Keywords

1 Introduction

The use of digital platforms has increased significantly over the past two decades. Hospitals have moved beyond the initial investments that were limited to Electronic Health Records and/or Virtual dispensaries, towards a more holistic view of digitalization in healthcare. The latter includes a view of a digital environment, where the different data streams can be integrated or connected in ways that reflect local and national needs and priorities. Furthermore, digital health has been recognized as a technological approach that can address the gap between urban and rural populations (Marcin et al. 2016) and between high-income and Low-and Middle-Income Countries (LMICs) (Labrique et al. 2018). At the same time, a few publications have voiced concern that digitalization may actually be widening the gap in needs and capacities between different healthcare systems (Dorsey and Topol 2016; Scott Kruse et al. 2018; Yao et al. 2022). In the case of LMICs, it is easy to point to the challenges relating to infrastructure as the main barrier to digitalization implementation in healthcare. However, the digital health divide does not simply exist due to the connectivity or not to an internet line. Instead, the reasons for digitalization implementation are complex (as with many other specialized technologies) and intertwined, the result of a combination of persistent healthcare, social, economic, and political factors. Thus, technological availability and development provide an important entry point but should not be seen in isolation or removed from the local context in which digitalization takes place.

Several chapters within this book focus on infrastructural aspects in relation to digitalization of healthcare in LMICs, for example Chap. “Digitization of Physical Health Data in Low- and Middle-Income Countries” on the ‘Infrastructure needs, risks and opportunities’, Chap. “Proliferation, Ingestion, and Interpretation of Health Data in Low-and Middle-Income Countries (LMICS)” on ‘Future sustainability’ of digitalization, etc. Complementing the above-mentioned chapters, the question in this chapter is uniquely viewed through the lens of the digital divide and how technological availability and development can create additional challenges or promote sustained growth and development. The current chapter has been structured as a scoping review as it seeks to present an overview of a potentially large and diverse body of literature pertaining to a broad topic. Some of the specific thematic groups that have been identified can form the basis of future systematic reviews, with a sharpened and more specific focus.

2 Methodology

A scoping review of the literature was done, to map out the gaps regarding digital health and the digital divide based on technological availability and development. Studies and articles that describe these gaps were identified from two databases: PubMed and EBSCOhost. The search was done on February sixth, 2023, using the search terms (digital health or digital medicine or electronic health or ehealth or digital health care or mhealth) AND (digital divide or digital gap or digital inequality or digital inequalities or digital inclusion), since inception of the databases and only published in English. The results of the databases and manual searches were exported into EndNote. Duplications were removed using EndNote-based methods as reported previously (Bramer et al. 2016) and double-checked manually. Two reviewers (RB and SP) independently screened by the following eligibility criteria: (i) detailed discussion of the digital divide, at least within a section of the publication; (ii) detailed discussion of digital health implementation, technology and/or policy. Non-English articles, commentaries, and posters were excluded. The difference of opinion between the reviewers was resolved by a discussion with a third party (ZK). The chapter was reviewed and edited in its entirety and independently by a third party (SN), for any potential misalignments. The study screening processes are shown in Fig. 1. The thematic grouping of the identified articles was conducted following a similar methodology, RB and SP conducting the thematic groupings independently and any difference of opinion resolved by ZK as a third party.

A P R I S M A flow diagram. It involves identifying records from PubMed and E B S C O host, screening 1744 records after removing duplicates, obtaining 1342 records after removing posters, narrowing down to 76 records after exclusion criteria, and finally including 35 records after second screening.

Fig. 1 PRISMA graph of the scoping review for the current book chapter

3 Results

Search results: From the PubMed database, 970 articles were retrieved, 50 were chosen on the first screening (reading abstract) and these were reduced to 31 articles on the second screening (reading the main body of the article). From the EBSCOhost database, 1651 articles were retrieved, 878 were excluded as were duplicates with those identified by PubMed, resulting in 774 unique articles. Twenty-six articles were chosen on the first screening (reading the abstract), reduced further to 4 articles on the second screening (reading the main body of the article). Thus, 35 articles were used in this scoping review, and all have been included within the references of this chapter. It is interesting to note that most of the identified articles had simple mentions of the search terms in passing and thus the observed high attrition rate, however, very few dedicated a specific section or any detailed forethought on the topic. The retrieved articles have been divided in the thematic groups presented below.

3.1 Affordability and Cost of Technology (Saeed and Masters 2021; Paccoud et al. 2021; Jiang and Liu 2020; Bayard et al. 2022; Freeman et al. 2022; Haenssgen 2018; Nagler et al. 2013; Kemp et al. 2021)

A low social-economic status (SES) is a determining factor for the availability of technology and digital health. Populations with lower incomes face more challenges in access to and are less likely to adopt digital health technologies, which may lead to more severe health inequalities. This observation is supported by the fact that there is an income gradient associated with having access to telehealth. What is more, it was shown that socially disadvantaged groups of patients tend to be excluded from technology-based intervention research primarily based on their lack of access to computers and/or mobile phone devices.

3.2 Device Type (Marcin et al. 2016; Freeman et al. 2022; Arcury et al. 2020; Giansanti and Veltro 2021; Graetz et al. 2018; Reddy et al. 2022; Graetz et al. 2016; Frutos et al. 2022; Patel et al. 2022; Lama et al. 2022; Scott Kruse et al. 2018; Greenberg et al. 2018; Schrauben et al. 2021; Broffman et al. 2023; Moon et al. 2022; DeGuzman et al. 2020; Sanders et al. 2013; Zhang 2022; Toscos et al. 2019; Singh et al. 2022)

People living in rural areas and areas with higher levels of poverty are disproportionately affected, and they are more likely to be reliant on the use of lower-performing devices, such as smartphones, as opposed to PCs or tablets, for internet usage. With access to digital health only via mobile phone, many patients accessed mobile-only virtual services less frequently than those who used computers since there are applications with only computer-based access or applications that are less able to operate natively on several platforms and/or lower-performing devices. A statistically significant correlation was found between having a personal computer and internet access and patient health record use. These factors contribute to the difficulties in performing and the probability of completing remote consultation visits. These articles provide evidence for the links between digital health utilization and computer characteristics and the quality of the device. For example, once people own a certain hardware (Like PC or tablet) they’re more likely to be more computer literate than mobile-only patients. However, this does not mean that device performance affects the utilization of digital health tools, as modern healthcare applications function on multiple platforms and devices in an effort to capture the widest used base possible.

3.3 Connectivity (Bayard et al. 2022; Freeman et al. 2022; Reddy et al. 2022; Graetz et al. 2016; Patel et al. 2022; Lama et al. 2022; Scott Kruse et al. 2018; Greenberg et al. 2018; DeGuzman et al. 2020; Toscos et al. 2019; Mackert et al. 2016)

Many countries cannot embrace the latest healthcare innovations due to geographical restrictions or a lack of consistent internet connectivity. Unequal access to high-speed or broadband internet service and digital health itself magnifies disparities and limits access to web-based patient portals across patient sub-populations, especially in already disadvantaged groups that are typically hard to reach. Furthermore, a limited number of digital health infrastructure providers highlights gaps in digital health availability. Residents with a lesser ability to obtain and afford access to a fixed broadband signal exhibited limited skills in utilizing technology.

3.4 Accessibility (Saeed and Masters 2021; Haenssgen 2018; Piers et al. 2023)

Digital health expansion could improve the quality of life; however, the digital divide could exacerbate disparities, especially among people with disabilities. Communication disabilities represent an obstacle to accessing technologies; in particular, deafness needs to be acknowledged. Nonetheless, disabilities that cause difficulties in accessing these tools need to be taken into account. One current major barrier to digital health access for people with disabilities is the design of digital health technologies, whether those are provided through websites or applications, which has accessibility issues that prevent people with disabilities from being able to utilize these technologies. It has also been shown that disparities in the digital divide largely influence patients with mental health/psychological disorders.

4 Digital Literacy (Paccoud et al. 2021; Jiang and Liu 2020; Bayard et al. 2022; Freeman et al. 2022; Nagler et al. 2013; Kemp et al. 2021; Frutos et al. 2022; Scott Kruse et al. 2018; Toscos et al. 2019; Sayed and Mamun-ur-Rashid 2021; Masucci et al. 2006; Kim and Kim 2010; Choxi et al. 2022; Gordon and Hornbrook 2018; Kumar et al. 2019)

One of the common barriers to adopting digital healthcare is a lack of technological experience or familiarity. It has been shown that the quality of digital health services depends both on patients’ and providers’ familiarity with the medium of communication. One of the identified issues is that medical personnel are not adequately trained or experienced in fully utilizing the technological capabilities available to them. On the other hand, people with limited technology skills may be reluctant to use or unable to access technology to acquire health information on their phones. And even feel left behind with digital health, despite having access to a computer or smartphone. Having low skills in using a cell phone or computer represents a significantly lower use of digital health services. Additionally, it was shown that interest in and successful use of the digital health system were not correlated to any other factor (age, gender, education level, or ownership of a computer) but to skills in technology use. Low digital literacy was related to increased anxiety about using digital health.

4.1 Health Literacy (Kemp et al. 2021; Arcury et al. 2020; Graetz et al. 2018; Reddy et al. 2022; Schrauben et al. 2021; Moon et al. 2022; Singh et al. 2022; Mackert et al. 2016; Piers et al. 2023; Sayed and Mamun-ur-Rashid 2021; Gordon and Hornbrook 2018)

Knowledge of digital health (even in general terms) positively and significantly influences the use and acceptance of digital health services. It was shown that the use of digital health tools has been consistently lower in patients with low health literacy. Moreover, they were less likely to be perceived as easy or useful. The ability and confidence to use digital health technologies to obtain health information and advice decline with age and are less prevalent among ethnic minorities. Furthermore, a study identified that only less than a third of internet and smartphone users have proficiency in the use of digital health technologies, and an even smaller fraction have adequate digital health literacy. It has been shown that health literacy can be improved by digital health technology itself, which will enhance patients’ participation in digital health care.

4.2 Cultural Barriers (Yao et al. 2022; Haenssgen 2018; Kemp et al. 2021; Reddy et al. 2022; Sayed and Mamun-ur-Rashid 2021)

Even within regions with full access to technologies, uneven access to technologies was found due to cultural barriers. Discriminating societal norms and restrictive cultural beliefs, in addition to poor health literacy, weave together a web of cultural barriers, in which the hardest-hit groups are females. In some regions where women have low socioeconomic status (SES), they are discouraged from going on the web and do not have access to cell phones. In addition, female sex is correlated with a decreased probability of completing a digital health visit or compliance with remote counseling/monitoring. A great number of sociocultural factors related to institutional, economic, cultural, and educational barriers negatively impact women’s physical well-being and their access to appropriate health-care services in developing countries. Furthermore, language barriers (including translation inaccuracies) can play an important role in digital health’s utility.

5 Discussion

Several of the identified articles, beyond the description of barriers and different challenges relating to digital health and the digital divide, provided accompanying potential solutions (Bayard et al. 2022; Reddy et al. 2022; Zhang 2022; Liang 2012; Bashshur et al. 2020). These can be summarized in the 9 points shown below:

  1. 1.

    It is necessary to minimize the cost of scaling up the technology by developing modalities that are feasible, affordable, and acceptable to the people and the community.

  2. 2.

    A digital health site in a rural public library would enable greater access to digital healthcare services by removing obstacles caused by insufficient residential broadband access. The library serves as a proxy example for state-sponsored public service, where existing access opportunities can be identified.

  3. 3.

    If markets with competitive internet service providers fail to bring bandwidth and equipment to geographically isolated areas, then the respective governments should consider implementing policies to cover the gap.

  4. 4.

    To provide equitable access to care, legislation supporting reimbursement of digital health services is crucial.

  5. 5.

    To address disparities and increase accessibility of digital health, it is necessary to have a program that provides underserved communities with information technology education and training to improve its use, alongside improved digital infrastructure, and strategic resource allocation. Importantly, even though targeting underserved communities, this support should be available to all who want to make use of it.

  6. 6.

    Having a mobile-accessible patient health record can help engage patients in managing their health through convenient and timely access.

  7. 7.

    mHealth interventions should employ phone features that are accessible and familiar to the target audience to avoid denying intervention benefits to those with low mobile phone literacy and therefore widening health disparities.

  8. 8.

    A framework within healthcare organizations that should include standardized protocols for effective deployment of digital health to triage patients at the point of need and the efficient use of relevant technological innovations.

  9. 9.

    Primary healthcare facilities are the entry point to healthcare for the largest part of LMIC populations. Thus, they should be enabled to provide wider access to digital health information to disseminate the best resources that would maximize adoption and long-term use.

This summary of recommendations from the identified manuscripts reflects well the priorities set by the G20 health meeting in 2020, resulting in the ‘Recommendations from the Riyadh Global Digital Health Summit’ of ‘Riyadh declaration’ (Al Knawy et al. 2020). Even though the declaration focused on infectious diseases, as opposed to a wider healthcare view (also due to the G20 meeting taking place during the height of the COVID-19 pandemic), there are marked similarities. For example, the fourth recommendation mentions exactly “Ensure that countries prioritize digital health, particularly improving digital health infrastructure and reaching digital maturity”. A further, more detailed breakdown of these recommendations has gone a step further, placing strong emphasis on community participation and action in digital health to build resilience in healthcare systems as a whole and establish the foundation for effective prevention, preparedness, and response to healthcare pressures (Al Knawy et al. 2022), complemented by appropriately trained leadership (Al Knawy and Kozlakidis 2021; Al Knawy 2021). Additionally, emphasis was placed on techquity, i.e., the strategic development and deployment of technology in health care and health to achieve health equity, and system transformation (Al Knawy et al. 2022). It is anticipated that further granularity will be achieved in years to come, linking policy recommendations to actions and measurable outputs, aimed to address the digital divide, technological development and availability.

6 Conclusion

Digitization in healthcare has been an ongoing trend for several decades, strengthened by the acute needs presented by current health topics such as the COVID-19 pandemic, non-communicable diseases, and the mental health crisis. While in many cases technological development has been a conduit for reducing healthcare inequalities, in others it has had the opposite effect. One of the reasons for the suboptimal impact of technology has been the digital divide, i.e., the lack of technological availability and development. This chapter has utilized the methodology of a scoping review to identify the key factors in recent scientific literature that relate to the root causes of the digital divide. Key aspects such as connectivity, digital literacy and accessibility have been firmly mentioned through most of the identified publications. Also, through the scoping review recommendations were identified. This chapter has highlighted the diverse factors affecting the digitization of healthcare in relation to the digital divide, as well as the potential actions that can mitigate this divide based on digital technology availability and development.