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 (Preprint)

Abstract

BACKGROUND Digital health interventions (DHIs) aim to support health-related knowledge transfer e.g., through websites or mobile applications (apps). They have the potential to either increase health inequalities due to the digital divide or to reduce health inequalities by making healthcare available to those who might not otherwise be able to access it, such as geographically remote populations. They can also overcome language barriers though translated content and enable people to access support and advocacy from family members or friends. However, public health programmes and patient-level healthcare delivered digitally need to consider ways to mitigate the digital divide through DHI design, deployment, and engagement mechanisms, to reach digitally excluded populations. OBJECTIVE The objective of this systematic scoping review was to identify the features of DHI design and deployment conducive to improving access to, and engagement with, DHIs by people from demographic groups likely to be affected by the digital divide. The review was conducted during the evolving Covid-19 pandemic, and its findings informed the rapid design, deployment, and evaluation of a post-Covid-19 rehabilitation DHI called ‘Living With Covid Recovery’ (LWCR). LWCR needed to be engaging and usable for patients with a wide range of demographic characteristics, to avoid exacerbating existing health inequalities as far as possible. LWCR was introduced as a service in 33 participating NHS hospital clinics from August 2020, was used by 7,679 patients, and the study ran until 20th December 2022. METHODS This systematic scoping review followed the methodology recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR) guidance. The following databases were searched for primary research studies published in English from 1 October 2011 to 1 October 2021: Cochrane Library, Epistemonikos, NICE Evidence, PROSPERO, PubMed (with MEDLINE and Europe PMC) and Trip. In addition, we used OpenGrey and Google Scholar to search for grey literature. We selected publications that met the following inclusion criteria: primary research papers that explored and/or evaluated features of DHI design and deployment intended to enable access to and engagement by adults from demographic groups likely to be affected by the digital divide (e.g., older age; minority ethnic groups; lower income/education level). The data from studies that met the review inclusion criteria were extracted, narratively synthesised, and thematically analyzed. RESULTS A total of 22 papers were included in the review. Inclusion criteria were met for 19 papers of 1245 hits retrieved by the search and three further papers were added from a search of publications included in relevant reviews. DHIs evaluated in the studies included: telehealth, virtual assistants, text message interventions, decision aids and e-health learning programs. The main themes resulting from analysis of extracted data relating to design considerations included: co-development with end-users and user testing for iterative design cycles to produce DHIs that help improve digital skills and digital health literacy through use; tailoring for low literacy levels through animations, pictures, videos and writing for a low reading age; use of virtual assistants to collect information from patients and guide use of a DHI. For deployment, themes revealed included: provide devices and data, if possible, otherwise use text messages or signpost to sources of cheap/free devices and free WiFi; provide ‘human support’ for implementation / onboarding and troubleshooting; provide tailored digital skills education as part of the intervention; and incorporate peer/family support. CONCLUSIONS Taking these “universal precaution”’ can help reduce the digital divide. The results helped guide the iterative design and successful deployment of the LWCR DHI. They also have wider implications for practitioners, policy makers, and researchers, and will inform best practices in the design and delivery of DHIs for equitable health improvement INTERNATIONAL REGISTERED REPORT RR2-10.2196/32538