Digital Primary Care Services, Procedural Justice and Intersectionality: A Critical Realist Approach

Healthcare systems in many international contexts have been rapidly digitalised in recent years. Yet, despite the significant transformation of such systems and well-documented evidence of ethnic inequalities in the use of health services, the consequences of such changes on fairness in decision-making processes or procedural justice for racially minoritised people have been under-explored. Further, little attention has been paid to the influence of social determinants of health and systems of oppression, such as racism and patriarchy, on digital healthcare and the ways in which these intersect with each other. We developed a novel critical realist intersectional theoretical and analytical framework to interrogate procedural justice in digital primary care as experienced by racially minoritised people, employing the widely used criteria of voice, trust and impartiality. Analysis of interviews with 100 people from racially minoritised communities in the United Kingdom revealed serious shortcomings with respect to all three criteria, which need to be urgently addressed. We propose a multi-pronged approach, which recognises high levels of digital poverty, variations in digital literacy and proficiency in English and the need for more attention to the design of digital services and workforce training, along with proactive use of digital services to address existing ethnic inequalities.