Title: Digital interventions for cardiometabolic disease in South Asians- a case study for opportunities, risks and inequalities in digital health
Funder: Department of Health and Social Care

Abstract: RESEARCH QUESTION Are there inequalities in digital health interventions(DHI) for diabetes mellitus(DM) and cardiovascular diseases(CVD),particularly in black and minority ethnic(BME) and low socioeconomic status(SES) groups? BACKGROUND DHIs can have wide-ranging benefits in CVD and DM.Associations between ethnic and socioeconomic status(SES), CVD and DM have been studied,but not together for DHIs. BME and low SES groups may be disadvantaged whether in health literacy,access to internet health resources,mhealth,patient web portals or personal health records. Despite large-scale roll-out of DHIs around the NHS, there is evidence of lack of BME inclusion in testing of these technologies. Investigation in a specific ethnic group,South Asians,of the potential for digital approaches for DM and CVD to improve or exacerbate ethnic inequalities,can inform future policy to avoid health inequalities. AIMS 1. To identify data on DHIs for CVD and DM in South Asians compared to other populations 2. To identify reasons at levels of individual, intervention, healthcare system and society for any observed differences for DHIs in CVD and DM in South Asians 3. To make recommendations for monitoring,analysis,evaluation and policy regarding DHIs to reduce health inequalities by ethnicity and SES. OBJECTIVES 1. To synthesise literature and policies for DHIs in prevention of CVD and DM, especially in BME groups 2. To investigate determinants of uptake, use and effectiveness of DHIs for CVD and DM in South Asians, compared with White British individuals at levels of individual and intervention. 3. To assess healthcare system- and society-level facilitators and barriers to DHIs in CVD and DM in South Asians 4. To develop policy recommendations regarding DHIs for CVD and DM in South Asians and other BME groups,and the most deprived 30% of the population METHODS We will focus on four areas:(i)review of literature and policies; (ii)individual- and intervention-level factors; (iii)healthcare system- and society-level factors; (iv)policy recommendations for DHIs in South Asians and other BME groups. First, we will conduct a scoping review to identify frameworks to study uptake of DHIs for CVD and DM prevention;a realist review to assess evidence for differential uptake of DHIs for CVD and DM by ethnicity;and a policy content analysis of DHIs in CVD and DM,particularly regarding BME groups. Second, we will complete a qualitative analysis(focus group discussions and semi-structured interviews) of barriers and facilitators of uptake, use and effectiveness of DHIs for CVD and DM in South Asians. Third, in a mixed-methods study, we will synthesise evidence from four sources (focus group discussions, key informant interviews, routine data, online survey), we will investigate society- and system-level factors affecting DHIs in South Asians. Fourth, we will develop a policy recommendation for DHIs in South Asians and BME to reduce likelihood of health inequalities on the basis of ethnicity and SES TIMELINES FOR DELIVERY This is a three-year project with four work packages matching the four objectives: 1(0-12months); 2(9-24 months); 3(9-30 months) and 4(12-36 months). ANTICIPATED IMPACT AND DISSEMINATION Our findings will improve existing and future digital health policies for CVD and DM.Our results will be disseminated via a study website,publications and NHS networks.

Lay abstract: The NHS needs to use digital technologies, such as apps and websites, to help deliver healthcare. This can help some people, but some people may be disadvantaged. It is possible that delivering healthcare digitally, i.e. using digital health interventions, could widen current health inequalities. One group that may be disadvantaged by digital health is South Asian people. Our three-year project focuses on digital health interventions for cardiovascular disease and diabetes. South Asians are particularly likely to develop cardiovascular disease and diabetes, so it is especially important that interventions aimed at treatment or prevention of these illnesses are suitable for these individuals, and lessons learned are likely to be relevant to other populations. We will see if people of South Asian backgrounds use digital health interventions for cardiovascular disease or diabetes differently to the majority population, and if they do, try to find out why that is the case, and what can be done to reduce differences. We will do this by reviewing published research and policy documents to find out whether existing data show different uptake, use and effectiveness of digital health interventions for cardiovascular disease or diabetes in South Asians; what previous work has been done on reasons for any differences; and what work has been done to try and overcome any differences. We will hold focus groups and undertake individual interviews to try and understand whether, how and why people from South Asian backgrounds use technology and how this might differ from the majority population. We will also hold focus groups and undertake surveys to understand factors in healthcare and society that contribute to differences in uptake, use and effect. We will explore how much of any difference is due to ethnicity, and how much is due to other factors which can be changed,such as education, deprivation, health literacy or digital literacy, cultural factors or health beliefs. We will structure our findings to show what changes are needed by individuals, by health care systems, and by society as a whole to enable digital health interventions to work for everybody. Our findings will improve existing and future digital health policies for CVD and DM for South Asians and the broader population. We will use this information to make suggestions on policy on development, evaluation and implementation of digital health interventions. Patients and public have identified digital health, especially in black and minority ethnic people (including South Asians), as important for research and a concern for health inequalities. Patients and public are part of our study team and involved throughout the project, particularly in focus groups. Results will be disseminated via a study website, and our research and NHS networks. By consultation with stakeholders, we will ensure results are publicised.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: METABOLIC AND ENDOCRINE;CARDIOVASCULAR