Digital interventions have become increasingly popular due to their potential to increase access to healthcare for people with chronic conditions and reduce the burden on a stretched healthcare system.
This has been amplified during the COVID-19 crisis, where much face-to-face support has been reduced or is no longer available. However, there are concerns that digital health provision may exacerbate existing health inequalities.
Chronic or long-term conditions, such as diabetes, are estimated to account for 87% of deaths and have a significant impact on an individual’s quality of life. Even in high-income countries, people with lower socioeconomic status experience chronic illness more commonly and with greater severity than average for the rest of the population.
We also know that people with existing health conditions, in low paid or insecure work and who are socially isolated may find it more challenging to engage in healthy behaviours and access the services they need.
Both self-care and digital interventions have been proposed as methods for increasing healthcare provision while relieving pressure on healthcare services. The underlying assumption with self-care interventions is that they provide healthcare where there was none, by encouraging people to be their own health resource.
Digital interventions have the potential to increase access to good quality healthcare by providing support to an almost unlimited number of people from the same digital platform at the same time, and the interventions can be tailored to individual needs.
More recently, combinations of the two approaches, in the form of web-based self-care interventions have become more prevalent for a range of health conditions, particularly for chronic conditions. However, evidence of the impact of digital self-care interventions on health inequalities has so far been mixed.
Digital interventions designed specifically for those from underserved and disadvantaged groups have been found to benefit these populations. There is also evidence that access and usability for disadvantaged groups remain barriers. People from lower socio-economic groups and older adults are less likely to seek out health information online and have problems using the online information available.
Our recently published systematic review (JMIR) aimed to establish and investigate differences in the effectiveness of web-based behavioural change interventions for the self-care of high burden chronic health conditions (asthma, COPD, diabetes and osteoarthritis) across socioeconomic and cultural groups.
We found evidence that web-based self-care interventions for chronic conditions can advantage some (minority ethnic groups, divorced parents) and disadvantage other (low education, unemployed) social groups who have historically experienced health inequity.
The findings for gender and health literacy were mixed across diabetes studies, and the findings for age were mixed across the asthma, COPD and diabetes studies. There was no evidence that income, numeracy or the number of people living in the household modified intervention effectiveness.
Our review agrees with evidence from previous single studies that found that web-based self-care interventions can benefit under-served and disadvantaged groups, when the intervention has been designed specifically for them.
Some of the included studies that found evidence that underserved groups benefited more from the intervention had modified their interventions to be more accessible, usable or engaging for those from these groups.
Digital self-care interventions, therefore, have the potential both to exacerbate and address health inequalities related to accessing health care support, including during COVID-19. They can reduce health disparities, where the needs of the underserved groups have been considered in development and implementation.
However, it remains prudent to be cautious about over-reliance on digital support as these interventions can also increase health inequalities for some social groups. These inequalities may be further magnified when digital services are the only support available, rather than supplementary to usual primary care, as in the current pandemic crisis.
This research was funded by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR) (project reference 2019-5007) at the University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health.