The Perceived Usability of Virtual Visits Among Black Adults’ Receiving Oncology Care: A Qualitative Analysis

Abstract

Background

With the COVID-19 pandemic came rapid uptake in virtual oncology care. During this, sociodemographic inequities in access to virtual visits (VVs) have become apparent. To better understand these issues, we conducted a qualitative study to describe the perceived usability and acceptability of VVs among Black adults diagnosed with cancer.

Methods

Adults who self-identified as Black and had a diagnosis of prostate, multiple myeloma, or head and neck cancer were recruited from 2 academic medical centers, and their community affiliates to participate in a semi-structured interview, regardless of prior VV experience. A patient and family advisory board was formed to inform all components of the study. Interviews were conducted between September 2, 2021 and February 23, 2022. Transcripts were organized topically, and themes and subthemes were determined through iterative and interpretive immersion/crystallization cycles.

Results

Of the 49 adults interviewed, 29 (59%) had participated in at least one VV. Three overarching themes were derived: (1) VVs felt comfortable and convenient in the right contexts; (2) the technology required for VVs with video presented new challenges, which were often resolved by an audio-only telephone call; and (3) participants reported preferring in-person visits, citing concerns regarding gaps in nonverbal communication, trusting providers, and distractions during VV.

Conclusion

While VVs were reported to be acceptable in specific circumstances, Black adults reported preferring in-person care, in part due to a perceived lack of interpersonal connectedness. Nonetheless, retaining reimbursement for audio-only options for VVs is essential to ensure equitable access for those with less technology savvy and/or limited device/internet capabilities.

Introduction

During the COVID-19 pandemic, virtual healthcare visits (real-time video or telephone calls with a medical provider) became necessary, especially among immunocompromised oncology patients. With increasing pandemic-related safety restrictions and limitations on in-person cancer services, there was a rapid uptake of virtual technology. As safety measures relaxed, the use of virtual visits (VVs) waned. Still, there are indications of longevity.^1,2 Virtual care offers many benefits to patients including reduced travel time, the ability to receive care in the comfort of one’s home, and overall convenience; documented disadvantages include limited physical examination and inability to complete laboratory tests.³ While early applications of telemedicine technology focused on uptake amongst rural and patients with less resources, few studies have evaluated patient’s perception of oncology VVs after the height of the pandemic and none have focused on the perceptions of self-identified Black patients.⁴

Studies have found that Black patients are less likely to participate in video-based VVs compared with telephone VVs, in part due to technological challenges, patient preference, and technology literacy.^5,6 Even with navigation support, Black adults are less likely to participate in video VV.⁷ While previous studies have explored patient perceptions of virtual care, many did not report race or involved only a small number of Black adults.^1,4,8-15 Furthermore, these studies focus on patients that have had experience with VVs. Knowing the decreased uptake among Black adults, perceptions of adults not having experienced VVs could provide insight into barriers to uptake of this new technology. We assessed perceptions of virtual care usability and acceptability 18-24 months after the onset of the COVID-19 pandemic among Black adults with cancer.

Methods

Setting, Participant Identification, and Recruitment

To ensure comprehensive reporting of methodology, the Standards for Reporting Qualitative Research (SRQR) were used.¹⁶ We used the electronic health records (EHR) at 2 academic medical centers and their community affiliates (in North Carolina and Michigan) to identify Black adults ≥ 21 years old with a prostate, multiple myeloma, or head and neck cancer diagnosis (hereafter adults). These academic centers were chosen in part because they both provide cancer care to large numbers of Black adults. The disease sites were chosen because of their disproportionate prevalence among and known care quality inequities faced by Black adults.^17-24 Adults with evidence of cancer treatment (for head and neck cancer), evidence of bone marrow biopsy and diagnosis (for multiple myeloma), or evidence of diagnosis (prostate cancer) between June 1, 2019 and March 31, 2021 and an outpatient visit to an oncology, radiation oncology, urology, or otolaryngology clinic within the 12-month period ending March 31, 2021 were study eligible. Adults were recruited using random sampling to participate in one, ~40-minute in-depth interview regarding their experiences with and perceptions of VVs. As this study aimed to identify an in-depth understanding of peoples' perceptions, and due to limitations on in-person gatherings during the time of data collection, interviews were chosen over focus groups. To achieve meaning saturation, per an a priori specified study protocol, we aimed to recruit 48 adults, stratifying recruitment by disease type and health system to achieve our goal of a minimum of 24 participants at each organization and a minimum of 16 for each disease site.²⁵

Three trained interviewers (3 females of diverse racial/ethnic backgrounds: Black, Middle Eastern Northern African, White) with backgrounds in public health, social work, and human biology placed a voice-only call to eligible adults using random number-ordered lists. Prior to the call, a letter of study introduction was sent via US Postal Service. Each adult was called up to 5 times; voice messages were left when possible. After confirming study eligibility by self-reporting race and cancer diagnosis, all participants provided verbal consent for study participation. Participants received a $35 incentive. All interviews were conducted from September 2, 2021 to May 13, 2022.

The University of North Carolina at Chapel Hill Institutional Review Board (IRB) reviewed and approved the study protocol. A patient and family advisory board (PFAB) comprised of Black adults impacted by cancer was convened to ensure community engagement throughout the research process using regularly scheduled meetings to discuss proposal development, strategies for recruitment, and interview guide development. Once data were collected, PFAB members provided input regarding theme development and results interpretation. Two members of the PFAB also participated in monthly investigators calls.

Data Collection

Guided by the Technology Acceptance Model (TAM),²⁶ the interview guide elicited participant's use and perceptions of VVs (Supplementary Table B). As such, we were particularly interested in participant’s perceptions of the usefulness of virtual visits as well as their ease of use. To understand study participant's lived healthcare experiences, the interview guide also asked respondents to describe particularly positive and negative experiences. After obtaining information specific to VV use experience, subsequent questions were tailored to those experiences. All members of the core investigation team with backgrounds in cancer care delivery, clinical medicine, epidemiology, health communication and decision-making, health services research, and public health were involved in the development of the interview guide. Interviews were audio-recorded and transcribed verbatim using automated audio-transcription within the web-enabled conference software with a research assistant correcting transcripts for completeness/accuracy.

Data Analyses

During analyses we began by identifying topical issues raised by study participants, regardless of the interview question that generated the response. This was done via multiple small group meetings within which 4 research team members with backgrounds in epidemiology, health communication, and health services research independently reviewed batches of 2-3 transcripts to identify and discuss key topical issues raised by the study participants. As such, as this group worked through transcripts, they identified topical issues raised by participants in response to specific questions contained within the semi-structured interview guide (eg, family engagement during virtual visits) as well as topical issues that participants raised more broadly regardless of the specific question asked (eg, comparisons of patient-provider communication during virtual and in-person visits). We continued this process until there was a round without the identification of a new topic. This resulted in the identification of 16 topics, three pertaining to healthcare experiences in general and 13 specific to VVs (Supplementary Table A1). One research assistant (a pre-med undergraduate student) then used these topics along with an “other” option to code the interview data within Atlas.ti (Version 22.2.3). Because she did this over a 5-month period, she recoded 5 of the initially completed transcripts as she finished organizing the last few transcripts within Atlas.ti. In so doing, we were able to evaluate possible temporal changes in how she coded the data by estimating intra-rater reliability via unweighted Cohen’s kappa (Cohen’s κ 0.79).

Once all data were organized within Atlas.ti, as a second step (step 2), 2 team members (a health services researcher and a head and neck surgeon) used the 6 topic reports that collectively contained the majority (59%) of the quotations to begin thematic identification using an immersion-crystallization process.²⁷ For data immersion, each independently read the reports to become familiar with the data and to begin to gain insights into emergent themes. After this initial immersion, the two team members came together to share and discuss their initial thoughts, aligning relevant quotes to emerging overarching themes to assist with crystallization. This continued through 3 cycles, after which preliminary findings (emergent overarching themes and quotes) were shared during a standing research team meeting (that included all members of the research team, including two PFAB members) (step 3) as well as a Patient and Family Advisory Board meeting to assist with meaning interpretation and the identification of subthemes (step 4). The same two researchers then repeated the same immersion, crystallization process with data from the remaining topical reports to confirm overarching themes and assist with subtheme identification (step 5). The final themes and subthemes with illustrative quotes were then shared again with the larger research team (step 6) and the PFAB (step 7) for further corroboration. Finally, to ensure that the themes and subthemes represented perceptions of patients receiving care within both organizations, with all 3 types of cancer, and with and without virtual visit experience, we confirmed that quotes mapped to the final themes and subthemes represented participants from each subgroup. Illustrative quotes are presented using a study identification number that embeds information regarding health care organization, cancer type, and virtual visit experience as described in the key in Table 1. Unless otherwise noted, we found themes and interpretations to apply wholistically to the sample.

Results

Study Participants

A total of 49 adults were interviewed (Table 2). Twenty-nine (59%) reported having experienced a VV, with 10 reporting both video and telephone VVs, 11 reporting only telephone VVs, and 8 reporting only video VVs.

To contextualize their perceptions of VV, participants’ were asked to describe particularly positive and negative experiences with health care in the past. When describing positive experiences, participants tended to focus on relational communication describing their providers as attentive and accessible, compassionate, caring, and nice, while also being clear about what to expect (Table 3). Negative experiences were elicited and focused on physical discomfort associated with cancer care (eg, side effects and symptoms) and inattentive, disrespectful, and inaccessible communication (Table 3).

Perspectives on Virtual Visits

Our analyses identified 3 overarching themes pertaining to VVs. Each of these themes were reported by participants having experienced video visits (quote demarcated using a _V), telephone visits (_T), both visit types (_B), and no history of VVs (_N). First, VVs were perceived as acceptable: VVs were seen as a comfortable and convenient alternative to in-person office visits, when clinically appropriate. Second, indicative of obstacles to their ease of use, telephone-only visits were critical to overcoming the technology-related challenges introduced by VVs. Finally, despite acknowledgements of acceptability, Black adults preferred in-person visits. Additional thematic details and illustrative participant quotations are provided below and in Table 4.

Virtual Visits Are a Comfortable and Convenient Option When Appropriate

In general, participants reported a willingness to use VVs to interact with their oncology team:

So, I was a little hesitant about it, but it was fine. … I just had to adjust, the getting comfortable with it in my head and it was fine. (A_MM_06_B)

Particularly among patients having completed VVs, VVs were favored due to their comfort and convenience and were especially appreciated when a participant was not feeling well. Participants acknowledged the convenience of staying home and avoiding travel-related logistics, describing decreased time- and travel-related costs associated with VVs compared to in-person visits and how VVs resulted in needing less time away from work.

Well... It’s cheaper […] if you ain’t got to spend no gas money driving down there. (B_MM_04_T)

Especially during the COVID-19 pandemic, participants perceived VVs as enabling them to communicate with their providers while keeping themselves safe.

…really wasn’t comfortable going to […] the office. So that the virtual appointment made it a lot better.– (B_HN_09_T)

Participants qualified their acceptance of VVs, stating acceptance when visit purpose was appropriate for the virtual format. Participants, regardless of VV experience, felt VVs appropriate for follow-ups, medication check-ins, and receipt of laboratory testing results. They also acknowledged their appropriateness when the visit involved only information transfer between them and their providers such as discussing results or medication changes.

I am all for virtual visits, as long as they’re within the scope of what’s needed (B_HN_04_N)

…is very convenient for things of that, […] maybe discussing my medication change or something like that– (B_HN_13_T)

Despite the acceptance of VVs, participants reported feeling reassured knowing that an in-person option was available if needed and that they could alternate between in-person and VVs as needed, whether they had VV experience or not.

And it was just a check in, if something was wrong, I could have changed it (B_HN_11_N)

Yes, I’d continue to have them, especially the way we doing them now, where it’s two months of virtual visits and […] then the next month, you know, in-person visit. (B_MM_10_B)

Virtual Visits Presented Technology-Related Challenges That Are Easily Resolved by Diverting to a Telephone Call

Both participants with and without experience with VV conveyed anxiety and stress around VV technology. They experienced anxiety and hesitation about their device availability, capabilities, skills, and confidence in VV technology. They also noted issues with the technology, such as dropped connections, and/or internet connectivity.

Well, it gave me some anxiety at the beginning, when I was doing it incorrectly and trying to get online and not being successful.– (B_HN_12_B)

I don’t have a lot of confidence in my abilities when it comes to technical things.– (A_HN_09_N)

Despite these concerns, participants with experience in either telephone and/or virtual visits discussed how, with support from family and clinic staff, they could use VVs successfully. Importantly, the ability for the provider to call them via telephone (ie, a voice only visit) as a backup was reassuring to participants and a necessary solution when VVs did not work.

…they did like a uh, a pre-test like the day before to see about a good connection.– (A_P_04_B)

…they tried to video about three times. It never worked, but they did come through with the telephone visit.– (A_MM_03_T)

Black Adults Preferred In-person Visits

While participants generally accepted VVs, there was still a preference for in-person visits regardless of their prior experience with VV.

I want to be in the present (B_MM_03_V)

… I think it’s the lazy way out. Certain things should be virtual; your doctor shouldn’t be one of [th]em. (A_P_09_N)

Participants felt that even though the informational content of VVs might be equal to in-person visits, nonverbal communication had important shortcomings. Participants felt less connected with their providers, missed physical touch, and felt important body language cues were (or would be) missing, all of which were felt to be important communication elements not present in VVs.

…but not being face-to-face with a person for me personally is just that I feel a little disconnected from a doctor.– (A_P_06_V)

They also look at you […] emotionally how you are doing […] with your cancer treatment and that’s kind of hard to gauge […] in a virtual visit– (B_MM_10_B)

Although expressed only by participants who had not experienced video visits (ie, telephone visits only or no virtual visits), trust-related issues were raised, particularly not being sure if they were talking to a doctor or if the doctor was being honest with them.

… it could be anybody telling you that, so you want to make sure that it’s the doctor and he’s confident and comfortable in explaining that to you…– (B_HN_13_T)

I think maybe the doctor can see more about what’s going on, if you could do face-to-face. And I can tell more about what, about their honesty, by looking at them face-to-face.– (B_P_09_T)

Participants also felt there were shortfalls in visits when the provider and participant were not in the same location. Participants described potential distraction issues both on the provider’s and patient’s sides.

So, I think it depends on where they [the providers] are—if they are able to give you their undivided attention. I think that makes a big difference in your care as well, and your truth.– (B_HN_04_N)

“…but I could see you [the patient] could be distracted because you are at home (B_HN_12_V)

Discussion

We explored the acceptability and usability of VV among Black patients receiving oncology care who, due to systemic and structural racism, continue to be marginalized in healthcare, particularly specialty cancer care.²⁸ Black patients highly valued communication and honesty in health care interactions with their doctor and their perceptions of VVs reflect this. Regardless of prior VV use, participants felt VVs were a useful method of accessing routine cancer care, such as medication check-ins or follow-ups. However, participants raised concerns that technology challenges infringed on valued communication with their doctor. Importantly, the option to resort to a telephone visit (ie, audio-only option) served to assuage concerns and ensure access to patients who lacked required technology, connectivity and/or skills. Nonetheless, consistent with the communication factors that patients reported driving prior positive health care experiences, Black adults reported that VVs were less favorable than in-person visits due to a perceived lack of interpersonal connectivity and, among patients who had not experienced a video visit, trust-related concerns. Ultimately, participants voiced a clear preference for in-person visits as their primary modality for receiving oncologic care.

Given the risks of in-person care during the COVID-19 pandemic, Medicare greatly expanded payment for telemedicine, which facilitated the rapid uptake of VV technology.^29-32 More recently, CMS proposed discontinuation of reimbursement for telephone-only services. We found telephone visits played an essential role as a back-up for video visits when technology-related problems arose. Telephone visits also afforded access to virtual care when patients either lacked the devices required for video visits, the necessary connectivity, or felt uncomfortable using devices. The importance of including telephone visits to enhance virtual care equity is echoed in the literature. During the pandemic, multiple studies have reported Black adults used audio-only visits more frequently than video visits.^6,31,33,34 Additionally, older Black adults with Medicare may face increased barriers to accessing virtual care, which typically require computer or smartphone access, compared to audio-only visits through a telephone due to communication issues like difficulties seeing or hearing and a lack of access to technology.⁵ Given such findings, it is essential that CMS and private insurers reinstate reimbursement parity for audio-only VV offerings to preempt further inequity in cancer care access and delivery.

Our interviews also unveiled new challenges in patient-provider communication during VVs that warrant addressing. Black adults placed considerable value on communication in determining the positivity (and conversely negativity) of their healthcare experiences. Participants noted that limitations in interpersonal and nonverbal communication were major drawbacks of VVs. In their study comparing the perceptions of Black and Hispanic participants prior to participating in a VV, George et al highlighted Black adults’ concerns about the lack of physical presence of the physician, reduced attentiveness of providers, and negative impact on their trust in providers.^35,36 Similarly, our study found negative perceptions of prior in-person health visits tended to hinge on ineffective or inaccessible communication. Communication is the foundation to establishing rapport and trust with patients and can have major implications on treatment decisions and oncologic disease outcomes, such as survival.^37,38 While virtual care may make certain aspects of communication more difficult, patient engagement is still possible.³⁹ If virtual cancer care is integrated into normal practice, adding effective virtual communication strategies to the provider’s toolbox is an important area of future exploration and skill development.

Ascertaining the appropriate context and role for virtual health care delivery is essential to its success. Particularly in oncology, there are opportunities for VVs to be complementary to in-person visits, as demonstrated in the Veteran’s Affairs system where virtual care was coupled with in-person visits to deliver safe and effective oncology care.⁴⁰ Both in our study and others, VVs have high acceptance and satisfaction for follow-up visits.⁴¹ Our results illustrate how VVs, when used alternatively with in-person visits, may augment office based care, allowing for additional comfort and convenience when an in-person visit is not necessitated by a patient’s care needs, and importantly such use was reported as acceptable by Black adults.

To our knowledge, our study the first to focus on the perceived usability of VVs among Black adult VV users and nonusers receiving oncology care. Despite this novelty, we included only adult patients with head and neck cancer, prostate cancer, or multiple myeloma from two oncology academic practices. As such, our findings may not generalize to patients with other cancers or those receiving care at other practices. Importantly, however, we found consistency in themes and subthemes across organization and cancer type. There may, however, be additional, more nuanced phenomenon, regarding Black adult’s perceptions of virtual visits that we have not identified. We did, however, use random sampling to identify study participants. Furthermore, patients were included regardless of whether they had participated in a VV, affording us viewpoints from both users and non-users—something that has been missing from prior studies. Additionally, although the TAM²⁶ was used to create a robust interview guide, there may be other aspects of VVs that were incompletely captured. Nevertheless, topic and theme identification was completed wholistically, using accepted evidence-based standards for qualitative methods. In addition, interviews were completed when virtual care practice was evolving rapidly and understanding of its implications on care quality remains unknown. As well, while this study offers a comprehensive understanding of differences in oncology virtual care for Black adults, underlying structural inequities need to be considered in interpretation in these results and ultimately addressed to ensure equity within virtual oncology care services.

Despite these limitations, our findings offer insights into Black adults’ perceptions regarding the usability and acceptability of VV within oncology care. In so doing they fill a void by adding perspectives from a subgroup of patients whose voice has not been well represented within the literature on virtual visits. Importantly, our sample includes both adopters and nonadopters of VV technology allowing an understanding of barriers not included to date. These findings also suggested meaningful ways to improve the acceptability and accessibility of VVs among Black adults receiving oncology care. These include: 1) having and articulating a plan to telephone patients if the VV connection fails (eg, “if we lose connection, I will call your phone. Is this a good number with which to contact you?) and offering verbal support and reassurance if connections are suboptimal; 2) ensuring the surroundings and verbal communication during the VV demonstrate that patients and providers are able to give their undivided attention; 3) offering the option to escalate care to an in-person visit should the need arise; and 4) offering training and practice sessions prior to the VV to decrease anxiety regarding connectivity issues that surround VVs. These, along with an organizational and provider focus on equity in VV delivery, are required to ensure training time for providers and resources for patients are available to improve equity of VV delivery.

Acknowledgements

We would like to acknowledge the contributions of members of a patient and family advisory board and research interviewers. We would like to specifically thank Mr. William Middlebrooks, Mr. Mark Harris, Ms. Regina Jones, and Dr. Lonnie Merrick for their thoughtful input and feedback.

Funding

This article is supported by The Genentech Health Equity & Diversity in STEM Innovation Fund.

Conflict of Interest

Samantha Tam report research funding from Genentech for the present study. Christine Neslund-Dudas owns stock in Gilead, Pfizer, and Viatris, and has received research funding from Genentech for the present study. Alan C. Kinlaw reported research funding from Genentech. Trevor J. Royce is employed by Flatiron Health, Inc., which is an independent subsidiary of the Roche Group, and reports stock ownership of Roche, serves in an advisory role for Agilix Health, and ownership/equity in Lumata Health, VitriVax, and Sonovascular. William A. Wood reports research support from Genentech and Pzifer, advising and equity in Koneska Health, consulting activity with Teladoc Health, and advising for Quantum Health. The other authors indicated no financial relationships.

Author Contributions

Conception/design: S.T., C.N.D., A.C.K., T.J.R., A.B.S., J.N.S., W.A.W., J.E.L. Collection and/or assembly of data: C.N.D., A.M.B., L.C.J.B., P.P., J.E.L. Data analysis/interpretation: S.T., C.N.D., A.M.B., L.C.J.B., I.F., J.E.L. Manuscript writing: S.T., C.N.D., A.M.B., L.C.J.B., I.F., T.J.R., A.B.S., J.N.S., W.A.W., J.E.L. Final approval of the manuscript: All authors.

Data Availability

The data underlying this article will be shared on reasonable request to the corresponding author.

Previous Presentation

Presented in part at the Health Care Systems Research Network Annual Meeting 2022, Pasadena, CA, USA, and the International Conference on Communication in Healthcare 2022, Glasgow, Scotland.

References