During the COVID-19 pandemic, the Canadian health-care system has seen a rapid uptake of all digital health technologies, including e-health, telemedicine and medical test result platforms to support remote health-care access.
At the same time, COVID-19 has worsened pre-existing health inequities experienced by new immigrants. Almost half (49 per cent) of immigrants report they are “very” or “extremely” concerned with their own health because of the pandemic compared with Canadian-born citizens at 33 per cent.
As of June 2020, immigrants and refugees accounted for 43.5 per cent of all COVID-19 cases in Ontario, despite the fact they constituted just slightly more than 25 per cent of the province’s population. During the pandemic, a higher proportion (28 per cent) of recent immigrants reported fair or poor self-rated mental health compared with established immigrants (20 per cent).
To support health-care delivery to immigrants and help them take advantage of digital health technologies, there are challenges: we’re going to need to provide greater technological access to lower-income people; institute programs to increase digital literacy; reassure newcomers about confidentiality concerns; address language issues that can block or harm some needed health-care delivery; improve community services; and provide greater education about these issues to health-care providers.
A basic component of accessing services using digital health technologies is an electronic device that supports the health-care provider-patient interaction. With added economic constraints – including increased financial challenges to pay to immigrate to Canada as well as employment precarity during the COVID-19 pandemic – the financial costs associated with e-health access can be insurmountable for some.
There is also the cost of paying for reliable communication mediums, such as wi-fi with adequate bandwidth or a mobile plan that includes sufficient calling minutes. In addition, access to a special device or app that supports remote telemedicine phone or video calling is required. Libraries typically provide free access to technology and wi-fi. However, during the COVID-19 pandemic, added restrictions in requiring pre-registered time slots or library closures have limited access for many people. Initiatives to provide free wi-fi for vulnerable populations during the pandemic, as seen in the City of Toronto, can help alleviate financial pressures. However, this has been created as a temporary service. Long-term internet and device-access programs should be considered to support vulnerable populations.
Various platforms, including Cisco Webex, Zoom for Healthcare, and eVisit Inc., are being used by health-care providers in Ontario to provide remote telehealth services. However, many of these platforms require the patient to find the telehealth access information online, call the telehealth phone number, open an emailed web link from the telehealth provider, and download video-conferencing software applications. Digital literacy and navigation of online e-health platforms can be particularly challenging for those with less technological experience and competency.
Many individuals have cited greater familiarity with popular technological applications such as Facebook Messenger or What’s App for telehealth video-conferencing. However, many commonly used video-conferencing platforms are not compliant with the Personal Health Information Protection Act (PHIPA) which governs medical confidentiality in Ontario. Digital skills capacity-building can assist in navigating newer online platforms. Digital literacy is more than technological know-how. It is a combination of knowledge, skills, abilities and practices to know, find, use and evaluate the technologies. Identifying usability preferences can assist in tailoring and facilitating digital health interactions on virtual platforms.
Privacy and confidentiality concerns
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COVID-19 physical-distancing measures have forced many individuals to spend increased time at home. The mandatory 14-day quarantine for newcomers, remote employment, job loss, reduced hours of community services, and the closure of schools and child-care services have aggravated the problem. In those situations, individuals compete for time and space at home to hold video- or telephone-conferencing appointments. Lack of privacy during telehealth appointments when children, partners, parents or roommates are present can dissuade telehealth use or information-sharing with health-care providers. Notably, intimate-partner violence-screening and disclosure at home via telehealth can place an individual’s safety at greater risk. Providing flexible scheduling and hours of service will assist in accommodating these privacy considerations.
Moreover, there is a lack of data investigating new immigrants’ trust towards digital health technologies in Ontario and Canada. However, a general population sample poll conducted by the Canadian Medical Association has demonstrated that more than 85 per cent of respondents were either very concerned or somewhat concerned about ownership and use of their health data. Other concerns include who has access to their health information and the occurrence of data breaches on digital health platforms. The current government-supported telehealth platforms must comply with PHIPA regulations. However, app manufacturers and private businesses are not regulated under that law, thereby leaving health information collection by non-governmental health applications unregulated in Ontario. Clear communication regarding data protection may assist in building trust and identifying potential security concerns of new users.
A 2016 Statistics Canada report found that 649,000 people in Canada reported being unable to conduct a conversation in either English or French – and 175,000 of these respondents lived in a private household where no one older than 15 could conduct a conversation in English or French. Immigrants may have a very different understanding of health services, based on their experiences with the health system in their country of emigration. A benefit to telehealth services is the capacity to include interpreters when clinical calls are made from remote locations where prompt access to translation services may otherwise be challenging to obtain. Language barriers further impede newcomers’ abilities to navigate clinic or hospital websites, which are primarily in English, to access telehealth information online, and to download and set up software to support a telehealth appointment. Providing translated information on accessing telehealth services to immigrant and settlement sector services can assist in supporting an understanding of the process of accessing remote digital health-care services.
As health misinformation increases online, digital health services need to establish avenues to facilitate user trust. That is particularly important among new immigrants, who may not be familiar with Canadian health-system services. Comprehensive education, awareness and orientation programs are imperative to building an understanding of digital health systems. Further regional collaboration between primary health-care telehealth services and settlement sector services can assist in supporting telehealth access and awareness among newcomers. Educational materials need to be offered in multiple languages in video or written form, outlining the function of telehealth as a confidential online health system and how to access this service.
Telehealth education for health-care providers using interpreters may assist the providers in developing an awareness of how to navigate these digital communication limitations. Increased knowledge of current digital health regulations, challenges to digital health access, and awareness of digital skills-building support programs will assist providers in supporting new immigrants as digital health system users. Education surrounding inequities to digital health access among marginalized groups can assist health-care providers in assessing their patients’ digital health-care needs and in providing appropriate supportive referrals.
Understanding the lived experiences of new immigrants with respect to digital health accessibility should be at the centre of any policy interventions. As the Canadian health-care system continues to develop its digital health capacities during the COVID-19 pandemic and beyond, considerations must be given to achieving greater digital health inclusivity to support optimal health outcomes.