You are a Nurse Practitioner with a practice in a COVID-19 hotspot. The pandemic has forced you to transition into providing virtual care. You are wrapping up your last telemedicine visit of the morning. Your patient is an 80-year-old Chinese female with a possible skin infection. Her granddaughter is with her and translates for you as you run through your HPI questions. Your patient’s granddaughter has a smart phone, and she positions the camera with a good view of the affected area, which is on the patient’s back. You think about your elderly patients who live alone and are not so fortunate to have access to and help with technology. You wonder what options are available to provide equal access to care for all of your patients.
Welcome to another HiQuiPs post! This is the first of a two-part series in which we will be introducing digital inequity and discussing measures to help our vulnerable patients to bridge Canada’s digital divide.
The Digital Divide
The COVID-19 pandemic catalyzed fast implementation of virtual medicine. Concerns for social distancing and infection control forced many in-office visits to be replaced with telemedicine visits (phone calls or video chats). Many patients find this technology patient centered, as it improves access and convenience, and delivers safe, efficient care in multiple clinical settings.(1) However, there are vulnerable populations who have increased challenges with accessing virtual health care. This has created a digital divide, a lack of access to information technologies related to social inequalities.(2)
Some of the most vulnerable populations include Black, Latino, and other ethnic minorities, low-income populations, Indigenous peoples, homeless peoples, the elderly, and rural populations.(3) These patients have also been shown to consistently have worse patient outcomes. There have been social and racial inequities observed during the COVID-19 pandemic in the US and UK, with a significant variation in deaths based on social determinants of health such as age, sex, ethnicity, income, and education.(4,5) There is mounting evidence that these inequities also exist in Canada.(4,5) A report by Public Health Ontario in 2020 identified a higher percentage of positive COVID-19 tests in neighbourhoods with the highest ethnic concentration (41% vs. 8%), greatest material deprivation (24% vs. 17%), and the lowest income (26% vs. 16%) compared to the lowest quintiles of each measure.(5)
Another vulnerable population to highlight is individuals with severe mental illness.(6) Those with severe mental illness also have a higher prevalence of chronic physical illness, which may result in increased reliance on digital technologies for self-care.(6) This population faces common barriers to digital inclusivity in addition to barriers linked to mental illness, such as cognitive deficits and symptoms such as hallucinations.(6)
The challenges creating the digital divide can be broken down into 3 main issues:
Access to technologies
Access to internet services
Access to Technologies
One barrier to accessing online health care is lack of a device to connect to the internet with. Devices and smartphones that allow for more immersive virtual care options such as video chat are also more expensive. The cost of smart phones and computers is a big factor, with fewer devices per person among lower-income households.(3) Canada-wide, 96% of households have a computer.(3) However, 7% of households with incomes less than $30, 000 and 7% of individuals who are not employed or are unable to work do not have a computer.(3) 26% of households with incomes less than $20, 000 and 20% of individuals 60+ do not have a smart phone.(3)
Access to Internet Services
In Canada, there continue to be gaps in internet infrastructure preventing internet availability, affordability, and sufficient connectivity to certain populations. A report from Ryerson University shows that of the 2% of Toronto households without Internet, 50% are not connected due to the cost, with 61% saying it is impacting their ability to access critical services and information, including health care.(3) Canada is one of the most expensive countries in the world for fixed broadband internet. On average, 100 Mbps internet speed costs $79 CAD/month in Canada, $10 CAD/ month in Russia, and $8 CAD/ month in Ukraine.(7) In some rural and First Nations communities, inhabitants pay around $130/ month for internet.(8) The concerns do not end with finding the funds to obtain broadband connectivity. Having suitable internet infrastructure to provide adequate service is another concern. The internet connectivity in rural, remote, and First Nations communities is significantly worse than that of their urban counterparts.(9) The Canadian Radio-television and Telecommunications Company (CRTC) recommends that every household have access to broadband with download speeds of at least 50 Mbps, a speed which allows streaming of high-definition video and files in less than 5 seconds.(10) Overall, the CRTC states that 86% of Canadian households have this level of service.(8) In rural communities, that number drops to only 40%, and in First Nation communities, only 30% of households have the recommended Internet speed.(8) The Canadian Internet Registration Authority (CIRA) reports that between April 2019- March 2020, the average Ontario download speed was 52 Mbps.(8) Many countries around the world offer internet speeds of 100 Mbps or higher. Canada is one of the few countries to continue to provide internet speeds less than 9 Mbps.(11)
Healthcare providers see patients at their most vulnerable moments. Building trusting relationships between patients and healthcare providers often takes the power of body language to convey empathy and security.(1) This is often lost during virtual visits and can foster mistrust of technology and telemedicine. For patients who do not speak English or French, the lack of integrated translation services can create even greater distance between patient and provider.(1) For patients with mental illness, power imbalances and the history of mistreatment and abuse in mental health institutions, and symptoms of mental illness such as delusions and hallucinations, may result in existing mistrust in medicine that can be further exacerbated with the addition of new technology and the virtual setting.(12) Additionally, all patients with limited experience with technology and low digital literacy are susceptible to being left behind. In particular, frail and/or elderly patients, as these patients are often burdened with many comorbidities, may require help with IADLs and ADLs, and are in lower income brackets.(1)
After your last appointment of the morning, you begin to research Canada’s digital divide. You speak to your colleagues whom you share a practice with. When patients call your office to book appointments, your team makes a point to ask each patient about their comfort with telemedicine and any barriers they or those they know, face. Your practice begins to better understand your vulnerable populations. Next, you wonder what you can do to help.
That’s it for this post! Join us for part 2 where we discuss different community supports and avenues for advocacy that healthcare providers can undertake to help decrease digital inequity in healthcare.
Senior Editor: Ahmed Taher
Copyedited by: Tayler Young
Rashid M. Virtual Inequity: Do virtual visits risk leaving some people behind? Canadian Family Physician. 2020. Available from: https://www.cfp.ca/news/2020/09/25/09-25
Shaw J, Brewer LC, Veinot T. Recommendations for Health Equity and Virtual Care Arising From the COVID-19 Pandemic: Narrative Review. JMIR Form Res. 2021. doi:10.2196/23233
Andrey S, Masoodi MJ, Malli N, Dorkenoo S. Mapping Toronto’s Digital Divide. 2021.
Subedi R, Greenberg L, Turcotte M. COVID-19 Mortality Rates in Canada’s Ethno-Cultural Neighbourhoods. 2020.
Public Health Ontario. COVID-19 – What We Know So Far About… Social Determinants of Health. 2020. Available from: https://www.publichealthontario.ca/-/media/documents/ncov/covid-wwksf/2020/05/what-we-know-social-determinants-health.pdf?la=en.
Spanakis P, Peckham E, Mathers A, Shiers D, Gilbody S. The digital divide: amplifying health inequalities for people with severe mental illness in the time of COVID-19. Br J Psychiatry. 2021. doi:10.1192/bjp.2021.56
OECD fixed broadband basket, high user, June 2017. Organisation for Economic Co-operation and Development. 2017. Available from: https://www.oecd.org/sti/broadband/broadband-statistics/
Stewart B. How COVID-19 worsens Canada’s digital divide. 2020.
Camillo C, Longo J. A Tectonic Shift in the Digital Divide: It’s Now Deeper than a Technological Gap. 2020.
Broadband Fund Closing the Digital Divide in Canada. Canadian Radio-television and Telecommunications Commission. 2021. Available from: https://crtc.gc.ca/eng/internet/internet.htm#about
Picodi. Prices of the internet around the world. 2019. Available from: https://www.picodi.com/ca/bargain-hunting/prices-of-the-internet-around-the-world
Jaiswal J. Whose Responsibility Is It to Dismantle Medical Mistrust? Future Directions for Researchers and Health Care Providers. Behav Med. 2019. doi:10.1080/08964289.2019.1630357