The first definition of health equity described “health inequities” as “unnecessary, avoidable, unfair and unjust differences in health” [1]. Some years later, Braveman and Gruskin [2] discussed some general issues in the previous definition and proposed “health equity as the absence of systematic disparities in health or the major social determinants of health between groups with different levels of social advantage/disadvantage” [2]. In 2006, Whitehead and Dahlgren claimed that “equity in health should imply that virtually everyone could attain their full health potential and that no one should be disadvantaged from achieving their potential because of their social position or other socially determined circumstance” [3, 4]. In recent years, international interest in this topic has increased, thanks to the documents of the World Health Organization that underline the importance of guaranteeing all people the opportunity to develop their health potential, the importance of reducing the risk that someone may be disadvantaged, and the need to promote interventions aimed to increase “health equity” [5-7].

With the progressive digitization of people's lives and in the specific healthcare context, the issue of equity in the healthcare domain has extended to digital environments or e-environments, assuming the connotation of “Digital Health Equity” (DHE). In the documents of 2021 and 2022, the World Health Organization defines “digital health” and therefore focuses on DHE, thus defining an action strategy on digital health that recognizes the centrality of promoting equity and preventing the risks of discrimination and marginalization [6, 7].

In this general framework, Telemedicine and e-Health represent the two main e-environments in the healthcare context where the risks of inequity could be described [8]. Telemedicine refers to the provision of healthcare in situations where the health professional and the patient are not in the same physical location; in clinical-diagnostic-therapeutic evaluation, it is a clinical path in which digital remote interactive communication is established. Communication between the patients and the health professionals is activated, and data and information are moved [9, 10]. The patients are in their homes or at other sites, and they are in a different place from the clinicians; in this regard, it is also called “remote patient monitoring”. Although it is sometimes considered as a sort of synonym, the concept of e-Health, on the other hand, refers to a broader concept than Telemedicine as it refers to the more general use of technologies in the healthcare context [5-7]. Since the 1990s, this term has been used to describe the use of technologies and the Internet to enhance or provide access to knowledge and services in healthcare settings. Today, this concept has been extended to include the experience of all the “actors” involved and to include services, products, processes, and all the infrastructures involved in digitization in the healthcare sector [8].

Although the digitization process was slow and gradual in the last decade, in the last three years, this process has had a sudden and quick acceleration during the COVID-19 pandemic; the methods and tools of Telemedicine and the use of e-Health have spread to guarantee a continuity, albeit partial, in the provision of health services [9-11]. All this has been possible thanks to an emergency modification of the methods and regulations previously defined and this has made it possible to highlight virtuous phenomena and positive processes, and also to discover possible risks [8-15]. Innovations in digital health, Telemedicine, and e-Health have shown great potential in the promotion of health outcomes, but there can be unintended consequences related to the risk of inequalities [16]. Now, in a new phase after the COVID-19 pandemic, previous emergency experiences allow us to have some useful discussions on the progressive digitization process. These discussions are particularly relevant in the context of the so-called risk of the “digital paradox” of Telemedicine; it means that people could have better support from the digitization process, but they can also incur a high risk of difficulty in accessing services and information, and they can have a higher risk of exclusion from Telemedicine if all the elements and variables that can influence the use and the access to the processes, products and environments of Telemedicine are not correctly taken into account [17-19]. The current use of Telemedicine and e-Health has highlighted even more the need to better understand how to promote equity and how to prevent marginalization; thus, a general question arises: could the progressive digitization in health contexts help in the reduction of inequalities and the promotion of equity, or could it lead to an exacerbation of inequalities?

Keeping in mind these aspects, in this paper, we have aimed to review the papers that have investigated the topic of DHE in Telemedicine and e-Health and discuss the following research questions:

1) How did previous papers define and describe DHE in Telemedicine and e-Health?

2) How did previous papers describe barriers and risk factors in the promotion of DHE in those e-environments?

3) How did previous papers describe the advantages of the use of Telemedicine and e-Health for the promotion of DHE?

4) How did previous papers describe ways to improve equity in e-Health and Telemedicine?

After examination of the included articles and according to the quality of the studies and the research questions, we did both quantitative and qualitative analyses of the papers according to the proposed research questions. Then, we synthetized and grouped the papers according to the four research questions. The findings have been summarized using a narrative and systematic review. Table 1 describes the 31 papers that have met the selection criteria.

As expected, according to the novelty of the topic, the included papers have revealed that only recently, the authors have addressed the themes of the review. The selected articles have been published in the last five years, mainly in the last 3 years, and only one article has been published in 2018 [21]. The geographical distribution of the papers has suggested a prevalence of interest in the USA [14, 17, 22-37], Canada [15, 21, 38-40], and in Australia [9, 41, 42]; one paper has been from Korea [43], and only some authors from Europe have addressed the topic [44, 45]. The papers have been mainly editorials [21, 22], commentaries [27, 36, 38, 46], or viewpoint papers [14, 23, 29, 39], and only a few research articles have focused on the themes of this scoping review [12, 17, 24, 25, 41, 44]. According to the digital e-environments or e-platforms considered, even if all the papers refer to Telemedicine and/or e-Health, some other fields are considered, like Telehealth [13, 14, 17, 22, 24, 25, 34, 36, 42] and mobile health [14, 21, 26, 37]. Some authors have focused their attention on health data and described the role of electronic health records [28, 31, 43], electronic medical records [28], personal health records [43], and patient-generated health data [43] in promoting DHE.

In the following, we have briefly described the findings from the sorted papers according to the main research questions.

This review has summarized the evidence regarding the promotion of DHE in Telemedicine and e-Health. On the one hand, some authors have recognized the role of Telemedicine and e-Health in reducing the gap in access to health services and promoting greater equity and opportunities for access. On the other hand, the same authors and other authors, however, have identified fields that could be improved. It is, therefore, quite clear that the diffusion of Telemedicine tools can increase the general possibilities of treatment for all people, and some advantages are well known to be strongly linked to the possibility of creating and maintaining certain conditions necessary to guarantee equity of access and use, also by virtue of the aforementioned acceleration of the diffusion process of Telemedicine during the COVID-19 pandemic, which has allowed its widespread diffusion in both primary and special care [8-15]. Some authors have also highlighted that the diffusion of Telemedicine can be considered as a sort of double-edged sword; on the one hand, Telemedicine can increase the possibility of accessing treatment, but on the other hand, the most vulnerable populations from both a socio-economic and health point of view, who could benefit the most from Telemedicine, could be those less ready to use it [29, 47], and this raises reflections on the potential inequalities of access that could result from the massive use of Telemedicine [26, 44], with reference to the so-called “inverse care law” [48].

In this paper, we have addressed four research questions to discuss these issues in a deeper way. The first research question has addressed the definition of DHE in Telemedicine and e-Health. Even if there is no unique definition, there is a general agreement on the idea that it is a complex and multidimensional phenomenon, where there are at least three/five different levels: the individual level, the interindividual level, the social level, the community level, and the institutional level, with interdependence among the different levels and the mutually reinforcing effects between all of them. There is also an agreement on the role of the so-called “enablement environment” that can promote or reduce DHE and the relationship between DHE and social determinants of health (SDOH/s). Some authors have introduced and described the so-called digital determinants of health (DDOH), which interact with SDHs in the promotion or reduction of DHE in Telemedicine and e-Health.

The second research question has focused on the risks and the obstacles in the promotion of DHE in Telemedicine and e-Health. There is a close link between the first and the second research questions because the description of risks and obstacles in the promotion of DHE is strictly correlated to the definition of DHE proposed by each paper. There is a general agreement on the idea that when promoting DHE, some people may incur some risk/s of inequities and/or they may incur some obstacles. While sometimes those risks/obstacles are described in a general way (categories of risks) or in a specific way (description of single risk), other approaches have described group/s of people that may incur some kind of risks/obstacles. The last approach may have inferred, as a negative consequence, that some groups of people could be considered as implicit “bearer” of some kinds of risks and obstacles.

The third research question has described the general and specific advantages of the use of these two e-environments in the health context to promote equity. There is a general agreement on the idea that there can be advantages and benefits both for users/patients and for health professionals, with differences and points of contact between them.

The fourth research question has analyzed the different approaches to improve equity in digital health through Telemedicine and e-Health described by the authors. There is a close link between the fourth and the second research questions because interventions aimed at promoting DHE are strictly related to the risks and obstacles described in each paper. The sorted papers have described the different approaches: firstly, an approach that addresses a specific field and level to improve equity, and secondly, an approach that proposes general and multidimensional model/s. According to the second approach, any intervention may consider all the levels and address all of them to guarantee their effectiveness in the promotion of DHE, taking into account the interdependence among the different levels and the mutually reinforcing effects between all of them.

This scoping review has some limitations related to the nature of the topic and the need for a better understanding of the complex causal process/es that can generate equity or inequity.

As has already been said, there is a broad international debate on the concept of “health equity”, and also on the concept of “equity” in a broad sense, from which derives the general awareness that by promoting equity in different life contexts and life domains of people, there may be some critical loci. If this awareness is in part increasingly shared, less shared is the discussion on those critical loci and on the complex causal process/es that can generate those critical loci. In other words, there is no agreement on the causal processes that can limit equity and, as a negative effect, promote “inequities” or “less equity”. There are two different approaches in the analysis of those causal processes. There is a general tendency to compare a process-based vision (which sees the “lack of equity” as the result of a negative interaction between the “person” and the “environment” in a broad sense, be it physical or social) with visions that see the “lack of equity” as an intrinsic risk to the person (almost a characteristic or an attribute of him/her, rather than the consequence of the interaction between this “person” and an “environment”, once again both physical and social). Because of this general tendency and in a similar vein to what happens in the field of disability, equity and lack of equity can also be perceived alternatively as “attributes of the person” or as “the consequence of a negative process of interaction between the person and an environment”. In the field of disability and the field of equity, these two visions tend to coexist, although the second is the one more consistent with current conceptualizations [49]. Unfortunately, even the first vision has a huge and negative effect, sometimes influencing the a priori definition of groups of people who in themselves “can/necessarily have to run the risk of less equity”, and thus generating processes of a priori categorization and stigmatization. This dichotomous vision, “process” versus “attribute”, can also have effects on the terminology or terminologies used: “processes for the promotion of equity and equal opportunities” in the first case, and groups of people as “bearers of less equity” (often labeled with terms, such as “marginalized” or “under-resourced) in the second case. This categorical approach inherently carries the risk that only little attention will be paid to the need to prevent the risks inherent in negative interactive processes and little attention will be paid to the promotion of virtuous interactive processes aimed to increase equity and support the promotion of one’s health potential. We deem it useful to point out that the second vision of inequities or less equity clearly has a procedural and dynamic value, also for intervention; it is not the single individual or group that incurs the risk of disadvantage, but the disadvantage is the consequence of the interaction between any person and an environment that is “not sufficiently equipped to promote health equity”.

In summary, the present paper has discussed DHE in Telemedicine and e-Health. Promoting equity of access to healthcare is a significant challenge in contemporary times and the near future. The progressive digitization of healthcare and the dissemination of Telemedicine’s tools and methods currently represent some of the ways in which this challenge is being addressed; these being complex tasks is evident from the choice of the word “challenge”, which connotes their specificity and which stimulates a cautious attitude of analysis and study of all the variables involved.

While on the one hand, the construct “equity” applied to the health context highlights the importance of creating and sustaining the conditions to allow anyone to be able to reach (and develop) their “health potential”, it also raises numerous questions on “how this can happen”. On the other hand, the progressive digitization of the healthcare context also highlights further areas of discussion and analysis. There are some specific lessons learned during the current and previous use of Telemedicine and e-Health, also taking into account the emergency experience during the outbreak of COVID-19 when the e-environments became necessary to guarantee care and continuity in healthcare provision. Bearing in mind all those aspects, what may be the next steps in the understanding of this field of study, with the aim to increase DHE?

In agreement with the results of the scoping review, we believe it is useful to list the reasons/variables that can facilitate the occurrence of the condition of disadvantage and to consider all these variables with the aim of promoting equity and reducing risks of inequities. We agree with the need to have an overall and integrated picture of all these variables, a multilevel complex model of “Telemedicine and e-Health ecosystem”, like the ones proposed by various papers of this review and considering the interdependence among the different levels and the mutually reinforcing effects between all of them. Thus, health policymakers and health professionals should collaborate with communities and people to minimize the risk of inequity in access to health services and information and in the use of Telemedicine and e-Health. Moreover, government, scientific societies, stakeholders, and health policymakers may have a central role in planning and implementing specific interventions to promote health equity and DHE, providing system-level changes according to the chosen multilevel complex model of “Telemedicine and e-Health ecosystem”.