Improving the equity of digital health technology by using the Health Equity Impact Assessment Digital Health supplement (HEIA-DH)

Research team: Amanda Gambin, Syed Mustafa Ali, Helen Chadwick

Chief investigators: Allison Crawford (University of Toronto and the Centre for Addiction and Mental Health); Sabine van der Veer (University of Manchester)

Funder: International Centre for Translational Digital Health 


Adapting the Health Equity Impact Assessment (HEIA) to include a Digital Health supplement

The rapid advance of digital health creates an imperative to focus attention on health equity. A team of researchers at the University of Toronto and the Centre for Addiction and Mental Health (CAMH) in Toronto, Canada, proposed the Digital Health Equity Framework (DHEF) to prompt service providers, organisations and tech developers to consider health equity when designing and implementing digital health technologies. The DHEF highlights social, cultural and environmental factors that shape how we interact with digital healthcare, creating “digital determinants of health,” including: access to digital health resources; use of digital resources for health seeking/avoidance; digital health literacy; beliefs and values about digital health; and integration of digital health resources into community and health infrastructure.

To enable systematic application of the DHEF to understand equity in digital health, the team leveraged the Health Equity Impact Assessment (HEIA) developed by the Ministry of Health and Long-Term Care in Ontario, Canada (Ontario MOHLTC, 2012); it aims to identify unintended potential impacts (positive or negative) of a policy, programme, or initiative on marginalised groups, and to generate recommendations to reduce inequities (Ontario MOHLTC, 2012). The HEIA is the Canadian equivalent to the NHS Long Term Plan – Equality and Health Inequalities Impact Assessment, which is promoted by NHS England for similar purposes. Through consultation with clinical programs across CAMH, the team developed the HEIA- Digital Health Supplement (HEIA-DH) heia-digital-health-supplement2022 pdf

Digital Health Equity Info-sheet : HEIA-DH infosheet-QR-10-11-2023

The five phases in the HEIA-DH support anyone involved in digital health to:

1) consider health equity relevant to their digital technology

 2) engage appropriate stakeholders to identify barriers and facilitators to engagement, collaboratively develop mitigation strategies for improvement or to bolster facilitators, and by encouraging discussion of how changes can be evaluated and meaningfully disseminated to the larger community.To access a copy of the HEIA-DH –  heia-digital-health-supplement2022 pdf

Interested in more information about the adaptation of the HEIA? Click here find out more about the adaption of HEIA.

Refining the HEIA-DH

The initial version of the HEIA-DH was developed and tested in the context of established virtual mental health services. Through collaboration with the University of Manchester, the Toronto team was able to extend the application of the HEIA-DH to other types of digital health technologies in different stages along the translational pathway: the early stage Manchester Digital Pain Manikin app  and the later stage REmote MOnitoring of Rheumatoid Arthritis (REMORA) system. 

For both the Manchester Digital Pain Manikin app and the REMORA system, the HEIA-DH guided focus groups conducted with app-users and developers, community members, researchers, and healthcare experts. The findings can be found here ; those for the pain manikin are currently being written up for publication. Respective development teams are now working on prioritising and co-designing mitigation strategies to manage the health equity impact of their technology.

Engaging patients and communities


  • Engage and partner with patients at all stages in development of the digital health technology, in particular people representing underserved, under-researched, or structurally marginalised groups.
  • Provide meaningful roles for the patient and community partners you engage
  • Look at models of co-design as part of your engagement strategies
  • Remunerate patient partners and community organisations for the contribution of their time
  • Re-engage after adaptations are made (e.g., by sharing the results, co-designing high priority mitigation strategies)
Readiness for engagement


  • Consider whether the patient population you would like to engage has the skills and comfort level to engage meaningfully
  • Make sure that engagements recognise the strengths of the groups/communities you consult, rather than solely focusing on needs and gaps
  • Consider the digital literacy, stigma and resources required to participate
  • Consider whether the format of engagement will be a facilitator or barrier (e.g., 1:1 versus focus groups; language of engagement; virtual versus in-person)
  • Can the person facilitating the engagement create a culturally safe space?
  • Pay attention to power when bringing together people from different stakeholder groups (e.g., people with lived experience and health care professionals)
Look at available data


  • Search for readily available information on health equity issues for (specific groups of) target users of your digital health technology
  • An environmental scan may include: literature reviews, feasibility data, prevalence surveys, census data, pilot data, individual interviews, practice-based experience data
  • Consider exploring literature on other but related digital (health) technologies.
Conducting a HEIA-DH session with stakeholder representatives


  • Facilitation is critical to the success of the HEIA-DH. The facilitator sets the tone of the focus group by clearly stating the objectives of the session, outlining rules for sharing and for creating a safe space for all members. The facilitator is also tasked with ensuring the group walks through the stages of the HEIA-DH as they pertain to the specific technology. As a result, we have developed a facilitator checklist to support future external use of the HEIA-DH.
  • Presenting concepts related to digital health equity, as well as concepts related to the technology, in an accessible way to ensure all members can participate meaningfully. For many participants in our sessions, it was the first time they had engaged in formal discussions of health equity. We are working to develop plain language descriptions of the DHEF and the HEIA-DH.
  • Use a visualisation tool to support discussions (e.g. note taking on flipcharts with post-its or on an interactive whiteboard) is highly recommended to support and sustain participant engagement across the stages of the HEIA-DH.

Conclusion and Next Steps

The project highlighted the importance of community engagement and diverse representation in digital health technology design. Our rich discussions demonstrated the valuable input community members and patient groups offer to the field. In addition to developing a HEIA-DH toolkit, Toronto and Manchester continue to collaborate to further understand how health equity considerations vary throughout the translational pathway of digital health technology, and on refining methods for identifying and addressing these considerations.

To advance digital health equity, we have disseminated the HEIA-DH for external use. Through our collaboration, the Toronto team have conducted facilitator training for the team at the University of Manchester. Future initiatives include the development of a training toolkit to support digital health technology developers and researchers to use the HEIA-DH for exploring digital health equity considerations in the context of their technology.

We are currently looking for more technologies to be assessed using this approach, not only for improving the technology but also for further refining the HEIA-DH methodology. Get in touch at express your interest and discuss opportunities for collaboration.