Ensuring Digital Health Reduces Not Aggravates Inequities in Healthcare

Our Take:

There is immense potential for digital health to empower marginalized communities by increasing access to information and quality care. However, as seen during the COVID pandemic, the design and dissemination of digital health tools can perpetuate existing inequities in our society. Going forward, health equity frameworks must be incorporated into the future design and testing of digital health tools, to ensure that they help bridge the digital divide.

Key Takeaways:

Disparities in digital access exist among nonmetropolitan households, racial/ethnic minority, and low-income households with over 32% without a desktop or laptop computer with high-speed Internet and 22% without a smartphone (Journal of Rural Health)
The average medical visit takes approximately 2 hours, including the actual appointment (20 minutes), travel, waiting, paying, and completing paperwork (Harvard Medical School)
Over 2 million women left the labor force during the height of the pandemic between February and October 2020 (National Council on Aging).
individuals earning more than $75,000 annually had a greater rate of growth in having ever used the Internet than those earning less than $20,000 (Pew Research Center)

The Problem:

People of color, older adults, those with limited English proficiency, and rural and low-income communities have often faced disproportionate access to digital health interventions. For example, according to a 2022 article in the Journal of Rural Health, “Significant disparities in digital access exist among nonmetropolitan households, racial/ethnic minority households, and lower-income households with the authors noting that of over 105M households, over 32% were without a desktop or laptop computer with high-speed Internet, almost 22% were without a smartphone with a

data plan for wireless Internet, and 14% were without any digital access.” This is despite the clear benefits that these services provide to these communities which typically lack access to care and as a result often have higher burdens of chronic conditions.

Access to digital health can reduce barriers to care due to increased flexibility for childcare or work commitments, comfort, reduced commute time, and transportation costs. Digital health interventions can also increase access to personal health data and health information, increasing patient self-efficacy. However, these digital applications are rarely designed with a focus on communities with an expressed need. For example, both the design and testing of digital health products are not often adapted to frequent users like the elderly with special needs. As pointed out in a recent study entitled “Digital health platforms for the elderly? Key adoption and usage barriers and ways to address them”, “studies argue that certain designs are needed that are more adapted to the conditions of individuals with impairments – for example, those suffering from hearing and visual impairment.”

Background:

During the COVID pandemic, it was evident that access to digital healthcare and its potential benefits were not universal. In a recent study examining the impact of the COVID pandemic on the use of digital health tools, the authors found that populations with a history of digital exclusion such as older adults (ages 65+), low income, or educational attainment, and racial/ethnic minorities had lower odds of using the internet and a variety of digital health tools including telemedicine during the pandemic. The study also found that individuals earning more than $75,000 annually had a greater rate of growth in having ever used the Internet than those earning less than $20,000 which suggests a widening of the digital use disparity between socioeconomic groups.

In addition, digital health tools are often unable to meet the needs of medically marginalized communities. For example, the Department of Labor cites that women often serve as caregivers and primary healthcare decision-makers in their households, therefore it is integral that women have access to the knowledge and tools to satisfy their multiple roles within their communities. For example, according to the National Council on Aging, over 2 million women left the labor force during the height of the pandemic between February and October 2020. Nevertheless, digital tools are often not designed with this population in mind. As noted in a recent article from the Yearbook of Medical Informatics,” working women with children may not be able to adopt advice from stress-relief applications suggesting spending time with family. These unrealistic recommendations can cause guilt or increase stress levels due to a perceived failure to follow recommendations.” This is particularly troubling when one considers that the top two leading causes of death for women are heart disease and cancer which also mimic national mortality trends. Moreover, digital health solutions that target chronic conditions prevalent among women are rarely funded to meet their actual needs. Many of the sexual and reproductive digital health applications that currently exist also fail to reach priority subgroups with disproportionate inequities in sexual and reproductive health. For example, Black women participate in digital pregnancy services less often, despite the maternal and infant mortality rate remaining the highest in the U.S.

Implications:

As we move toward a more virtual healthcare delivery system, the lack of a health equity framework in digital healthcare will only continue to exclude marginalized communities from equitable access to care, further exacerbating health inequities in those communities. As noted in a recent article in PLOS Digital Health, “to be truly inclusive, digital healthcare must go beyond digitizing what exists and must pursue digitalization at scale. It is essential that adoption of digital healthcare occurs hand-in-hand with community driven need for the solutions and digital literacy education.”

Indeed, another article entitled “The need for feminist intersectionality in digital health” stated that intentional development of inclusive digital health applications is integral to excluding biases from the design of digital health applications. It is imperative that researchers also consider disparities in digital literacy and access to high-speed internet and smartphones in their study protocol. As the article went on to highlight, the adoption of plain language, clear communication techniques, and inclusive content can further support the uptake of digital health applications among diverse communities with differing levels of digital literacy and education.

As the aforementioned PLOS article pointed out, to reduce digital inequities, underrepresented populations in the utilization of digital health applications such as women, racial and ethnic minorities, and rural communities need to be included in the design and testing of applications. Community-engaged research designs can also be an avenue to include traditionally underrepresented communities in digital health research and design. Patients, especially from historically medically marginalized communities must be included in developing solutions to meet their healthcare needs.

Existing and emerging frameworks exist and are available to help increase our understanding of and address the root causes of health inequities and bias in our health system. These should at least be consulted when developing digital tools to at least avoid exacerbating existing disparities with new developments in digital healthcare. Authors Allison Crawford and Eva Serhal, have developed a Digital Health Equity Framework which considers socio-economic factors, cultural contexts, digital literacy, and access to the health system and availability of quality health services. This framework prioritizes health policy and regulation for digital health intending to address health inequity, as well as community needs, context, and inclusion

In addition, in 1989 legal scholar Kimberlé Crenshaw developed a theory of intersectionality that posits that intersections of factors such as race, class, and gender are influenced by larger structural systems such as racism, classism, and sexism. While originally developed to highlight the ways in which prevailing legal and policy conceptions of discrimination overlooked the experiences of Black American women, it is increasingly suggested as an innovative framework with the potential to advance understanding of, and action on, health inequalities, as noted by authors like Daniel Holman. Clearly, frameworks like the Digital Health Equity Framework and Intersectionality are necessary to help us better assess the root causes of health inequities and ultimately identify solutions to reduce those causes. Incorporating these frameworks early on in the design, production, testing and implementation of digital health solutions can help tailor interventions to specific subpopulations with disparate health outcomes and assess differences in the uptake of digital health applications.