Digital Health Literacy: how we can achieve more scalable and inclusive adoption.

Digital technologies have the potential to improve our health. For example they can improve access to care, provide verified health and lifestyle information so that we can better self care and understand our condition which will improve treatment adherence. However not everyone can leverage these benefits through the barriers they face in using technology. Amongst many different barriers are the ones faced by those who don’t have the skills to use technology and can’t easily understand the health information it displays.

This is called Digital health literacy, sometimes referred to e-health literacy which blends two building-blocks that historically were treated separately. The first is general digital capability, the skills needed for basic device operation, digital navigation and online privacy awareness for example. The second is health literacy, the reading, numeracy and critical-thinking skills required to make sense of clinical terms, weigh up health risks, follow instructions and understand, appraise and act on health information delivered through websites, portals, apps, wearables, or text messages.

The scale of the gap is significant. Lloyds Bank’s 2024 Consumer Digital Index  reports that 16.8 million UK adults fall into the “low or very-low” digital capability group. In the USA, the last National Assessment of Adult Literacy found that only 12% of U.S. adults meet “proficient” health-literacy standards, and this was a survey completed before wearables and patient portals were widely used.

The populations that most affected by low digital health literacy are hardly surprising and include, older adults, people in the lowest income quintile, those with no formal qualifications, migrants with limited English, and many minority-ethnic communities. For these high-risk populations, digital technology serves to practically exclude and further the belief that technology is "not built for people like me”. This digital exclusion can result in missed health screening email reminders, remote consultations that are unattended, portal messages that are left unread and home-monitoring kits that remain unconnected.

The cost of poor health literacy can be measured both clinically and financially. U.S. studies have attributed as much as US $105–238 billion to avoidable annual expenditure directly attributed to limited health literacy, increasing spend on additional emergency visits, hospitalisations, and chronic-disease complications that flow from poor understanding of medication, follow-up, actions and self-management advice. Low health literacy has been linked with worse health outcomes, low treatment adherence, avoidable admissions and even reduced life expectancy.  In the UK, remote-monitoring pilots had lower enrolment and higher attrition in deprived postcodes. Health equity also suffers: when digital services become the “default front door,” those with the lowest digital health literacy are literally left outside.

One reason the gap persists is that the design of many health technologies, assumes a fairly high reading age and a standard degree of digital skills across its user base. In addition, the language used in many digital health tools are more complex than is recommended for written health information. Systematic reviews of popular health apps routinely find average readability at U.S. tenth-grade level or higher, well above the eighth-grade ceiling recommended for public information.  Many technologies don’t include standard accessibility functionality such as captions, alt-text, or screen-reader compatibility. Consent and onboarding screens are often lengthy, with legally dense privacy policies that silently nudge low-literacy users toward either disengagement or uninformed agreement.

So what does good look like?

What is clear is that if we are to widen adoption across society, technology needs to be designed with greater consideration and appreciation of the needs of individuals with lower digital skills and literacy abilities. 

These 5 steps will help.

1. Diagnose

Includive design of digital information required greater use of plain-language, which means text that can be understood with those with a reading age of 11 years or lower. There are tools available that can help to assess the reading age and comprehension of the language used during the design process, or alternatively as a means to audit existing technologies, for example during procurement.

However inclusive design requires more than just reading-level adjustments. Digital textual information can be combined with supportive visuals, the use of which has been shown to consistently improve comprehension and understanding. Best practice now requires multimodal presentation, which means plain-language text complemented by, for example, short explainer videos with captions, audio read-aloud, or illustrated quick-guides that can support and accommodate more diverse learning styles, and those with low literacy and low vision.

All digital assets must comply with WCAG 2.2 the industry standard criteria for accessibility and includes aspects such as contrast, font scalability, keyboard accessibility, and alternative text. Automated assessment tools can be deployed such as automated WCAG checkers that can catch contrast, alt-text, and navigation flaws. Digital content should be assessed and validated through tools such as SMOG, which assesses for reading age, or Flesch-Kincaid grade-level calculators used to assess for reading ease and the PEMAT (Patient Education Materials Assessment Tool) or the CDC Clear Communication Index which will provide feedback on understandability and actionability.

2. Co-design

The best way to assess whether your technology or digital information can be used across a patient population, is to ask them. Patients, drawn from all relevant population groups should be engaged through a deliberate, standards-led co-design process.  in which a diverse group with limited digital skills, and their carers can provide feedback on both technology design and the understandability of the digital information. Facilitated design workshops routinely uncover avoidable barriers such as technical jargon that is embedded in push notifications, onboarding flows that assume credit-card ownership, or error messages that lack plain-language and understandable recovery steps. Their feedback can ensure that better accessibility and plain-language principles can be embedded before launch.

3. Screen

In order to understand who within your patient population may require additional help in using technology, there’s a need to screen patients to understand skills gaps. Digital skills screening tools can be slipped into everyday clinical workflows.  The Newest Vital Sign, for example, asks a person to read an ice-cream nutrition label and answer six numeracy questions; it takes about three minutes yet reliably pinpoints limited health-literacy.  The eight-item eHEALS questionnaire does something similar for digital confidence, asking how comfortable someone feels finding, evaluating and applying health information online.  These tools can be administered in outpatient clinics or community-outreach events, and give clinicial team an instant sense of who might need extra help to get going or be assisted with set-up.  Crucially, early identification of skills gaps will prevent the “silent drop-outs” that so often sabotage digital health adoption months down the line.

4. Support

Technology that meets every accessibility standard can still fail if patients lack a suitable device, affordable data, or the confidence to use it. Structural enablers are therefore as critical as interface design.  One proven approach is the deployment of trained digital-health navigatorstrained “digital health navigators”, library staff, community health workers, or social-prescribing link workers who act as “digital guides”, navigators who sit side-by- with patients to install apps, practise video consultations, and support troubleshooting to improve technology use and have been shown to improve the use of health technologies in those that might otherwise have been left behind. Digital navigator-led coaching has resulted in increasing digital technology registrations, improved health data collection and tracking and overall increased adherence to digital tools. 

Parallel partnerships with the voluntary sector can further remove affordability barriers.  For example, collaboration with the Good Things Foundation’s National Databank who supplies data-enabled smartphones and tablets, and delivers free, community-based digital-skills courses to households that might otherwise remain offline.  Together, navigators and third-sector schemes create the practical conditions under which accessible technology can achieve meaningful, equitable adoption.

5. Monitor

Post-launch, continuous equity monitoring is essential. Usage data, active log-ins, task completion rates, remote-monitoring adherence for example should be stratified by demographic information such as age band, deprivation quintile, preferred language, disability code and other relevant metrics.  Dashboards that flag statistically significant gaps  should trigger a pre-defined remediation steps such as, rapid user-retesting, content review and revision, expanding skills coaching. 

As healthcare digitisation accelerates, theres a need to reconsider design and deployment strategies to be better aligned around the needs of patients who are at a digital disadvantage.  Through careful consideration of their needs, organisations can ensure that digital tools are improve health and clinical outcomes across every segment of the population and avoid widening existing disparities.

Is Digital Health a subject that interests you?

✅  Join the Digital Health Equity LinkedIn Group here

#digitalhealthequity #healthinequalities #digitalhealth #tacklinginequalities #DigitalTransformation #ClinicianAdoption #DigitalClinician #HealthcareInnovation #digitalhealthliteracy