The digital health divide: how do patients with chronic disease and socioeconomic disadvantage experience and access digital health?

Problem

The rapidly increasing presence of digital health promises to improve healthcare delivery for all. However, the digital health divide describes a pattern where socioeconomically disadvantaged patients, who already have poor access to traditional health, are now further marginalised through lower utilisation of digital health services. The digital health divide is particularly pronounced in chronic disease and evident in primary care. While some quantitative data describes an association between digital health exclusion and socioeconomic disadvantage, there is scarce qualitative and mixed methods research exploring the barriers and enablers of digital health access in this population. Our aims were to explore how patients with chronic disease and socioeconomic disadvantage experience digital health in the context of Australian primary care, to identify barriers and enablers to digital health access and benefits and to test these findings in a quantitative survey.

Approach

The study design was exploratory sequential mixed methods. We completed 19 semi-structured interviews with socioeconomically disadvantaged patients recruited through three general practices and one service organisation in Australian rural, outer-suburban and urban regions. Two interviewers thematically analysed the transcripts with an inductive coding scheme, which was iteratively reviewed by the wider research team. We applied the final themes as the structure for a patient survey, in order to measure the degree and association of observed barriers in a wider population. The specific survey questions were developed out of this structure, using other survey questions and validated tools where possible, such as eHeals (a digital health literacy scale). Two experts and five patients completed pilot testing for content and face validity. We administered this survey among 400 patients of varying socioeconomic status recruited through 36 Australian rural, outer-suburban and urban general practices.

Findings

Barriers to accessing digital health tools included 1) a stronger patient preference for human-based health services, 2) low trust of digital health services, 3) high financial costs of necessary tools, maintenance and repairs, 4) poor public internet access options, 5) reduced capacity to engage due to increased life pressures and 6) low self-efficacy and confidence in starting the digital health process. When patients engaged with digital health, we saw a positive feedback cycle of growing skills and confidence, enabled by good social support and health provider recommendations. Our quantitative analysis of survey data, including how relative socioeconomic disadvantage influences barriers and enablers will be completed by July 2020.

Consequences

Barriers to digital health for socioeconomically disadvantaged patients are more complex than financial costs, are often cumulative, and are associated with general socioeconomic determinants for health. Our hope is to communicate with digital health policymakers, practitioner and innovators to highlight target areas for change that will improve the accessibility of digital health for primary care patients.