“The people who need these things the most are the least likely to receive them.”
This is an Inside Science story.
Technologies like smartwatches, mobile apps and websites have been touted as an accessible and effective way for people to monitor and increase their physical activity and improve their health. But a new analysis has found that in reality it only applies to people with high socio-economic status. As with so many other areas of healthcare, the poorer seem to see little or no benefit from these digital interventions.
“While people may have the same access to these interventions, we still see this harmful reverse care law – the people who need these things the most are least likely to receive it effectively,” said Mark Kelson, who studies health statistics at the University of Exeter in the UK
Kelson and his colleagues analyzed data from 19 different studies conducted around the world between 1990 and 2020 that looked at digital interventions designed to help increase physical activity and improve health. They then compared how the interventions affected people with higher and lower socioeconomic status, and found what Kelson calls one of the clearest and most robust outcomes he has ever seen in his career. For those with high socioeconomic status, there was a moderately positive effect – those who received the interventions increased their physical activity by about 1,500 to 2,500 steps per day compared to those who did not receive interventions. But there was virtually no effect among those with lower socioeconomic status. The results were published this month in the International Journal of Behavioral Nutrition and Physical Activity.
This is the kind of result that “beats fear into the hearts of behavioral interventionists,” Kelson said, because health needs are much greater in economically disadvantaged groups – poorer people tend to be less active and have more health problems than richer ones. . So in this case, the people who need the most help are the ones who get the least benefit, while those who need the least get more of a boost. “Everyone is eager to increase physical activity to improve public health,” he said. “But even with the best of intentions, we may end up increasing health inequalities. We really need to be aware of the socio-economic divide.”
The study did not examine why people with lower socioeconomic status with the same access to an intervention as a pedometer and associated fitness app would benefit less. But Kelson wonders if there are likely to be a few overlapping causes of inequality. Poor people tend to have less free time for leisure activities, which is the category of physical activity associated with the most health benefits, so they have less capacity to take advantage of digital initiatives with a focus on exercise. And people with lower socioeconomic status also tend to be less familiar with the use of the digital technologies involved in these interventions, affecting how well they engage with them, the researchers wrote in the paper.
The first step in overcoming this digital divide is for researchers to recognize it and then explore it more systematically in their research, Kelson said. But they should also consider how they design their interventions and look for ways to make technology more accessible and useful to poorer people.
Lucy Yardley, a health psychologist at the University of Bristol, said a more person-based approach to designing digital health interventions can help reduce the differences in outcomes between socioeconomic classes. This means that public health experts have to work hard to understand what barriers their subjects encounter and constantly revise the intervention until those barriers are gone.
These tweaks can be as simple as changing the language used. For example, most digital fitness interventions are written for an average reading level for college graduates, which may make them harder for people with lower reading and writing levels to engage in. Or they may lack clear definitions of terms. In a project aimed at increasing physical activity among people with diabetes who had lower levels of health skills, Yardley found that many had misunderstood what counts as “moderate intensity” exercise and loaded much higher activity levels into the planner, and thus they got the wrong advice as a result.
Other tweaks may involve dealing with barriers of time, money or location, Yardley said. Instead of suggesting a long walk in a park that may not be accessible, researchers could offer simple exercises that people can do at home in front of the television, with a few cans of food. “You have to start with the person in their context, understand their needs and motivations and base the intervention around that,” Yardley said.
Kelson said addressing socio-economic barriers will also benefit researchers who design and study the interventions. When some subjects receive no benefit, the average of the results across all participants ends up reducing the effect you would see under ideal conditions.
“We have to come up with something that is accessible to a large group of people, but a different set than the ones that most of the activity interventions address,” Yardley said.
Inside Science is an editorially independent non-profit news service for print, electronic and video journalism owned and operated by the American Institute of Physics.
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