Problem Statement 

In the United States, the lack of digital literacy among socioeconomically challenged and limited English proficiency (LEP) communities significantly impacts telehealth use and worsens healthcare outcomes, necessitating policy interventions to improve digital health literacy, skills, and equity. This is most acutely seen in inner cities.

Annotated Bibliography 

The following is a focused bibliography which, while far from exhaustive, provides ample and contemporaneous evidence for the link between digital literacy and competency and health indices.

1. Vargas Bustamante, A., Silver, J., Martínez, L. E., Anaya, Y., Ruiz Malagon, J. C., Benitez Santos, N., Félix Beltrán, L., Bañuelos Mota, A., Rich, J., & UCLA Latino Policy and Politics Institute. (2023). Equity gaps in telehealth use to manage chronic conditions during COVID-19. In UCLA Latino Policy and Politics Institute [Report]. https://latino.ucla.edu/wp-content/uploads/2023/01/equity_gaps_in_telehealth_01.24.2023.pdf 

This paper investigates the disparities in telehealth use among racial and ethnic minorities during the COVID-19 pandemic. The study analyzes data from over 155,000 patient visits in Los Angeles   and notes that while there was a sharp rise in the use of telehealth services, barriers were encountered by LEP and non-English speakers, low-income individuals, and those who lacked general digital literacy. The authors arrange the article in a number of numbered key findings. These findings note disparities were particularly pronounced among Latino and Black populations, which already faced higher rates of chronic conditions like diabetes and hypertension. The report points to the need for policy interventions that improve technology access, general digital literacy, and language support. This will allow LEP and non-English populations equitable access to healthcare delivery through telehealth, and the better outcomes associated with its use. 

2. Crawford, A., & Serhal, E. (2020). Digital health equity and COVID-19: The innovation curve cannot reinforce the social gradient of health. JMIR. Journal of Medical Internet Research/Journal of Medical Internet Research, 22(6), e19361. https://doi.org/10.2196/19361 

This study focuses on the challenges and disparities in equity created with the sudden innovation and deployment of digital health stemming from the Covid-19 pandemic. The authors suggest what they call the Digital Health Equity Framework (DHEF) to help integrate digital and other social determinants of health. Their aim is to prevent future digital health advances from widening existing health disparities, a part of the digital divide. Points noted include the need or equitable access to digital health tools, the importance of inclusiveness in design, and the need for healthcare providers to become active advocates for these priorities. They note that such providers are in a unique position to address digital literacy gaps. The authors conclude by suggesting developing metrics that measure digital literacy and creating policies that prioritize equity across all populations, especially vulnerable and marginalized groups.  

3. Whitehead, L., Talevski, J., Fatehi, F., & Beauchamp, A. (2023). Barriers to and facilitators of digital health among culturally and linguistically diverse populations: Qualitative Systematic review. JMIR. Journal of Medical Internet Research/Journal of Medical Internet Research, 25, e42719. https://doi.org/10.2196/42719  

In this systematic review, the authors identify both barriers and facilitators that impact the acceptance and use of digital tools, the authors refer to as digital health technologies (DHTs). Their study looks specifically at culturally and linguistically diverse (CaLD) communities. The authors evaluated themes across 34 studies and categorized them into seven analytical themes. Themes created were technology use, design impact on use, language, culture, health/medical aspects, trustworthiness/reliability, and interaction with others. The paper highlights the significant impact of culture and language in shaping digital tools for accessibility and effectiveness and how cultural sensitivity will be central in these efforts. The authors note the promise of such efforts at bridging the digital divide. They advocate for elevating digital literacy in CaLD communities, something that will lead to greater acceptance, usability of DHTs, and improved health outcomes in these marginalized communities.  

4. Del Pilar Arias López, M., Ong, B. A., Frigola, X. B., Fernández, A. L., Hicklent, R. S., Obeles, A. J. T., Rocimo, A. M., & Celi, L. A. (2023). Digital literacy as a new determinant of health: A scoping review. PLOS Digital Health, 2(10), e0000279. https://doi.org/10.1371/journal.pdig.0000279  

This scoping review addresses digital health as a social determinant of health, focusing on its role in accessing and using digital health information and resources. The study reviews definitions, assessment tools, and effective interventions related to digital health literacy. Of note is the degree to which the lack of digital literacy acts as a barrier, contributes to health disparities, and impacts vulnerable and marginalized populations. Their findings emphasize the effectiveness of educational efforts, training sessions, and social support as interventions. The authors call for improved metrics and tools for literacy assessment, and targeted interventions that will bridge the digital divide to improve health outcomes. This review highlights the need for policy that addresses digital health literacy through interventions and reducing inequities, particularly among communities facing barriers to the use of digital health tools.     

5. Tan-McGrory, A., Schwamm, L. H., Kirwan, C., Betancourt, J. R., & Barreto, E. A. (2022). Addressing virtual care disparities for patients with limited English proficiency. The American Journal of Managed Care, 28(1), 36–40. https://doi.org/10.37765/ajmc.2022.88814 

The authors of this article examine how virtual care, while beneficial during the Covid-19 pandemic, disenfranchised patients with Limited English Proficiency (LEP) and non-English speakers. The authors further examine the various barriers encountered, including navigating telehealth services while lacking language support, multilingual capabilities and a lack overall digital literacy. They recommend integrating equity into design and implementation of future virtual care platforms to ensure quality care for everyone. The authors note a need to increase access to digital technology, provide for digital literacy training, and ensure that telehealth platforms support a variety of languages. The article focuses on the need for active efforts at bridging the digital divide and improving  healthcare access and outcomes for LEP and non-English speaking patients. 

6. Campos-Castillo, C., & Anthony, D. (2020). Racial and ethnic differences in self-reported telehealth use during the COVID-19 pandemic: a secondary analysis of a US survey of internet users from late March. Journal of the American Medical Informatics Association, 28(1), 119–125. https://doi.org/10.1093/jamia/ocaa221 

   This study examines racial and ethnic disparities in telehealth usage, with a specific focus on non-English speaking, LEP, and ESL communities. The authors note a significantly lower use of telehealth services  within these communities due to limited digital literacy. The paper points out the extent to which these disparities contribute to worse health outcomes and increased disparity. To address these issues, the authors suggest specific policies aimed at improving digital education and ensuring access to telehealth. Emphasis is placed on the need for culturally and multilingual telehealth platforms supported by digital literacy training programs. 

7. Veinot TC, Mitchell H, Ancker JS. Good intentions are not enough: how informatics interventions can worsen inequality. J Am Med Inform Assoc. 2018 Aug 1;25(8):1080-1088. doi: 10.1093/jamia/ocy052. PMID: 29788380; PMCID: PMC7646885. Good intentions are not enough: how informatics interventions can worsen inequality - PubMed (brown.edu) 

This article points out the unintended consequences of digital health tools like telehealth platforms. The authors note that despite their potential to improve health outcomes, the same technology can exacerbate health inequity. More specifically, they note that these interventions often disproportionately benefit those who are already enjoy a socioeconomic advantage. Such advantaged populations have better access to technology and better digital literacy. The importance of designing and evaluating these digital tools with a focus on equity is noted. The paper refers to this as intervention-generated inequality (IGI). Recommendations are made for inclusiveness in design, research and development using input from diverse populations, and the need for safeguards to ensure equitable, measurable health benefits.  

8. Lyles, C., Schillinger, D., & Sarkar, U. (2015). Connecting the dots: health information technology expansion and health disparities. PLoS Medicine, 12(7), e1001852. https://doi.org/10.1371/journal.pmed.1001852 

This article explores the expansion of digital health tools and their impact on health disparities. The authors focus on digital health literacy among non-English and ESL communities and include a “clinical vignette” that illustrates how a patient, who speaks only Spanish is unable to access what her doctor recommended. Even after logging on, the information lacks meaningful information. The paper emphasizes that lacking digital health literacy, these populations experience greater health disparities. The authors recommend targeted policies to bridge the digital divide, including digital literacy education, support for underserved populations, and ensuring digital health are culturally appropriate and multilingual.