Artigo de revisão
DIGITAL HEALTH: BARRIERS THAT CAN COMPROMISE THE PRINCIPLE OF EQUITY
Como citar: Miziara CSMG, Liu B, Miziara ID. Saúde digital: barreiras que podem comprometer o princípio da equidade. Persp Med Legal Pericia Med. Vol. 10, 2025; 250413.
https://dx.doi.org/10.47005/250413
Recebido em 05/11/2024
Aceito em 27/12/2025
The authors report no conflict of interest.
DIGITAL HEALTH: BARRIERS THAT CAN COMPROMISE THE PRINCIPLE OF EQUITY
Resumo
INTRODUÇÃO: A saúde digital apresentou uma rápida expansão após a pandemia de COVID-19, introduzindo novas ferramentas tecnológicas que facilitam o acesso a informações e serviços de saúde pública. No entanto, essa expansão não abrangeu todas as camadas da população, acentuando desigualdades sociais e comprometendo um dos princípios fundamentais do SUS: a equidade. É necessário que estudos mostrem as barreiras e os facilitadores de acesso às plataformas de saúde digital. MÉTODOS: Trata-se de um estudo de revisão narrativa da literatura, realizado na base de dados PUBMED. Foram aplicados os descritores "[digital health[Title]) AND (equity[Title])", considerando artigos publicados nos últimos cinco anos e disponíveis na íntegra. RESULTADOS: Foram selecionados 51 artigos que identificam as principais barreiras e facilitadores ao acesso à saúde digital, levando em conta a diversidade populacional. DISCUSSÃO: Os desafios da saúde digital foram categorizados em quatro áreas principais: a) Individual; b) Interação; c) Comunidade; d) Sociedade. CONCLUSÃO: A saúde digital é uma ferramenta essencial para a saúde pública e para a prática médica, pois as plataformas digitais, tanto online quanto móveis, são valiosas para o acesso a informações e serviços de saúde. Entretanto, é crucial assegurar o acesso universal a essas tecnologias, garantindo igualdade de oportunidades, especialmente em um país com marcantes desigualdades sociais. Ampliar o acesso às ferramentas digitais pode reduzir a polarização e favorecer a inclusão, particularmente das populações marginalizadas. A despeito do número limitado de estudos, é imperativo aprofundar a discussão sobre os fatores que influenciam a iniquidade para viabilizar soluções que promovam a equidade na saúde digital
Palavras Chave: equidade; saúde digital e determinantes digitais da saúde.
Abstract
INTRODUCTION: Digital health has experienced rapid expansion following the COVID-19 pandemic, introducing new technological tools that facilitate access to public health information and services. This expansion has not reached all segments of the population, thereby accentuating social inequalities and compromising one of the fundamental principles of Brazil's Unified Health System (SUS): equity. It is necessary for studies to identify both the barriers and facilitators to accessing digital health platforms. METHODS: This is a narrative literature review study conducted on the PUBMED database. The descriptors "[digital health[Title]) AND (equity[Title])" were applied, considering articles published in the past five years and available in full text. RESULTS: A total of 51 articles were selected that identify the main barriers and facilitators to accessing digital health, taking into account population diversity. DISCUSSION: The challenges of digital health were categorized into four main areas:a) Individual ;b) Interpersonal Interaction ;c) Community ;d) Society. CONCLUSION: Digital health is an essential tool for public health and medical practice, as digital platforms, both online and mobile, are valuable for accessing health information and services. However, ensuring universal access to these technologies is crucial to guarantee equal opportunities, especially in a country with marked social inequalities. Expanding access to digital tools can reduce polarization and promote inclusion, particularly for marginalized populations. Despite the limited number of studies, it is imperative to deepen the discussion on the factors that influence inequity to enable solutions that foster equity in digital health
Keywords (MeSH): equity; digital health; and digital determinants of health
- INTRODUCTION
In recent decades, technological advancements have been substantial, driving transformations in global connectivity across various sectors, including healthcare [1, 2]. The World Health Organization (WHO) considers digital health to have significant potential to reach a larger number of individuals, facilitating access to available healthcare services. The National Science and Technology Council of the United States (USA) reported that digital health can reduce costs and save time for patients, while also expanding their access to healthcare services [3]. This technology can eliminate the need for transportation and optimize time by enabling remote consultations [4]. Such tools experienced exponential growth during the COVID-19 pandemic [5, 6, 9], especially in the areas of telemedicine and remote patient monitoring, which were rapidly implemented to mitigate the risks associated with in-person care [1-3, 10, 11]. These initiatives contributed to reducing the spread of COVID-19 [6, 10].
The term “digital health” refers to tools and technologies aimed at improving individual and collective health by enabling easier access to health information and care experiences, as well as reducing inefficiencies and costs within the healthcare system [2, 5]. These technologies include patient portals, telemedicine [2, 12], telehealth, wearable devices [13, 14], artificial intelligence (AI) algorithms [15], mobile applications, and other forms of remote monitoring [3, 6, 8, 12, 16], as well as electronic health records [9].
These technologies have the potential to enhance access, utilization, and the care experience for individuals [1, 14]. However, despite their benefits, access barriers remain, particularly for underprivileged populations, which can exacerbate existing inequalities [1]. These inequalities are driven by social and digital determinants of health [6, 7, 17, 18]. Economic, educational, and social inequalities directly affect people’s risks and opportunities, influencing their exposure to violence, discrimination, environmental challenges, as well as access to housing, food, water, and adequate healthcare services [3, 10]. All these factors impact access to digital health.
The advancement of healthcare technologies may threaten one of the fundamental principles of the Unified Health System (SUS), which is equity. This principle is intrinsically linked to equality and social justice, aiming to reduce inequalities by “treating unequals unequally.” Since its inception by the Federal Constitution of 1988, the SUS has guaranteed universal access to the public health system. According to Article 196, “health is a right of all and a duty of the State, guaranteed by social and economic policies that aim to reduce the risk of disease and other injuries, and ensure universal and equal access to actions and services for promotion, protection, and recovery” [19]. Health equity is a citizenship right, grounded in the assurance of a fair and equal opportunity to benefit from medical care [8, 20]. A lack of equity, therefore, represents a violation of rights and citizenship.
- METHOD
This study is a narrative literature review using the PubMed database and including governmental websites. Descriptors were applied according to MeSH ([digital health[Title]) AND (equity[Title]). The search period spanned from March 1, 2024, to May 31, 2024. Articles published in the last five years, in Portuguese or English, and available in full text were included. The initial selection was conducted by reading titles, followed by an analysis of abstracts, which needed to contain at least the two descriptors or address the topic more broadly. Articles that, while addressing equity and digital health, focused specifically on particular diseases were excluded
- RESULTS
Using the descriptors, an initial 51 articles were identified on PubMed; after applying inclusion and exclusion criteria, 27 articles were selected. From the analysis of these articles, barriers and facilitators for access to digital health technology were identified, considering population diversity. These factors were categorized into four main areas: a) Individual – related to digital literacy, which depends on the skills and abilities required for language comprehension, in addition to interest and willingness to use technology; b) Interpersonal – involving technological prejudice, still present in some communities; c) Community – referring to the infrastructure available for vulnerable populations; d) Social – related to public technology policies implemented at the federal, state, and municipal levels [6-8, 21].
- DISCUSSION
Equity in health is directly influenced by social and digital determinants [1-3, 7, 17]. New health-related technologies are well-accepted by most studies analyzed, yet social conditions and access to remote information raise concerns regarding equity [1-3, 5, 7, 14, 17, 18]. The beneficial impacts of digital health technology innovations are linked to the potential to improve health outcomes, increase information availability, enhance security, and improve the quality and experience of healthcare for patients [1]. However, these digital tools may have unintended consequences for socially marginalized and disadvantaged populations, contributing to, exacerbating, or creating health disparities [1-3, 5, 10, 12, 16, 17].
Levels of Influence on Digital Health Equity
Access to digital health is influenced by factors at four primary levels: individual, interpersonal, community, and social.
- Individual Level: Digital Literacy
Digital literacy is essential for experiencing health technologies, encompassing skills for digital usage and comprehension as well as interest and willingness to use these technologies [7, 11, 21]. It refers to the personal experience with digital health technology, including usage patterns and habits [1-3, 5, 7, 8, 17]. Developing digital competence is complex and covers four levels: functional (basic digital skills), informational (ability to search, locate, understand, and evaluate digital information), critical (ability to evaluate relevance, reliability, and risks of sharing and receiving health information through digital sources), and translational (ability to apply digital health information across different contexts) [2]. These factors vary by age and social context, and despite improvements in digital literacy among the elderly during the COVID-19 pandemic, further advances are needed [22].
Initiatives such as Age UK’s “Digital Champions” program aim to enhance these skills in the elderly, offering connectivity and technology loans [22]. This program aims to recruit and train 600 volunteers by 2026 to help elderly people improve their digital skills and provide connectivity and technology loans [22]. Other intervention projects aimed at simplifying the complexity of using these tools, as well as providing health information through formats, short videos, and text messages, can also improve literacy [2, 21].
- Interpersonal Level: Trust and Technological Prejudice
This level addresses technological prejudice, which is still present, and the importance of trust relationships in patient-doctor and patient-technology interactions [3]. It therefore involves relational factors connecting people to digital health technologies and to each other [7].
Trust must be ensured not only in patient-doctor relationships but also in patient-technology, doctor-technology, and community-doctor relationships, as all these connections contribute to better health outcomes [3]. Prejudice, especially racial and socioeconomic, can reduce access, even where services are available [3, 23]. Stigmas and distrust, reinforced by biased algorithms, can negatively impact marginalized groups, such as Black and LGBTQIA+ populations, perpetuating inequalities through AI algorithm biases [3, 7, 24]. Multidisciplinary strategies are essential to ensure the representation of all populations in algorithm models.
According to Obermeyer et al., the presence of racial bias was observed in an algorithm used in the US health system, particularly in cases where race was self-reported [3]. Another study identified the existence of structural racism within an artificial intelligence (AI) algorithm developed by people embedded in structurally racist contexts. Additionally, the data used to program these algorithms may not adequately represent underrepresented groups, compromising equity [15].
Treatment strategies based on biased data can result in variable effectiveness for excluded populations, leading to adverse outcomes. Therefore, improving the accuracy and performance of algorithms by ensuring the inclusion of disadvantaged populations in these models is essential. Addressing these gaps requires collaboration between multidisciplinary development teams with diverse backgrounds and experiences.
- Community Level: Infrastructure and Digital Access
Access to digital health technologies is unequal due to factors such as digital “redlining,” which excludes disadvantaged groups from accessing digital tools [4, 7, 14, 16]. Studies show that people with lower income and education levels face access barriers to smartphones and broadband internet, especially in rural areas [1, 2, 7, 8, 10, 16]. In addition, groups like homeless youth possess digital skills but are unable to access health tools in their environment [16]. Vulnerable populations, such as Black women and the LGBTQIA+ community, face barriers in health portals, resulting in distrust and aversion to using these technologies [3].
An American study evidenced factors influencing access to smartphones and the internet, concluding that populations with higher annual income and educational level had greater access to smartphones; purchasing power, age, and rural residence are also directly related to broadband access [10]. These results were confirmed by the rate of video teleconsultations during the COVID-19 pandemic [2].
Digital health access limitations should not be considered solely as a lack of electronic devices. An American study showed that although African Americans owned smartphones, they had limited access to mobile health interventions even after sociocultural adaptations for patients or community members from racially and ethnically diverse backgrounds [14]. Vulnerable populations show interest in digital health, but often, the systems are inaccessible to them; homeless youth, for instance, possess the basic skills, interests, and needs to participate in digital health interventions, but cannot access the tools and digital health technologies in their living environment [16].
Another barrier is the inaccessibility of patient portals for users relying on assistive technology, users with intellectual and communication-related disabilities [3]. Black women had lower enrollment rates in digital services during pregnancy, physical activity applications, and digital health for sexually transmitted diseases, compared to women of other races or ethnic groups [3, 15]. The same occurs in LGBTQIA+ patient care portals, where gender identifiers may not be represented in patient interfaces, potentially leading to stigmatizing treatment by providers, billing errors, inadequate communication in generated processes, and poorer health outcomes, triggering loss of trust, prejudice, and care avoidance [3].
Wearable devices fall under health-related technological advances and can be considered true trackers [13]. Studies report less reliability in heart rate monitoring for people with darker skin, as the devices’ optical sensors or green light are absorbed by melanin, becoming a barrier to precise heart rate monitoring [14]. A solution could be red light (infrared spectroscopy), but it is significantly more costly [14]. Thus, individuals with higher digital literacy and socioeconomic resources have a disproportionate advantage in accessing the benefits of wearables for detecting and predicting health states and diseases [13].
- Social Level: Public Policy and Digital Inclusion
Promoting equity in digital health depends on public policies that promote access to technology and infrastructure equitably at the federal, state, and municipal levels [7]. The lack of federal regulations and underinvestment in underserved areas worsen digital disparities [21]. A human-centered approach and active inclusion of underrepresented groups in developing these technologies are essential for ensuring effective and inclusive tools [1, 8, 22].
This level depends on investments in public technological policies at the three government levels—federal, state, and local—to support the adoption of health technology, development of innovation, and security [7, 20, 21, 23], as key determinants to achieve equity in digital health. Supporting health systems and hospitals to have equitable access to technology, infrastructure, and resources necessary to ensure successful interventions [10]. Therefore, guaranteeing equal access requires the intervention of behavioral science specialists [2] to apply human-centered methods [1, 2, 10, 16, 17, 25, 26]. This involves co-design, evaluation [6, 14, 16, 25, 26], and tool use with the general population, enabling rapid and interactive development of technological products and actively involving stakeholders at all development stages [1, 2, 14]. For this to be feasible, these technologies must present studies that do not underrepresent any population [1, 8, 22]. It is essential to identify and incorporate underserved populations in developing health interventions to ensure effective and equitable tools [1].
According to Jaworski et al., five strategies can reduce existing health disparities, focusing on equity and considering the importance of digital literacy, access limitations to technological tools, and actions that elevate the perspectives and needs of underserved populations, always based on ethical strategies in collecting and using digital health data [2].
For Miller et al., certain tactics can support digital technology development: a) “partner” structure—partnership with a diverse group of key stakeholders and potential users; b) “identify”—identify the potential impact of digital health intervention on health inequalities; c) “demonstrate”—demonstrate how to use the technology; d) “access”—improve technology access; e) “report”—report the impact of research on health equity [10].
Tech industries are also well-positioned to complement health equity strategies through access to healthcare tools, supporting healthcare infrastructure, and creating programs with approaches to social determinants of health [27]. A possible solution would be providing free or low-cost access to technologies and services without compromising health care, thus reducing digital health access disparities [28].
- CONCLUSIONS
Digital health is a tool with the potential to improve healthcare quality; however, it can highlight social inequality. Although few studies are available, discussing the main factors related to inequity is essential in the search for solutions to ensure equity in digital health. It is crucial to ensure that digital health innovations are evidence-based and do not increase or create health disparities, as failure to recognize these disparities may perpetuate and expand digital inequity.
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