Health is about much more than genetics and medical care.
Research has shown that the conditions in which people are born, grow, live, work and age—what researchers call the ‘social determinants of health’ — also have a great deal to do with how healthy we are (Magnan, 2017).
These circumstances are shaped by the power, wealth, and distribution of resources globally, nationally, and locally, and may determine access and quality of medical care. And so, opportunities to live a healthy life are not evenly distributed.
Some nations are better than others at creating policies and health care systems to address those social determinants of health which contribute to poorer health outcomes. These communities recognise that health equity is crucial to a vibrant nation.
Health equity means increasing opportunities for everyone to live the healthiest life possible, no matter who we are, where we live, or how much money we make.
When everyone has an opportunity to live a healthy life, we are all better off.
I recently had the privilege of facilitating a Roundtable discussion on the topic ‘Expanding Digital Health’ — a topic grounded in an ethical call for greater health equity.
The Australian National University (ANU) and Good Things Foundation Australia spear-headed this timely discussion series, with the aim of building a more coordinated community of practice to address the digital health divide.
Series Two of this program was held in February and April 2021 and focused on telehealth and digital health technologies, such as electronic prescriptions. The recommendations that emerged warrant attention.
Digital health is broadly defined as “the field of knowledge and practice associated with the development and use of digital technologies to improve health” (WHO, 2020) across the full range of health technologies introduced into care, including telehealth, mobile health apps and wearable technologies, and online health services and tools.
The digital divide is the chasm between those who have access to technologies and the digital literacy to work them, and those who do not. The digital divide fuels and is fuelled by other leading social determinants of health, and ultimately hasan impact on patient wellness and health equity.
The digital divide can lead to disparities in patient portal adoption, telehealth care access, or the ability to use patient-facing practice management software, such as online appointment schedulers.
The first group of people that comes to mind when we speak about the digital health divide are older people. There is clear evidence to support the effectiveness of targeted interventions to ensure that older Australians have the skills, technology and help required to benefit from digital health solutions.
More recently, however, we have learned that the digital divide is more nuanced. For instance, some older adults may be able to use telehealth, while some younger, low-income patients might not have the infrastructure to access it.
Recent experiences of health care service delivery during the COVID-19 pandemic shone a light on telehealth disparities.
Language barriers dissuaded patients from accessing telehealth. Additionally, traditionally underserved patients without a usual source of care may have been more used to accessing urgent care services and were less likely to have an established health care provider with whom they could pursue telehealth.
People with unreliable broadband services also face challenges accessing digital health care.
Additionally, a wide range of individuals may have low digital health literacy, (defined by the World Health Organisation as the ability to seek, access, and make use of health information via electronic media), which is another factor that perpetuates digital health inequity.
As such, while telehealth brings significant opportunities for increased access to health care services for many people, particularly those living in rural and remote areas, a significant barrier remains – how to connect with people who have low or no digital health literacy skills or confidence.
A concerning trend, highlighted by research undertaken by Macquarie University’s Australian Institute of Health Innovation, is the overall low use of video telehealth by general practice (as compared to telephone). The study also reported lower uptake of any type of telehealth service by people in lower socioeconomic areas.
Unless we pay adequate attention to health equity when we develop digital health solutions, we risk hard-wiring further health inequities into these solutions (Crawford & Serhal, 2021).
Digital health technologies may interact with social, cultural, and economic determinants of health to indirectly contribute and compound health equity. For example, someone with unreliable access to broadband, a low level of health literacy, and for whom English is a second language, may also be struggling financially. A sweeping rollout of a digital health solution runs the risk of leaving these individuals even further estranged from a health care system that already seems elusive.
Issues such as a lack of internet connectivity and video chat/webcam in both urban and rural areas can hinder the effectiveness of telehealth to its full capability especially among culturally and linguistically diverse communities, those in low income households, and the medically underserved.
Experts who participated in our discussion series confirmed that many health care providers lack competencies, training, and confidence to deliver helpful digital health services.
Others may enthusiastically embrace digital health solutions but lack the empathy to anticipate how their patients and communities may experience or interact with technology.
It is also important to remember that the social aspects of health care delivered in-person by doctors, nurses, allied health professionals and community health workers are potent mechanisms to combat mistrust and strengthen therapeutic relationships (Clare, 2021). Digital innovations that do not incorporate the human connection so vital to positive health care delivery may miss the mark.
Ad hoc solutions to poor digital health literacy and digital health access will not improve health equity. Rather, a multifaceted social determinants of health strategy, plus technology investments, is needed.
There is growing evidence that the digital divide has exacerbated the social and economic factors which create barriers to health care delivery and well-being.
Systemic coordination is required to bring our efforts together.
The key recommendations that arose from this series were:
The Expanding Digital Health Roundtable discussion series underscored the need for health care providers and consumers to work collaboratively to better understand what makes a quality telehealth consultation. Joint work is also needed on how to adopt digital solutions that benefit all patients, including those who are digitally disadvantaged.
We have an opportunity to actively tackle the digital health inequities emerging, with the promise of a healthier and more prosperous future for all.
Written by Emeritus Professor Linda Kristjanson AO, Patron, Good Things Foundation Australia.
Clare CA (2021) Telehealth and the digital divide as a social determinant of health during the COVID-19 pandemic. Network Modelling Analysis in Health Informatics and Bioinformatics. 10:26.
Crawford, A., Serhal, E. (2020) Digital Health Equity and COVID-19: The Innovation Curve Cannot Reinforce the Social Gradient of Health. J Med Internet Rees 2020;22(6):e19361.
Magnan S (2017) Social determinants of health 101 for health care: five plus five. NAM perspectives. Discussion paper. National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201710C
World Health Organization. 2020 March 22. Draft global strategy on digital health. 20-2024. URL: https://www.who.int/docs/default-source/documents/gs4dhdaa29f352b0445bafbc79ca799dce4.pdf
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