Access to digitalized primary care: Intersectionality-informed narratives from minoritized ethnic communities in the UK

Introduction
The value of intersectional approaches in addressing multiple discriminations and oppressions as well as positions of privilege in healthcare is gaining increasing recognition (Gkiouleka et al., 2018, Heard et al., 2020). However, frustratingly, ethnicity has remained a neglected parameter in efforts to ensure equitable health outcomes (Chouhan and Nazroo, 2020) despite evidence of poorer health among some minoritized ethnic (ME) communities (Marmot et al, 2020) and lower satisfaction with GP services (NHS England, 2023). Such disparities provide a compelling argument for greater attention to access and contact with GPs among ME communities. GPs play a key role in early diagnosis of illness, treatment, and referring patients to specialist services (Sripa et al., 2019).

As part of the transition to a ‘Digital First’ approach, individuals seeking GP appointments are increasingly expected to use online booking systems and engage in online consultations, However, worryingly, limited attention has been paid to digital inclusion as a social determinant of health (Chidambaram et al., 2024). The Topol Review (2019) has highlighted the risk of increased racialized exclusions due to the lack of resources and

capacity to engage with digitalized health services among ME communities. Further, current understanding of how individuals’ ethnicity interacts with other dimensions of inequality, such as age, gender, religion, and income to influence access to healthcare services is limited. Our paper takes a critical realist approach to intersectionality (Archer, 2003; 2007) and builds on Levesque’s et al. (2013) patient-centered access framework to explore the risk of exclusion of individuals from ME communities from digitalized primary care services.

Methodology
We carried out 100 interviews with ME individuals from four case study sites (Manchester, Bradford, the London Borough of Tower Hamlets and Glasgow) to capture the complex challenges experienced by ME communities in accessing and using digitalized health platforms. A purposeful sampling strategy was employed to recruit the ME groups which were most at risk of digital exclusion and racialized discrimination due to their disadvantaged socio- economic status and visibility, namely Bangladeshi and Pakistani communities (Marmot et al, 2020) and African, Caribbean, Indian and Chinese groups. We also purposively sampled from three age groups: young (18 to 35) middle-aged (36 to 64) and old (65 and above). The majority were women (60%). All collected information was anonymized, coded in NVivo and thematically analyzed by identifying clusters of ‘enablements’ and constraints (Archer, 2003 and 2007) and drawing on Levesque’s et al. (2013) five dimensions of accessibility, namely: ability to perceive, ability to seek, ability to reach, ability to pay and ability to engage with digitalized healthcare.

Results
Participants’ engagement with digitalized primary care services ranged from complete digital inclusion to complete exclusion. The lack of adequacy of alternative channels, such as phones, indicates that some individuals were not only at risk of digital exclusion but of being entirely excluded from primary care services. Engagement with services was in many cases facilitated by clusters of enablements including access to adequate digital devices, affordable data, informal support, bilingual staff and practitioners who were willing to use alternative channels such as phones. Conversely, clusters of constraints often operated to prevent engagement. For instance, most ME individuals categorized as old had completely withdrawn themselves from independently using digital services due to language- and literacy-related barriers, lack of access to digital devices and limited digital literacy. In contrast, some young people with high degrees of digital literacy who were proficient in English reflected that they preferred to use online services to minimize the risk of encountering racialized attitudes of staff.

Individuals across all age groups on low income struggled with the affordability of digital services since this involved possession or access to digital devices with sufficient memory space and paying for mobile data. Some young and mid-aged individuals experienced challenges in completing online forms to communicate symptoms due to limited proficiency in English and digital literacy, revealing only partial engagement with online services. People with darker skin reflected that some health professionals’ over-reliance on photos at the booking stage may hinder their ability to access timely treatment due to lack of visibility of their symptoms.

Gender intersected with age and ethnicity in participants’ ability to book appointments among female participants, some of whom had to share a device to secure a GP appointment for themselves, as well as others, particularly in multi-generational households.

Conclusion
The rapid transformation of primary care services has, in many cases, presented new challenges to individuals from ME communities in engaging with primary care. While some examples of good practice have emerged, overall, little attention appears to have been paid to enabling individuals to overcome multiple barriers. Greater recognition of the differential abilities of individuals from ME communities to engage with online services is urgently needed to ensure more equitable access to primary care in the UK.