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The rapid virtualization of health services during the COVID-19 pandemic has drawn increasing attention to the impact of virtual care technologies on health equity. In some circumstances, virtual care initiatives have been shown to increase health disparities, as individuals from underserved communities are less likely to benefit from such initiatives.
The purpose of this paper is to describe a protocol for a scoping review of reviews that aims to map review-level evidence that describes challenges and strategies for promoting effective engagement with virtual care technologies among underserved communities.
Our methodology was adapted from seminal scoping review guidelines provided by Arksey and O’Malley, Levac at al, Colquhoun et al, and the Joanna Briggs Institute. Our search strategy was developed for the following databases: MEDLINE (on Ovid), EMBASE (on Ovid), CINAHL (on EBSCO), Scopus, and Epistemonikos. Supplementary searches will include the use of Google Scholar and reference tracking. Each citation will be independently screened by 2 researchers at the title and abstract level, and full-text screening will be performed in accordance with our eligibility criteria. The eligibility criteria focused on the inclusion of methods-driven reviews (ie, systematic reviews, scoping reviews, meta-analyses, realist reviews, and critical interpretative syntheses) to enhance rigor and quality. Other inclusion criteria included a focus on virtual care services that facilitate bidirectional patient-provider communication (ie, video, telephone, and asynchronous messaging visits) for underserved populations (ie, those who experience social disadvantage due to race, age, income, and other factors related to the social determinants of health).
This scoping review of reviews will provide a broad overview of identified challenges associated with the accessibility of virtual health care services among underserved communities. In addition, strategies for improving the access to, uptake of, and engagement with virtual care technologies among underserved communities will be identified. The knowledge synthesized from this review will aid in developing and implementing virtual services that acknowledge the unique needs of populations who experience barriers to care and disproportionately worse health outcomes. The results will also inform gaps in current research.
The rapid shift toward virtual health services has highlighted the urgent need to critically examine the intersection of virtual care and health equity. Although technology-driven innovations in health care generally aim to improve access, quality, and health outcomes, it is also possible for these innovations to produce intervention-generated inequities. Assessing current review-level evidence on the key challenges and strategies for improving the application of virtual care in underserved communities is imperative for ensuring that virtual care benefits all populations.
PRR1-10.2196/22847
In response to the COVID-19 pandemic, virtual visits have rapidly transitioned from representing a small fraction of health care delivery to being the primary means of connecting patients and providers [
Many anticipate that several of the physical distancing measures that were implemented due to the COVID-19 pandemic may continue for the long term and that virtual care will continue to be ubiquitous in health service delivery [
Although several reviews have identified gaps in technology access, use, or literacy [
To inform our research question, we chose to conduct a scoping review of reviews to comprehensively, systematically, and feasibly map a large and diverse body of literature. Our approach was informed by guidance from the methodological frameworks created by Arksey and O’Malley [
Standardized reporting guidelines outline elements that should be included in research studies to enhance their transparency [
To establish our research questions, we first conducted an exploratory review of the literature on health equity in virtual care interventions. Following this review and extensive consultations with the members of our research team who had subject matter expertise, we made iterative improvements to clarify the concept and purpose of this study. After refining the study purpose, we established the following overarching research question: what challenges and strategies related to enabling the access to, uptake of, and engagement with virtual care for people from underserved communities have been documented in the literature?
The following subquestions will be used to further inform our investigation: (1) what is the review-level evidence regarding challenges that inhibit the access to, uptake of, and engagement with virtual care technologies among underserved communities; and (2) what is the review-level evidence regarding strategies for improving the access to, uptake of, and engagement with virtual care technologies among underserved communities?
In order to identify relevant studies that would inform our research questions, we first operationalized the following 2 key concepts within our study: virtual care and underserved populations. We then decided on the types of studies that would be the most relevant to include in the search strategy.
For the purposes of this scoping review, we defined virtual care as “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care” [
We defined an underserved community as a group of people with increased susceptibility to health and health care disparities due to a combination of individual, environmental, and social factors that have been collectively defined as social determinants of health [
Since our objective is to summarize a broad and diverse range of literature on virtual care, we will limit the inclusion of study types to the following methods-driven reviews: systematic reviews, meta-analyses, meta-syntheses, scoping reviews, realist reviews, and critical interpretive syntheses. Including studies with well-developed and established review methodologies will help reduce the risk of capturing poor quality studies. In addition, synthesizing review-level evidence will allow us to capture the vast amount of published literature on virtual care interventions in a logistically feasible manner [
We developed comprehensive search strategies in collaboration with an academic librarian (KF) at the University of Toronto. These search strategies were developed for the following databases: Ovid MEDLINE: Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, and Ovid MEDLINE 1946-present; EMBASE (on Ovid), CINAHL (on EBSCO); Scopus; and Epistemonikos. The databases were selected based on subject area coverage and functionality. Additionally, guidelines provided by Goosen et al [
To supplement our search, we will use Google Scholar to identify relevant reviews that were not captured during the database searches. Key terms for each concept will be applied, and the first 3 pages of the search results will be reviewed. Potentially relevant items will be selected and deduplicated against our original set of search results and sent for screening. In addition, we will hand search the reference lists of included studies to identify any potentially relevant citations that may have been missed during the initial database search.
The inclusion and exclusion criteria for study selection (
Reviews of interventions that target or describe the impact of the intervention on an underserved population (ie, those who experience social disadvantage due to older age, gender identity, racial or cultural identity, immigration or refugee status, low income or low socioeconomic status, and rurality).
Reviews on health care–focused technological interventions.
Reviews focused on virtual care interventions, as defined in Section 2.4.1, Consultations between remote client and healthcare providers, in the World Health Organization’s Classification of Digital Health Interventions. These include telephone communication; video communication; asynchronous SMS text messaging; asynchronous email messaging; portals, apps, and other applications for bidirectional patient-provider communication; and remote monitoring tools that incorporate bidirectional communication functionality (ie, the tools listed previously).
All health system settings in high-income countries.
Methods-driven literature reviews, including systematic reviews, meta-analyses, scoping reviews, realist reviews, and critical interpretive syntheses.
Reviews of interventions that target or describe the impact of the intervention on a general or clinical population instead of underserved populations as described within our inclusion criteria.
Reviews of technological interventions that do not explicitly focus on bidirectional provider-patient communication (eg, patient portals that only focus on providing patients with access to their health information, remote monitoring tools without bidirectional patient-provider communication functionality, and provider-provider communication tools).
Studies focused on middle-income and low-income countries.
Reviews and knowledge syntheses that are not methods based.
Primary research studies that use qualitative and quantitative methods.
Opinion papers, commentaries, editorial reviews, and letters to the editor.
Study protocols, dissertations, and conference abstracts/proceedings.
A screening guide, which was developed by 1 reviewer (SB) with feedback from the research team, will be used to determine if the inclusion and exclusion criteria have been met. In total, 5 researchers (JKF, KD, PC, SB, and TTJ) will independently pilot test the screening guide with a test sample of 200 abstracts. Results will be discussed, and revisions to the screening guide will be made as needed. An example of an included article and an excluded article will also be presented to the project team to ensure the appropriateness of included articles.
After establishing the screening guide and completing a pilot test, a 2-stage screening process will be implemented. First, all available titles and abstracts will be independently screened by 2 reviewers to determine the eligibility of articles for inclusion. Reviewers will meet regularly to discuss any challenges related to study selection and refine the inclusion and exclusion criteria as needed. Conflicts will be resolved by a third reviewer or through group discussion. The second stage of study selection will involve the examination of the full-text articles accepted in the first stage of study selection to determine their eligibility for inclusion. Any included full-text articles will be independently reviewed by 2 reviewers based on the inclusion and exclusion criteria. Once again, any conflicts between reviewers will be resolved by a third reviewer or through discussion with the research team. The study selection process will be summarized in a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
A data extraction form will be developed and pilot tested by 5 reviewers (JKF, KD, PC, SB, and TTJ). A draft version of this form is provided in
Based on the studies used for developing the search strategy, the proposed fields for extraction include the following: (1) review identifiers (ie, authors, year of publication, review type, number of studies in the review, reported timeframe, place of publication); (2) the nature of the virtual care intervention(s) (ie, categorization and purpose of the technology); (3) setting and population (ie, the physical setting or geographical location of the intervention and demographic characteristics of the population); (4) the reported challenges for implementation, adoption, and engagement; (5) the reported strategies for improving implementation, adoption, and engagement; and (6) key study outcomes or conclusions.
A qualitative descriptive approach will be used to synthesize the data collected. The common characteristics of review articles will be identified to descriptively analyze the extent, nature, and distribution of included review articles. These characteristics include the review articles’ methodology, technologies described, target population(s), country/region of origin, and content. In keeping with established scoping review guidelines [
This scoping review is currently in the study selection phase. Electronic database searches were completed in August 2020, yielding 9666 unique references. Following title and abstract screening, 9526 records were excluded based on the inclusion and exclusion criteria. As a next step, the resulting 140 references will undergo full-text review. Data synthesis will follow, and the authors anticipate that the results of this study will be submitted for publication in January 2021.
Digital health interventions that are developed without context and without sensitivity to diverse needs can exacerbate pre-existing health disparities, thereby widening the gap between those with privilege and those without [
A potential limitation of this study is the lack of quality assessment for included articles. Although a quality appraisal is not required in scoping reviews [
The rapid virtualization of health services during the COVID-19 pandemic has highlighted the urgent need to critically examine the intersection of virtual care and health equity. Although technology-driven innovations in health care generally aim to improve access, quality, and health outcomes, it is also possible for these innovations to produce intervention-generated inequities by differentially benefiting those with more social and economic privilege than others [
Search strategy for Ovid MEDLINE: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, and Ovid MEDLINE 1946-Present.
Draft data extraction form.
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature Search extension
Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews
None declared.