Multi-level barriers to digital health literacy in the Deep South.
Authors: Bourne Garrett , Henderson Nicole , Hildreth Keyonsis , Azuero Andres , Chu Daniel I , Caston Nicole E. , Dent D'Ambra , Hardy Claudia M. , Herring Loretta , Ingram Stacey A. , McGowen Chelsea , Young Pierce Jennifer , Williams Courtney , Rocque Gabrielle Betty 
Published: October 2023

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Background: Technology is increasingly used to facilitate healthcare interactions. However, poor digital literacy has the potential to create disparities amongst vulnerable populations. While health literacy has been well described, little is known about potential barriers to digital health literacy from the varied perspectives of patients, providers, and community health workers. Methods: This qualitative study explored barriers to digital health literacy among a convenience sample of (1) patients and (2) providers at two academic institutions participating in a digitally delivered remote symptom monitoring program, and (3) community health workers serving patients with cancer across the state of Alabama. Semi-structured interviews, conducted between December 2021 and May 2023, occurred over the phone, digital videoconference, and in-person and lasted approximately 30 minutes. Interviews were recorded, transcribed, and inductively content coded for recurring themes and exemplary quotes by two independent coders using NVivo software. Results: Interviews (N=47) included 19 patients with cancer, 15 providers, and 13 community health workers. Interviewees discussed varied difficulties associated with uptake of the digitally delivered remote symptom monitoring program. Patients primarily focused on discrete logistical problems with technology, while providers commented on patient attitudes toward technology and the program more broadly. Community health advisors further identified technological barriers experienced by patients, such as unfamiliarity with current technology, lack of affordability or access to technology, limited technological training, difficulty reading small digital text, and privacy concerns. For example, one community health worker reported, “They don't know how to use FaceTime on their phones. And some of them only have phones that don't have the capability of using that sort of technology. Most of them don't use e-mail at all.” Community health workers also discussed patient-provider communication barriers, including excessive use of medical jargon, provider cultural illiteracy, provider withholding of information from patients, and language barriers. One community health worker noted, “there are sometimes when... patients cannot actually understand the medical terminology. I believe that if it could just be broken down for them, that the literacy would be improved.” Conclusions: Technological- and communication-based barriers impact the uptake of digitally delivered remote symptom monitoring in patients with cancer receiving treatment in Alabama. Guided efforts focused on solving the most frequent and significant barriers including both unfamiliarity with and lack of access to technology could aid in increasing digital health literacy, thus decreasing potential inequities.