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It is well publicized that mobile and digital technologies hold great promise to improve health outcomes among patients with chronic illnesses such as diabetes. However, there is growing concern that digital health investments (both from federal research dollars and private venture investments) have not yet resulted in tangible health improvements. We see three major reasons for this limited real-world impact on health outcomes: (1) lack of solutions relevant for patients with multiple comorbidities or conditions, (2) lack of diverse patient populations involved in the design and early testing of products, and (3) inability to leverage existing clinical workflows to improve both patient enrollment and engagement in technology use. We discuss each of these in depth, followed by new research directions to increase effectiveness in this field.
Depression and diabetes are highly comorbid disorders that are of major public health concern, particularly among low-income populations [
Technology-based interventions like text messaging and smartphone applications have shown some efficacy in helping patients engage in the healthy behaviors but similarly remain siloed in their approaches. Thinking creatively about targeting common elements such as physical activity management to improve mood as well as blood sugar levels is one novel way to ensure that patients facing multiple chronic conditions do not need to download or enroll in multiple programs to be able to work on improving their health. For example, there is evidence that 1-way educational content delivered via texting can improve diabetes outcomes for vulnerable patient populations [
Underserved and vulnerable patient populations from low-income and racial/ethnic minority backgrounds face the disproportionate burden of chronic disease like diabetes in the United States, and yet few digital health products are designed with these patients’ needs and skills in mind. As of October 2015, smartphone ownership in the United States was at 68% with Latinos (64%) and African Americans (68%) very close to the overall ownership rate. Individuals with incomes under $30,000 (52%) and those whose highest level of education was less than high school (41%) or high school (56%) had lower rates of smartphone ownership rate [
We see a role for mobile technology to extend existing care processes to provide support for patients in between office visits to reduce the burden on providers and to make integrated treatment more personalized, efficient, and available [
In addition, clinical practitioners recognize the importance of increasing holistic support for patients with both depression and diabetes [
As the first steps in creating technology relevant for diverse patients with both diabetes and depression, we have ensured that our research team (1) reflects both behavioral health and physical health expertise and (2) is situated within outpatient clinics that serve predominantly low-income patients who bring a wide variety of life experiences to this work. We will use this environment to ensure that our user-centered design and technology usability testing represents a diversity of people so that the final products can be applied more broadly. Sampling directly from patient populations served in public health care systems and community health centers can ensure that the future uptake of the technology will not be hindered by fundamental challenges of digital literacy, health literacy, and/or language accessibility.
Moving forward, we will also continue to aim for clinic integration whenever possible. The roles of technology and in-person clinic relationships are likely cyclical and reinforcing. For example, the perceived connection with a provider may be a powerful component that increases enrollment into technology programs offered within a clinic setting. In turn, the technology might provide engagement/usage data that can then allow clinics to know to whom and when to reach out to solve barriers and improve sustained participation in the program. In other words, rather than offering one-on-one support to all participants, technology can help triage one-on-one intensification
Finally, our team will continue to investigate technologies that are widely accessible for low-income and diverse populations rather than designing for the newest devices or services. For example, the widespread use, low cost, and highly scalable nature of text and other messaging technologies (eg, WhatsApp, Facebook Messenger) makes them potential tools in reducing disparities. While the digital divide is wide for use of broadband Internet and for smartphone use, mobile technologies are pervasive across the socioeconomic spectrum, making messaging an ideal tool to increase the reach, adoption, and implementation of efficacious interventions for chronic illness. Furthermore, text messaging is a powerful common denominator technology that can be powerful when combined with back-end programming and machine learning that can take data that are received and act upon them in a personalized manner. When these data are analyzed and visualized by a clinician, they can also inform provider decision making. For example, clinicians could be alerted when individuals have had long periods of lower than average activity or mood to intervene and problem solve at indicated times. The bottom line is that technologies continue to change, but our research program will focus on key functions like messaging that will continue to be a core tool of digital health for many years to come.
In order for digital health technologies to achieve their promise, they must address health in a more holistic way that helps prevent and treat the various health conditions that people manage without having to engage in various interventions. In this essay, we have presented the example of diabetes and depression as 2 interventions that can be addressed simultaneously by a broader vision of supporting key health behaviors like physical activity and stress management. It is also important to create and test these technologies with populations most impacted by health problems, in particular, vulnerable and underserved populations. Last, in order to reach scale, digital health technologies should be integrated into clinical care so that data can be integrated and used to improve quality and efficiency. If these steps are taken, we believe that digital health can maximize its positive impact on improving population health.
Adrian Aguilera was supported by National Institutes of Health grant K23MH094442. Courtney Lyles was supported by Agency for Healthcare Research and Quality grant R00HS022408.
None declared.