Examining Intersectionality and Barriers to the Uptake of Video Consultations Among Older Adults From Disadvantaged Backgrounds With Limited English Proficiency: Qualitative Narrative Interview Study.

backgroundThe rapid shift to video consultation services during the COVID-19 pandemic has raised concerns about exacerbating existing health inequities, particularly for disadvantaged populations. Intersectionality theory provides a valuable framework for understanding how multiple dimensions of disadvantage interact to shape health experiences and outcomes.

objectiveThis study aims to explore how multiple dimensions of disadvantage-specifically older age, limited English proficiency, and low socioeconomic status-intersect to shape experiences with digital health services, focusing on video consultations.

methodsFollowing familiarization visits and interviews with service providers, 17 older people with multiple markers of disadvantage (older age, low socioeconomic status, and limited English proficiency) were recruited in the Redbridge borough of London. Data collection included narrative interviews and ethnographic observations during home visits. Field notes captured participants' living conditions, family dynamics, and technological arrangements. Guided by intersectionality theory and digital capital concepts, interviews explored participants' experiences accessing health care remotely. Intersectional narrative analysis was used to identify key themes and examine how different forms of disadvantage interact. We developed theoretically informed narrative portraits and user personas to synthesize findings.

resultsAnalysis revealed that the digitalization of health care can exacerbate existing inequities, erode trust, compound oppression, and reduce patient agency for multiply disadvantaged patient populations. Examining intersectionality illuminated how age, language proficiency, and socioeconomic status interact to create unique barriers and experiences. Key themes included the following: weakened presence in digital interactions, erosion of therapeutic relationships, shift from relational to distributed continuity, increased complexity leading to disorientation, engagement shaped by previous experiences of discrimination, and reduced patient agency.

conclusionsThis study provides critical insights into how the digitalization of health care can deepen disparities for older patients with low income and limited English proficiency. By applying intersectionality theory to digital health disparities, our findings underscore the need for multifaceted approaches to digital health equity that address the complex interplay of disadvantage. Recommendations include co-designing inclusive digital services, strengthening relational continuity, and developing targeted support to preserve agency and trust for marginalized groups in an increasingly digital health care landscape.