Telemedicine, e-Health, and Digital Health Equity: A Scoping Review

Background: 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). Telemedicine and e-Health, which represent the two main e-environments in the healthcare context, have shown great potential in the promotion of health outcomes, but there can be unintended consequences related to the risk of inequalities. In this paper, we aimed to review papers that have investigated the topic of Digital Health Equity in Telemedicine and e-Health [definition(s), advantages, barriers and risk factors, interventions]. Methods: We conducted a scoping review according to the methodological framework proposed in PRISMA-ScR guidelines on the relationship between Digital Health Equity and Telemedicine and e-Health via Scopus and Pubmed electronic databases. The following inclusion criteria were established: papers on the relationship between Digital Health Equity and Telemedicine and/or e-Health, written in English, and having no time limits. All study designs were eligible, including those that have utilized qualitative and quantitative methods, methodology, or guidelines reports, except for meta-reviews. Results: Regarding Digital Health Equity 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. When promoting Digital Health Equity, some people may incur some risk/s of inequities and/or they may meet some obstacles. Regarding intervention, some authors have proposed a specific field/level of intervention, while other authors have discussed multidimensional interventions based on interdependence among the different levels and the mutually reinforcing effects between all of them. Conclusion: In summary, the present paper has discussed Digital Health Equity in Telemedicine and e-Health. Promoting equity of access to healthcare is a significant challenge in contemporary times and in the near future. 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”. An overall and integrated picture of all the variables that promote DHE is needed, taking into account the interdependence among the different levels and the mutually reinforcing effects between all of them.


INTRODUCTION
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][6][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 clinicaldiagnostic-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][6][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][10][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][9][10][11][12][13][14][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][18][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?

Protocol and Study Design
The protocol was developed using the scoping review methodological framework proposed in PRISMA-ScR guidelines [20] (Fig. 1).We have reported data according to these guidelines.
We have conducted a literature review on the relationship between DHE and Telemedicine and e-Health via Scopus and Pubmed electronic databases.The following inclusion criteria were established: papers on the relationship between DHE and Telemedicine and/or e-Health, and written in English.All study designs were eligible, including those that utilized qualitative and quantitative methods, methodology, or guidelines report, except for meta-reviews.We have excluded papers written in other languages than English.Considering the novelty of the topic, no time limits have been considered.

Data Search
Literature search was conducted by two authors (DRP and GPC) in the following online databases: Scopus and PubMed.These databases were chosen to cover health sciences.We have used the following search keywords: DHE combined with the "AND" Boolean operators and "Telemedicine" combined with the "OR" Boolean operators, and "e-Health".

Study Selection
The literature was selected, and the results have been analyzed.According to the needs, the keywords were searched in the publication title or abstract.A total number of 580 records was found.Two authors (DRP and GPC) independently reviewed the chosen references, deciding to exclude further papers and remove duplicate references.A total number of 51 papers was found.

Data Extraction
Papers were analyzed with respect to their content, and papers with content that was not fully within the scope of this review were eliminated.A group of 37 fulltext articles were considered.Starting from the references in the full text of the articles derived from the literature review, some other papers were included (5 articles).After the reading of the full-text, a total of 31 papers were then considered for the final analysis.

Quality and Risk of Bias Assessment
According to Tricco and colleagues [20] and considering the peculiarity of the scoping review, we did not appraise the methodological quality or risk of bias of the included papers.

RESULTS
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.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][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37], Canada [15,21,[38][39][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 eplatforms 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.

How Did Previous Papers Define and Discuss DHE in Telemedicine and e-Health?
To date, there is no complete agreement on the definition of DHE, although the aforementioned documents of the World Health Organization represent a common thread between the different positions proposed by the authors [5][6][7].However, the main shared elements among all the most recent definitions seem to be the promotion of one's health potential through digital tools [24,35,44], the reference to a list of risk factors [25,38,42] or to single risk factor [13,27] that can lead to some forms of marginalization, and the reference to the description of group/s of people at higher risk of inequalities [12, 13, 15, 17, 21-24, 27-30, 32, 34, 35, 40-49].
Regarding "health potential", only some papers refer directly to it, while other papers have been found to use related words like "full potential" [35], "optimal health" [24], and "greatest standard of health" [27]; sometimes the idea of "health potential" is considered only indirectly, like in the paper of Kaihlanen and colleagues ("digital inequalities may in turn cause significant disadvantages, such as an increased risk of health deterioration") [44], or in the paper of Foley and colleagues that highlighted the idea that "benefit from knowledge and practices related to the development and use of digital technologies (may) improve health" [41].Also, Crawford and Serhal chose a similar approach and focused on "poor health outcomes" ("unexamined inequities in access to and implementation of digital health can recapitulate and deepen the inequalities that have long existed within our health care system, and they can contribute to poor health outcomes") [39].
Regarding the description of group/s of people at higher risk of inequalities, while the World Health Organization' documents make a general reference to the concept of disadvantage, there is a common reference to a set of people or groups that could incur in forms of marginalization and could meet some barriers in the development of their health potential [5][6][7].Those people are sometimes described in a general way as "groups of people with reduced resources" [23,30,36,42], or as "marginalized group/s or individuals" [15,21,22,28,38,46].Some papers have described in a deeper way the group/s of people that could incur some forms of inequity (Table ) contd (people with disability, people living in lower socioeconomic areas, cultural ethnical, and economically diverse communities, elderly people, and people who live in rural areas) [27,40].As a general view, some authors converge in identifying social, linguistic, cultural, geographical, and health factors that can be associated with a greater risk of lack of equity of access (albeit with interesting differences between authors).Some papers have focused on specific reasons, like low digital literacy skills [42], while other papers have described a longer list of possible reasons, proposing a more general description of a "complex causal model" [27,[31][32][33].Other papers have also described other general or specific reasons that can promote inequities, like social vulnerability, complex health problems, language barriers [42], and low financial and economic resources [17,25].Some authors have highlighted the multidimensional nature of DHE (individual level, contexts, social determinants of health, and the enabling environment) and the need to consider different levels to achieve a comprehensive knowledge of it [31,38].Anaya and colleagues [22] took a further step forward in defining the multidimensional features of "equity in digital healthcare" in Telemedicine, highlighting its complexity.Richardson and colleagues [31] proposed a general model where socalled social determinants of health (SDOH) [2,47] are considered to contribute to the promotion of DHE, and they also proposed to integrate the SDOH with the socalled digital determinants of health (DDOH) at individual, interpersonal, community, and societal levels [31].

How Did Previous Papers Describe Barriers and Risk Factors in the Promotion of DHE in those eenvironments?
Barriers and risk factors in the promotion of DHE in Telemedicine are discussed considering both the perspective of the users/individuals and the perspective of the professionals.
When the users' perspective is considered, authors have described the following main barriers and risks: limited availability of devices, limited access, limited knowledge and previous experiences in the use of devices, tools, and e-environments, and language barriers, like those related to low English fluency [22,33,38,40,41,43,44].
Other kinds of barriers are described from the perspective of the users, like the one related to the need to have private space in the home (or in other facilities) with the aim to guarantee privacy and confidentiality during Telemedicine consultations [44].Other authors have focused on the role of trust and confidence of users [28,41] and lack of interest and motivation [34] in the effective use of instruments and tools of Telemedicine.Some papers have described the role of formal and informal social networks and the effects of isolation on the access to information and tools needed to use Telemedicine tools and e-environments [41] and on the availability of help and support if needed [44].The role of poverty and low income in the availability and access to eenvironments has also been considered [41,42].Some authors have focused on the risks from the perspective of healthcare professionals, describing the point of contact with users (like the risk of the digital divide, mainly on the first two levels according to Shaw and colleagues [15], availability of devices and software, and experiences and specific knowledge in the use of eplatforms and e-environments) [15,17].Some peculiar risks have also been described for healthcare professionals; they can meet some difficulties in performing clinical skills through the tools of Telemedicine (devices, software, e-platforms, and eenvironments) and they can need some specific training and/or support to transfer their skills on those tools and eenvironments [8].
Although a lot of papers have discussed various barriers in access to digital health e-environments, only some authors have proposed an integrated and multilevel description of them [31,33,44,47].
In some papers, barriers of DHE and inequities are used as synonyms for "digital divide" [15,27].Some papers have described the relationship between DHE and the digital divide according to two different approaches: firstly, defining "digital divide" as a general construct [27], and secondly, defining "digital divide" in a deeper way [15,38].Shaw and colleagues proposed an integrated definition of the digital divide, the so-called "three levels of digital divide": the first level refers to the access to digital tools/processes, the second level refers to the knowledge/skills necessary to access tools and digital processes, the third level refers to the possibility or not of using digital tools and digital processes to obtain useful results for one's life [15,38].In the first level, people may have difficulty accessing Telemedicine services due to availability/not availability of devices, software, and Broadband access.In the second level, people may have difficulty accessing Telemedicine services due to language difficulties and/or barriers (English-speaking proficiency or need of an online translator or an interpreter), or limited knowledge and experiences in the use of computer and/or the required software and/or the required eplatform.In the third level of the digital divide, people may have the devices and knowledge needed to access Telemedicine services and e-health, but they are not ready to use digital tools and digital processes to obtain useful results for his/her own life.Shaw and colleagues [15] focused on the perspective of the users, but a similar approach has been discussed also considering the health professionals' perspective [11,17].

How did Previous Papers Describe the Advantages of the Use of Telemedicine and e-Health for the Promotion of DHE?
There is a general agreement on the idea that Telemedicine can produce overall advantages.The main advantage is to maintain access to care, continuity of care, and communication between patients and health professionals in critical and emergency situations, like the one related to the COVID-19 outbreak [17,24,27,39,41].Some authors have described positive effects for users/patients: it can reduce general and specific costs [27], like those related to transportation and the loss of working hours, and it can reduce the time needed for a visit [22].Some authors have focused on the positive effects on patients ' satisfaction, engagement, and communication with clinicians [24].Some papers have described the positive effects on safety and health outcomes and the care of people with complex care needs and several illnesses and disorders [27,45].
When the positive effects on health professionals have been considered, engagement and communication are described, and the reduction of workload is discussed (even some papers have also described the risk of an increase in the professionals' workload) [47].
Regarding e-Health, there is a general agreement on some overall advantages, like improving access to healthrelated information [27]; even some authors have discussed the risk of spread of "fake news" and/or inaccurate information in the health field [45].
Regarding health data, Foley and colleagues [41] have highlighted the positive effects of gathering, tracking, and delivering health-related information for individuals and populations (even some papers have described some risks in this regard related to privacy and other issues in data management).

How did Previous Papers Describe Ways to Improve Equity in e-Health and Telemedicine?
There are two general approaches currently suggested by the authors who have dealt with these topics for the promotion of DHE: firstly identifying single areas of intervention and single levels of action, and secondly proposing general models of approaches.
In the first approach, individual areas for improvement are identified at the individual, community, and health policy levels.For example, Anaya and colleagues, in 2022, referred to the importance of improving the digital knowledge and skills of possible users of Telemedicine services, as well as improving the availability of the necessary infrastructures (including the availability of devices, hotspots, and dedicated spaces) [22].Chang and colleagues [17] proposed some policy recommendations focused on economic issues of Telemedicine: reimbursement of telehealth visits when delivered by telephone and expanding free Broadband access.Lopez de Coca and colleagues proposed specific interventions aimed to reduce the risks of fake news spread with e-Health portals and e-environments [45].
The paper of Saeed and Masters (2021) focused on the need to improve internet access and educate/support patients in the use of technologies, tools, and software, and to derive benefits from these technologies in their lives [33].
The second approach also includes the work of Shaw and colleagues in 2021 [34], where there have been identified three general areas of strategies useful for promoting equity in Telemedicine and in digital health contexts: simplifying complex interfaces and information flow, using intermediaries, and creating mechanisms through which people at risk of disadvantage in accessing digital healthcare can provide useful inputs for the design and implementation of Telemedicine interventions [34].The same authors have also identified three different levels of intervention for the promotion of DHE: political and managerial level to guarantee the presence of the required infrastructures and allow the reimbursement of services to facilitate access to all segments of the population; at the level of health services for monitoring the quality of services and their actual usability by groups at greater risk of discrimination in order to ensure the training of the various health professionals involved; at the level of the community and of individual patients for direct involvement in the various phases and for the implementation of interventions aimed at increasing the level of basic and more sophisticated digital knowledge and skills, useful for being able to use Telemedicine tools and services [34].have also described strategies and tools that can be used to reduce the risk of inequity in digital healthcare, focusing in particular on overcoming some barriers experienced by people in terms of the digital divide (increasing awareness of the gap in knowledge in the technological field and in digital literacy between professionals and service users, promotion of training courses, promotion of interventions aimed at increasing useful knowledge for health professionals and for device and software manufacturers to allow progress in design, implementation and use of Telemedicine services, promotion of reflections and interventions aimed at increasing equity of access and usability, and taking into account individual differences in digital literacy) [42].Brewer and colleagues, in 2020, focused on the design and implementation tools and methods that involve the direct involvement of communities and of those groups that could incur the greatest risk of exclusion [23].Lyles and colleagues [47] agreed on a similar approach; in order to avoid the risk of a lack of equity in access and usability in the health sector, it is very important to take these aspects into account right from the planning, implementation, and then monitoring stages of each intervention in the field of digital health [47].
Anaya and colleagues [22] hypothesized the creation of a "Telemedicine ecosystem", which represents an example of the second approach, in which different levels are taken into consideration (both individual skills, the availability of infrastructures, and the different environmental conditions and economic and political support for the implementation and feasibility of the interventions).As a step forward, they have reflected on strategies that can be implemented to promote equity and limit the risk of marginalization and lack of use of people according to an approach that some authors call "creation of an ecosystem for the promotion of equity in Telemedicine" [22] and which requires the collaboration of all the actors involved in the process of designing, implementing, disseminating, and using Telemedicine systems.
Crawford and colleagues [39] referred to the "Digital Health Framework", which integrates digital determinants of health and DHE in each implementation of digital health solutions and programs, enabling the direct involvement of people from "marginalized and vulnerable groups" in the position of digital health leadership or in co-designing at all stages of innovation and implementation.
A common approach among different papers is the reference to multiple levels of analysis and intervention: individual level, interpersonal level, community level, and societal level [31][32][33], and the awareness of the complex causal model [31].

DISCUSSION
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][9][10][11][12][13][14][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 eenvironments 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".

CONCLUSION
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 eenvironments 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".

STANDARDS OF REPORTING
PRISMA guidelines and methodology were followed.

Fig. ( 1
Fig. (1).PRISMA 2020 flow diagram for systematic reviews resulting from a search of database and other sources for scoping review. .....

Table ) contd..... Author/s (year) Country/s Definition of Digital Health Equity Description of People at Risk of Inequities Kind of Study Telemedicine (TM)/e- health (E)/TeleHealth (T)/ Digital Health (D)/Mobile Health (M)/electronic Health Records (EHR)/Electronic Medical Records (EMR)/personal health records (PHR)/ patient-generated health data (PGHD) Field/s (if declared) Barrier/s and Risks in TM and E in the Promotion of Digital Health Equity Advantages of TM and E in Promoting Digital Health Equity Areas/levels of Improvement
(Table ) contd.....

if declared) Barrier/s and Risks in TM and E in the Promotion of Digital Health Equity Advantages of TM and E in Promoting Digital Health Equity Areas/levels of Improvement
(Table ) contd.....

Table ) contd.....
).The research group is composed of the Global Community of Longevity, IERFOP, and a research group from the Department of Education, Psychology, and Philosophy of the University of Cagliari, Italy.G.P.C. is a Ph.D. student receiving an NRRP scholarship under Ministerial Decree no.351 This publication (communication/thesis/article, etc.) was produced while attending the Ph.D. program in Philosophy, Epistemology, Human Science at the University of Cagliari, Cycle XXXVIII, with the support of a scholarship financed by the Ministerial Decree no.351 of 9th April 2022, based on the NRRP, funded by the European Union, NextGenerationEU -Mission 4 "Education and Research", Component 1 "Enhancement of the offer of educational services: from nurseries to universities" and Investment 4.1 "Extension of the number of research doctorates and innovative doctorates for public administration and cultural heritage".