Introduction

The current backdrop in the United States includes a mix of supportive legislation and major historical events that amplify the ongoing effects of historical inequity. In 2020, the 21st Century Cures Act (“Cures Act”) was released by the Office of the National Coordinator for Health Information Technology (ONC). These rules call for improvements to how health data is collected and shared in the hopes of accelerating digital innovation [1]. The Cures Act creates conditions for more widespread adoption of digital health by historically underserved groups and establishes a mandate for those developing digital health tools to take specific steps toward more equitable design. Meanwhile, national crises such as the COVID-19 pandemic and the murder of George Floyd have sparked renewed energy toward addressing historical inequities in healthcare [2,3]. It is beyond time for those who create digital health tools to harness that energy into action.

We offer several strategies to promote health equity considerations throughout the digital health tool design process, as well as case study examples of how these processes support user experience and outcomes, with the goal of equipping those developing digital tools with methods to design more equitable outputs. These strategies may benefit what we term practitioners, or anyone developing a digital health tool, including academics, industry organizations, designers, behavioral scientists, and others. Due to the number of digital health technologies utilizing behavioral science approaches, and the authors of this paper including behavioral scientists in their number, behavioral science is well represented in the methodologies and case studies presented. Our focus is on how the design phase of product development can promote health equity, recognizing that it is only one of the target areas for equity consideration in the development and implementation of digital health tools [4].

Defining “Digital Health Tools”

We define digital health tools as any product that uses information and communication technologies such as computing platforms, software, connected devices, or sensors to help people or their providers support their health. Digital health tools, sometimes referred to as mobile health (mHealth), health information technology (HIT), wearable devices, or telehealth and telemedicine, may provide positive benefits related to access to and cost of care and quality of outcomes. Their intended users may include people in a consumer or patient context, providers such as nurses, doctors, or coaches, and nonprofessional caregivers. We focus on digital health tools which are patient- or caregiver-facing, rather than intended for provider or organizational use, with the belief that the greatest opportunity to improve health equity comes from directly supporting the people who experience inequity.

Digital health tools address a breadth of topics, including the diagnosis of diseases, delivery of treatment, support for behavioral changes, or improvement of healthcare delivery and health promotion. Digital health tools span from highly regulated solutions such as “digital therapeutics” to consumer products such as the Apple watch or Noom’s weight management services, to low-code apps developed for research projects or pilots [5,6]. The techniques in this paper can be applied to digital health tools across the full spectrum of regulation, technological sophistication, and application domains.

Defining “Health Equity in Digital Health”

Health equity can be considered both a process and an outcome. Health equity is achieved with the attainment of the optimal level of health for all members of society through valuing individual and social group differences, continuous efforts to address avoidable inequity and social injustices, and eradication of disparities in health and access to healthcare [7]. Sometimes health equity in digital health is mistakenly perceived as providing a unified or standardized digital health tool to all segments of the society. However, equal services do not necessarily lead to equity, given that underserved groups may have different needs to achieve equal outcomes. For practitioners, this has implications for every part of the digital health product life cycle. Achieving health equity requires digital health tools to be created with a systemic lens that considers all factors related to their users’ ability to seek health services, properly utilize health products, or achieve optimal health outcomes by using these tools. Health equity frameworks can provide that lens that ensures that factors causing inequity within the intended audience are addressed within the design process. These factors include sex and gender, age, ethnicity, race, national origin, language, ability, religion, sexual orientation, educational level, health status, location of residence, broadband internet availability, socioeconomic status (SES), and immigration status [8].

Digital health also offers unique challenges compared to analog approaches in that technology itself has equity implications. For example, digital health tools that use artificial intelligence (AI) may be subject to potential bias related to algorithm design [9]. There also may be decisions around what equipment or technology is necessary for people to use a digital health tool; the use of modalities such as virtual or augmented reality or even smart watches may inadvertently exclude members of disadvantaged groups from the benefits of digital health [10], as indicated by research showing a negative relationship between SES and access to digital health [11]. The “Digital Divide” refers to challenges impacting availability, affordability, accessibility, quality, security and privacy, and digital literacy that ultimately perpetuate health disparities and widen the healthcare inequity gap [12]. While digital modalities such as email and text message [13,14] are widely available across income and educational levels, access to the internet and devices may be limited or inconsistent due to effects of digital redlining [15], such that some digital health tools may exacerbate disparities [16]. And even when access exists, some people may have low levels of digital self-determination reflecting a lack of knowledge about how to effectively engage with technology [17] (i.e., digital literacy). Finally, delivering equitable digital health tools requires consideration not just of health literacy and numeracy, but also digital health literacy, which looks at the ability to evaluate and use health information delivered via technology [18,19] and may not cleanly overlap with other literacy constructs. Research suggests digital health literacy is quite variable, particularly among underserved populations [11,19].

That said, there is a reason why digital health has appealed to equity-focused practitioners. Internet access is increasingly ubiquitous, with 93% of adults in the US using the internet in 2021, up from 90% in 2019 [20]. This increase in use, corresponding to the onset of the COVID-19 pandemic, includes increased uptake of digital health interventions [21]. There is promise for digital health, if equity can be addressed.

Focus on designing for equity

The design phase determines whether a digital health intervention will be able to address or overcome disparities. Early decisions about a product’s components and functionality matter for how it can ultimately be used, as well as its relevance and acceptability [22]. Design is typically a cross-functional phase with inputs from people not formally trained to consider health equity such as UX and interaction designers, software engineers, or content writers. When trained practitioners working on interventions raise health equity considerations, other team members can be made aware of potential downstream impacts of their design decisions and coached to recognize opportunities for equity. Inappropriate designs can lead to problems that will be difficult to rectify in later stages of development, resulting in products that are neither effective nor widely adopted. Iterative design phases (such as new releases for digital products [23]) offer another opportunity to enhance the delivery of equitable support after a product’s initial release. Finally, for some organizations, an explicit focus on health equity could have implications for funding opportunities and product-market fit.

A recent scoping review of the equity impact of digital health design practices found key gaps around rigorous and consistent application of design methodologies, scaling digital health tools beyond pilots, and embedding equity-focused evaluation mechanisms [24]. While the implementation and operation of digital health interventions must also support equitable outcomes, their ability to do so is rooted in whether the design process considers the context in which it will be used and mechanisms for scale and evaluation. Similarly, while measurement of equitable outcomes is critical for ensuring a tool delivers them, no amount of measurement will make a poorly designed tool work. A focus on designing for health equity may therefore have outsized impact on results.

Frameworks for understanding determinants of health equity

Given the variety of factors that can negatively impact health equity, practitioners must systematically evaluate how to position their work to address the most relevant ones. To support the identification and overcoming of equity challenges, we highlight several frameworks (PROGRESS-Plus, eHLF, DHE, HEIF) that address different phases of the development and implementation of digital health interventions, as well as end-user characteristics related to equity. Practitioner teams can reference these frameworks early in their process and use them to identify specific factors to target in the interest of equity.

Methods and techniques for equitable design

Equitable design, rooted in equity-centered thinking, demands a conscious and intentional approach prioritizing inclusivity, collaboration, and attentiveness to the diverse needs of marginalized communities [24]. It requires a multifaceted strategy that addresses the intricacies of human–technology interactions, societal influences, and the needs of diverse influencers in context and goes beyond the scope of traditional human-centered design by addressing the social and ethical dimensions of technology in concert with co-design principles [39]. A broader examination of power dynamics is needed to ensure members of underserved groups can access and meaningfully use digital health tools.

While equitable design has a noble aspiration, several challenges make it difficult in practice [24]. A significant issue is gaining access to and recruiting members of the underserved groups in the formative design stages [16]. Access may be difficult due to factors such as geographical isolation, a lack of resources to participate in design activities, or community wariness of outsiders stemming from historical exploitation or neglect. Even if access is gained, recruiting members from these groups to actively participate in design activities can be challenging due to cultural, linguistic, or socioeconomic factors. For example, individuals may not have the time to participate due to work commitments or not see value in contributing. Another complication is that competing pressures from funders or organizational leaders may render it infeasible for practitioners to invest the substantial time and resources needed to develop a nuanced understanding of contextual factors that influence the target audience. Thus practitioners may not always fully understand the needs, capabilities, and preferences of underserved communities to create suitable digital health tools. These barriers, combined with industry pressure, cognitive biases, and a lack of awareness, may tempt practitioners to follow existing design paradigms that are not inclusive or equitable. Finally, there is the challenge that many existing design techniques do not explicitly call for a consideration of equity as part of their use, which makes it easy to follow a “correct” process without delivering equitable outcomes.

That said, practitioners can use many techniques from human-centered design that offer concrete methods to address health equity and can be integrated with the product design process. These design techniques are not equity focused unless practitioners deliberately insert a focus to understand and promote equity, so explicit intention on the part of design teams is a prerequisite. Several similar frameworks, such as IDEO’s “inspiration, ideation, implementation” [40] and Stanford d.school’s “empathize, define, ideate, prototype, test [41]” are prevalent in the design industry thanks to the evangelism of their originators. Despite differences in labels and stages, these frameworks share the core principle of centering the design process around individuals with firsthand experience to ensure that the final product or resource is well suited for its intended users. This focus on the end user creates the opportunity for practitioners to work with members of underserved groups in the service of equity. Below, we discuss approaches from human-centered design and how they can accommodate concrete methods for practitioners to create more equitable digital health tools.

IDEAS framework and toolkit

The Integrate, Design, Assess, and Share (IDEAS) framework and toolkit incorporate user-centered design elements for intervention design [48]. While IDEAS maps neatly onto the Double Diamond, it also explicitly incorporates behavior change theories and includes a toolkit with concrete processes to support the development of equitable digital health interventions [49–51]. IDEAS is composed of 10 phases (empathize, specify, ground, ideate, prototype, gather, build, pilot, evaluate, and share) that are grouped into 4 overarching stages (see Table 1). The IDEAS framework has been used across a number of health behavior design applications ranging from apps to increase physical activity in college students [52] and adult Latinas [53] to interventions to aid cancer survivors [54].

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Table 1. An overview of the stages and phases, along with component activities, of the IDEAS framework.

Adapted from Mummah and colleagues [48].

https://doi.org/10.1371/journal.pdig.0000591.t001

With the first 2 stages of the IDEAS framework, the aim is to gather information from users and important influencers about unmet needs and target behaviors of interest and later to elicit feedback on the use of the intervention technology. These are particularly important stages for applying the equity considerations identified using frameworks like PROGRESS-Plus, eHLF, DHE, and HEIF to make sure that diverse voices are included. While the IDEAS framework has been used to design for medically marginalized populations [48,55], it does not directly reference equitable design. Therefore, it is incumbent on the practitioners using the framework to ensure attention to equity is incorporated throughout all design phases.

Community collaboration techniques

Collaboration with community-embedded organizations adds layers of imperative complexity to the design process. This approach empowers community members as collaborators, adding perspectives that ground research in real-world context and lived experiences. The input of multiple individuals and influencer groups leads to product designs acceptable to horizontal (actual communities) and vertical (community leaders) user groups. Benefits include the improved likelihood that the final product will be considered acceptable, need minimal adaptation for use, and promote sustainable use and equitable health outcomes [56].

Collaboration with community-embedded organizations and providers can significantly mitigate the challenges of equitable design, particularly in gaining access to and recruiting members of underserved groups [57]. These entities often have established trust and rapport within the community which can help overcome wariness of outsiders. They can also provide valuable insights into the specific cultural, linguistic, and socioeconomic factors that might affect participation, thereby helping to tailor recruitment strategies more effectively. For example, in the development of a digital health intervention for low-income Mexican-American women who work on farms, leveraging the help of a community activist facilitated access and built trust within the community [58]. In contrast, lack of initial trust building with a community-based prenatal care organization led to low uptake and ultimate abandonment of the project in another study [59].

Collaborating with community-embedded organizations and providers can serve as a bridge to target communities. This facilitates a more inclusive and effective design process and direct access to the populations with the most need for health promotion and treatment. One final best practice that practitioners can enact when working with community-based partners is to always share study results back to the community organization and providers and reinforce the value they provided to the project. This practice helps to facilitate viable long-term research relationships with community partners and build trust that data is being used to serve the community as well as research.

Multiple design techniques focus on collaboration with community organizations and influencers to design solutions for specific community needs [60]. Table 2 offers an overview of some of them.

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Table 2. An overview of several community collaboration design techniques that can be used to improve health equity.

https://doi.org/10.1371/journal.pdig.0000591.t002

Participatory Design/Co-design: In participatory design, members of the communities for whom a product or service is intended are brought directly into the design process as co-creators. Non-designers are enlisted alongside experts for input and hands-on product work, in recognition that end users embody a design competence that can be tapped to develop or improve that product [69]. One of the distinguishing characteristics of participatory design is the removal of typical power relationships where the practitioner has an advantage over the participant [70]. Recent frameworks examining the protection of vulnerable individuals engaging in participatory design emphasize that lived experience is in fact expertise and should be regarded as such [71]. Participatory design has roots in Lewin’s “action research,” which was undertaken in partnership with people experiencing the phenomena being studied [72]. At its most extreme, participatory design enlists future users as full partners in the design process; in reality, participatory design typically offers inputs to the design process that are then evaluated and interpreted by expert practitioners [73]. Design teams may also choose to use participatory design methods to inform discrete aspects of their process [74] or gather user requirements [75].

Participatory design facilitates the expression of latent needs [76] that people may not be aware of through introspection or able to articulate, but which nonetheless may heavily influence preferences and use of digital health tools. It builds on traditional research methods of self-report and behavioral observation to incorporate activities in which people create research artifacts. The toolkit of participatory design includes creating tangible items, storytelling about them, and acting or playing [77]. The toolkit can be applied across design activities such as field studies, workshops, collaborative prototyping, or evaluation [78]. Ideally, participatory design activities are facilitated by experts with an eye to participants’ level of ability and ensuring a safe space for active engagement [79].

Participatory design can help mitigate issues of recruitment of underserved groups by creating a collaborative environment where users feel safe and empowered to share their thoughts and ideas. It also ensures that the final product is not only technically feasible (as determined by practitioners) but also culturally and contextually appropriate, thereby increasing the likelihood of adoption and sustained use. In fact, participatory design methods do seem to yield more appealing and well-rated products for their end users [80].

The Double Diamond model, IDEAS framework and toolkit, and methods of community collaboration are useful for practitioners to reference in the conceptualization and development of digital tools to ensure equity issues are carefully considered. In the next section, we offer several case studies where practitioners have used these and similar methods with equity considerations to design digital health tools.

Digital health equity case studies

In this section, case studies of digital health tools that have been developed using the design methods previously described illustrate the practical application of these methods in real-world scenarios. Each case study showcases a unique approach to design, reflecting the diverse contexts and populations these methods can serve. These examples provide insights into the versatility and impact of these design approaches in fostering innovation, inclusivity, and equity-centered thinking. Table 3 includes brief overviews of several case studies, followed by a deeper review of a selected few to explore how the design methods were used and how they specifically translated into product features, user experience considerations, and outcomes.

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Table 3. Examples of digital health tools that employ equity-centered design principles.

https://doi.org/10.1371/journal.pdig.0000591.t003

Case studies using the Double Diamond model and IDEAS framework

Recall that the Double Diamond model alternates between divergent and convergent phases of work across a broad set of underlying research and design activities. The IDEAS framework fits the broad constraints of the Double Diamond but includes the application of behavioral theories as a necessary design step. The following case studies demonstrate how the Double Diamond model and IDEAS framework can be applied to the design of digital tools to support health equity.

Case studies using community collaboration methods

The digital tools in this section were all developed using some form of community collaboration, ranging from targeted participatory design activities to long-term partnerships with community organizations to support development and implementation.

Discussion

In this paper, we call on digital health practitioners to bring an explicit focus on health equity to their work via deliberate infusion of equity considerations into design methodologies. We recommend they begin by evaluating which determinants of health equity are most relevant for their target population. This can be achieved by using frameworks such as PROGRESS-Plus, eHLF, DHF, and HEIF to understand end users, and the context and way in which a digital health tool will be used. These frameworks help practitioners identify specific dimensions to consider in their digital health tool, such as race, SES, access to technology, historical inequities, or community relationships. Each framework focuses on a different aspect of equity with some shared themes such as literacy considerations and accounting for the context in which people live. Therefore, designers may need to consult multiple frameworks to ensure they address the relevant equity domains. The frameworks described in this paper are not exhaustive; others, such as ConNECT [111], may further enrich designers’ viewpoints on how to address health inequity.

Once designers have focused on a population and problem space and understood the key equity dimensions at play for their work, they must choose methods to operationalize health equity. The design world offers a rich toolkit of options that can be infused with an equity focus by designers. These include versions of the Double Diamond model, the IDEAS framework and toolkit, and a variety of community collaboration techniques including participatory design. A characteristic shared by these and other methods is the need for the design team to ensure they are using the tools in support of health equity, as the tools themselves are topic neutral. Attention to the equity dimensions identified at the outset of the design project is a must, with intentional focus on how the needs of underserved groups can be understood and met.

This paper includes several examples of digital health tools that were designed with focus on equity within diverse populations such as older adults, LGBTQ youth, African Americans churchgoers, and adults with special needs. The solutions targeted diverse health needs including emotional well-being and mental health, coping with health conditions such as dementia, Parkinson’s disease, and cardiovascular disease, or the promotion of spiritual well-being. The digital health solution case studies used a variety of tools including the Double Diamond model, IDEAS framework, and community-based design methods, with an explicit focus on incorporating an equity focus to those methods.

Community partnerships can help make equity-focused research more successful. Community organizations can act as intermediaries in logistical arrangements, potentially solving issues related to geographical isolation or lack of resources. They can assist in organizing community meetings at convenient times and locations, making it easier for individuals with work commitments to participate. These organizations can also help articulate the immediate and long-term value of participating in the design process, thereby encouraging active community involvement. For practitioners working in academic settings, most research-active universities and academic medical centers support community advisory boards or community engagement principles. Such organized research supports can help directly link investigators to leadership in appropriate community-based organizations (e.g., faith-based institutions, community health centers) serving the populations of interest [112].

The selection of which specific design methods to use is often driven by practical considerations, as illustrated in the case studies of equity-focused digital health tools. The level of collaboration of the FAITH! app team with the AA church community, or Hopelab with LGBTQ+ youth, represent gold standards in soliciting input from and involving end users as co-designers. It was vital that the creators of the FAITH! app work with community church leaders both to ensure appropriate cultural tailoring and to facilitate community access to the app and gain the trust of end users. And as a social innovation lab, it is within Hopelab’s mission and purview to deeply embed with the young LGBTQ+ community in the creation of digital health tools that address their needs. The choice of methods may also be driven by considerations like product maturity; the researchers working on PINATA leveraged paper-based tools to understand user needs for a nascent technology, while Skylight solicited feedback on a working version of the app.

These case studies also illustrate how health equity considerations can be brought to bear at different stages of product maturity. To achieve equity-centered design, it is never too late or too small. Case studies demonstrate some designers starting with simple steps to equity-centered design while building their product, and some initiating their equity-centered design steps in later stages, integrated into subsequent iterations of their product. The Hopelab team, for example, incorporated end users as co-designers from the outset, while the Skylight team began soliciting direct input from end users after developing an initial prototype. The ability to shift toward a greater equity focus over the life of a product is promising for teams who have met challenges including such considerations in their initial work.

It is also possible to make small initial forays into equitable design. For first-timers, trying a few more accessible equity-centered design steps could provide better data about the cost, value, and potential challenges of these steps to win continued support and work more efficiently. The Double Diamond methods offer one such entry point by allowing for inclusion of secondary research, which can be a benefit for resource-constrained teams or those with limited access to community users. If practitioners haven’t incorporated equity in their solution, it’s not too late.

There are many benefits to equity-focused design including the establishment of partnerships, the development of trust and empathy with target audiences, and creating a space for conversation about inequity and its causes [113]. Collectively, interventions that are developed with community participation and input at each stage are more likely to engender trust that facilitates their uptake, effectiveness, and impact. While there are challenges associated with these design approaches, the benefits are compelling and suggest the effort is worthwhile.

Designing for implementation

While an in-depth discussion of implementation strategy was beyond the scope of this paper, it bears mentioning that consideration of implementation must be included in the design process. Digital health interventions cannot be successful without being designed to support implementation and future dissemination “out in the wild” [114]. The determinant frameworks mentioned above, particularly the HEIF, incorporate aspects of context to facilitate digital health designs that will fit the settings in which they will be used. As previously mentioned, the list of frameworks is not exhaustive and additional implementation science frameworks (e.g., Consolidated Framework for Implementation Research (CFIR) [115]; the Practical Robust Implementation and Sustainability Model (PRISM) [116]) can be leveraged to support the understanding of context. Beyond considering the end user and the immediate context in which the digital health tool will be used, it is important to also consider how organizational and societal contexts may influence equitable widespread adoption and sustainability of the product. For example, it is possible digital interventions targeting rural individuals may require design features that overcome the societal context of limited, unreliable internet availability in these regions. Using participatory methods to design for dissemination, scale, and sustainability (including ongoing support from community members), is necessary to ensure the tool equitably reaches and continues to be used by the target audience to reduce health disparities [117]. Designing for dissemination and sustainability should include partners beyond the end user, such as organizational leadership, payers, and policy makers, who may positively or negatively influence the widespread, long-term use of the tool.

Measurement of whether digital health tools successfully addressed disparities is critical to understand the implications of these equity-centered design processes. A systematic review found 5 main methods of assessing digital health equity, including (1, 2) descriptions of reporting and analysis in both systematic reviews and primary research; (3) assessing effects (and effect sizes) across sociodemographic factors; (4) applicability assessment of tools against under-served populations; and (5) influencer/expert assessment [118]. A scoping review of the impact of human centered design processes on health equity found most inquiries focused on immediate impact on research participants (e.g., satisfaction), rather than behavioral or health outcomes associated with any resulting tool [24]. Assessments of whether digital health tools achieve health equity are, at best, inconsistently performed at present time and represent a major area of opportunity. Furthermore, using frameworks such as RE-AIM to evaluate the implementation, reach and maintenance of the digital health tool is necessary to ensure the tool reaches your intended audience and continues to generate the intended impact [119]. These measurement strategies should be planned from the outset.

Limitations and opportunities

There are of course challenges to successfully executing an equity-focused design process. A major limitation is access to community members. From a practical perspective, it can be expensive and time-consuming to engage community members in co-design—not just for the sponsoring organization, but also potentially for the community members themselves. It may be necessary for designers to find ways to collaborate outside of typical working hours or in locations convenient to the community to minimize disruption to participants’ routines. It can also be challenging to establish a new relationship with a community organization or leaders, or to maintain existing ones over time [120]. Yet, these relationships can be critical to the success of the digital health tool.

There are also ethical considerations to enlisting community members in design work. While a thorough discussion of the potential pitfalls is beyond the scope of this paper, several instructive reviews exist to help guide ethical practitioner behavior [121,122]. This guidance is particularly crucial when the digital tool being developed addresses vulnerable characteristics (such as having a stigmatized health condition or engaging in stigmatized behavior) where individuals could experience harm because of their participation. Other ethical concerns include how to respond emotionally to difficult disclosures or situations, ownership of research insights and resulting products [123], and how to report on research when doing so might create risk for participants [124]. Practitioner teams must thoroughly consider the potential risks of community-based methods and take steps to minimize them. An ethically conducted community design project should not only minimize risk to the community, it should confer benefits aligned with the Belmont principles [125], such as the introduction of a needed tool or upskilling community members through their participation in the project.

Another limitation to the proposed approach to improving digital health tools’ ability to deliver equitable results is that evaluating success is difficult. As noted earlier, evaluations of whether a digital health tool achieves equitable outcomes are inconsistently done and reported. Many of the tools that have been developed with a deliberate focus on health equity are also relatively new, which limits the ability to report on whether equity has been achieved on lagging indicators such as disease prevention or sustained biometric improvements (which may explain the lack of such outcomes in a recent scoping review [24]). Initial outcomes associated with these digital health tools seem positive, although time is required to accumulate evidence for the effectiveness of these approaches in achieving health equity. We hope to see an increasing number of proof points with time as these digital health tools mature and new ones are introduced.

Moreover, while the diversity of approaches accommodated within these design tools is a strength in that it makes equitable design more accessible to practitioners, it can also be a limitation in that it is difficult to establish clear standards for what appropriate usage looks like. A challenge faced during our analysis of the cases was that authors rarely mentioned the specific tools they used for designing equitably, limiting the ability to compare approaches in the current literature. Again, this is an opportunity for the field to improve as more equity-focused processes are put into practice. Given some of the ethical concerns outlined above, it is also critical to evaluate whether the process of creating these tools was equitable, which would be facilitated by direct description of those processes. We optimistically believe that the need for better and more systematic evaluations of equity-related processes and outcomes represents a major opportunity in digital health.

In particular, there is an opportunity to evaluate the different health equity frameworks and design tools described in this paper against their impact on outcomes. As more of these digital health tools are put to use, there should be an accumulation of data that permits an assessment of outcomes and a comparison of which tools might be most fit for purpose. Research may elucidate which frameworks or tools are most relevant for specific communities, target behaviors, or types of digital health tools; these findings can then guide subsequent design teams in their choice of methods.

Ultimately, we hope to see the development of a standardized evaluation checklist that facilitates design teams to understand the impact of digital health tools. Such checklists have shown promise in evaluating health equity in other domains, including adverse events in gynecologic care [126], supporting policymaker evaluation of programs [127], and evaluating global health partnerships [128]. A checklist approach could encourage and facilitate the consultation of equity frameworks early in the design process to identify equity considerations, the selection of appropriate design methods to understand user needs and tool requirements, choices about implementation methods, and the design of an evaluation strategy to assess outcomes and iteration opportunities.

Conclusions

In the past few decades, practitioners have seen but not realized the promise of digital health tools to support diverse populations in understanding, managing, and improving their health. While technology offers a scalable way to personalize the delivery of services [129], it has been fraught with challenges ranging from the Digital Divide and lack of digital self-determination, to inadequate attention to structural or historic inequities, to commercial pressures that complicate investments in community research. However, the changing legislative and social environment in the United States has made it imperative to renew focus on ensuring that digital health tools deliver equitable experiences and outcomes to end users. We offer strategies for achieving that by considering equity dimensions via frameworks when initiating a digital health tool design project and selecting research and design methods that accommodate a nuanced consideration of end user needs. A series of case studies of existing digital health tools show how these methods have been successfully used, as well as where there are opportunities for improvement and standardization. Finally, we call on the members of our extended practitioner community to join us in highlighting health equity in their work. The time to focus on health equity in digital health is now, and we are the people to do it.