Barriers and facilitators to pediatric telehealth use in English- and Spanish-speaking families: A qualitative study

Abstract

Background

With the rapid increase in telehealth use during the COVID-19 pandemic, concerns have been raised about the potential for exacerbating existing healthcare disparities in marginalized populations. While eliminating barriers such as transportation and time constraints, telehealth may introduce barriers related to technology access. With little known about the patient experience accessing telehealth during the COVID-19 pandemic, this study seeks to understand the barriers and facilitators to telehealth use as well as interventions that may address them.

Methods

We conducted qualitative interviews with parents of pediatric patients of a primary care clinic in a diverse community during the study period of March–May 2021. The interviews explored barriers and facilitators to telehealth during the COVID-19 pandemic. Interviews were balanced across language (Spanish and English) as well as across visit type (in-person vs. telehealth). Recruitment, collection of demographic information, and interviews were conducted by telephone. The conversations were recorded and transcribed. Once thematic saturation was achieved, the data were analyzed using a modified grounded theory approach.

Results

Of the 33 participants, 17 (52%) spoke English and 16 (48%) spoke Spanish. A total of 17 (52%) had experienced a telehealth encounter as their first visit during the study period while 16 (48%) had an in-person visit. Five themes were identified: (1) a recognition of differences in technological knowledge and access, (2) situational preferences for telehealth versus in-person visits, (3) avoidance of COVID-19 exposure, (4) convenience, and (5) change over time. English-speaking patients expressed greater ease with and a preference for telehealth, while Spanish-speaking participants expressed more technological difficulty with telehealth and a preference for in-person visits. Suggested interventions included informational tutorials such as videos before the visit, technical support, and providing families with technological devices.

Conclusion

In this study, we examined patient and family perspectives on pediatric telehealth during the COVID-19 pandemic. Implementation of the suggested interventions to address barriers to telehealth use is essential to prevent further exacerbation of health disparities already experienced by marginalized populations.

Keywords

Telehealth language qualitative pediatric equity ethnicity under-served populations barriers facilitators patient experience

Introduction

Telehealth use in ambulatory medical care has been steadily increasing and has grown particularly rapidly during the COVID-19 pandemic.^1–5 This rapid growth of telehealth during the pandemic was a key component of healthcare delivery as telehealth enabled ongoing access to care for many patients while also reducing the potential for viral transmission.

Legitimate concerns have been raised, however, regarding the potential for telehealth to worsen existing healthcare disparities. ^6–8 The technology may introduce additional barriers for patients with limited English proficiency, with lower health literacy or digital literacy, or with limited access to devices or broadband connectivity. This effect has been termed “the digital divide.”^9,10 Importantly, these barriers may affect both access to and efficacy of telehealth.¹¹ In contrast, however, telehealth could also reduce barriers to care by eliminating the need for transportation and associated costs of an in-person visit. A few studies have examined the transition to virtual care during the pandemic and its effect on healthcare access for underserved populations.^12–14 However, the experience of this change by patients and families has been more difficult to capture.¹⁵

Given how little is known about the experience of patients and families accessing telehealth during the COVID-19 pandemic, the goal of this work is to better understand barriers and facilitators to telehealth use among pediatric patients, and specifically to compare barriers and facilitators between English- and Spanish-speaking parents. While telehealth as a term can refer to multiple forms of remotely delivered technologically facilitated care, this study focuses on virtual visits occurring through online videoconferencing or phone.

Methods

Between March and May 2021, we conducted a qualitative (in-depth interview) study with a purposive sample of parents of patients from a pediatric primary care clinic affiliated with an academic medical center located in a diverse community. Interviewees were parents of children who had received care in the clinic prior to initiation of the study and were selected to balance across language (English vs. Spanish) and telehealth use (in-person vs. telehealth visit). We chose to use in-depth qualitative interviews to identify the range of opinions and new ideas and concepts. Interview questions were designed to examine barriers and facilitators to telehealth and develop novel, patient-centered ideas for interventions (Supplementary Table 1). While we use the term telehealth in this manuscript, the interview guide referenced telemedicine visits as we felt this term would be most understandable to patients. Team members (GC, AA) were trained in qualitative interviewing by researchers with extensive prior qualitative experience and training (MSK, AC), and underwent practice interviews prior to beginning the study. In addition, transcripts were reviewed and interview feedback was provided after early interviews to improve quality.

There is no standard accepted sample size for qualitative research, but most papers report thematic saturation at around 6–12 interviews for a group of individuals with similar demographic characteristics or characteristics of interest.¹⁶ We aimed to interview individuals in the following groups: (English-speaking with in-person clinical visit, English-speaking with telehealth visit, Spanish-speaking with in-person clinical visit, and Spanish-speaking with telehealth visit) until thematic saturation was reached in each group.

Due to the ongoing COVID-19 pandemic, telephone recruitment and consent were used. Potential participants were called by a bilingual member of the study team (GC, AA) and underwent a verbal informed consent process. Participants completed a brief demographic survey prior to the interview. Interviews focused on barriers and facilitators to telehealth use, and on the experience of receiving care during the COVID-19 pandemic. All interviews were recorded and professionally transcribed. A coding tree was developed based on the interview guide and was refined with input from the entire team. Transcripts were coded by two independent members of the research staff (GC, AA) with differences resolved by consensus. Coding and theme development were ongoing throughout the study process, with changes to the coding tree and interview guide as themes were identified. Analyses used a modified grounded theory framework,¹⁷ and thematic saturation was identified by consensus. Coded data from English-speaking and Spanish-speaking participants were organized by theme in a matrix to facilitate the comparison of responses. This research was approved by the Partners Human Research Committee, and was performed and presented in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist. Where quotations are included from Spanish speakers to preserve meaning to the greatest degree possible, the original Spanish is presented with an italicized English translation.

Results

There were 33 participants, of whom 17 (52%) preferred English and 16 (48%) preferred Spanish. A total of 17 (52%) had experienced a telehealth encounter as their first visit during the study period and 16 (48%) had an in-person visit. The demographics of the study cohort are shown in Table 1, with differences in educational attainment and insurance status between the language groups. Of note, some English-speaking participants identified as Hispanic/Latinx.

Table 1.

Demographic information of study participants by language group.

	English	Spanish	Total n (%)
Age
18–30	3^a	1	4 (12)
31–40	11	11	22 (67)
41–50	2	2	4 (12)
51–60	1	2	3 (9)
Gender
Male	5^a	0	5 (15)
Female	12	16	28 (85)
Other	0	0	0
Race/Ethnicity
Hispanic	8^a	16	24 (73)
Non-Hispanic White	2	0	2 (6)
Non-Hispanic Black	5^c	0	5 (15)
Non-Hispanic Asian	2	0	2 (6)
Education
Less than high school	1	11	12 (37)
High school/GED	2	3	5 (15)
Some college	6	0	6 (18)
Finished college	6	1	7 (21)
Graduate degree	2	1	3 (9)
Insurance^b
Private	5^a	1	6 (18)
Public/State	12	13	25 (76)
Not Sure/No response	0	2	2 (6)
“How confident are you filling out medical forms by yourself?”
Extremely	12	2	14 (42)
Quite a bit	2	4	6 (18)
Somewhat	3^a	7	11 (33)
A little bit	0	2	2 (5)
Not at all	0	1	1 (2)
Total	17^a	16	33

These data include the demographic information for one pediatric patient that was over 18 years of age and completed the interview without a parent/guardian.

Zero responses for self-pay insurance.

One individual classified here as non-Hispanic Black, identified as White, Black, and other (Trinidadian/West Indian).

There were five main themes that were identified from our interviews, along with several recommendations from participants about how to improve telehealth access. The themes were: (1) a recognition of differences in technological knowledge and access, (2) situational preferences for telehealth versus in-person visits, (3) avoidance of COVID exposure, (4) convenience, and (5) change over time. Overall, English-speaking patients more often mentioned the advantages of virtual visits, whereas Spanish-speakers more commonly discussed the advantages of in-person visits.

Recognition of differences in technological knowledge and access

Participants described technological challenges around connectivity, access, and knowledge. English-speaking participants tended to describe hypothetical barriers or challenges that might affect other individuals: “I think the biggest issue is more of like the technology barriers. Not everyone wants to adapt or I know it's hard to adapt to be able to use the technology as best as they can for telemed especially.” Several participants commented on how older individuals may struggle more with virtual visits. Interestingly, one participant highlighted the physician‘s challenges with the telehealth system: “And then, at the appointment, I logged in, and they put me in a waiting room, and I kind of just waited for the doctor to come in. And then he was a little fumbly with the Zoom or accessing the Zoom which, again, I understand. I think it's a learning curve for some of the older generation, so I didn't have a problem with that.”

While some Spanish-speaking participants expressed similar sentiments, others reported needing assistance from their children or extended family to connect to virtual visits “Yo casi no sé mucho meterme en cosas así pues en los teléfonos o sobre una computadora, yo nunca la he usado … Sí, necesito siempre la ayuda de mis hijas.” (I almost don‘t know much about going into those things like telephones and computers, I have never used them…I always need the help of my daughters.) Additionally, some Spanish-speaking participants suggested that limited literacy may serve as a barrier to the use of telehealth: “Pero donde ya me explica el doctor cómo es, cómo uno entra y todo pues, ya sentí más fácil, en el caso mío que sé leer, pero en el caso de personas que no saben leer es muy difícil para ellas.” (But where the doctor already explained how it is, how you enter and everything, I felt it was easier, in my case where I know how to read, but in the case of others who don‘t know how to read, it‘s much more difficult for them.)

Situational preferences

The discussion around situational preferences was similar across language groups, with parents describing the importance of an in-person exam for specific conditions or for obtaining services such as vaccines, “Because like I said, she has a breathing disease, and they used to hear her lungs. It's something that they cannot do through the telehealth. And also, they always check in the oxygen levels, and they do a breathing test every time that we go. So they do a multiple things that they cannot do through the telehealth.” Additionally, communication was often described as being better through in-person visits, such as “Porque siento yo que mirándolo físicamente-- le voy a dar la experiencia cuando he visitado al [redacted]. Ahí, “¿quiere traductor?” -me dice-, “sí", te ponen ahí a una persona. Y yo los estoy mirando, y ellos si me ven que yo tengo una duda, ellos me dicen: “¿Qué no entiende? ¿O qué no entendió?". Yo les explico, entonces vuelven ellos a decir lo que yo quiero que ellos me digan o lo que yo quiero dar a entender.” (Because I feel that looking at him physically —I’m going to give you an experience of when I visited [redacted] there. “Would you like an interpreter?” they asked. “Yes.” They put this person there. And I am looking at them and they see that I have doubts, they ask, “What don‘t you understand? Or what didn‘t you understand?” I explain so then they say again what I want them to tell me or what I want to understand.) In addition, some participants commented that mental health visits were easier via telehealth: “But thus far, I really do-- I see the benefit for sure. I’m not sure about the more hands-on healthcare, but when it comes to psychiatry, I can say that telemedicine is a very good option, at least one that benefits me. If anything, it made me feel more comfortable to share my symptoms just because I’m at the comfort of my own home, and so I’m more inclined to open up rather than being in the place where I know that I am sick because of the hospital environment. So I guess being comfortable really helps with that.”

Avoidance of COVID-19 exposure

Both English- and Spanish-speaking parents emphasized the importance of telehealth visits for keeping their children safe from COVID-19 exposure, “Back then, we were so scared to go, especially to go to the hospital, and I was trying to keep them at home, especially not to risk my daughter.”

Convenience

The convenience of virtual visits was discussed by both groups, such as “Y a veces, cuando es así, cita personalmente, hago el esfuerzo, porque casi siempre las pido por la tarde, porque yo trabajo; entonces, yo corro para allá, para el hospital. Pero cuando es virtual se me hace muy bien, porque ya yo estoy en la casa, ya estamos explicándole a la doctora o ella nos explica a nosotros cómo es acerca de la cita.” (And sometimes, when it‘s like that, an in-person appointment, I make an effort because I almost always ask for them in the afternoon because I work. So then I run over there, to the hospital. But when they are virtual I feel like they are very good, because I am in my home, already explaining to the doctor or she is explaining to me what the appointment will be like.) However, convenience was more frequently mentioned by English-speakers, including: “I do not think that people have to be doing all this traveling and going into [Hospital] and whatever. I just don't think it's necessary. But for something like a follow-up, I don't see why it's necessary for somebody to be going all the way into the city. I just think that's just ridiculous.”

Change over time

Both groups reported being skeptical of telehealth in the early stages of the pandemic, but that the method became more acceptable to them over time (Table 2).

Table 2.

Themes and illustrative quotes.

	English	Spanish
Recognition of differences in technological knowledge and access	Because they send me a link, and they said how to—first is that I have to [pre-accept?] the visit, the telehealth, and then when I press the link that they send it to me in there, it was doing nothing. (VV)I mean, definitely, if people don't have wi-fi it can be difficult, especially if it's a video one. (VV)It was just simple, like simple instructions. And I got the link. I went, and the doctor connected, and everything went better than I thought. (VV)Some of the parents, they don't know how to use a computers or the technology, and that can be so stressful and frustrating. (VV)Sometimes the Wi-Fi crashes, and depending on the people's devices, their devices might have better quality features or so that accommodate the apps. (IP)	Tal vez. Yo tengo el acceso al teléfono, pero las otras personas, no sé si todas tienen teléfono o computadora Maybe. I have access to the telephone, but other people, I don‘t know if everyone has access to a telephone or computer. (VV)Yo creo que las personas que no tienen acceso a Internet y a un teléfono es porque nos sabemos si están pasando por necesidad o están preocupados o están angustiados. I believe that people that don‘t have access to internet or to a telephone, it is because we don‘t know if they are experiencing necessity or if they are worried or anxious.(IP)Fue rápido, fue fácil. Y sí, ¿cómo le explico? Me llamó la enfermera primero y luego hablé con el doctor y todo fue bien. It was fast, it was easy. And yes. How do I explain? The nurse called me first and then I spoke with the doctor and everything was good.(IP)Creo que hay padres que no tienen los recursos para comprar una computadora. Me imagino que así, es también, algunas madres que no pueden asistir a las citas, no tienen con qué conectarse, no tienen celular. I believe that there are parents who don‘t have the resources to buy a computer. I imagine that that is also some mothers that cannot attend visits don‘t have what to connect themselves with, they don‘t have a cell phone. (VV)La verdad yo no puedo mucho andar en eso, pero mis hijos me han ayudado… Como abrir correos electrónicos, como para poder hacer esas cuentas que hacen, porque yo no sé mucho de eso. The truth is that I can‘t go on much with that, but my children have helped…How to open emails, how to set up accounts that they make, because I don‘t know much about that. (IP)Ya son personas más avanzadas de edad y tal vez la tecnología para ellos tal vez es un poco más complicada. Now they are people who are older in age and maybe technology for them is a bit more complicated. (VV)
Situational preferences for telehealth versus in-person visits	Once I figured out that it was a virtual visit and not an in person one, it went fine. It was definitely much easier to do with a toddler than to actually bring him in. (VV)It's kind of like in between because with telemedicine you can't really examine a person. (IP)I love in-person visits. I feel like it's more unique and more personalized. (VV)Well, there are some kinds of visits had to be done in person. For example, my major issue of [redacted] is her allergy. And she needs to do some—she actually does take allergen [inaudible] treatment and that had to be done in person. Some other issues can be done virtually. So we would like to have both options open. (IP)The baby, because they need a vaccination, that's not something you can do over the phone. (VV)Yeah, I feel like virtually is very quick and not much is done compared to an in person visit where it's like an actual office visit where you see the doctor and you talk to them and they check you out. (IP)Otherwise the doctor sees what you guys are talking about and then can diagnose you better than a virtual. Because I think, in-person—virtual, he is just—the doctor will be just doing a guess-work, trial, and error. But if the person is there and you do some lab tests and other stuff, he really knows what you’re doing and how to treat you. (IP)It's just better to communicate face-to-face. It's just easier to understand. You can kind of understand their facial expressions and just the way they behave when we communicate. (IP)	Depende del caso, porque si a la niña le van a hacer un chequeo, vacunas, y todo eso, personal; pero si solo va a ser para un seguimiento, como ella sigue y todo eso, virtuales. It depends on the case, because if they are going to check the girl, vaccines, and all that, personally; but if it is only for a follow-up, how she is doing and all that, virtually. (VV)Yo siento que se puede hacer así, virtual también si no es muy urgente ir hasta el hospital I feel that they can be done like that, virtual also if it is not very urgent to go to the hospital. (VV)Pero es bueno que los revisen físicamente porque ahí ya ellos los miran en persona y saben exactamente si están bien o están mal, o uno los cuida bien o no. But it is good that they check them physically because there they see them in person and know exactly if they are good or bad, or you look after them well or not. (IP)Porque el médico puede revisar a mi hijo, lo ve, si algo está mal o él necesita o yo necesito que él vea, que falte; entonces para mí es mejor que sea físico y no virtual. Because the doctor can check my son, he sees, if anything is wrong or if he needs or I need that he sees, what is missing so for me it‘s better to be physical and not virtual. (VV)Y cuando va a hacer una cita, un chequeo del bebé, yo siento bien que lo hagan virtual, pero ya cuando va a ser un físico o algo ya más, que van a hacer un chequeo, me imagino, sangre, al bebé, ya iría personalmente uno. And when it‘s going to be an appointment, a check for the baby, I feel good that they do it virtually, but when it is something physical or more, that they will check, I imagine, blood, of the baby, now I would go personally. (VV)Porque así los niños—hay cosas que mis hijos pueden hablar con su doctora, como, por ejemplo, sus necesidades, lo que ellos quieren, que a veces con uno, conmigo como mamá, pueden tener pena. Y ya tengo un niño de 16 años. Y él con su doctora tiene mucha confianza y habla lo que él necesita. Ella es un amor para los niños. Ella sabe cómo conllevarse con mis hijos para que ellos tengan esa confianza con ella. Because then the children- there are things that my children can talk to their doctor about, like, for example, their needs, what they want, where sometimes with one, with me as their mom, they can be embarrassed. And I now have a 16-year-old boy. And he has much confidence with his doctor and talks about what he needs. She is a love for the children. She knows how to get along with my children so that they confide in her. (VV)
Avoidance of COVID-19 exposure	Convenient and no need to go through all the trouble to the hospital, to avoid the COVID-19 exposure risk. (IP)Because like the whole thing with COVID-19, I feel like other people are not as cautious, other patients. And I’d rather be safe with my kids at home. (VV)When everything start, everyone was so scared to go out and get exposed and always there are hospital is the last place that you wants to go when something like that is happening, so that's why I was trying to avoid the hospital. (VV)I wouldn't have to expose myself and my son to all the people. (IP)Well, to stay home away from other places because not every place you walk into is sanitized, and not everybody sanitizes, so I’d rather be home and do virtual (VV)	En mi caso, está bien las visitas virtuales porque uno no arriesga a los niños a ciertas enfermedades y estamos más protegidos. In my case, it is good the virtual visits because one does not put the children at risk of certain illnesses and we are more protected. (IP)Me daba miedo por el contagio, también. I was afraid because of the contagion, also. (VV)para mí es fácil, es porque yo no arriesgo la vida mía ni la de mis hijas al salir de casa, por lo que se está viviendo de la pandemia. For me it‘s easy, it is because I don‘t risk my life or that of my daughters leaving the house, because of what is being lived in the pandemic. (IP)
Convenience	I don't know, but I feel more accessible now than before. There's more technology involved, but there's more easy access to get in touch with the rest of the doctors and communicate to everybody in one platform (VV)And I think that was a very helpful method to be in touch with doctor. (VV)For example, just as I said, we don't need to go through the travel or the parking, all this stuff. (IP)Yeah, I just think it's less time-consuming. I think it's just as effective. I mean, I can think about some of the therapists or consultations or anything like that. They’re not doing anything for you one-on-one in those doctor's visits. I just think it eliminates so much more hurrah of going into the office, checking in, sitting there. (VV)virtually, you just need to stay at home and open your video… we don't need to go through the travel or the parking, all this stuff (IP)So having this online platform really helps with that for the convenience of time, but also not having to commute. (IP)	Porque no va al hospital uno, se ahorra de—a mí, yo tengo mi otro hijo en la escuela, me tocaba dejarlo que me lo cuidaran. Ir a la cita, tiene que uno llegar a la hora que es, si no, la pierde. Because one doesn‘t go to the hospital, you save—for me, I have another child in school, I had to leave him to be taken care of. Go to the appointment, you have to arrive at the time it is, if not, you lose it. (VV)Se me hace más fácil, porque yo puedo estar en la casa. Yo [inaudible] así, estoy en casa, me llaman y a veces estoy con mis niños jugando, y dejo de jugar un rato con ellos, les recibo la llamada. I feel it is easy, because I can be at home. I then, am in home, they call me and sometimes I am playing with the children, and I stop playing for a while, I answer the call. (IP)Yo, cuando tengo cita de mi niño, soy sincera en decirle que a veces me atraso un poquito. I, when I have an appointment for my son, I am being honest when I tell you that sometimes I am a bit late. (IP)Y a veces, cuando es así, cita personalmente, hago el esfuerzo, porque casi siempre las pido por la tarde, porque yo trabajo; entonces, yo corro para allá, para el hospital. And sometimes, when it‘s like that, in-person appointment, I make an effort, because I almost always ask for the afternoon, because I work; So then, I run over there, to the hospital. (VV)
Change over time	I was so skeptical at first I’m like, “Video, oh my gosh. What am I supposed to get from the doctor if I’m just looking at him on the phone?” But it wasn't bad. It was fine. It was okay. (VV)	No, es fácil porque ya tengo más o menos una idea cómo o si no, ellos me dicen, cuelgue y que ellos me van a—cuando no he podido las primeras veces, ellos me dicen cómo lo tengo qué hacer. Y ya, es fácil para mí. No, it‘s easy because I more or less have an idea of how to, if not, they tell me, hang up and they will—when I can‘t the first times, they tell me how I have to do it. And now, it‘s easy for me.(VV)

IP: in-person visit; VV: virtual visit.

Recommendations

Participants made several recommendations for improvements to telehealth delivery systems. Recommendations included phone and technical support, including detailed instruction on the use of the platform via phone call with video tutorials and step-by-step instructions. Participants recommended simplifying the process wherever possible: “Oh, a tutorial to find and to tell you where things are in the app or the website. Because if I see it on the website, it's different on a computer than on my app on the cell phone, you know what I mean? It's just different. You just have to take your time to do it, and not everybody has the time to sit down and navigate their way to learn it again.” Both language groups also requested notifications and appointment reminders, and discussed strategies for helping individuals navigate potential financial barriers to telehealth access, such as, “Maybe notifying people of free public wi-fi and just having maybe videos to show people how to do it correctly.” Several Spanish-speaking participants commented on the importance of having a Spanish-speaking provider: “No, mi preferencia fuera siempre la misma: que fuera en mi idioma.” (No, my preference would always the same: that it be in my language.)

Suggested solutions included providing detailed training and technical support for families accessing telehealth services, with video options: “Like sometimes they send you a video like how-- I know I have done that before. Like they’ll send you a video on how to do it before you actually have to do it. So whenever you’re confirming the appointment-- because usually, you get the message about the appointment when they call. Add to that message the video on how they have to do it so that when it's time for them to do it, they’re ready. They already know what they have to press and how it works,” as well as reminders. It is important to remain cognizant of language preferences when developing some of the previous interventions like video tutorials,²⁰ a concern that arose in English-speaking families as well. “If it's in multiple languages, yes. Or I find a lot of the, let's say, people-- my husband, for example, he's from Honduras and a lot of them, even though they’re young, in their 30s, they don't understand that type of technology because in their country they may not have it like that. So I don't know, unless it's in other languages and maybe if it's quick.”

Some Spanish-speaking families suggested that the clinic assist families without resources by allowing them to borrow technology similarly to what is being done by some schooling systems. “Sí hay métodos de ayudar, como las escuelas ahorita, que, para que los niños no asistieran a la escuela les obsequiaron una computadora mientras ellos regresan. Y están usando esa computadora, porque, creo que hay padres que no tienen los recursos para comprar una computadora. Me imagino que así, es también, algunas madres que no pueden asistir a las citas, no tienen con qué conectarse, no tienen celular. Y ayudándoles, que todos colaboremos a ver quién necesita un iPad o un teléfono, aunque sea.” (There are ways to help, like schools right now, to assist children schools are presenting students with computers until they return. And they are using the computers, I believe, because their parents don‘t have the resources to buy a computer. I imagine that this would also help mothers who cannot attend appointments because they cannot connect themselves, they do not have phones. And helping them, that we all collaborate to see who needs an iPad or phone at least.) (Table 3).

Table 3.

Recommendations and improvements.

Phone/tech support	So the actual app and the website changed. That's what's different from when I started using it and now. I don't know, a tutorial would be nice to see where we can find things in the app (VV)So maybe during the appointment, like a brief explanation of how to download the app, how you would use the app, or like a tutorial so they could understand it better. It might encourage them to do some more telemed visits. (VV)I think if anything having the support—the virtual support chats where you can talk with someone to walk you through it because I remember when I first tried to download the Patient Gateway—I also had trouble with it myself—and I remember my psychologist tried to walk me through it. But even through the online thing was kind of tough to kind of understand what she was trying to say. (IP)Probably something quicker, maybe like sending them just a quick link as a text where they can just press it and that's it instead of having to go on the app and searching the tab of where you’re supposed to find to start a virtual visit. Maybe something just like a quick text link to their phone could be easier. (IP)	Yo pienso tal vez, una llamada y explicándoles a ellos por teléfono más bien qué es lo que tienen que hacer. I believe that maybe, a phone call and explaining to them over the phone better yet what they have to do. (VV)
Tutorial	The application. Now it's no MGH, it's MGC or something like that because it's [inaudible]. So the actual app and the website changed. That's what's different from when I started using it and now. I don't know, a tutorial would be nice to see where we can find things in the app (VV)If it's in multiple languages, yes. Or I find a lot of the, let's say, people-—my husband, for example, he's from Honduras and a lot of them, even though they’re young, in their 30s, they don't understand that type of technology because in their country they may not have it like that. So I don't know, unless it's in other languages and maybe if it's quick, if it's something quick that they can watch really quickly, yes (VV)It could be step-by-step on how to access virtually within different—for example a laptop or a phone.(IP)	Paso a paso, como usar el link, me imagino, para hacer una videollamada. Step by step, how to use the link, I imagine, to do a video call. (IP)Pues explicando paso a paso. Por video sería lo ideal. Eso para mí sería lo ideal, un video Well explaining step by step. Through a video series would be ideal. That for me would be the ideal, a video. (IP)
Notifications	So sometimes it's easy to forget the appointment. So it would be very helpful—actually, I have this from my own experience. So if you can have the reminder call 10 min before the virtual appointment, [inaudible] someone to call in advance, “You have your virtual appointment in 10minutes,” that’d be really helpful. (IP)	Bueno, me imagino, lo mismo como han hecho conmigo de mandar un texto primero a la persona para notificarle que van a tener una cita virtual y cómo lo van a hacer o cómo lo tienen que hacer. Well, I imagine, the same what they have done for me of sending a text first to the person to notify them that they are going to have a virtual visit and how they are going to do it or how they have to do it. (VV)
Financial resources	I know some people, their phone or internet had been cut off at least once a month because they’re not able to pay. So if they can get help paying their bills, I think that would be helpful. (IP)I don't know. I would say probably offering them—there's a lot of—I’ve heard that there's new programs that they do—some bucks for a month for elderly people I think for internet. Maybe they can do it for people who are low income. (VV)I know there was a program with the—I think if you had, not welfare—what was it? If you had food stamps, you were able to get a free phone, and it was a newer type of phone that has these types of capabilities… (VV)	Sí hay métodos de ayudar, como las escuelas ahorita, que, para que los niños no asistieran a la escuela les obsequiaron una computadora mientras ellos regresan. Y están usando esa computadora, porque, creo que hay padres que no tienen los recursos para comprar una computadora. Me imagino que así, es también, algunas madres que no pueden asistir a las citas, no tienen con qué conectarse, no tienen celular. Y ayudándoles, que todos colaboremos a ver quién necesita un iPad o un teléfono, aunque sea. Yes there are ways of helping, like with schools right now, for the children to not attend school, they provide a computer until the children return. And they are using that computer, because, I believe that there are parents that don‘t have the resources to buy a computer. I imagine, that there are also mothers who cannot attend appointments, who don‘t have how to connect themselves, who don‘t have cellular phones. And helping them, that we all collaborate to see who needs an iPad or a telephone at least (VV)
Preference for providers that speak native language		Es mejor así personal, viendo así con la persona. Personal, así, que alguien que sí sabe hablar el español y hacerlo así. Its better like that personally, seeing the person. Personally, like that, that someone that knows how to speak Spanish and do it like that (VV)Pues, prefiero siempre en persona, sería mejor. Well, I prefer in person, it would be better. (IP)
Work note		Supongo que sería bueno que sí se les diera a los padres también cuando es así las llamadas en Zoom—como cuando uno va en persona-, verificación de que uno sí accedió a la cita, de que uno sí—para los trabajos tanto para las escuelas. No sé cómo le dicen, lo que le dan a uno cuando uno las pide para el trabajo. I suppose that it would be good that they give the parents also when the calls are like that on Zoom—like when one goes in person- verifying that one did attend the appointment, that one did—for jobs as well as for schools. I don‘t know how to say, what they give to you when you ask for work. (IP)

IP: in-person visit; VV: virtual visit.

Discussion

In this study, parents identified five themes around telehealth access: (1) a recognition of differences in technological knowledge and access, (2) situational preferences for telehealth versus in-person visits, (3) avoidance of COVID exposure, (4) convenience, and (5) change over time. Overall, English-speaking parents were more positive about telehealth, more likely to discuss barriers as hypotheticals rather than lived experience, and more likely to describe convenience as an important facilitator. Spanish-speaking parents, in contrast, described more challenges around technology access, and a stronger preference for in-person visits for both clinical and communication-based reasons. Both groups were similar in their discussion of the advantage of avoiding COVID-19 exposure and becoming more comfortable with virtual visits over time. Participants faced barriers at individual (e.g. limited literacy), structural (e.g. affordability of Wi-Fi), and institutional (e.g. telehealth portal not easily available in Spanish) levels.

Large-scale survey and chart review-based research demonstrates racial/ethnic disparities in access to telehealth during the COVID-19 pandemic.^2,6,18 This study provides urgently needed user-centered insights into possible mechanisms behind these disparities.¹⁹ Our Spanish-speaking participants echoed findings from other studies with respect to internet/data access barriers for individuals with limited English proficiency.¹⁸ Spanish-speaking parents’ need for assistance from younger family members to access telehealth appointments is an important finding with implications for the design of technical support.

Additionally, participants emphasized the importance of addressing the financial challenges that serve as a barrier to telehealth access and increasing knowledge about available assistance programs. Finally, participants strongly preferred providers who could speak their language, and Spanish-speaking parents often preferred in-person visits even when their telehealth provider also spoke Spanish.

Although not frequently mentioned in our interviews, audio-only telehealth visits may also help to reduce technology-related barriers to participation,^20,21 but may increase the feeling that something is missed without an in-person exam or even the opportunity to conduct a video physical exam. Previous work has found that Hispanic and Spanish-speaking patients were less likely to use video visits, and more likely to have phone-only telehealth visits during the initial stages of the COVID-19 pandemic.¹²

Limitations

The study has several potential limitations. We interviewed only parents who spoke either English or Spanish and so these findings may have limited generalizability to the experience of families speaking other languages, specifically those with non-Roman alphabets who may face additional struggles using patient portal systems to access telehealth services. We also interviewed families over the phone and so were limited to those who had telephone access. Additionally, the clinic from which we recruited participants has a high rate of bilingual clinicians and so many of our Spanish-speaking patients have Spanish-speaking providers for their children at baseline, potentially reducing the barriers to communication they faced interacting with the clinic providers. Additionally, as with all interview studies, our work may be subject to social desirability bias where the interview participants did not want to criticize provided services to someone who was perceived as a representative of the service provider (hospital), despite an introduction that made it clear that the research team was separate from the provision of clinical care. Finally, while we describe the variation in themes across linguistic groups, this is not a prevalence sample and the groups differ in educational attainment and other baseline characteristics; the study is designed only to describe the range of potential themes but not the number of people with each opinion or idea.

Conclusion

In this study, we examined patient perspectives of telehealth during the COVID-19 pandemic. The qualitative interviews highlight individual, structural, and institutional barriers as well as facilitators of telehealth use. English-speaking participants expressed a greater ease with as well as a preference for telehealth while Spanish-speaking participants expressed more technological difficulty with telehealth and a preference for in-person visits. Suggested interventions included providing informational tutorials such as videos prior to the visit and technical support during the visit should issues arise, as well as providing technological devices to those without. Utilization of interventions to address barriers to telehealth use is essential to prevent further exacerbation of health disparities.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iDs

Margaret E Samuels-Kalow

Carlos A Camargo

Supplemental material

Supplemental material for this article is available online.

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