Can digital navigators help reduce inequities in healthcare? A systematic review

Abstract

Background

Navigating the healthcare system is complex. Care fragmentation is a major issue. Patient navigators have emerged to improve care continuity, especially for vulnerable individuals. With digital health expansion, digital navigator (DN) roles have been created to foster digital literacy, access and equity.

Objectives

To identify DN's roles in reducing health inequities and examine its terminology, professional background, training, techniques, skills, communication methods and outcomes.

Methodology

Systematic review across five databases. Data extraction included DN characteristics and outcomes. Thematic analysis compared expectations and findings.

Results

Sixteen studies were reviewed. Findings suggest that the DN may help reducing inequities in healthcare access, though it is not guaranteed. Gaps were found in DN roles, competencies, training and terminology. Most studies emphasised technical support, communication and clinical integration, with limited focus on social issues. Disparities were noted between expected and reported roles.

Conclusion

The DN role shows promise, especially in fragmented systems, but remains underexplored. Current approaches emphasise technology over social support. Broader understanding and implementation are needed.

Keywords

Patient navigation digital health health inequities health services accessibility systematic review

Introduction

Navigating a health system to seek care can be complex and overwhelming. To support patients in their journey, patient navigation (PN) emerges in the 1990s in the USA and Canada, to improve cancer screening in vulnerable populations.¹ PN has been defined as an individual or team who perform specific activities to facilitate patients, families and caregivers access to healthcare and social services, promoting continuity of care by removing barriers and ensuring efficient use of the healthcare system.² PN aims to bridge gaps in healthcare and reduce access barriers for clinically, socially and/or medically complex patients, acknowledging the relationship between health and social care, and the negative impact of fragmentation.^1,2

Patients requiring navigation services often have complex needs and seek multiple specialists’ care, besides having repeated interactions with services, requiring referrals, adopting different modalities of care, and are often homebound, facing communication issues, or needing mental health or pain management support.^3,4

In high-income countries, PN has been associated with optimised cancer diagnosis, treatment adherence and positive outcomes, especially in vulnerable populations.⁵ Despite that, it remains palliative as causes of unsuccessful coordination and integration of care still need to be addressed.² Lack of clarity around the need for a PN, or its workflow, roles or responsibilities, results in diverse designs and targeted populations, reflecting diversity in current models of care.²

The COVID-19 pandemic highlighted social and health inequities, access issues, fragmentation and lack of coordinated care. While digital health is a promising solution, its implementation can reinforce, exacerbate or even create new inequities,⁶ disproportionately affecting underserved groups, such as those from low socioeconomic background, low digital literacy, culturally and ethnically marginalised. This reflects existing social inequities in digital health access, use and literacy.^7,8

Digital navigators (DN) emerge in 2019 as a strategy to enhance and facilitate use and access of digital health technologies and services for continuous care.⁹ Those include video consultations, remote patient monitoring, mobile health apps, wearables, electronic health records and medical artificial intelligence.¹⁰ As digital healthcare emerged, the concept of ‘end-users’ will be adopted in this paper instead of ‘patients’ to name informed and active participants in managing their own health through digital means.¹¹

DN has been described as individuals or groups that offer technical and/or psychosocial support in implementing digital technologies in healthcare.^12–15 They might be a clinician, medical assistant, nurse, case manager, peer specialist, admin staff or someone from the community with specific expertise in digital health.^12,14

Aiming to expand care reach, provide technical support and integration of clinical, administrative, technical workflows, DN has had positive outcomes.^9,14 For instance, a DN program in Boston reported increased enrolment rates in health web portals among Black and Hispanic populations.¹⁶ While DN does not address structural issues, it aims to evolve with technology and potentially reduce healthcare barriers.¹³

DN is a potential education strategy on the use of mobile health apps.⁸ Other related responsibilities of this emerging role include evaluation, installation and troubleshooting apps and data collection, allowing healthcare professionals to focus on clinical issues.¹⁵ Broad DN responsibilities include identifying user's eligibility for the technology, training on platform use, technical support and monitoring outcomes.¹⁷

Additionally, DN may increase equitable healthcare access by offering targeted and personalised services that boost engagement, digital literacy and care integration.^9,12–15 Addressing digital inequities is challenging, particularly considering complex overlaps of multiple layers of discrimination, shaped by social, power, demographic, spatiality and cultural intersectionality.¹⁸ It is necessary to examine how individual characteristics, including race, gender, income, age, education, place of residence and migrant status, are related to access and use of digital health modalities, considering such association exists in health services in general. These findings can guide the development of urgent digital equity policies in healthcare.⁸

Defining DN's role involves outlining its scope of practice, competencies and target problems to which it aims to address. Although DN is increasingly adopted worldwide, its competencies and responsibilities vary widely across healthcare settings and systems. This review aims to identify the role of DN in reducing healthcare inequities. Secondary objectives included summarising terminology used to describe DN, former occupation of the professional who became a digital navigator, required training, used techniques, skills, methods of communication and related outcomes.

Methods

A systematic review of literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist (Supplemental Material 1).¹⁹ The protocol for this review was registered at the Open Science Framework (https://osf.io/u3gzx/).

Search strategy

We adopted the PICo strategy²⁰ to frame our research question and define search strategies for the following databases: PubMed, Embase, CINAHL, Web of Science and EBSCO PsycInfo (Supplemental Material 2). Our targeted population (P) were adults, our phenomenon of interest (I) was DN and the context (Co) was digital health inequities. Searches were conducted in September 2024 with no restriction on publication period.

Eligibility criteria

Included articles were original studies in English, Portuguese and Spanish, exploring the role of DN to support the use of any modality of digital healthcare, including telehealth (telephone and video consultations), mobile health apps and web health portals.

Articles not referring to DN as individuals (e.g. AI system) were excluded. Studies describing DN services targeting healthcare professionals, exclusively theoretical or not mentioning health inequities were also excluded. Posters, abstracts, editorials, commentaries, literature reviews and opinion pieces were all excluded.

Screening and data extraction

References were screened using Covidence online platform. After removing duplicates, three reviewers (X, Y and Z) screened the references by title/abstract followed by full-text, each with two votes. Conflicts were solved during virtual meetings between reviewers. Manual inclusions were made based on the reference list of screened articles.

A data extraction spreadsheet was developed according to the research question, including study characteristics (author, year, country, study design, objectives, participants, sample size, health specialty, targeted condition, context of the problem and limitations) and DN characteristics (terminology, definition, roles, qualifications, training, description of the DN intervention, means of communication, goal-setting techniques, outcomes and challenges). In terms of the DN roles, techniques and skills applied; and expected outcomes to promote equity, a categorisation was developed summarising the main findings of five theoretical articles (Table 1).^12–15^,17

Table 1.

Digital navigator (DN) roles, applied techniques and equity-expected outcomes categories.

Category	DN roles	Techniques and skills	Equity-expected outcomes
1. Access, engagement and integration	Engage with end-users¹² Monitor adherence¹⁷ Ensure the implementation of a framework for digital inclusion¹⁷	Encouragement towards goals achievement^13,15 Measure engagement through automated messages¹² Interviewing and communication methods¹⁴ Engagement techniques^12,14	Improved workflow integration,¹³ engagement^14,15 and access to healthcare¹³ Deliver care to individuals in underserved areas¹³
2. Targeted/customised intervention	Recommend technologies based on users’ needs and characteristics¹⁴ Evaluate end-users’ eligibility and identification¹⁷	Create personalised toolkit with surveys, sensors, learning and interventions for each user¹³	Established technologies that meet the needs individuals and/or communities¹²
3. Enhanced communication, information and data use	Ability to communicate well and bridge communication gap between healthcare team and users ^13,15 Review and interpret quality data to enhance care¹⁵ Ensure data privacy¹⁵	Monitor app use¹⁵ Track and report appropriate end-user-level quality outcomes¹⁷ Observe data trends¹⁵ Provide continuous feedback¹³ Instil trust and transparency¹⁴ Keep records of regulatory compliance¹⁷	Increased data quality and enhanced care¹⁵ DN integrated to the health system and community¹²
4. Clinical and therapeutic support	Provide support for technology incorporation to treatment¹³	Identify clinical red flags (situations requiring prompt intervention),¹⁴ and trends and topics to be discussed during cosultations¹⁵ Basic therapeutic and clinical knowledge (e.g. terminology and data)¹⁴ Maintain compliance with relevant clinical policies and procedures¹⁷	Support shared decision making and therapeutic alliance¹⁴ Add value to clinical visits¹⁵ Improve clinical outcomes^12,13
5. Technology support and use	Teach basic technology skills¹³ Provide technology support^12,13,17 (troubleshooting, setting, onboarding, customising and monitoring tools)^13,17 Evaluate and recommend technologies,¹⁴ optimising accessible forms of digital technology to users¹⁴	Gain core smartphone skills¹⁴ Familiarise themselves with the app¹⁵ Guide end-users¹⁵ Troubleshoot^13–15^,17 Create solutions for demands¹⁴ Evidence-based app evaluation frameworks and tools^14,15	Support access and use of digital tools^12,15 Increase comfort with technology use¹³ Improve digital literacy^12,13 Improve integration of technology use in healthcare¹⁴ Ensure the utility of chosen digital technologies¹² Create solutions to challenges that might be delaying potential benefits of digital health tools¹⁵

Source: Elaborated by the authors.

Data analysis

After finishing data extraction, each column of the spreadsheet was checked for consistency. Quantifiable aspects of DN (terminology, role, outcomes, training, means of communication and professional background or job title) were summarised and reported using frequencies and percentages. Qualitative findings were thematic synthesised.²¹ A comparison between expected categories described in Table 1 and the findings from included studies was performed and a summary was cross-tabulated into five categories: (1) access, engagement and integration; (2) targeted/personalised intervention; (3) enhanced communication, information and data use; (4) clinical and therapeutic support; and, (5) technology support and use; under each of the three DN characteristics: (1) DNs roles; (2) techniques and skills; and, (3) equity-related outcomes. It is important to note that these categories encompass a wide range of activities attributed to DN in the reviewed literature, including functions that may extend beyond its core scope. These variety of activities were retained to comprehensively capture how digital navigation has been operationalised across current studies. Discrepancies in category allocation or description were discussed and adjusted during online meetings.

Quality assessment

Quality assessment of included studies was conducted using SQUIRE 2.0 (Standards for Quality Improvement Reporting Excellence), a guideline that provides a structured framework to improve transparency, completeness and accuracy of reporting for studies that describe interventions to improve the quality, safety and value of healthcare.²² We attributed one point to each of the 18 SQUIRE categories, and zero if they were absent. The assessment was completed by the lead author (X) and uncertainties were discussed virtually between the authors (X, Y and Z). The higher the final SQUIRE 2.0 score, the better the reporting quality of included studies (maximum of 18).

Results

The search retrieved a total of 3521 references and 1641 duplicates were removed. The screening process is illustrated in Figure 1. Sixteen studies were reviewed.

Figure 1.

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flowchart diagram of identification, screening and inclusion process.

Study quality

Assessment of the studies using SQUIRE 2.0²² has revealed a mean score of 16.94 out of 18. Ten studies (62.5%) scored 18, three (18.7%) 17 and the remaining three (18.7%) between 13 and 14. The most common reason for lower scores was unclear disclosure of ethical considerations (31.25%).

Study characteristics

Included studies have primarily focused on mental health (depression, anxiety, psychosis, behavioural change and general mental health),^23–30 HIV,^31–33 gerontology,^34,35 type 2 diabetes,^16,29 cardiovascular³⁶ and oncology care.³⁷ One study (6.2%) was conducted in Canada, whereas the remaining 15 (93.8%) were from the USA. Most studies (81.2%) were published after 2020. A summary of included studies is shown in Table 2.

Table 2.

Summary of included studies (n = 16).

Author, year, country	Study design	Specialty/condition	Targeted population/area	Description of intervention
Alon, 2024, USA²³	Qualitative study	Mental health	Mental health workforce: clinicians, community centre staff members and other employees in different organisations (veterans, community centres and psychiatric hospitals). Cities: Boston, Houston and New York	Digital navigation training
Arayasirikul, 2022, USA³¹	Prospective cohort study	HIV care	Young people living with HIV self-identifying as cisgender men who have sex with men or trans women in San Francisco	Six-month digital HIV care navigation intervention (eNav), with focus on dose-response outcomes
Bender, 2022, Canada³⁷	Pilot feasibility study	Oncology	Men with prostate cancer and their family or caregivers in urban cancer centres in Toronto and Vancouver	Peer navigation program for a web-based app
Bondar, 2022, USA²⁵	Prospective cohort study	Mental health	Employees who had depression and/or anxiety across 40 USA states	Mental healthcare platform for employees
Camacho, 2023, USA²⁶	Pilot feasibility study	Mental health	Individuals experiencing anxiety and other mental health issues recruited online	Comparison of DN guide and support in using a mental health app (mindLAMP)
Casper, 2009, USA³⁶	Case study	Cardiology	Home care nurses and people with chronic heart disease	Home care nursing supported by a technology core and home-based technology (HeartCarell)
Chen, 2024, USA²⁸	Case study	Mental health	Patients receiving care in a hybrid clinic (synchronous telehealth visits and asynchronous use of app between visits) offering cognitive behavioural therapy with digital support in Boston	Implementation of the DN within a short-term, cognitive-behavioural therapy-focused hybrid clinic (mindLAMP)
Chu, 2022, USA³⁴	Case study (quality improvement project)	Gerontology	Older adults who had a primary care physician in San Francisco and had a scheduled visit	Quality improvement intervention to telemedicine access (Video Visits for Elders Project – VVEP)
Green, 2023, USA²⁷	Development and usability study (quality improvement project)	Mental health	Patients and clinicians from a clinical-high-risk-for-psychosis clinic (CEDAR) and a first-episode-psychosis clinic (ASPIRE) in Boston	Quality improvement project to explore feasibility of digital mental health interventions supported by a DN (mindLAMP)
Hernandez-Ramos, 2021, USA²⁹	RCT	Mental health	English- and Spanish-speaking adults with diabetes and depression, lower socioeconomic backgrounds (income, education and occupation) and with limited digital literacy, receiving care at a public healthcare system (publicly insured) in San Francisco	mHealth to increase physical activity among end-users
Macrynikola, 2023, USA²⁴	Case study	Mental health	People living with mental health conditions referred from primary care in Boston	Implementation of a hybrid mental health model with DN support (Digital Clinic)
Mechanic, 2022, USA³⁵	Case study (quality improvement project)	Gerontology	Adults with video appointments at an academic hospital's primary care and gerontology clinics in Boston	Implementation of a novel DN to reduce barriers to successful video consultation use
Mohr, 2019, USA³⁰	RCT	Mental health	People with depression or anxiety recruited online, on print sources, research registries, commercial recruitment firms and media coverage	Coached versus self-guided treatment and weekly recommendations to try different apps vs no recommendations (IntelliCare)
Rodriguez, 2023, USA¹⁶	Pilot implementation study	Diabetes care	People with type II diabetes who spoke English or Spanish with a focus on stratification by race and ethnicity, attending primary care clinic in Boston	Implementation of a Digital Health Navigator Program for type 2 diabetes in a patient portal (Epic's MyChart)
Trujillo, 2020, USA³²	Pilot feasibility study	HIV care	Young people living with HIV self-identifying as gender men who have sex with men or trans women in San Francisco	Six-month digital HIV care navigation intervention (eNav)
Zulkiewicz, 2021, USA³³	Pilot implementation study	HIV care	People with HIV attending HIV primary care clinics in rural, urban and suburban settings, with a focus on stratification by race and ethnicity	Pilot implementation of a web-based video counselling intervention (Positive Health Check)

Source: Elaborated by the authors.

HIV: human immunodeficiency virus; RCT: randomised controlled trial; DN: digital navigator.

Eight studies (50.0%) used either the term digital navigator,^{23,24,26–28} digital care navigator^31,32 or digital health navigator¹⁶ to refer to the team member supporting technology implementation for patient care. Seven (43.7%) studies have used a variety of terminologies: some more specific to the technology or intervention (technical assistance,^33,36 telehealth patient navigator³⁵ or VVEP team³⁴), others related to the navigation (peer navigator³⁷ or care navigator²⁵) and others more broad (coach³⁰). One study did not assign a specific name to refer to DN.²⁹

Training was mentioned in half of the studies (50.0%), with the duration varying from 6³⁵ to 10 h,^24,26,28 1 day²³ or 6 weeks.³⁷ Training content covered basic technology, digital literacy (62.5%),^{16,23,24,26,27} specific skills of the tool used (87.5%)^{16,23,24,26–28}^,35 and DN-specific competencies and techniques (87.5%),^{16,23,24,26–28}^,37 such as outreach ability and organisational awareness. Two studies (25.0%)^24,28 have described training based on the simulation or observation of DN in practice.

Modalities of digital healthcare included mobile apps (43.7%),^24,26–30^,36 web or online programs (25.0%),^16,25,33,37 telehealth (12.5%),^34,35 SMS text-messages (12.5%)^31,32 and one study (6.2%) described DN training without specifying the modality.²³ Communication between digital navigators and end-users included text-messages,^{16,26,29–32}^,37 phone^{16,25,29,30,35} and video calls,^25,29,34 e-mail,³⁷ pager,¹⁶ letters¹⁶ and in-person.^16,33 Five studies^{23,24,27,28,36} did not specify any means of communication. DN roles were performed by research assistants^16,23,26 or coordinators,³⁴ clinicians,^25,27 community healthcare workers,²³ other health staff,^23,24,27 medical students,³⁴ volunteers,^23,28 peers²³ or tech-smart individuals.²⁴ Eight studies^29–33^,35–37 did not specify the professional background of navigators.

Table 3 summarises the main aspects of the DN that could be quantified as either present or not (DN terminology, DN role, DN-related outcomes and DN training) or details of how they were described (mean of communication and DN professional background or job title).

Table 3.

Summary of quantifiable digital navigator (DN) aspects included in the original articles (n = 16).

Specifications	Number of studies (%)
Used the term DN or similar
Yes	8 (50.0)
No	8 (50.0)
Identified the role of the DN
Yes	11 (68.7)
No	5 (31.3)
Identified DN-related outcomes
Yes	13 (81.2)
No	3 (18.8)
Described DN training
Yes	8 (50.0)
No	8 (50.0)
Mean of communication DN-end-user (could be multiple)
Message	7 (43.7)
Phone call	5 (31.2)
Video call	3 (18.7)
In-person	2 (12.5)
E-mail	1 (6.2)
Pager	1 (6.2)
Letter	1 (6.2)
Non-specified	5 (31.2)
DN professional background or job title
Research assistant or coordinator	4 (25.0)
Health staff (not a clinician)	2 (12.5)
Volunteers	2 (12.5)
Community healthcare workers	1 (6.2)
Clinician	1 (6.2)
Peers	1 (6.2)
Medical students	1 (6.2)
Tech-smart individuals	1 (6.2)
Non-specified	8 (50.0)

Source: Elaborated by the authors.

The roles described in 11 studies (68.7%),^16,23–28^,31,32,34,37 as well as the techniques described in 12 (75.0%),^{16,24,26,28–35}^,37 and equity outcomes reported as directly related to DN’ practice in 13 (81.2%),^{16,23,26–35}^,37 were organised in Table 4, following categories created in Table 1.

Table 4.

Summary of DN roles, applied techniques and skills, and equity-expected outcomes extracted from included studies (n = 16) and classified according to categories from Table 1, including the number of articles reporting each category.

Categories	DN roles	Techniques and skills	Equity-related outcomes
1. Access, engagement and integration	n = 6 (37.5%)	n = 9 (56.2%)	n = 6 (37.5%)
1. Access, engagement and integration	Engage with end-users^24,26,28,31Determine level of access to devices³⁴and interest in portal use¹⁶	Reminders about appointments³⁵ and incomplete activities²⁶Regular communication^24,30,35,37 and contact after long periods of disengagement^28,30 Motivational interviewing^31,32Support the choice of digital healthcare activities or interventions²⁶Promote AACCS framework (Access, Align, Connect, Care and Sustain)²⁷	Improvement in engagement and motivation³²Increased logins to the app³⁰ and completion of activities²⁶Moderate levels of adoption and penetration of technology into care²⁷High satisfaction with DN, positively correlated with engagement²⁸Reported HIV stigma experiences associated with engagement³¹
2. Targeted/personalised intervention	n = 7 (43.7%)	n = 4 (25.0%)	n = 8 (50.0%)
2. Targeted/personalised intervention	Assess needs, barriers and facilitators to care^16,24,25,37Social support^31,32Customise technology to specific needs²⁸	Regular record of activities, identifying needs and barriers³⁷Constellation of needs framework³⁷Analyse digital profiles²⁹Personalised recommendations^26,31,37	Targeted to the specific populations/area with positive outcomes: Black¹⁶; from multiple ethnicities^31,32; non-White²⁵; younger people^31,32; older adults³⁵; men with cancer³⁷ women²⁸; trans women^31,32; people with HIV^31,32; mental health conditions^24,28; type 2 diabetes¹⁶; comorbidities²⁸; not college educated^31,32; with unstable housing^31,32; recently encarcereted³¹
3. Enhanced communication, information and data use	n = 8 (50.0%)	n = 5 (31.2%)	n = 3 (18.7%)
3. Enhanced communication, information and data use	Assist clinical integration and care navigation^26,31Promote self-management³¹Information support^{16,24,31,32,37}and sharing^23,24,31Data monitoring,^24,28summarisation,²⁸interpretation^23,24,28 and sharing^23,28	Regular meetings with end-users²⁸Interaction guide³⁷Note behavioural trends²⁸Review app use²⁸Answer questions¹⁶Dashboard for case management³⁷Share data with clinician³⁷Generate, review and discuss data report^24,28Active listening³²	Knowledge share between teams³³Perceived autonomy and informational support³⁷Increase in access to health library³⁷High satisfaction with the DN³⁷Perception of commitment and safety²⁹
4. Clinical and therapeutic support	n = 8 (50.0%)	n = 2 (12.5%)	n = 4 (25.0%)
4. Clinical and therapeutic support	Promote uptake, wide implementation and support of digital tools in clinical setting^23,27,28Provide emotional³⁷ and clinical^{16,23,26,31,37} supportEnable therapeutic alliance^16,31	Monitor alerts for suicidal or self-harm risk³⁰Outreach ability¹⁶	Increased engagement rises the odds of detecting often undetectable viral load³¹ and decreases negative mental health symptoms³¹Perceived emotional support,³⁷ improvement in anxiety,²⁶ improvement in depression but not anxiety³⁰Better quality of life²⁶
5. Technology support and use	n = 7 (43.7%)	n = 7 (43.7%)	n = 3 (18.7%)
5. Technology support and use	Enhance digital literacy^16,23,24,28Provide technical support,^24,26 including onboarding and setup,^24,26,34 and technology recommendations²³	Discuss digital literacy barriers²⁸Onboarding session,²⁹support app installation³⁴ and troubleshoot^{24,26,28,29,33}Practice connection to video appointment³⁴Education about apps and skills taught by apps³⁰	Success in video-enabling participants,³⁴ with high completed video consultations^34,35 and attendance rates³⁵More log-ins to the app³⁰

Source: Elaborated by the authors.

HIV: human immunodeficiency virus; DN: digital navigator.

Is the DN contributing to reduce health inequities?

DN roles in the included studies focused primarily on providing technical and clinical support, utilising data to leverage clinical practice, promoting intervention engagement and assessing individual health and digital needs. When comparing this review's results (Table 4) to potential expectations of a DN described in existing non-empirical (theoretical) literature (Table 1), contributions exceeded expectations, particularly under ‘Clinical and therapeutic support’, presenting roles beyond technology incorporation to treatment, such as emotional³⁷/clinical^{16,23,26,31,37} support and therapeutic alliance.^16,31 Both social^31,32 and tailored technology support²⁸ were roles described in included studies under ‘Targeted and customised intervention’ not described in the literature. Under ‘Enhanced communication, information, and data use’, included studies failed to mention DN role in ensuring data privacy, but highlighted DN's performance in promoting data use for self-management.³¹ Regarding ‘Technology support and use’, one important addition was the role of DN in improving end-users’ digital literacy.^16,23,24,28

Techniques and skills used by DN had gaps and additions in all categories when comparing the methods – Table 1 and results – Table 4. Some gaps were therapeutic and clinical knowledge, documentation and policies compliance, personalised toolkits and encouragement towards goals. However, some techniques not mentioned in the literature, such as discussing digital literacy barriers,²⁸ outreach ability,¹⁶ active listening,³² regular meetings with end-users,²⁸ recording activities,³⁷ and identifying needs,³⁷ barriers^28,37 and digital profiles²⁹ were reported as techniques and skills used by DN in the included studies. When relating these techniques to Behaviour Change Techniques (BCTs), they mostly fall under the ‘goals and planning’ and ‘feedback and monitoring’ categories – problem solving, goal setting and monitoring of behaviour. BCTs are components of an intervention that are designed to alter behaviour by targeting its underlying determinants, allowing interventions to be clearly specified, replicated and evaluated^.38

For equity-expected outcomes, ‘Clinical and therapeutic support’ mostly described mental health outcomes while ‘Access, engagement and integration’ mostly described engagement-related outcomes. There were insufficient outcomes in included studies when comparing methods – Table 1 with what was achieved by DN (results – Table 4). For instance, no studies evaluated DN's performance in optimising shared-decision making, data quality, self-management, workflow integration or care delivery in underserved areas. However, a few outcomes not listed in the literature (emotional³⁷ and informational³⁷ support, access to health library³⁷ and satisfaction with DN³⁷) were identified in the included studies. Figure 2 synthesises the DN roles, techniques and skills associated with positive outcomes in the included studies.

Figure 2.

DN roles, techniques, and skills associated with positive outcomes in included studies.

Perceptions from targeted populations described in the studies were also not listed in Table 1. A few end-users receiving cognitive behavioural therapy in a hybrid clinic (i.e. synchronous telehealth and asynchronous mobile app) felt supported, and reported positive experiences and new skills gained.²⁸ They also viewed the digital intervention as a good way to access care.²⁸ End-users receiving digital HIV care navigation described a community sense, better medication tracking, less missed appointments and support to talk to clinicians.³² Despite having DN available, challenges with the technology were still mentioned.²⁷

Discussion

Our results suggest that DN has the potential to reduce healthcare inequities. Most studies analysed have primarily examined their role in supporting technology use, increased communication and clinical integration, often neglecting how social factors impact integration of care across the health system. These were expectations described in literature, which demonstrates a gap in studies that tested DN role in overcoming socioeconomic barriers to promote integrated care, highly relevant when attempting to reduce healthcare inequities.

Our findings also demonstrate a gap in DN scope of practice, including clear roles and competencies. Heterogeneity in DN characteristics was found across studies, including training, background, qualifications and terminology adopted. Eight different names were reported across included studies. Other terms to describe similar interventions such as phone navigator,³⁹ human support⁴⁰ or technology specialist⁴¹ are reported, with differences. For example, when compared to a coach, DN has been described as ‘more engaged approach, […] which seeks to integrate more aspects of care’.⁴² Inconsistent terminology makes the search for relevant studies a challenge, and hinders the development of a consistent scope of practice, with appropriate roles and training.

Other reviews of DN in mental health focused on motivation, engagement, treatment adherence, technical and clinical support, access and feedback,^40,42,43 aligned with our study findings. Including DN as a part of the staff has also been described as improving telehealth adoption, adaptation, effectiveness and satisfaction^.44 When tracing back to the origins of PN (bridge gaps in cancer prevention and treatment)¹ and care navigation (guiding individuals in the health continuum beyond healthcare),^45,46 essential components, such as providing service information³⁹ to support care journeys appear to be missing. Many techniques depicted aimed mostly to engage end-user's with the intervention or technology, particularly troubleshooting, similar to what has been reported previously.^39,40,42,43 At this point, it remains unclear whether the primary purpose of DN is to bridge the gap between end-users and health services using digital health tools or, alternatively, and not additionally, to focus on bridging the gap between end-users and digital healthcare tools themselves, increasing digital health use and adoption.

Besides, a core DN skill when the goal is to reduce inequities, is cultural competence,³⁹ widely neglected in the included studies. Cultural competence is essential to ensure improved outcomes, enhance communication, increase satisfaction,⁴⁷ provide appropriate quality care to different groups and reduce health inequities.⁴⁸ Study findings show a cultural competency training is perceived as beneficial by participants.⁴⁴

Training programs for DN in our findings focused solely on technical, operational and clinical skills, offering no attention to the social dimensions of the role. Basic smartphone use and troubleshooting, mobile app assessment tools, clinical terminology, data knowledge and engagement techniques^13,14 were mostly outlined, but rarely detailed. There was insufficient description of the essential skills for DN, despite the existence of evidence-based manuals^14,49 outlining a curriculum for effective DN training.

Eight studies targeted DN interventions to specific populations, focusing on equity-related outcomes,¹⁶ such as workflow integration,¹³ care delivery in underserved areas¹³ and integration of DN into systems.¹² Again, care navigation appears overlooked, with limited attention to care integration, social and cultural factors impacting health equity and access.

Other findings referring to DN's reach, beyond closing access disparities and promoting digital literacy and integrated care, highlight the temporary or transitional role of DN in supporting the uptake of digital technologies.²⁶ Once individuals become proficient in using digital health tools, they tend to rely less on DN. In contrast, some authors present DN as a figure who can become a permanent point of reference for end-users.³⁷ While additional strategies in DN practice may help mitigate digital barriers, they are unlikely to eliminate those entirely.²⁹ In this sense, having DN scope of practice aligned with healthcare equity goals¹⁶ seems reasonable to sustain positive impact and better outcomes.

Nearly all studies reported DN interventions developed in the USA, where access challenges and healthcare fragmentation persist⁵⁰ despite advanced technology and substantial investments. If DN is widely developed in this context, it becomes critical to prioritise equity over technical support to promote healthcare integration. Besides, included studies hardly presented population size, socioeconomic status and availability of local health services, essential characteristics to fully understand healthcare inequities. Most included studies focused on metropolitan areas,^{16,23,27–29}^,31,34,35,37 while others did not specify the location, relying on virtual recruitment.^26,30 Considering the incipient nature of DN, these initiatives may not yet have been extended to more marginalised populations or rural and remote regions. Our findings suggest that it may be particularly worthwhile to explore the development of DN initiatives in countries or regions with fragmented systems or limited access to healthcare.

Studies using virtual recruitment should also outline geographical coverage, not only to provide an overview of the population and needs, but also to allow identification of appropriate referral destinations. There is no one-size-fits-all approach for DN interventions and, despite the need for clarity in their scope of practice and training, adapting it to individual and local needs which vary geographically, culturally and regionally, is also in its core competencies.

The rapid development of digital health has evidenced and reinforced persistent health inequities, underscoring the importance of investing in integrated health systems and careful designing digital healthcare with strong focus on equity.^8,51 Multilevel efforts should be coordinated to address health inequity, especially regarding digital disparities, with involvement from government, industry and, the entire healthcare team including DN. An intersectoral approach, such as providing digital health education and facilitate access to devices and internet connection, can foster greater digital inclusion.¹⁶

Strengths and limitations

This study summarises latest findings on DN roles and characteristics without restricting the analysis to a specialty or health condition, an approach not previously undertaken. The focus of DN in addressing health inequities remains underexplored, and this article may open pathways for future research, which may include other related aspects such as digital engagement and motivation.

Some limitations should be acknowledged. Terms such as ‘coach’ and ‘human support’ were not part of the initial search and were instead identified during screening, which could have resulted in the exclusion of some relevant studies; with manual inclusions adopted to mitigate this. Additionally, the emerging nature of the topic limits the number of available studies, evidencing inconsistent terminology, which poses challenges for comprehensive search and synthesis. Consequently, the findings contribute to addressing the main research question, although inconclusively, which leaves room for further investigation.

Conclusion

This review found a gap in the literature when it comes to the role of DNs to reduce healthcare inequities, an emerging topic. Despite the promising potential of DN, studies describing DN interventions with focus on reducing inequities were incipient. Having an individual or a group supporting the integration of digital healthcare modalities and system navigation is particularly relevant when fragmented care is in place and in countries or locations marked by deep or growing social and health inequities. The literature supports the relevance of DN, which appears diverse and multifaceted, with heterogeneous professional practice, training, techniques, skills and outcomes. However, current implementation remains strongly focused on technological aspects, with less attention to social support and healthcare integration. Our findings suggest that although DN holds promise, there is still a lot to be developed and investigated to fully understand its potential, sustainability and limitations. Focusing on social and cultural factors to reduce barriers to care seems to be the best approach to optimise DN applications and benefits.

Supplemental Material

sj-docx-1-jtt-10.1177_1357633X261457758 - Supplemental material for Can digital navigators help reduce inequities in healthcare? A systematic review

Supplemental material, sj-docx-1-jtt-10.1177_1357633X261457758 for Can digital navigators help reduce inequities in healthcare? A systematic review by Giulianna Ornellas, Mariana Vercesi de Albuquerque and Soraia de Camargo Catapan in Journal of Telemedicine and Telecare

Supplemental Material

sj-docx-2-jtt-10.1177_1357633X261457758 - Supplemental material for Can digital navigators help reduce inequities in healthcare? A systematic review

Supplemental material, sj-docx-2-jtt-10.1177_1357633X261457758 for Can digital navigators help reduce inequities in healthcare? A systematic review by Giulianna Ornellas, Mariana Vercesi de Albuquerque and Soraia de Camargo Catapan in Journal of Telemedicine and Telecare

Footnotes

ORCID iDs

Giulianna Ornellas

Mariana Vercesi de Albuquerque

Soraia de Camargo Catapan

Ethical considerations

This article does not contain any primary data with human or animal participants, and informed consent is not required.

Funding

The authors disclosed receipt of the following financial support for the research and authorship of this article: This work was supported by the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) [Funding Code 001].

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

All data analysed in this study are from previously published articles, which are publicly available and cited in the references.^16,23-37

Supplemental material

Supplemental material for this article is available online.

References

Freeman

. The history, principles, and future of patient navigation: commentary. Semin Oncol Nurs 2013; 29: 72–75.

Carter

Valaitis

Lam

, et al. Navigation delivery models and roles of navigators in primary care: a scoping literature review. BMC Health Serv Res 2018; 18: 1–13. DOI: 10.1186/s12913-018-2889-0.

Ferrante

Cohen

Crosson

. Translating the patient navigator approach to meet the needs of primary care. J Am Board Fam Med 2010; 23: 736–744.

Kokorelias

Shiers-Hanley

Rios

, et al. Factors influencing the implementation of patient navigation programs for adults with complex needs: a scoping review of the literature. Health Serv Insights 2021; 14: 1–17. DOI: 10.1177/11786329211033267.

Dalton

Holzman

Erwin

, et al. Patient navigation services for cancer care in low-and middle-income countries: a scoping review. PLoS One 2019; 14: 1–14. DOI: 10.1371/journal.pone.0223537.

Freire

Louvison

Feuerwerker

LCM

, et al. Regulação do cuidado em redes de atenção: importância de novos arranjos tecnológicos. Saude soc 2020; 29: 1–9. DOI: 10.1590/s0104-12902020190682.

Abdi

Tinessia

Mahimbo

, et al.

Is it time to retire the label “CALD” in public health research and practice?

Med J Aust 2025; 222: 220–222.

Badr

Motulsky

Denis

. Digital health technologies and inequalities: a scoping review of potential impacts and policy recommendations. Health Policy 2024; 146: 1–9. DOI: 10.1016/j.healthpol.2024.105122.

Hoffman

Benedetto

Huang

, et al. Augmenting mental health in primary care: a 1-year study of deploying smartphone apps in a multi-site primary care/behavioral health integration program. Front Psychiatry 2019; 10. DOI: 10.3389/fpsyt.2019.00094.

10.

Catapan S de

Sazon

Zheng

, et al. A systematic review of consumers’ and healthcare professionals’ trust in digital healthcare. NPJ Digit Med 2025; 8: 1–9.

11.

Ferguson

. From patients to end users. Br Med J 2002; 324: 555–556.

12.

Rodriguez-Villa

Naslund

Keshavan

, et al. Making mental health more accessible in light of COVID-19: scalable digital health with digital navigators in low and middle-income countries. Asian J Psychiatr 2020; 54: 1–14. DOI: 10.1016/j.ajp.2020.102433.

13.

Rodriguez-Villa

Rauseo-Ricupero

Camacho

, et al. The digital clinic: Implementing technology and augmenting care for mental health. Gen Hosp Psychiatry 2020; 66: 59–66.

14.

Wisniewski

Gorrindo

Rauseo-Ricupero

, et al. The role of digital navigators in promoting clinical care and technology integration into practice. Digit Biomark 2020; 4: 119–135.

15.

Wisniewski

Torous

. Digital navigators to implement smartphone and digital tools in care. Acta Psychiatr Scand 2020; 141: 350–355.

16.

Rodriguez

Charles

Bates

, et al. Digital healthcare equity in primary care: implementing an integrated digital health navigator. JAMIA Open 2023; 30: 965–970.

17.

Offodile I

IAC

Seitz

Peterson

. Digital health navigation: an enabling infrastructure for optimizing and integrating virtual care into oncology practice. JCO Clin Cancer Inform 2021; 5: 1151–1154.

18.

Zheng

Walsham

. Inequality of what? An intersectional approach to digital inequality under COVID-19. Inf Organ 2021; 31: 1–6.

19.

Page

McKenzie

Bossuyt

, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Br Med J 2021; 372(71): 1–9. DOI: 10.1136/bmj.n71.

20.

Porritt

., Evans

. Bennett

., et al. Systematic reviews of qualitative evidence (2024). Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis, 2024.

21.

Thomas

Harden

. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol 2008; 8: 1–10. DOI: 10.1186/1471-2288-8-45.

22.

Goodman

Ogrinc

Davies

, et al. Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. BMJ Qual Saf 2016; 25: 1–24. DOI: 10.1136/bmjqs-2015-004480.

23.

Alon

Perret

Cohen

, et al. Navigator training to increase access to mental health care in community-based organizations. Psychiatr Serv. 2024; 75: 608–611.

24.

Macrynikola

Nguyen

Lane

, et al. The Digital Clinic: an innovative mental health care delivery model utilizing hybrid synchronous and asynchronous treatment. NEJM Catal 2023; 4: 1–15. DOI: 10.1056/CAT.23.0100.

25.

Bondar

Babich Morrow

Gueorguieva

, et al. Clinical and financial outcomes associated with a workplace mental health program before and during the COVID-19 pandemic. JAMA Netw Open 2022; 5: 1–13. DOI: 10.1001/jamanetworkopen.2022.16349.

26.

Camacho

Chang

Currey

, et al. The impact of guided versus supportive coaching on mental health app engagement and clinical outcomes. Health Informatics J 2023; 29: 1–12. DOI: 10.1177/14604582231215872.

27.

Green

Rodriguez

Keshavan

, et al. Implementing technologies to enhance coordinated specialty care framework: implementation outcomes from a development and usability study. JMIR Form Res 2023; 7: 1–14. DOI: 10.2196/46491.

28.

Chen

Lane

Burns

, et al. The Digital Navigator: standardizing human technology support in app-integrated clinical care. Telemed J E Health 2024; 30: e1963–e1970. DOI: 10.1089/tmj.2024.0023.

29.

Hernandez-Ramos

Aguilera

Garcia

, et al. Conducting internet-based visits for onboarding populations with limited digital literacy to an mhealth intervention: development of a patient-centered approach. JMIR Form Res 2021; 5: 1–9. DOI: 10.2196/25299.

30.

Mohr

Schueller

Tomasino

, et al. Comparison of the effects of coaching and receipt of APP recommendations on depression, anxiety, and engagement in the IntelliCare platform: factorial randomized controlled trial. J Med Internet Res 2019; 21: 1–12. DOI: 10.2196/13609.

31.

Arayasirikul

Turner

Trujillo

, et al. . The dose response effects of digital HIV care navigation on mental health and viral suppression among young people living with HIV: single-arm, prospective study with a pre-post design. J Med Internet Res 2022; 24: 1–10. DOI: 10.2196/33990.

32.

Trujillo

Turner

, et al. Digital HIV care navigation for young people living with HIV in San Francisco, California: feasibility and acceptability study. JMIR Mhealth Uhealth 2020; 8: 1–9. DOI: 10.2196/16838.

33.

Zulkiewicz

Burrus

Harshbarger

, et al. Identifying implementation strategies that address barriers and facilitate implementation of digital interventions in HIV primary care settings: results from the pilot implementation of positive health check. AIDS Behav 2021; 25: 154–166.

34.

Chu

Kaplan

Lee

, et al. Increasing telehealth access to care for older adults during the COVID-19 pandemic at an academic medical center: video visits for elders project (VVEP). Jt Comm J Qual Patient Saf 2022; 48: 173–179.

35.

Mechanic

Lee

Sheehan

, et al. Evaluation of telehealth visit attendance after implementation of a Patient Navigator Program. JAMA Netw Open 2022; 5: 1–7. DOI: 10.1001/jamanetworkopen.2022.45615.

36.

Casper

Brennan

Burke

, et al. HeartCareII: patients’ use of a home care web resource. Stud Health Technol Inform 2009; 146: 139–143.

37.

Bender

Flora

Soheilipour

, et al. Web-based peer navigation for men with prostate cancer and their family caregivers: a pilot feasibility study. CurrOncol 2022; 29: 4285–4299.

38.

Michie

Richardson

Johnston

, et al. The Behavior Change Technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med 2013; 46: 81–95.

39.

Fernandez

Savas

Lipizzi

, et al. Cervical cancer control for Hispanic women in Texas: strategies from research and practice. Gynecol Oncol 2014; 132: 26–32. DOI: 10.1016/j.ygyno.2013.12.038.

40.

Bernstein

Weingarden

Wolfe

, et al. Human support in app-based cognitive behavioral therapies for emotional disorders: scoping review. J Med Internet Res 2022; 24: 1–22. DOI: 10.2196/33307.

41.

Noel

Carpenter-Song

Acquilano

, et al. The technology specialist: a 21st century support role in clinical care. NPJ Digit Med 2019; 2: 1–3. DOI: 10.1038/s41746-019-0137-6.

42.

Meyer

Wisniewski

Torous

. Coaching to support mental health apps: exploratory narrative review. JMIR Hum Factors 2022; 9: 1–8. DOI: 10.2196/28301.

43.

Perret

Alon

Carpenter-Song

, et al. Standardising the role of a digital navigator in behavioural health: a systematic review. Lancet Digit Health 2023; 5: e925–e932. DOI: 10.1016/S2589-7500(23)00152-8.

44.

Gallegos-Rejas

De Guzman

Kelly

, et al. Strategies to improve telehealth access for culturally and linguistically diverse communities: a systematic review. J Public Health 2025; 47: e374–e390. DOI: 10.1093/pubmed/fdaf030.

45.

Kallmyer

Bass

Baumgart

, et al. Dementia care navigation: building toward a common definition, key principles, and outcomes. Alzheimers Dement (N Y) 2023; 9: 1–12. DOI: 10.1002/trc2.12408.

46.

Rodriguez

Cappelletti

Kurian

, et al. Transitional care navigation. Semin Oncol Nurs 2024; 40: 151580. DOI: 10.1016/j.soncn.2024.151580.

47.

Truong

Paradies

Priest

. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Serv Res 2014; 14: 99.

48.

Brach

Fraser

. Reducing disparities through culturally competent health care: an analysis of the business case. Qual Manag Health Care 2002; 10: 15–28.

49.

Emerson

Dinkel

Watanabe-Galloway

, et al. Adaptation of digital navigation training for integrated behavioral health providers: interview and survey study. Transl Behav Med. 2023;13:612–623.

50.

Kern

Bynum

JPW

Pincus

. Care fragmentation, care continuity, and care coordination—how they differ and why it matters. JAMA Intern Med 2024; 184: 36.

51.

Ford

Sowden

Olivera

, et al. Transforming health systems to reduce health inequalities. Future Healthc J 2021; 8: e204–e209. DOI: 10.7861/fhj.2021-0018.

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