Design and deployment of Digital Health Interventions (DHIs) to reduce the risk of the Digital Divide: a systematic scoping review conducted to inform development of the Living with Covid Recovery (LWCR) DHI

Abstract

Background: Digital health interventions (DHIs) can support health-related knowledge-transfer e.g., through websites or mobile applications, and may reduce health inequalities by making healthcare available where access is difficult and translating content to overcome language barriers. However, DHI can also increase health inequalities due to the digital divide. To reach digitally excluded populations, design and delivery mechanisms need to specifically address this issue.

This review was conducted during the evolving Covid-19 pandemic and informed the rapid design, deployment, and evaluation of a post-Covid-19 rehabilitation DHI: ‘Living With Covid Recovery’ (LWCR). LWCR needed to be engaging and usable for patients and to avoid exacerbating health inequalities. LWCR was introduced as a service into 33 NHS clinics, used by 7,679 patients, and evaluation ran from August 2020 - December 2022.

Objective: to identify evidence-based DHI design and deployment features conducive to mitigating the digital divide.

Methods: Cochrane Library, Epistemonikos, NICE Evidence, PROSPERO, PubMed (with MEDLINE and Europe PMC) and Trip; OpenGrey and Google Scholar were searched for primary research studies published in English from 1 October 2011 - 1 October 2021:

Setting and population: adults likely to be affected by the digital divide, including older age; minority ethnic groups; lower income/education level; in any healthcare setting.

Interventions: any DHI with features of design and/or deployment intended to enable access and engagement by the population of focus.

Comparators: any or none.

Outcome measures: any related to participants’ access and/or use of DHI and/or change in digital skills and confidence.

Data from studies that met the inclusion criteria were extracted, narratively synthesised, and thematically analysed.

Results: 22 papers met inclusion criteria. DHIs evaluated included: telehealth, text message interventions, virtual assistants, self-management programmes, and decision aids.

Design themes included: co-development with end-users, user-testing through iterative design cycles, DHIs that also helped improve digital skills and digital health literacy, tailoring for low literacy through animations, pictures, videos and writing for low reading ages; virtual assistants to collect information from patients and guide use of a DHI.

Deployment themes included: free devices and data, or signposting to sources of cheap/free devices and WiFi, text message interventions, providing ‘human support’, providing tailored digital skills education as part of the intervention, and enabling peer/family support.


Limitations: our search extended to late-2021, and there has been a massive increase in the literature following the pandemic. However, as our review was undertaken to inform the LWCR DHI design and deployment, we have reported the results that informed this work. The studies included in the review were heterogeneous, so generalisability may be limited. Few RCTs assessed DHI impact on digital health skills using validated measures.

Conclusions: using the design and deployment findings described above into account when developing DHIs may help overcome the digital divide. Beyond informing the LWCR DHI development, the review findings have wider implications for the equitable design, delivery, and evaluation of DHIs.

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Identifiers

ORCID for Katherine Bradbury: orcid.org/0000-0001-5513-7571

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