Digital Health Literacy Inequities During the COVID-19 Pandemic

The COVID-19 pandemic accelerated the digitization of healthcare services, as safety precautions prompted a transition of care delivery from in-person to virtual. The health risks posed by the COVID-19 virus incentivized providers to expedite the integration of technology with existing delivery services in order to support patients during the pandemic. The federal government, recognizing this shifting reality, further incentivized virtual healthcare by expanding telehealth coverage and allowable services.

The implementation of digital healthcare services has been a positive development, as it has expanded access to care by removing barriers that prevent people from seeking treatment. However, the digitization of healthcare has exposed another underlying health inequity: the gaps in digital health literacy that exist within American society[1]. When the majority of care delivery is carried out online, individuals’ ability to access the Internet and proficiency in navigating virtual health applications determines their access to adequate healthcare. If this disparity goes unaddressed, those without Internet access and/or digital health literacy suffer adverse health outcomes as a result.

Digital Health Literacy

Digital health literacy is defined as “the ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem.”^[2] Today, many healthcare services—including telehealth, electronic health records, and logistical functions of care—utilize the Internet. In order to take advantage of these offerings, patients must have a high level of digital health literacy. This means they must have access to the Internet and an Internet-enabled device, as well as the technological proficiency to navigate the websites and applications on which they are hosted.

Unfortunately, the level of technological access and knowledge among United States residents has not kept pace with the country’s widespread adoption of virtual healthcare services, with certain groups disproportionately impacted by digital health literacy disparities. For instance, age is a key factor in determining who is more comfortable utilizing digital care: younger populations are more likely to do so, even though older populations are more likely to need its advantages. Among the obstacles preventing older individuals from accessing virtual healthcare services are physical disabilities and unfamiliarity with the Internet^[3].

Additionally, there are many cultural and competency barriers that prevent populations from accessing digital care in an equitable manner—illustrated in striking statistics like the following:

At least 21 million people in the United States do not have access to broadband Internet^[4].
Only 22% of diabetes treatment apps are available in Spanish, even though Spanish speakers have a higher likelihood of having diabetes.
Over 33% of American households led by someone older than 65 do not have adequate computer access, and over half do not have adequate smartphone access. Additionally, these households are often disconnected from other people, meaning they are less likely to have support systems they can ask for assistance with navigating healthcare technology.
52 million Americans who have computer access do not know how to correctly use all the features of the computer[5].

These existing inequities in digital health literacy were compounded by the COVID-19 pandemic, further impacting vulnerable populations’ ability to access care and making it difficult for them to secure a spot in line for the COVID-19 vaccine.

Telehealth

Telehealth has been a critical resource during the COVID-19 pandemic. In March 2020, stay-at-home orders across the United States barred or deterred people from receiving in-person healthcare, making telemedicine the most viable alternative source of care. However, digital health inequities limit the ability of the most vulnerable populations to use telehealth for necessary care.

The most prominent discrepancies in telehealth utilization emerged across age, sex, and race. A study in the Population Health Management journal showed that younger people in urban areas have utilized telehealth the most during the pandemic. These results reflect a younger population that is more digitally adept and engaged with the latest technological advances in healthcare. Although older people have increased their use of digital technologies for healthcare provision during the pandemic, they are still not entirely comfortable with technology and telehealth and have under-utilized these services.

A study in the Journal of the American Medical Association showed that Black and Latinx people were disproportionately represented among those less likely to receive telehealth care during the pandemic, due to barriers such as language limitations or lack of Internet service. The same study showed that women were less likely to use telemedicine services (especially those involving videoconferencing) during the early months of the pandemic, possibly due to their elevated responsibility for childcare during these months.

These studies reveal that, although telehealth may be offered to everyone, digital literacy and access inequities mean not everyone is in the same position to use it.

Online Vaccine Registration Platforms

The U.S. COVID-19 vaccination rollout has faced similar challenges to telehealth administration, with virtual appointment registration platforms exposing digital health inequities that prevent vulnerable individuals from getting their shots in a timely manner.

The United States is on pace to open COVID-19 vaccine registration to the general public by May 1^st; however, this positive news has been diluted by nationwide frustration with the initial months of the vaccine registration process. Many people have complained about the difficulty of getting an online appointment through state-run websites, which—facing overwhelming demand—have been slow to load or simply not functional. To help manage the vaccination rollout process, the Centers for Disease Control and Prevention (CDC) launched a new $44 million Vaccine Administration Management System (VAMS). The system was supposed to create a centralized platform for vaccine appointment registration. In reality, VAMS only hindered registration efforts by cancelling appointments, locking support staff out of their dashboards, and generally being an unreliable source of information. As a result, states began to pursue their own solutions and avoided using VAMS, making the process more disjointed and confusing for those trying to sign up for appointments.

Amidst the widespread confusion and technological difficulties of the vaccine rollout, younger people are the U.S. residents most likely to have the time and capability to devote to virtual appointment registration. Additionally, younger and more technologically adept individuals have found innovative, online ways to find and distribute information about COVID-19 vaccines—for example, creating Facebook groups or Twitter accounts to share breaking, real-time updates about available vaccine doses that must be administered before they spoil.

The reliance on online resources for vaccine distribution rewards those who have the time and capability to scour the Internet and find this information, leaving vaccine-eligible, less digitally-literate older populations (who are likely to have trouble navigating these online infrastructures) at a distinct disadvantage^[6]. Though older populations are among the highest-priority vaccine eligibility groups in both CDC guidance and state-specific rollout strategies, they have struggled to take advantage of their eligibility to successfully get vaccinated and protect themselves from the risk of infection.

Improving Digital Health Literacy

By accelerating the nationwide adoption of healthcare technology, the COVID-19 pandemic has demonstrated the increasing urgency of addressing digital health inequities. Healthcare providers seeking to mitigate these disparities should focus on investing in resources to assist underserved populations. These may include offering training courses, increasing outreach to older populations to ensure they are aware of the methods of care available to them, and establishing digital applications and hotlines to assist people in accessing virtual care. Taking proactive measures to build digital literacy among patient populations is a vital step toward providing all communities equitable access to digital health innovations and services.

Kenneth Lam, a clinical fellow in geriatrics at the University of California San Francisco, believes that creating digital infrastructures that cater to those with the least experience or ability to utilize them is crucial to ensuring telemedicine services reach those in need[7]. Lam suggests that providers take the following steps to improve their online infrastructures:

Create actionable plans to overcome the high prevalence of inexperience with technology
Develop user interfaces that are designed with the older and disabled populations in mind, including those with hearing and visual impairments
Provide trainings on how to use digital platforms
Consider keeping offices open for patients for whom digital healthcare will not suffice or is inaccessible, even with training or assistance.

Lam’s final point underscores a crucial takeaway: the best way to ensure equitable access to health services is by offering them in multiple formats. In the case of the COVID-19 vaccine rollout, registration should not require the Internet; providers can make the signup process more accessible to populations lacking online access/digital literacy by also offering phone and/or in-person registration—as well as by implementing support systems to aid anyone who needs assistance navigating the process.

Digital health equity also requires equal investment from parties outside of the provider sphere. The federal government and states should devote funding to addressing the systemic issues underlying virtual healthcare access disparities—for example, increasing Internet access among their populations—in order to bring healthcare delivery into the modern era and ensure everyone is equipped to take advantage of digital care[8].

The COVID-19 pandemic has irreversibly changed the world of healthcare. Among the most significant of these changes is the now-widespread incorporation of technology into the healthcare delivery landscape. Analysis of the increased usage of technology in telehealth and the COVID-19 vaccine rollout process shows that older populations and minority groups are at a disadvantage when it comes to Internet access or competency, which adversely affects their access to health benefits. To ensure that all populations benefit from this shift to online resources both now and in the future, steps must be taken to reduce inequities in Internet access and digital health literacy.