Bridging the divide in digital therapeutics (DTx): Partnership strategies for broader representation across DTx development and deployment

Abstract

While Digital Therapeutics (DTx) are widely considered a key strategy to reach certain populations with unmet healthcare needs, a range of differences in the impact and adoption of DTx still exists. These differences are not just rooted in access, but also in gaps in knowledge about how to produce community-relevant DTx, primarily stemming from the implicit or explicit exclusion of those with both relevant trained expertise (gained through formal education or professional experience) and lived expertise (gained through personal and direct experience). This paper expands the traditional conceptualization of the digital divide beyond access to encompass four interconnected domains: the Digital Knowledge Divide, Digital Evidence Generation Divide, Digital Production Divide, and Digital Adoption Divide. Drawing on Ridgeway's cultural schema theory of status, we demonstrate how conventional team hierarchies in DTx development systematically allocate status and decision-making authority through automatic cultural defaults, credentials, professional roles, demographic characteristics, rather than through contextual assessment of who possesses the most relevant expertise for specific decisions. To address this challenge, we propose a theoretical framework for dynamic expertise integration that deliberately disrupts rapid-stabilizing hierarchies by creating explicit relational spaces where teams can recognize and value both lived and trained expertise contextually. We operationalize this framework through the DTx Team Building Worksheet, a practical tool that integrates team science approaches with Community-Led Transformation principles and Culturally and Community Responsive Design. The Worksheet provides structured processes for assessing diverse forms of expertise, defining roles dynamically, and identifying decision-making priorities that shift appropriately across the DTx lifecycle. This integrated approach including problem analysis, theoretical framework, and practical tool, offers a pathway toward more equitable DTx development by enabling teams to make status dynamics explicit, expand what counts as expertise, and establish new consensual norms about contextually-appropriate status allocation. We invite stakeholders across sectors to test and refine these tools in diverse contexts, recognizing that creating equitable DTx requires sustained commitment to partnerships that genuinely honor multiple forms of expertise and willingness to disrupt comfortable hierarchies in service of producing interventions truly designed for and with the communities they aim to serve.

Fig 1. The definitions of expanded digital divides.

Fig 2. Examples of lived and trained expertise.

Fig 3. Example of dynamics in decision-making priority over time throughout the DTx lifecycle.

The x-axis represents the four phases of the DTx lifecycle as described in the DTx RWE Framework (Phase I: Design, Phase II: Develop, Phase III: Test, and Phase IV: Monitor). The y-axis lists the modules from the Worksheet for DTx Team Activities, including the Product Module, Benefit Module, Outcome Module, Milestone and Resources Module, and Goal and Boundary Module. “LE” refers to an individual with lived expertise, while “TE” refers to an individual with trained expertise. The figure illustrates how, across different phases and modules, decision-making priority may shift toward the expertise most relevant for effectively advancing the project.