Home > Equity within digital health technology within the WHO European Region: a scoping review.

WHO Regional Office for Europe. (2022) Equity within digital health technology within the WHO European Region: a scoping review. Copenhagen: WHO Regional Office for Europe. Licence: CC BY-NC-SA 3.0 IGO..

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Health-care providers are increasingly using digital health technology (DHT) to enable patients and the public to manage their health and engage with health-care systems; a process that rapidly accelerated as the COVID-19 pandemic shifted services online. The uptake and development of digital health systems has the potential for widespread benefits through more efficient and targeted health care. Yet a focus on digital approaches may inadvertently widen existing inequities in health if known inequalities in access, use and engagement with digital technology are not considered and addressed. Equitable patient-centred approaches are at the centre of the proposed action plan for digital health for the WHO European Region. This scoping review explores the extent of inequities in digital health across a comprehensive range of specific characteristics. It also identifies key areas that need to be considered when integrating digital health into health-care systems to ensure equity. 

While there are many different definitions of digital health, for the purpose of this report the WHO definition was used: “the field of knowledge and practice associated with the development and use of digital technologies to improve health”. This will include digital consumers using a range of connecting devices and will encompass other digital technologies such as artificial intelligence, big data and robotics. A scoping review identified 22 relevant quantitative and mixed-method reviews and metaanalyses published between 2016 and May 2022. Inequalities in access, use and engagement with digital technology were mapped against the PROGRESS PLUS framework: place of residence; race/ethnicity, culture/language; occupation; gender/sex; religion; education; socioeconomic status; and social capital; plus age, disability or complex needs (e.g. homelessness or substance misuse). Consistent evidence was found of the higher use of DHT:

  • in urban compared with rural areas;
  • in individuals of white ethnic origin and English speakers compared with those from ethnic minorities and those with language barriers;
  • in individuals with higher education;
  • in individuals with higher economic status; and
  • in younger individuals compared with older adults. 

Better access to DHT was found in individuals without any disability or complex health needs, and those of white ethnic origin and English speakers. This is one of the most comprehensive scoping reviews of equity in DHT, collating evidence across three dimensions of digital health (access, use and engagement) and 10 domains of equity as defined by the PROGRESS PLUS framework. By considering the role of equity within each of dimensions of digital health, the findings can help to inform future development and integration of digital technology into health-care system policy and practice within the WHO European Region. 

Some cross-cutting themes were identified by this scoping review and reflect key areas for future development. 

Interaction between equity domains. There was a tendency for reviews to consider singular domains of equity with few examining relationships between domains; for example, differences in use by urban and rural populations did not take account of differences in population demographics or health needs. A systematic approach using a common framework to monitor and report differences in the uptake and engagement with DHT for a population would enable more rapid learning in digital health innovation and inequalities.

Classification of DHT. There was considerable heterogeneity in how types of DHT were described, including assistive technologies, web-based platforms and monitoring systems. In addition, there are a number of classification tools, including that developed by WHO and used in this review. Adoption of a common approach to DHT classification would help to collate actionable evidence on digital health innovation and inequalities.

Lack of information on access. Few reviews examined access as an underlying driver of inequalities in digital health, with those considering it tending to be limited to technology and connectivity issues by place of residence. Given that those in greatest health need (older people, marginal groups, people with an existing disability) are those less likely to have access to digital platforms for health, examining the intersectionality (interconnectedness of different social classifications as no social identity category exists in isolation) between access and equity is important to protect against widening inequalities in digital health systems. Consequently, mapping inequities in digital infrastructure will support efforts to address this potential barrier to accessing DHT.

Digital literacy as a key driver. A number of reviews focused on differences in use and engagement across equity domains and identified digital literacy as a key driver. There are many digital skills initiatives for patients and health professionals across countries, including community and patient hubs, local government measures and opportunities to learn what works. Equity in digital health is impacted by interactions across diverse social and demographic factors, yet this was only considered by two of the identified reviews. Research needs to incorporate analyses to help in understanding intersectionality of factors contributing to equity in digital health and for identifying effective approaches to address knowledge, skills and confidence in the use of DHT by those most in need.

Content and design of DHT in relation to user needs. Multilayered interventions need to be considered to meet the unique needs of different populations, particularly vulnerable populations including those with disabilities or language barriers. Good engagement with DHT will vary with the clinical condition (within mental and physical health conditions), the health service need being addressed (clinician contact, health information) and the characteristics of the population group (demographics, digital literacy, social factors or preferences). Inclusive and participatory design approaches, such as co-design and co-production, are required to ensure that DHT approaches have usability and meet needs across population groups. A structured framework is required for evaluation and reporting for DHT and equity across the full range of potential users.

National standards and guidelines. There are a range of national standards and guidelines that emphasize the need to consider equity when developing and implementing digital technologies into the policy and practice of health-care systems. For example, the National Institute for Health & Clinical Excellence in the United Kingdom has produced an evidence standards framework for DHT that covers design, value, performance, deployment and equity. The equity component has the requirement that, if DHT claims to address health or care inequality, it should show evidence of challenging identified health inequalities or improving access to care among hardto-reach populations. Collation and sharing of good examples of approaches that health and care systems are currently taking to address equity in the development and introduction of DHT will help the expansion of effective DHT for all.

Item Type
Publication Type
Irish-related, International, Report, Review
Drug Type
All substances
Intervention Type
Treatment method, Alternative medical treatment
December 2022
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Licence: CC BY-NC-SA 3.0 IGO.
74 p.
WHO Regional Office for Europe
Corporate Creators
WHO Regional Office for Europe
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