Bridging the digital divide to promote prevention and control of non-communicable diseases for all in China and beyond

Leveraging digital health across the continuum of care for non-communicable diseases

Digital health solutions have emerged as transformative tools in healthcare, holding the promise to enhance the continuum of care for non-communicable diseases. Despite heterogeneity in design and effectiveness, a growing number of reviews show the benefits of digital health solutions in preventing and managing non-communicable diseases, across the care continuum (as depicted in figure 1), from health promotion and prevention,5 through diagnosis, treatment,3 and long term control,67 to rehabilitation.8 Interestingly, the focus of digital health solutions varied among the four major non-communicable diseases represented in the global agenda for their prevention and control. Modest evidence highlights the beneficial role of digital health solutions in lifestyle modifications and self-management support for hypertension, diabetes, and cardiovascular diseases67; however, the evidence leans more towards active treatment and survivorship support for cancer,9 as well as personal physiological monitoring for the chronic respiratory diseases.10

Fig 1

Potential benefit of digital health on the continuum of care for non-communicable diseases (NCDs)

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Moreover, digital health solutions are increasingly recognised as tools to tackle healthcare system challenges and improve universal health coverage. Telemedicine, for instance, plays a distinctive role in mitigating barriers to accessing healthcare services by extending care and health consultation to remote areas. Evolving evidence suggests that digital health solutions, enabled by electronic medical records, big data, and artificial intelligence, can enhance the efficiency of healthcare systems and bolster population level surveillance and management of non-communicable diseases.11

Emerging challenges of the digital divide caused by the irreversible trend of digitalisation

No doubt exists about the ongoing trend of digitalisation in healthcare in this information era. By 2021 global mobile cellular subscriptions per 100 people had increased to 107 from 76 in 2010, with a doubling from 64 per 100 people in 2010 to 122 in 2021 in China.12 Additionally, about 300 000 health and wellness mobile apps are available worldwide.13 The covid-19 pandemic acted as a catalyst, accelerating the global embracement of digital health solutions, and this transformation is expected to be irreversible post-pandemic. Nevertheless, increasing evidence indicates that the scale and speed of digitalisation has varied across settings and among different populations,1415 leaving the problem of a digital divide. For instance, a post-pandemic national survey in the US showed a sustained increase in internet usage and almost doubling of the likelihood of electronic communication with healthcare providers, with notably higher growth observed among more highly educated groups.16

The digital divide was originally conceptualised as disparities in accessibility of modern information and communication technologies across demographics and regions, and it has now been further delineated into three tiers of digital access, digital literacy, and digital assimilation.15 Digital access is obvious, manifesting as unequal access to the internet and mobile subscriptions across population groups. Notably, women, older people, and those with lower socioeconomic status experience relatively limited access to information and communication technologies, and such gaps are more pronounced in low and middle income countries.171819 The second and third tiers of the digital divide refer to varying levels of digital literacy and engagement, especially prominent among older people. Despite greater health needs and potential benefits, older people face complex and multifaceted barriers in engaging with digital health solutions, including declines in sensory and functional abilities, learning curves in adoption, lack of motivation to change, and inadequate supporting environments.202122 These three tiers of the digital divide highlight disparities in the accessibility, adoption, and utilisation of digital health solutions and are misaligned with the goals of equitable spread of innovations.

Will the digital divide exacerbate health disparities in prevention and control of non-communicable diseases?

The potential exists to narrow health disparities through digital health innovations, if digital health technologies are harnessed effectively to overcome major barriers in health equity and deployed widely to all disadvantaged populations. Telemedicine, for instance, plays a pivotal role in diminishing health disparities by overcoming geographical barriers and ensuring that people in underserved and remote areas receive timely and equitable medical care.

However, in reality, digital health innovations have evolved disproportionately at a rapid speed, incapable of resolving all challenges plaguing fractured healthcare systems or underlining inequities. Although difficult to measure systematically, wider gaps in the provision of digital health solutions have been observed,161819 translating into increasing health inequities across populations and settings. The first two columns of table 1 summarise the manifestation of the digital divide and its potential intermediate and long term effects on the prevention and control of non-communicable diseases from three perspectives: the individual level, the healthcare providers and institutional level, and the societal and global perspective.

At the individual level, the digital divide intertwines with demographic and social factors, such as gender, age, and poverty, recognised as the “causes of causes” of health inequity.23 In resonance with the principles of the “inverse care law,”24 people with fewer resources need more but receive fewer digital health solutions. Beyond grappling with the root causes of non-communicable diseases, they confront additional impediments, including limited awareness of innovations and lower capacity to utilise timely and convenient support facilitated by digital health solutions.15 Moreover, the under-representation of disadvantaged groups in the research and development of digital health solutions engenders inequities in the acquisition of health related big data, introducing bias that hampers overall effectiveness.14 This unequal access and imbalanced effectiveness amplify the pre-existing disparities in mobility, disability, and mortality caused by non-communicable diseases.

Among healthcare providers and institutions, the digital divide is evident in varying levels of adoption and integration of digital health solutions in clinical settings, potentially affecting the efficiency and quality of care delivery for non-communicable diseases. Reviews highlight the heterogeneous nature of trust, digital literacy, and adoption behaviours among healthcare providers, closely linked to clinical decision making performance and patient centred care delivery for non-communicable diseases.25 Notably, the velocity of digitalisation varies across institutions, reflected as divergence in the adoption and integration of major health information systems, such as electronic health records and decision support systems. Institutions with limited resources lag in this transformation, owing to financial constraints, inadequate infrastructure, limited leadership motivations, and low provider capacities.15182627 Such uneven institution level adoption of digital health solutions may affect the efficiency of supply chain and workflow management, which underpins service delivery for non-communicable diseases.

The digital divide may also exacerbate the existing global disparity in the burden of non-communicable diseases across countries. The global fight against non-communicable diseases is marked by considerable disparities, with about 80% of premature deaths related to non-communicable diseases occurring in low and middle income countries.28 Substantial barriers to infrastructure, financial investment, and policy environment hinder low and middle income countries from implementing non-communicable disease related digital public health practices, as well as digitalised surveillance and monitoring platforms.2223 In a vicious circle, the scarcity of evidence poses additional concerns for policy making, slowing down the integration of digital health solutions into the national non-communicable disease agenda.

Bridging the digital divide to promote prevention and control of non-communicable diseases for all: lessons from China

Given the inevitable impact of the digital divide on disparities in non-communicable diseases, identifying key strategies to diminish its negative effect on health inequities is crucial. Enhancing digital inclusion, a focal point to propel global digital health strategies,2930 is crucial for alleviating the disproportionate burden of non-communicable diseases among disadvantaged populations. Effective solutions to tackle each level of digital divide, summarised in table 1 (last column), are validated in studies, recommended by guidelines, or implemented in various settings.43031 China, as a key player leading the embracement and innovation of digitalisation, has significantly narrowed the extent of digital divide. Several impactful initiatives to enhance digital inclusion, detailed in box 1, have effectively improved digital inclusion in China. Notably, the gender parity score, calculated as the proportion of women who use the internet compared with men, has improved from 0.8 in 2014 to 0.95 in 2022. People aged 60 years and above accounted for 14.3% of netizens by the end of 2022, a substantial increase from 2.1% in mid-2014.12

China’s efforts in narrowing the digital divide serve as an example of overcoming barriers at various levels through multisectoral efforts. Nevertheless, different countries need to tailor digital health solutions strategies to their distinct context, considering the political and culture environment, healthcare system structure, and so on. Thus, no “one size fits all” solution exists for tackling the digital divide globally. Moreover, acknowledging that digital health is not a “panacea” for every challenge confronting healthcare systems in the prevention and control of non-communicable diseases is essential. Instead, we view digital health solutions as useful tools for overcoming these challenges to achieve a more cost effective and sustainable impact on health outcomes.

Ways forward to maximise the benefit of digital health solutions

To harness the power of digital health solutions for prevention and control of non-communicable diseases, actions are needed from all stakeholders, including both public and private sectors and multi-sectorial partnerships, to improve equitable reach, enhance effectiveness, and promote holistic integration. Firstly, we need to acknowledge the existence and significance of the digital divide in non-communicable diseases and health disparities, assess its current extent, and formulate tailored strategies.

Secondly, we should improve the effectiveness of digital health solutions. Involving healthcare providers, researchers, and potential consumers, especially those from socially deprived groups, in the development stage can enhance the credibility, equal adoption, and suitability of digital health solutions. This can increase the direct benefit for service users. Attention should also be given to the spillover effects on non-users, such as families or peers of users, who may benefit from digital health solutions through social contagions and shared behaviour change strategies. Such spillover effects have the potential to mitigate the negative impact of the digital divide.

Thirdly, seamless integration and better penetration of digital health solutions within the healthcare and community ecosystem can benefit individuals, communities, and societies as a whole in monitoring and control of non-communicable diseases. Strategies should combine a top down approach shaped by regional, national, and local policies, alongside a bottom up approach driven by consumer groups and private sectors. Further research on implementation is needed to translate these recommendations into practice, along with other concerns surrounding digital health solutions such as confidentiality, security, open sharing, cost, and regulatory factors, either in general or for non-communicable disease management in particular.