To Those Shaping Digital Healthcare: Inclusion Starts with You

Tech without inclusion is not progress. It is just another barrier. So how can we make sure digital health works for everyone?

Access is not Inclusion

Digital inclusion in healthcare means ensuring that everyone, regardless of age, income, education, ability, or background, has the access, skills and confidence to use digital technologies (1, 2). It includes access to reliable internet, suitable devices, content and empowerment to use digital tool meaningfully through digital literacy and training (1-5).

The meaningful use of digital tools depends on their usability, their complexity, their ethical acceptability and benefits. These factors are described by the Theoretical Framework of Acceptability (TFA) (6). This framework emphasises the importance of the perceived relevance and user trust for technology adoption.

Why Inclusion Must Come First

Without digital inclusion, innovations risk becoming another layer of exclusion. As health systems shift to digital platforms, those already excluded due to poverty, age, disability, chronic diseases or mental health conditions are at risk of being left behind (4, 5). Even though these groups could benefit the most from digital health applications, they are least likely to use them. This is called digital health paradox (3). Additional empirical evidence supports this concern (7). This highlights the urgent need that we must develop digital healthcare with equity at its core.

Inclusion Takes Work

To prevent digital health from becoming a source of inequality, we need to take thoughtful action. The study by Walness et al. (2024) shows that digital inclusion can only be achieved through user-centred design, practical support, and cultural sensitivity. This includes offering training to patients and healthcare professionals, providing accessible formats, such as larger fonts, desktop versions for mobile applications, translated video tutorials, and clearly communicating the benefits of digital tools as a supplement to traditional care (1).

Involving patients in the design process increases relevance and trust. The development of digital tools needs to be embedded in real-world settings, such as practices, clinics, or nursing homes. Finally, clinicians play a key role and need to trust, actively promote, and understand digital tools to ensure uptake and reduce unintentional gatekeeping (1).

From Nice-to-Have to Non-Negotiable

For digital health to deliver on its promise, there are certain requirements (see figure):

• Designing with those who are most excluded in mind from the outset.
• Embedding digital literacy support throughout health systems.
• Co-creating solutions with diverse users.
• Equipping clinicians to champion inclusion, not act as gatekeepers.

Figure. Key dimensions of the Theoretical Framework of Acceptability

Key dimensions of the Theoretical Framework of Acceptability (6) are directly addressed by these measures, with perceived effort reduced, intervention coherence (understandability) increased, and ethical alignment enhanced.

In other words, digital health solutions must actively work to fit into users’ lives rather than expecting users to adapt to the technology. Inclusion is not a feature. It is the foundation. Without it, digital health becomes just another form of inequality.

Literature

1. Wanless B, Hassan N, McClellan C, Sothinathan C, Abelleyra Lastoria DA, Herweijer T et al. How Do We Better Serve Excluded Populations When Delivering Digital Health Technology? Inclusion Evaluation of a Digital Musculoskeletal Self-Management Solution. Musculoskeletal Care 2024; 22(3):e1925.

1. Sun Z, Sun W, Gao H, Fa R, Chen S, Qian D. Digital Inclusion, Cultural Capital, and Health Status of Urban and Rural Residents: An Empirical Study Based on 2017 CGSS Database. Int J Environ Res Public Health 2023; 20(5).

1. Paccoud I, Leist AK, Schwaninger I, van Kessel R, Klucken J. Socio-ethical challenges and opportunities for advancing diversity, equity, and inclusion in digital medicine. Digit Health 2024; 10:20552076241277705.

1. Petrou C, Jameel L, Nahabedian N, Kane F. A call for digital inclusion initiatives in mental health services: An integrative review. J Psychiatr Ment Health Nurs 2023; 30(5):911–41.

1. Kluge HHP, Azzopardi-Muscat N, Novillo-Ortiz D. Digital health advances in the European Region, but uneven progress in digital literacy and inclusion leave disadvantaged populations behind. Int J Med Inform 2023; 178:105168.

1. Sekhon M, Cartwright M, Francis JJ. Acceptability of health care interventions: A theoretical framework and proposed research agenda. Br J Health Psychol 2018; 23(3):519–31. 7. Veinot TC, Mitchell H, Ancker JS. Good intentions are not enough: how informatics interventions can worsen inequality. J Am Med Inform Assoc 2018; 25(8):1080–8.

Further reading:A Ray of Hope: Innovations for Low- and Middle-Income Countries