How to Solve Digital Health’s Equity Problem

Maribel, 60 years old, is a monolingual Spanish speaker, and a diabetic for over 15 years. She faces unemployment because of corona, which is chopping away at her minor savings. Her gym closed because of social distancing and now weight gain creeps up on her. Health apps, to exercise and control her depression and diabetes, entice her. Yet, she has trouble finding, downloading and using apps.

Digital health innovations are skyrocketing. Many turn to mobile apps or online programs to stay healthy during social distancing. As gyms face closures, exercise apps prod users to stay active and diet apps dish out recipes on healthy eating. Mental health apps brighten mood and reduce stress.

These new innovations are exciting. So are the many free resources and tools some companies now offer. But, there is one far-reaching neglected fact:

Digital health suffers a massive equity problem.

Most digital health applications are not designed for people who are less tech savvy. Nor do they cater to those who have more trouble understanding health information.

Maribel is a fictional character. But her persona is inspired by participants in studies of the digital health lab where I am a researcher. She has little experience with tech. Regardless; she embraces the possibility of using health apps. She is an inspiration for designing digital health for those vulnerable and forgotten.

Digital health resources need to serve people like Maribel.

Health apps can help people self-manage their chronic diseases.

Maribel has diabetes and depression, two chronic health disorders that often concur. Apps or text-messages may jolt her out of her slumps. They can send her exercise tips, check-ins and supportive messages. Apps can grasp her progress like her physical activity goals, diet and mood.

Apps can also revolutionize self-monitoring. They can track things like sleep quality, heart health and blood sugar. If done right, this could transform healthcare. Apps will spur remote visits if they share the correct information with doctors. They also boost patient empowerment over their health.

This is especially important for vulnerable people with chronic illness.

Social distancing strips many people of crucial care. Telemedicine, doctor visits by video-calls, is now spiking in popularity. But some people don’t know how to use telemedicine, or can’t. Hispanics and African-Americans for example less often have high-speed internet access, necessary for using telemedicine.

Hispanics and African-Americans are vulnerable groups who die more often from COVID-19. But besides excess death due to COVID-19, worsening health for these groups might also cost lives. After all, their doctor visits will plunge. Also, their exercise levels will suffer because of say-at-home measures. Their loneliness will expand with social distancing. This is why, vulnerable groups need to be able to benefit from digital health resources.

This is the risk: COVID-19 sparks a heap of digital health innovation. But this is only for select groups: the rich, young and tech-savvy. Not the poor, low educated and non-whites.

How can digital health become accessible for vulnerable populations?

Digital health needs to be designed with and for vulnerable individuals. New, flashy technologies are now often shaped with high tech users in mind.

For example, top-funded digital health companies pilot most of their products in healthy volunteers. Only 30% of apps are tested in people with clinical conditions.

This is one of the reasons that depression and diabetes apps are difficult to use for the patients they should serve. They bruise usability with complex user interfaces. They crush engagement by failing to explain the purpose of the app.

Even core functions of most apps on the market are challenging for many. I discovered this firsthand when my partner attempted a video-call with his 83 year-old grandmother. Coaching her over the landline, she wrestled to answer a WhatsApp video-call. She had never learned to ‘swipe up’. Instead, she attacked the phone symbol leaping up on her screen. Then she stopped out of frustration.

Finding the right medium is essential.

Phones are crucial in delivering digital health resources. Over 80% of low-income individuals in the US own smartphones. Even those who don’t will likely carry a standard flip phone.

For the less tech-competent, app interfaces should be simple. They should have large buttons and easy navigation. They should be written at no more than a 6th grade reading-level.

My research group is developing a conversational agent (or chatbot) for vulnerable individuals. Conversational agents have potential for vulnerable groups. They can be text-based or communicate via voice message. This works well for those with low tech skills.

Conversation is not a new interface, rather the oldest interface humans master. If well-designed, chatbots can guide people to modify behavior and manage disease.

Our bot targets low-income English and Spanish-speaking people with chronic health disorders. This holds challenges. There are only a handful of chatbot studies in this group. User design studies, with our population, will discover if a chatbot can provide benefits. And also, if we can build it to engage those with low-tech skills.

We need to train those with few tech skills in the use of digital health tools.

This is an area that can transform through innovation. We can coach people over the phone or with instructional videos. After hours of phone training, my partner’s grandmother was, in the end, bravely video-calling. I hope that COVID-19 will launch the discovery of more innovative ways to teach tech skills to those who struggle.

Launching helpful digital resources for health management is crucial, especially now. But, these interventions need to grasp vulnerable populations. If not, health inequality will surge. New training methods should advance tech skills, guiding those with low tech literacy to use these applications. High-quality digital health resources should serve all.