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BACKGROUND: Digital consultations between patients and clinicians increased markedly during the COVID-19 pandemic, raising questions about equity. OBJECTIVE: To review the literature on how multiple disadvantage-specifically, older age, lower socio-economic status and limited English proficiency-has been conceptualised, theorised and studied empirically in relation to digital consultations. We focused mainly on video consultations as these have wider disparities than telephone ones and relevant data on e-consultations is sparse. METHODS: Using keyword and snowball searching, we identified potentially relevant papers published between 2012-2022 using OVID Medline, Web of Science, Google Scholar and PubMed. The first search was completed in July 2022. Papers were screened for relevance. Those meeting inclusion criteria were analysed thematically, summarised and their key findings tabulated, using GRADE-CERQUAL criteria for coherence, adequacy, and relevance. Explanations for digital disparities were critically examined, and a further search was undertaken in October 2022 to identify theoretical lenses on multiple disadvantage. RESULTS: Of 663 articles from the initial search, 27 met our inclusion criteria. Ten were commentaries and 17 were peer-reviewed empirical studies (11 quantitative, five qualitative studies, one mixed-method, one systematic review, one narrative review). Empirical studies were mostly small, rapidly conducted and briefly reported. Most papers identified marked digital disparities but lacked a strong theoretical lens; they tended to explain disparities by listing multiple 'barriers' including lack of technology, low digital literacy and suboptimal bandwidth. Proposed solutions tended to focus on identifying and removing these barriers, but authors generally overlooked the pervasive impact of multiple layers of disadvantage. The initial dataset included no theoretically-informed studies that examined how different dimensions of disadvantage combined to impact on digital health disparities. In our subsequent search, we identified three theoretical approaches that might help account for these digital disparities. Link and Phelan's fundamental cause theory addresses why the association between socioeconomic status and health is so pervasive and persists across time. Ragnedda & Ruiu's digital capital theory explains how people mobilise resources to participate in digitally-mediated activities and services. Crenshaw's intersectionality theory refers to the idea that systems of oppression are inherently bound together, creating singular social experiences for people who bear the force of multiple adverse social structures. CONCLUSIONS: A major limitation of our initial sample was the sparse and under-theorised nature of the primary literature. Lack of attention to how digital health disparities emerge and play out both within and across categories of disadvantage means that solutions proposed to date (whilst a commendable start) may be oversimplistic and insufficient. Theories of multiple disadvantage have a potential bearing on digital health, and there may be others of relevance besides the ones discussed here. We call for greater interdisciplinary dialogue between theoretical research on multiple disadvantage and the empirical studies of digital health disparities.

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Journal article


J Med Internet Res

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