Beyond the Digital Divide: The Path to Culturally Responsive Digital Health Interventions
By
Carl Dimitri
Innovative behavioral interventions—that prevent the spread of HIV, or improve mental health outcomes—only work for those who are able to access them, and only if they reach their intended communities.
In the United States, more than 20% of households faced COVID-19 lockdowns without regular access to a broadband internet connection. Our unequal access to smartphones, tablets, computers and the internet, became increasingly apparent and increasingly important during the pandemic, when many aspects of health care moved online. A recent commentary by Brown researchers examines the “digital divide,” and its impact on population health.
The commentary, “Challenges in implementing cultural adaptations of digital health interventions,” was led by Vasileios Nittas, postdoctoral research fellow in Brown’s Center for Alcohol and Addiction Studies, and Tyler Wray, associate professor of behavioral and social sciences at Brown’s School of Public Health. Nittas, Wray and their co-authors, including Sarah Chavez, postdoctoral fellow at Brown, outline how, beyond economic and physical barriers, cultural factors play a crucial role in limiting access to digital health resources. They advocate for the adaptation of digital health interventions (DHIs) to be more culturally responsive by aligning them with distinct norms, beliefs and values. This ensures that interventions are tailored to meet the specific needs of communities and will expand engagement with underserved populations.
The cultural adaptation of DHIs is an emerging area of research. Although we see more and more adapted DHIs, there are still many uncertainties and challenges.
Vasileios Nittas
postdoctoral research fellow, Center for Alcohol and Addiction Studies
“The cultural adaptation of DHIs is an emerging area of research,” said Nittas. “Although we see more and more adapted DHIs, there are still many uncertainties and challenges.”
While cultural adaptations of DHIs promise to reach and engage medically underserved populations, there is a lack of evidence of their effectiveness. One systematic review of 55 studies of DHIs for mental disorders shows mixed results. In some cases, culturally adapted interventions showed no significant improvement over non-adapted counterparts, leading to questions about whether the effort to adapt DHIs is worthwhile.
Nittas and Wray are cautious, however, about drawing definitive conclusions from the existing body of evidence. “The number of currently available studies is small,” they write, “and their chosen outcomes are heterogeneous. The majority of interventions lack theoretical guidance, suffer high participation drop-out rates and fail to describe how the intervention was adapted.”
Acknowledging the need for further research, the team calls for the development of frameworks to guide the cultural adaptation of DHIs. They stress the need to include digital literacy within cultural contexts to make these efforts more effective and accessible.
“The role of culture in how health technologies are used cannot be ignored,” Nittas said. “However, we still have a lot to learn on how to adapt DHIs efficiently to make sure that people are not left out systematically.”
A Wider World of Tech-Based Interventions
As the conversation around the digital divide and the need for culturally responsive digital health interventions gains traction, Brown researchers have been exploring the broader context of technology’s intersectionality with health care in a number of recent studies.
Professor Wray's work uses virtual reality to address anxiety disorders.
Tyler Wray, a clinical psychologist who is also the Edens Family Assistant Professor of Healthcare Communication & Technology at Brown, has led an extensive body of work exploring how technology can be used to improve health behaviors. Some of his recent studies examine the use of social media for public health outreach, digital tools for enhancing medication adherence and the application of virtual reality in treating anxiety disorders.
One notable study highlights the cost-effectiveness of targeted online ads on platforms like Google, Facebook and Instagram at engaging specific groups, such as individuals at high risk for HIV, for public health studies. Although platforms like Jack'd, Grindr and TrafficJunky were effective in reaching the target audience, they incurred higher costs. Successful ads featured eye-catching elements like suggestive imagery and familiar logos, and they emphasized the convenience of participating in studies from home. Ads that resonated most with Black and Hispanic men portrayed individuals of similar racial or ethnic backgrounds.
A key area of Wray’s work in the tech space involves using virtual reality to address anxiety disorders through a method known as virtual reality exposure therapy (VRET). Comparing VRET with the traditional in vivo exposure therapy—a method that gradually introduces patients to their fears in real-life settings—Wray’s team assessed 184 participants on their willingness, comfort, enthusiasm and belief in the effectiveness of these therapies. The study showed a strong preference for VRET, with 90.2% of participants open to trying it, compared to 82% for in vivo therapy. Participants favored VRET for its perceived safety, privacy and potential effectiveness, whereas concerns about in vivo therapy included the risk of exacerbating anxiety and embarrassment.
Despite VRET’s demonstrated efficacy, its adoption among therapists remains limited, largely due to logistical hurdles and concerns about overwhelming patients. Wray’s research advocates for VRET as a valuable alternative to in vivo therapy, calling for further studies to accelerate its integration into clinical practice and alleviate therapists’ concerns.
Wray emphasizes the importance of support from clinics, professional organizations, and insurers in promoting VRET’s broader use. Such efforts aim to make this innovative treatment more accessible, providing therapists with a powerful tool to manage anxiety disorders effectively.
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