inefficiencies and logistical barriers to participation. Decentralized trials and digital health solutions have been suggested as potential solutions and have certainly risen to the challenge during the pandemic. Clinical trial designs are now increasingly data driven. The use of distributed clinical data networks and digitization has helped to fundamentally upgrade existing research systems. A trial design may vary anywhere from fully decentralized to hybrid to traditional on-site. Various decentralization components are available for stakeholders to increase the reach and pace of their trials, such as electronic informed consent, remote interviews, administration, outcome assessment, monitoring, and laboratory and imaging modalities. Furthermore, digital health technologies can be included to enrich study conduct. However, careful consideration is warranted, including assessing verification and validity through usability studies and having various contingencies in place through dedicated risk assessment. Selecting the right combination depends not just on the ability to handle patient care and the medical know-how but also on the availability of appropriate technologic infrastructure, skills, and human resources. Throughout this process, quality of evidence generation and physician-patient relation must not be undermined. Here we also address some knowledge gaps, cost considerations, and potential impact of decentralization and digitization on inclusivity, recruitment, engagement, and retention. Last, we mention some future directions that may help drive the necessary change in the right direction.

The effect of digital interventions on related health literacy and skills for individuals living with chronic diseases: A systematic review and meta-analysis

BACKGROUND

Chronic diseases are a leading cause of death and disease burden globally. Digital interventions could be an approach to improve patients' ability to find, evaluate, and use health information.

OBJECTIVES

The main objective was to conduct a systematic review to determine the effect of digital interventions on digital health literacy for patients living with chronic disease. Secondary objectives were to provide an overviewof the design and delivery characteristics of interventions that impact digital health literacy in people with chronic disease.

METHODS

Randomized controlled trials examining digital health literacy (and related components) for individuals with cardiovascular disease, chronic lung disease, osteoarthritis, diabetes, chronic kidney disease, and HIV were identified. This review was conducted following the PRIMSA guidelines. Certainty was assessed using GRADE and the Cochrane risk of bias tool. Meta-analyses were conducted using Review Manager 5.1. The protocol was registered on PROSPERO (CRD42022375967).

RESULTS

9386 articles were identified and 17 articles representing 16 unique trials were included. Studies evaluated 5138 individuals with one or more chronic conditions (50% women, ages 42 ± 7-71 ± 12 years). The most targeted conditions were cancer, diabetes, cardiovascular disease, and HIV. Interventions included: skills training, websites, electronic personal health records, remote patient monitoring, and education. The effects of the interventions were related to: (i) digital health literacy, (ii) health literacy, (iii) health information skills, (iv) technology skills and access, and (v) self-management and participation in care. A meta-analysis of three studies identified the effect of digital interventions was better than usual care for eHealth literacy (1.22 [CI 0.55, 1.89], p < 0.001).

CONCLUSIONS

The evidence of the effects of digital interventions on related health literacy is limited. Existing studies reflect the heterogeneity in study design, population, and outcome measures. There is a need for further studies on the effects of digital interventions on related health literacy for individuals with chronic conditions.

Clinical Integration of Digital Patient-Reported Outcome Measures in Primary Health Care for Chronic Disease Management: Protocol for a Systematic Review

BACKGROUND

Health measurement guides policies and health care decisions are necessary to describe and attain the quintuple aim of improving patient experience, population health, care team well-being, health care costs, and equity. In the primary care setting, patient-reported outcome measurement allows outcome comparisons within and across settings and helps improve the clinical management of patients. However, these digital patient-reported outcome measures (PROMs) are still not adapted to the clinical context of primary health care, which is an indication of the complexity of integrating these tools in this context. We must then gather evidence of their impact on chronic disease management in primary health care and understand the characteristics of effective implementation.

OBJECTIVE

We will conduct a systematic review to identify and assess the impact of electronic PROMs (ePROMs) implementation in primary health care for chronic disease management. Our specific objectives are to (1) determine the impact of ePROMs in primary health care for chronic disease management and (2) compare and contrast characteristics of effective ePROMs' implementation strategies.

METHODS

We will conduct a systematic review of the literature in accordance with the guidelines of the Cochrane Methods Group and in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for its reporting. A specific search strategy was developed for relevant databases to identify studies. Two reviewers will independently apply the inclusion criteria using full texts and will extract the data. We will use a 2-phase sequential mixed methods synthesis design by conducting a qualitative synthesis first, and use its results to perform a quantitative synthesis.

RESULTS

This study was initiated in June 2022 by assembling the research team and the knowledge transfer committee. The preliminary search strategy will be developed and completed in September 2022. The main search strategy, data collection, study selection, and application of inclusion criteria were completed between October and December 2022.

CONCLUSIONS

Results from this review will help support implementation efforts to accelerate innovations and digital adoption for primary health care and will be relevant for improving clinical management of chronic diseases and health care services and policies.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42022333513; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=333513.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48155.

A Comparative Case Study Analysis: Applying the HIPE Framework to Combat Harmful Health Information and Drive COVID-19 Vaccine Adoption in Underserved Communities

This descriptive, observational paper utilizes the comparative case study approach to analyze the application of the HIPE™ Framework to two health campaigns addressing vaccine hesitancy in underserved communities. Exposure to inaccurate/misleading health information impacts vaccination adoption, especially for individuals with low health/digital literacy. Underserved groups-like minority, racial/ethnic, or rural populations-typically have lower literacy and higher rates of vaccine hesitancy. Grounded in persuasion and behavioral change theory, the Health Information Persuasion Exploration (HIPE™) Framework was applied to the Black/Haitian community in Miami-Dade, Florida and the Migrant Agricultural Worker Community in Central Valley, California. The campaigns addressed each community's unique characteristics via Detect, Analyze, Design, and Evaluate phases of the HIPE framework. Both campaigns achieved their respective vaccine uptake goals. For Miami-Dade, over 850 vaccinations were administered (the goal was 800 vaccinations), and vaccination rates increased by 25.22%. In Central Valley, vaccination rates for 5-11-year-old children in Merced and Stanislaus counties increased about 20% and 14%, respectively, and overall vaccination rates increased compared to surrounding counties. Discussion of the results and recommendations for future research highlight the potential efficacy of applying the HIPE™ Framework for developing health campaigns and response strategies to improve health outcomes.

The TeleTriageTeam, Offering Continuity of Personalized Care through Telemedicine: Development and Evaluation

BACKGROUND

If anything, the COVID-19 pandemic learned us how to rethink care delivery. It catalyzed creative solutions to amplify the potential of personnel and facilities. This paper presents and evaluates an acutely introduced triaging solution, that evolved into a tool to tackle the ever-growing waiting lists at an academic ophthalmology department: the TeleTriageTeam. A team of undergraduate optometry students, tutor-optometrists, and ophthalmologists collaborate to maintain continuity of eye care. In this ongoing project, we combine innovative inter-professional task allocation, teaching, and remote care delivery.

OBJECTIVE

This paper describes this novel approach, and reports on its clinical effectiveness, its impact on waiting lists, and discusses its transformation to a sustainable method for delivering remote eye care.

METHODS

Real-world clinical data of all patients assessed by the TeleTriageTeam between April 16, 2020, and December 31, 2021 are covered in this paper. Business data about waiting lists and patient portal access were collected from our hospital's capacity management team and IT department. Interim analyses were performed at different time points during the project and this paper will present a synthesis of these analyses.

RESULTS

A total of 3,658 cases were assessed by the TeleTriageTeam. For approximately half (48%) of the assessed cases, an alternative to a conventional face-to-face consultation was found. The waiting lists that had been built up during the first months of the pandemic diminished and have been stable since the end of 2020, even in periods of imposed lockdown restrictions and reduced capacity. Patient portal access decreased with age and patients who were invited to perform a remote, web-based eye test at home were on average younger than patients who were not invited.

CONCLUSIONS

Our acutely introduced approach to remotely review cases and prioritize urgency has been successful in maintaining continuity of care and education throughout the pandemic and evolved into a telemedicine service that is of great interest for future purposes, especially in the routine follow-up of chronic patients. TeleTriage appears as a potentially preferred practice for other clinics and medical specialties. The paradox is that judicious clinical decision making based on remotely collected data actually is possible, lest we as care-givers are willing to change our routines and cognitions regarding face-to-face care delivery.

CLINICALTRIAL

The tragic paradoxical effect of telemedicine on healthcare disparities- a time for redemption: a narrative review

BACKGROUND

Telemedicine has become more convenient and advantageous due to the rapid development of the internet and telecommunications. A growing number of patients are turning to telemedicine for health consultations and health-related information. Telemedicine can increase access to medical care by removing geographical and other barriers. In most nations, the COVID-19 pandemic imposed social isolation. This has accelerated the transition to telemedicine, which has become the most commonly utilized method of outpatient care in many places. Telehealth can assist resolve gaps in access to healthcare services and health outcomes, in addition to its primary function of boosting accessibility to remote health services. However, as the benefits of telemedicine become more apparent, so do the limitations of serving vulnerable groups. Some populations may lack digital literacy or internet access. Homeless persons, the elderly, and people with inadequate language skills are also affected. In such circumstances, telemedicine has the potential to exacerbate health inequities.

AIM AND METHODS

In this narrative review (using the PubMed and Google scholar database), the different benefits and drawbacks of telemedicine are discussed, both globally and in Israel, with particular focus paid to special populations and to the telehealth usage during the Covid-19 period.

FINDINGS

The contradiction and paradox of using telemedicine to address health inequities yet sometimes making them worse is highlighted. The effectiveness of telemedicine in bridging access to healthcare inequities is explored along with a number of potential solutions.

CONCLUSIONS

Policy makers should identify barriers among special populations to using telemedicine. They should initiate interventions to overcome these barriers, while adapting them to the needs of these groups.

Assessing Disparities in Video-Telehealth Use and eHealth Literacy Among Hospitalized Patients: Cross-sectional Observational Study

BACKGROUND

Medicare coverage for audio-only telehealth is slated to end this year after the public health emergency concludes. When the time comes, many patients may be unable to make the transition from audio-only to video telehealth due to digital inexperience. This study explores the second digital divide within video telehealth use, which is primarily characterized by skills and capabilities rather than access, by measuring eHealth literacy (eHL) and video capabilities in hospitalized patients.

OBJECTIVE

The aim of this study is to evaluate video capabilities, eHealth literacy, and engagement with video telehealth among hospitalized patients.

METHODS

The study design is a cross-sectional observational study of adult inpatients at the University of Chicago Medical Center. We assessed self-reported rates of audio versus video telehealth usage as well as the participants' self-reported willingness to use video telehealth for future health care visits. We used a multivariable binary logistic regression to determine the odds ratio for being unwilling to use video telehealth, adjusted for age, sex, race or ethnicity, educational level, eHL literacy scale (eHEALS), health literacy (brief health literacy screen), technology access, internet access, and video capability.

RESULTS

Of the 297 enrolled participants, median age was 58 years, most (n=185, 62%) identified as Black, half (n=149, 50%) were female, one-quarter (n=66, 22%) lacked home internet access, and one-third (n=102, 34%) had inadequate eHL.

CONCLUSIONS

Patients with low eHL reported greater participation in audio-only telehealth over video telehealth, of which the former may lose its flexible pandemic reimbursement policy. This may widen the existing health disparities as older adults and patients with low eHL face challenges in accessing video telehealth services. Low eHL is associated with lack of web-based skills, lower rates of video telehealth usage, and lower willingness to use video technology. The study results raise the question of how to improve video capability among patients who, despite having access to smartphones and laptops, face challenges in using telehealth optimally.

Weight Loss in a Digital Diabetes Prevention Program for People in Health Professional Shortage and Rural Areas

Individuals with prediabetes living in hard-to-reach and underserved areas experience barriers to accessing traditional in-person preventive health services. The National Diabetes Prevention Program (DPP) is a preventive health care program designed to reduce the risk of developing type 2 diabetes. Although there have been increasing numbers of remote DPPs accessible, there are little data on the clinical outcomes of digital DPPs for members living in hard-to-reach and underserved areas. This study assessed whether living in a designated Health Professional Shortage Area (HPSA) and a rural versus urban area impacted the weight loss of N = 7266 members of a fully digital program called Lark DPP. Secondary analyses included between-group comparisons of program retention and member characteristics, demographics, and socioeconomics. Percent weight loss did not differ by HPSA (P = 0.16) or rural/urban status (P = 0.15), despite greater potential barriers for members residing in HPSAs (eg, highest starting body mass index, lowest income, lowest education). Mean percent weight loss for members residing in an HPSA and rural area was mean (M) = 4.75%, standard error (SE) = 0.09; for members in a non-HPSA, rural area M = 4.96%, SE = 0.16; for members in an HPSA, urban area M = 4.55%, SE = 0.13; and for members in a non-HPSA, urban area M = 4.77%, SE = 0.13. Members of a fully digital DPP achieved weight loss that did not differ by HPSA or urban/rural designation. Fully digital programs offer a solution to reduce the risk of type 2 diabetes in areas where residents may not otherwise have access to diabetes prevention services.

"And then I found $5": Optimizing recruitment efficiency in remote clinical trials

Introduction

As clinical trials adopt remote methodologies, there is need to optimize efficiency of remote enrollment. Within a remote clinical trial, we aim to (1) assess if sociodemographic factors differ among those consenting via mail vs. technology-based procedures (e-consent), (2) determine if, among those consenting via mail, a small unconditional monetary reward ($5) increases likelihood of subsequent enrollment, (3) economically evaluate additional cost per additional participant enrolled with $5 reward.

Methods

In the parent nationwide randomized clinical trial of adult smokers (N = 638), participants could enroll via mail or e-consent. Logistic regression models assessed relationships between sociodemographics and enrollment via mail (vs e-consent). Mailed consent packets were randomized (1:4) to include $5 unconditional reward or not, and logistic regression modeling examined impact of reward on subsequent enrollment, allowing for a randomized study within a study. Incremental cost-effectiveness ratio analysis estimated additional cost per additional participant enrolled with $5 incentive.

Results

Older age, less education, lower income, and female sex predicted enrolling via mail vs e-consent (p < .05's). In adjusted model, older age (AOR = 1.02, p = .016) and less education (AOR = 2.23, p < .001) remained predictive of mail enrollment. The $5 incentive (vs none) increased enrollment rate by 9% (AOR = 1.64, p = .007), with estimated cost of additional $59 per additional participant enrolled.

Conclusions

As e-consent methods become more common, they have potential to reach many individuals but with perhaps diminished inclusion across all sociodemographic groups. Provision of an unconditional monetary incentive is possibly a cost-effective mechanism to increase recruitment efficiency for studies employing mail-based consenting procedures.

A profile of patients' and doctors' perceptions, acceptance, and utilization of e-health in a deprived region in southwestern China

BACKGROUND

E-health has the potential to promote health accessibility, performance and cost-saving. However, the adoption and penetration of e-health in underprivileged areas remains insufficient. We aim to investigate patients' and doctors' perception, acceptance, and utilization of e-health in a rural, spatially isolated and poverty-stricken county in southwestern China.

METHODS

A retrospective analysis based on a cross-sectional survey of patients and doctors in 2016 was conducted. Participants were recruited through convenience and purposive sampling, and questionnaires were self-designed and validated by investigators. The utilization, intention to use and preference of four e-health services were evaluated, including e-appointment, e-consultation, online drug purchase, and telemedicine. Predictors of utilization and intention to use e-health services were investigated by multivariable logistic regression.

RESULTS

A total of 485 patients were included. The utilization rate of any type of e-health services was 29.9%, ranging from 6% in telemedicine to 18% in e-consultation. Additionally, 13.9%-30.3% of respondents as non-users revealed their willingness to use such services. Users and potential users of e-health services were inclined to specialized care from county, city or province hospitals, and they were most concerned with the quality, ease of use and price of e-health service. Patients' utilization and intention to use e-health could be associated with education and income level, cohabitants, working location, previous medical utilization, and access to digital device and internet. There remained 53.9%-78.3% of respondents reluctant to use e-health services, mainly due to perceived inability to use them. Of 212 doctors, 58% and 28% had provided online consultation and telemedicine before, and over 80% of county-hospital doctors (including actual providers) indicated their willingness to provide such services. Reliability, quality and ease of use were doctors' major concerns regarding e-health. Doctors' actual provision of e-health was predicted by their professional title, number of years in work, satisfaction with the wage incentive system, and self-rated health. Nevertheless, their willingness to adopt was only associated with the possession of smartphone.

CONCLUSIONS

E-health is still in its infancy in western and rural China, where health resources are most scarce, and where e-health could prove most beneficial. Our study reveals the wide gaps between patients' low usage and their certain willingness to use e-health, as well as gaps between patients' moderate attention to use and physician's high preparedness to adopt e-health. Patients' and doctors' perceptions, needs, expectations, and concerns should be recognized and considered to promote the development of e-health in these underprivileged regions.

A systematic review and meta-analysis of psychosocial interventions for immigrant and limited English proficient cancer patients

OBJECTIVE

Immigrants, particularly those who are less acculturated and limited English proficient (LEP), often lack access to culturally and linguistically appropriate psychosocial care in cancer survivorship. We sought to determine what psychosocial interventions are available for immigrant and/or LEP cancer patients and to assess treatment and patient factors that may correlate with better psychosocial outcomes for this population.

METHODS

We conducted a systematic review and meta-analysis of studies published through August 2022 of interventions conducted with immigrant and/or LEP cancer patients aimed at improving psychosocial outcomes (i.e., quality of life, depression, cancer-related distress, and anxiety). Using Covidence, a software program for systematic review management, four independent raters screened 16,123 records with a systematic process for reconciling disagreement, yielding 48 articles (45 studies) for systematic review and 21 studies for meta-analysis.

RESULTS

Most studies were conducted with Spanish-speaking patients with breast cancer. Study participants (N = 5400) were primarily middle-aged (mean = 53 years old), female (90.0%), and Hispanic (67.0%). The weighted average effect size (g) across studies was 0.14 (95% CI 0.03-0.26) for quality of life (18 studies), 0.04 (95% CI -0.08 to 0.17) for depression (8 studies), 0.14 (95% CI -0.03 to 0.31) for cancer-related distress (6 studies), and 0.03 (95% CI -0.11 to 0.16) for anxiety (5 studies).

CONCLUSION

The interventions under review had small but beneficial effects on psychosocial outcomes for immigrant and LEP cancer patients. Notably, effect sizes were smaller than those found in previous meta-analyses of psychosocial interventions conducted in majority U.S.-born, non-Hispanic White, English-speaking cancer patient samples. More research is needed to identify key components and adaptations of interventions that benefit immigrant and LEP cancer patients to strengthen their effects for this growing yet underserved population.

Is the uptake, engagement, and effectiveness of exclusively mobile interventions for the promotion of weight-related behaviors equal for all? A systematic review

Mobile health interventions are promising behavior change tools. However, there is a concern that they may benefit some populations less than others and thus widen inequalities in health. This systematic review investigated differences in uptake of, engagement with, and effectiveness of mobile interventions for weight-related behaviors (i.e., diet, physical activity, and sedentary behavior) based on a range of inequality indicators including age, gender, race/ethnicity, and socioeconomic status. The protocol was registered on PROSPERO (CRD42020192473). Six databases (CINAHL, EMBASE, ProQuest, PsycINFO, Pubmed, and Web of Science) were searched from inception to July 2021. Publications were eligible for inclusion if they reported the results of an exclusively mobile intervention and examined outcomes by at least one inequality indicator. Sixteen publications reporting on 13 studies were included with most reporting on multiple behaviors and inequality indicators. Uptake was investigated in one study with no differences reported by the inequality indicators studied. Studies investigating engagement (n = 7) reported differences by age (n = 1), gender (n = 3), ethnicity (n = 2), and education (n = 2), while those investigating effectiveness (n = 9) reported differences by age (n = 3), gender (n = 5), education (n = 2), occupation (n = 1), and geographical location (n = 1). Given the limited number of studies and their inconsistent findings, evidence of the presence of a digital divide in mobile interventions targeting weight-related behaviors is inconclusive. Therefore, we recommend that inequality indicators are specifically addressed, analyzed, and reported when evaluating mobile interventions.

Pediatric central nervous system tumor survivor and caregiver experiences with multidisciplinary telehealth

PURPOSE

Telehealth use to facilitate cancer survivorship care is accelerating; however, patient satisfaction and barriers to facilitation have not been studied amongst pediatric central nervous system (CNS) tumor survivors. We assessed the telehealth experiences of survivors and caregivers in the Pediatric Neuro-Oncology Outcomes Clinic at Dana-Farber/ Boston Children's Hospital.

METHODS

Cross-sectional study of completed surveys among patients and caregivers with ≥ 1 telehealth multidisciplinary survivorship appointment from January 2021 through March 2022.

RESULTS

Thirty-three adult survivors and 41 caregivers participated. The majority agreed or strongly agreed that telehealth visits started on time [65/67 (97%)], scheduling was convenient [59/61 (97%)], clinician's explanations were easy-to-understand [59/61 (97%)], listened carefully/addressed concerns [56/60 (93%)], and spent enough time with them [56/59 (95%)]. However, only 58% (n = 35/60) of respondents agreed or strongly agreed they would like to continue with telehealth and 48% (n = 32/67) agreed telehealth was as effective as in person office visits. Adult survivors were more likely than caregivers to prefer office visits for personal connection [23/32 (72%) vs. 18/39 (46%), p = 0.027].

CONCLUSION

Offering telehealth multi-disciplinary services may provide more efficient and accessible care for a subset of pediatric CNS tumor survivors. Despite some advantages, patients and caregivers were divided on whether they would like to continue with telehealth and whether telehealth was as effective as office visits. To improve survivor and caregiver satisfaction, initiatives to refine patient selection as well as enhance personal communication through telehealth systems should be undertaken.

Comparison of eHealth Literacy Scale (eHEALS) and Digital Health Literacy Instrument (DHLI) in Assessing Electronic Health Literacy in Chinese Older Adults: A Mixed-Methods Approach

This study compared the reliability, construct validity, and respondents' preference of the Chinese version of 8-item eHEALS (C-eHEALS) and 21-item DHLI (C-DHLI) in assessing older adults' electronic health (eHealth) literacy using a mixed-methods approach. A web-based, cross-sectional survey was conducted among 277 Chinese older adults from September to October 2021, and 15 respondents were subsequently interviewed to understand their preference of scale to use in practice. Results showed that the internal consistency and test-retest reliability of both scales were satisfactory. For the construct validity, the C-DHLI score showed stronger positive correlations with having Internet use for health information and higher educational attainments, occupational skill levels, self-rated Internet skills, and health literacy than the C-eHEALS score. In addition, younger age, higher household income, urban residence, and longer Internet use history were only positively correlated with C-DHLI score. Qualitative data suggested that most interviewees perceived the C-DHLI as more readable than C-eHEALS for its clear structure, specific description, short sentence length, and less semantic complexity. Findings revealed that both scales are reliable tools to measure eHealth literacy among Chinese older adults, and the C-DHLI seemed to be a more valid and favored instrument for the general Chinese older population based on the quantitative and qualitative results.

e-Health Literacy Skills in People with Chronic Diseases and What Do the Measurements Tell Us: A Scoping Review

Background: Use of electronic health (e-Health) technologies has increased in the past decade and inadequate e-Health literacy may lead to health-related social inequality. This is especially true for patients living with chronic diseases who are often involved in self-care. However, the measurement of e-Health literacy represents several challenges. Among available instruments, the e-Health Literacy Scale (eHEALS) is the only instrument with available psychometric properties. Aim: To identify studies measuring e-Health literacy in adults living with chronic disease and its relationship to health-related behaviors and other perceptions such as quality of life, self-efficacy, or specific disease biomarkers, and studies analyzing the impact of educational intervention on e-Health literacy. Methods: The authors searched MEDLINE, the Cochrane Library, and Web of Science databases to identify studies published in English language until April 2022. Results: Seventeen studies involving 4,877 participants were included. A majority of the studies were cross-sectional with a lack of appropriate controls. Five of the included studies were experimental, involving 758 participants. All of them reported positive effects of educational interventions on the improvements in self-reported e-Health literacy skills. However, most studies were at risk of bias. Conclusion: Despite these limitations, the findings of this review indicate the positive relationship between e-Health literacy and various health care processes in adults with chronic diseases and highlights a need for prospective controlled studies. Promoting e-Health literacy might give better opportunities for the active involvement of people with chronic diseases in self-care and for the implementation of online interventions into existing system of care.

Reaching Out to Adolescents at High Risk of HIV Infection in Brazil: Demand Creation Strategies for PrEP and Other HIV Combination Prevention Methods

Using baseline data from the PrEP1519 cohort, in this article we aimed to analyze: (i) the effectiveness of demand creation strategies (DCS) to enroll adolescent men who have sex with men (AMSM) and adolescent transgender women (ATGW) into an HIV combination prevention study in Brazil; (ii) the predictors of DCS for adolescents' enrollment; and (iii) the factors associated with DCS by comparing online and face-to-face strategies for enrollment. The DCS included peer recruitment (i.e., online and face-to-face) and referrals from health services and non-governmental organizations (NGOs). AMSM and ATGW who agreed to participate in the study could opt to enroll in either PrEP (PrEP arm) or to use other prevention methods (non-PrEP arm). Bivariate and multivariate analyses were conducted and logistic regression odds ratios were estimated. The DCS reached 4529 AMSM and ATGW, the majority of which were derived online (73.8%). Of this total, 935 (20.6%) enrolled to participate (76.6% in PrEP arm and 23.4% in non-PrEP arm). The effectiveness of enrolling adolescents into both arms was greater via direct referrals (235/382 and 84/382, respectively) and face-to-face peer recruitment (139/670 and 35/670, respectively) than online (328/3342). We found that a combination under DCS was required for successful enrollment in PrEP, with online strategies majorly tending to enroll adolescents of a higher socioeconomic status. Our findings reinforce the need for DCS that actively reaches out to all adolescents at the greatest risk for HIV infection, irrespective of their socioeconomic status.

The Relation Between eHealth Literacy and Health-Related Behaviors: Systematic Review and Meta-analysis

BACKGROUND

With widespread use of the internet and mobile devices, many people have gained improved access to health-related information online for health promotion and disease management. As the health information acquired online can affect health-related behaviors, health care providers need to take into account how each individual's online health literacy (eHealth literacy) can affect health-related behaviors.

OBJECTIVE

To determine whether an individual's level of eHealth literacy affects actual health-related behaviors, the correlation between eHealth literacy and health-related behaviors was identified in an integrated manner through a systematic literature review and meta-analysis.

METHODS

The MEDLINE, Embase, Cochrane, KoreaMed, and Research Information Sharing Service databases were systematically searched for studies published up to March 19, 2021, which suggested the relationship between eHealth literacy and health-related behaviors. Studies were eligible if they were conducted with the general population, presented eHealth literacy according to validated tools, used no specific control condition, and measured health-related behaviors as the outcomes. A meta-analysis was performed on the studies that could be quantitatively synthesized using a random effect model. A pooled correlation coefficient was generated by integrating the correlation coefficients, and the risk of bias was assessed using the modified Newcastle-Ottawa Scale.

RESULTS

Among 1922 eHealth literacy-related papers, 29 studies suggesting an association between eHealth literacy and health-related behaviors were included. All retrieved studies were cross-sectional studies, and most of them used the eHealth Literacy Scale (eHEALS) as a measurement tool for eHealth literacy. Of the 29 studies, 22 presented positive associations between eHealth literacy and health-related behaviors. The meta-analysis was performed on 14 studies that presented the correlation coefficient for the relationship between eHealth literacy and health-related behaviors. When the meta-analysis was conducted by age, morbidity status, and type of health-related behavior, the pooled correlation coefficients were 0.37 (95% CI 0.29-0.44) for older adults (aged ≥65 years), 0.28 (95% CI 0.17-0.39) for individuals with diseases, and 0.36 (95% CI 0.27-0.41) for health-promoting behavior. The overall estimate of the correlation between eHealth literacy and health-related behaviors was 0.31 (95% CI 0.25-0.34), which indicated a moderate correlation between eHealth literacy and health-related behaviors.

CONCLUSIONS

Our results of a positive correlation between eHealth literacy and health-related behaviors indicate that eHealth literacy can be a mediator in the process by which health-related information leads to changes in health-related behaviors. Larger-scale studies with stronger validity are needed to evaluate the detailed relationship between the proficiency level of eHealth literacy and health-related behaviors for health promotion in the future.

eHealth Literacy and Patient Portal Use and Attitudes: Cross-sectional Observational Study

BACKGROUND

Throughout the COVID-19 pandemic, patient portals have become more widely used tools of patient care delivery. However, not all individuals have equivalent access or ability to use patient portals.

OBJECTIVE

The aim of this study is to evaluate the relationships between eHealth literacy (eHL) and patient portal awareness, use, and attitudes among hospitalized patients.

METHODS

Inpatients completed patient portal surveys; eHL was assessed (eHealth Literacy Scale). Multivariable logistic regression analyses adjusted for age, self-reported race, gender, and educational attainment were completed with significance at P<.006 (Bonferroni correction).

RESULTS

Among 274 participants, most identified as Black (n=166, 61%) and female (n=140, 51%), mean age was 56.5 (SD 16.7) years, and 178 (65%) reported some college or higher educational attainment. One-quarter (n=79, 28%) had low eHL (mean 27, SD 9.5), which was associated with lower odds of portal access awareness (odds ratio 0.11, 95% CI 0.05-0.23; P<.001), having ever used portals (odds ratio 0.19, 95% CI 0.10-0.36; P<.001), less perceived usefulness of portals (odds ratio 0.20, 95% CI 0.10-0.38; P=.001), and lower likelihood of planning to use portals in the coming years (odds ratio 0.12, 95% CI 0.06-0.25; P<.001). As time through the COVID-19 pandemic passed, there was a trend toward increased perceived usefulness of patient portals (53% vs 62%, P=.08), but average eHL did not increase through time (P=.81).

CONCLUSIONS

Low eHL was associated with less awareness, use, and perceived usefulness of portals. Perceived usefulness of portals likely increased through the COVID-19 pandemic, but patients' eHL did not. Interventions tailored for patients with low eHL could ensure greater equity in health care delivery through the COVID-19 pandemic.