Leveling Up: On the Potential of Upstream Health Informatics Interventions to Enhance Health Equity

I t is by now well-established that both health and health disparities are profoundly social phenomena. However, the majority of consumer health informatics interventions to date have focused solely on individuals, with particular attention accorded to influencing individual-level psychosocial characteristics and health behaviors. For example, a 2018 systematic review of mobile health intervention (mHealth) research for racial/ethnic minorities and/or those of low-socioeconomic status found that most interventions targeted individuals and were most commonly informed by psychosocial theories.1 This is despite the fact that interventions which rely primarily on individual effort, behavior, and choice tend to be less effective for marginalized groups—groups that experience socially stratifying processes of marginalization or exclusion from mainstream social, economic, cultural, or political life2—than those that target the context in which behavior occurs.3,4 Perhaps related to this individual focus, the impact of consumer health informatics interventions on marginalized groups is often limited. For example, the aforementioned systematic review revealed few significant impacts of mHealth interventions on health outcomes for these groups.1 In addition, as we have argued elsewhere, health informatics interventions are at particular risk of reinforcing health disparities by disproportionately benefiting nonmarginalized groups that already possess health-related advantages.5 The result can be intervention-generated inequality, in part from differential effectiveness of prevailing intervention models for marginalized groups.5 We contend that health informatics, including its subfields of consumer, population, and clinical informatics, will be more effective for marginalized groups (and less likely to produce intervention-generated inequality) if we better apply our understandings of the societal origins of health and health disparities to intervention design. We argue for greater emphasis on “upstream” interventions that focus on the social, political, economic, and physical contexts in which health is (re-)produced.6–8 We define these interventions, also called “structural” and “environmental,” as meso-level and macro-level interventions. In addition to the potential effectiveness improvements mentioned previously, these interventions may have multiple efficiency-related advantages through targeting multiple pathways to multiple health outcomes,8 and through reaching large numbers of people due to their lack of dependence upon individual patient/consumer agency for uptake.8