JMIR Publications

ABSTRACT

Background:

Digital health services can support the management of chronic diseases by facilitating self-management and providing access to health information and communication with health care providers. In hypertensive care, these services could complement long-term monitoring and prevention strategies. However, the use of these services remains uneven, particularly among older adults, individuals with lower socioeconomic resources, rural population, and those with limited digital health literacy. This could limit the potential of digital health services to improve care and perpetuate the digital divide.

Objective:

This study aimed to assess the use and interest in digital health services among statutorily insured patients with hypertension in northeastern Germany. It further examined how service use was related to sociodemographic and structural characteristics, digital health literacy, and clinical factors derived from claims data.

Methods:

This cross-sectional study, survey data were collected between 2023 and 2024 from AOK Nordost members in north-eastern Germany and linked with claims data from 2022 to 2023. Participants were adults with hypertension, who were recruited via stratified sampling by age (under 50 vs 50 years and older), sex, and residential area (rural vs urban). Interest in and use of digital health service was assessed across eleven categories of service, including self-management tools, communication-based telehealth, health information services, and administrative services. Digital health literacy was measured using the eHealth Literacy Scale (eHEALS). A comorbidity burden index was derived from claims data based on ICD-10. For each of the eleven services, multivariate logistic regression models were fitted and adjusted for nine covariates: age, gender, residential type, educational attainment, monthly net income, digital health literacy, Internet connection quality, partnership status, and comorbidity burden.

Results:

Of the 21,024 eligible individuals who were contacted, 1,751 (8.3%) responded to the survey and were included in the analysis. The mean age was 63.3 years (SD 22.1). Reading health information online (63.8%), general health apps (56.6%), and the insurance portal “Meine AOK” (50.3%) were the most widely used services among younger participants, compared to older participants, for whom the respective percentages were 23.1%, 11.7%, and 15.0% (all P<.001). Interest substantially exceeded current utilization for most services in both age groups. Attitudes toward digital health services varied significantly by age: 81.7% (602/737) of younger participants considered them beneficial compared to 55.0% (440/800) of older participants (P<.001). Overall, adequate digital health literacy (eHEALS score ≥27) was the most robust predictor, with significant positive associations across nine of eleven services. Younger age, female gender, urban residence, higher income, higher levels of education, reliable internet connectivity, being in a partnership, and comorbidity burden showed selective associations depending on the service.

Conclusions:

Digital health literacy is the most consistent modifiable factor associated with digital health service use across all service categories. The gap between interest and actual use suggests that adoption is not limited by demand alone, but also by barriers related to digital literacy, access, and support. Digital health services for chronic disease management should therefore be accompanied by supportive onboarding, reliable digital access, and multiple access routes, such as hybrid approaches, particularly in older patients and in rural areas. Clinical Trial: Clinical trial registration: https://drks.de/search/de/trial/DRKS00029761, identifier DRKS00029761