Research roundup: How telehealth can be used to address population health disparities

Since the start of the pandemic, telehealth has helped reduce the risks of contracting COVID-19 for health care providers and their patients. With the current widespread usage, telehealth could be one way to improve access to care for underserved populations during and after the public health emergency.

In this installment of “Research Roundup,” we look at research that explores the attitudes of and willingness to engage in telehealth by various population groups in the United States, including older adults, ethnic/racial minorities, and rural communities. These studies highlight the importance of considering community needs and cultural values and preferences to provide quality health care which may lead to improved outcomes.¹

Fischer, S. H., Ray, K. N., Mehrotra, A., Bloom, E. L., and Uscher-Pines, L. (2020). Prevalence and characteristics of telehealth utilization in the United States. JAMA Network Open, 3(10), e2022302.

A nationally representative sample of U.S. adults self-reported their use of various telehealth modalities and their attitudes toward using videoconferencing as a means of telehealth in the future. Prepandemic, an internet panel was selected to engage about 4,000 participants aged 18 years or older. 65% of invited participants responded to a short survey on previous telehealth use and willingness to participate in telehealth via videoconferencing in the future. Telehealth modalities in this study included patient portals, text messaging, email correspondence, telephone calls, and videoconferencing visits with a provider. A variety of demographic characteristics were considered when examining the results, and responses were weighted using probability sampling methods.

The survey found that 83% of respondents had used at least one modality (including telephone) but just 50% of individuals had used modalities other than the phone to interact with a physician. Women (53.8%) were more likely to have used telehealth compared to men (47.5%), and individuals in the western region of the U.S. (56.7%) were more likely to have used telehealth than elsewhere in the country. Less than 5% of respondents reported having ever used videoconferencing to communicate with a physician, with most reporting that their physicians did not offer it at that time (before the pandemic). However, a minority of respondents also indicated that they did not know how to use the technology or did not want to communicate that way. These responses were more likely among older adults and Black Americans.

The pandemic has forced individuals to become more comfortable and knowledgeable about using videoconferencing for health care. Still, it’s important to educate patients and providers on using telehealth and promote effective communication via technology to increase engagement for all communities.

Elk, R., Emanuel, L., Hauser, J., Bakitas, M., and Levkoff, S. (2020). Developing and testing the feasibility of a culturally based tele-palliative care consult based on the cultural values and preferences of southern, rural African American and White community members: A program by and for the community. Health Equity, 4(1), 52–83.

Watts, K. A., Gazaway, S., Malone, E., Elk, R., Tucker, R., McCammon, S., Goldhagen, M., Graham, J., Tassin, V., Hauser, J., Rhoades, S., Kagawa-Singer, M., Wallace, E., McElligott, J., Kennedy, R., and Bakitas, M. (2020). Community Tele-pal: A community-developed, culturally based palliative care tele-consult randomized controlled trial for African American and White Rural southern elders with a life-limiting illness. Trials, 21(1), 672.

Rural communities, older adults, and African Americans all face barriers to health care access (Watts et al., 2020). Elk et al. (2020) report on the development of a culturally based tele-palliative care consult program, and Watts and colleagues (2020) describe the ongoing clinical trial to test the efficacy of the program.

Elk and colleagues (2020) conducted focus groups with 31 family members to determine treatment needs and cultural values and preferences to develop a palliative care protocol which was then evaluated with health care providers and finally with a feasibility study. Both White and African American family members described the need for more respectful treatment of themselves and their sick family member by hospital physicians and indicated church and religion were important, especially among African American family members. These themes were incorporated into the telehealth consult program. The program was evaluated in rural South Carolina to determine its feasibility and acceptability by patients and their families and was found possible to implement. However, low referral by providers at hospitals was an obstacle, underscoring the need for everyone—including providers—to be supportive and engaged in telehealth options.

Pekmezaris, R., Williams, M. S., Pascarelli, B., Finuf, K. D., Harris, Y. T., Myers, A. K., Taylor, T., Kline, M., Patel, V. H., Murray, L. M., McFarlane, S. I., Pappas, K., Lesser, M. L., Makaryus, A. N., Martinez, S., Kozikowski, A., Polo, J., Guzman, J., Zeltser, R., … Granville, D. (2020). Adapting a home telemonitoring intervention for underserved Hispanic/Latino patients with type 2 diabetes: An acceptability and feasibility study. BMC Medical Informatics and Decision Making, 20(1), 1–14.

This study used a community-based participatory research approach alongside an eight-phase model to guide the adaptation of a telemonitoring intervention program for Hispanic/Latino patients. After compiling feedback from community focus groups, major themes were highlighted, such as technology acceptance and usability, language comprehension, and cultural congruence. These suggestions were adopted into the original telemonitoring program to adapt the program to the needs of the community. The program was then administered to 12 Hispanic/Latino patients with Type 2 Diabetes from outpatient clinics in the New York metropolitan area over the course of six months. The program included culturally-relevant educational videos to educate the patient on how to manage their condition. Several strategies to maximize acceptance and usability were identified including use of lightweight tablets to increase portability, addressing privacy and identity concerns, and ensuring the program was culturally congruent in terms of language and examples.

While telehealth has much promise for increasing access to care, efforts must be made to ensure that a full range of technologies, including phone services, are utilized to overcome barriers to access. Studies show that less familiarity with modalities, such as videoconferencing and patient portals, and less access to equipment needed to use these modalities can prevent individuals from seeking care. Collectively, these studies identify strategies for adapting procedures to telehealth to meet the specific needs of local communities. Patients need support to utilize telehealth and some providers might also need help and encouragement to recognize its value for their practices and for specific patient populations. Furthermore, adapting health care interventions in culturally congruent ways appears to increase the acceptability of these practices.

Psychologists may be in the unique position to help the systems in which they work to comprehensively evaluate the telehealth strategies in use, identify barriers to care for specific populations and design telehealth interventions to reach underserved populations. Given the efficacy and convenience of telehealth, engaging diverse populations in these different telehealth modalities by incorporating culturally-based care models and training health care professionals in cultural awareness when creating, adapting, or implementing telehealth programs will serve to increase their acceptability, use, and effectiveness.

APA is continually updating its resources during the COVID-19 pandemic, including information for practitioners and the public on telehealth and bias, discrimination, and equity. Practitioners are encouraged to review the professional literature and various APA-approved standards and guidelines which may be useful resources, particularly when considering the practice of telepsychology.