Removing inequities and biases in wearables

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Today, wearable medical devices play a prominent role in healthcare, granting clinicians and users the opportunity to learn more about their health and prevent illness, as well as enabling better management and treatment decision-making.

New figures forecast that the global medical wearables market will increase more than four-fold between 2021 and 2026, rising from $20 billion (€18 bn) to almost $84 billion (€77 bn). However, recent insights and research reveal inequities and biases in wearable devices, highlighting the need for objective data, collaboration and incorporating equity concerns into the approval process to address disparities.  

Newborn responses to illness are much more stereotyped than adults as many of their organ systems are just starting to work. As a result, their “responses to disease are often the same despite having different causes, again making diagnosis more difficult,” Kingsmore adds.

Consumer-grade wearable activity monitors give individuals access to real-world activity and health-relevant data, such as metrics including their estimated heart rate, along with inference data, such as stress levels, calories burned, and sleep quality. Wearable devices have sensors that measure these bodily responses, which can help us understand our health, particularly changes in health.

“The data provides quantified insights for many individuals that inform and incentivise their wellbeing and activity schedules,” Dr Sandra Woolley, School of Computer Science and Mathematics at Keele University, told Medical Device Network.

Connected devices are also a tool for medical practitioners to monitor, gather information and provide medical supervision to patients at home. Increasingly, for example, medical-grade NHS wearables such as 24-hour monitoring ‘Holter’ electrocardiography (ECG) monitors are also used to monitor patient health outside the clinic, says Woolley.

“The devices themselves don’t necessarily enable easier access to information and education about health, but companies that make the devices try to make the information available to users in an easily understood format,” said Dr Tamara Litwin, Epidemiologist, All of Us Research Program, Division of Medical and Scientific Research at the National Institutes of Health.

For example, learning about your resting heart rate is an opportunity to understand how your metrics compare with people within your demographic. “Education beyond the device data streams is often integrated into the apps, and it is up to the user to explore these topics and determine if/how to integrate them into their lives,” Litwin adds. 

“In the past, there were few apprehensions and ethical concerns about wearables and health data,” Woolley says. “However, concerns have increased with the occurrences of unintended data releases and data breaches,” Woolley details. Subsequently, people may have apprehensions about using wearables for their health and associate them with ethical issues.

In June 2022, reports of a security flaw in the US fitness app Strava came to light after disinformation watchdog FakeReporter found people could locate and identify security personnel. The news came four years after fresh concerns about the Strava fitness tracker revealing military personnel’s exercise routes, reiterating privacy worries about wearables.

In the UK, reports uncovered privacy breaches within the National Health Service (NHS). The British Medical Journal (BMJ) found NHS data users failed to comply with agreed terms for managing and using information received from NHS Digital. Although there was no evidence of malicious use or data selling, security breaches raise the issue of whether data handling is respectful and safe, exposing a lack of trust in digital devices and data-capturing programmes.

Companies have introduced wearable devices in the corporate environment to incentivise employee wellness. However, some may voice concerns over employee health tracking amid worries it invades privacy and snoops on their lifestyles and activities. Health insurance programmes also raise ethical concerns about the large amounts of personal information accessible to third parties without user consent.

Dr Litwin and fellow researchers’ 2022 study into wearable fitness tracker use found that most participants across all demographic groups were interested in using and learning more about fitness trackers. However, despite widespread interest in their use, the researchers warned that as device use increases, the sector needs to know how digital health technologies can help provide equitable healthcare across diverse communities.  

Calls for equitable healthcare in the wearables market illuminate current inequities and biases in the growing sector. Wearable devices are currently primarily accessible to individuals at higher income levels who are highly comfortable with technology, Litwin notes.

“Increasingly complex technology may exacerbate these disparities over time. There is also a very real risk that algorithms will be biased to reflect only the subset of individuals wearing/using devices instead of the general population.” 

Cost was the most significant barrier to more widespread wearable technology adoption in Litwin’s 2022 study. Another barrier was a lack of knowledge or awareness about fitness trackers and how to use them.

“There is now more awareness regarding inequity and bias in wearable devices, particularly since Sajid Javid highlighted the ‘racial bias in some medical instruments and the failings of pulse oximeters,” says Woolley.

A growing body of research relays the racial and ethnic discrepancy and bias in pulse oximeter performance devices. A 2022 research study found the device may factor in care disparities based on a patient’s race and ethnicity. Another 2022 study in the BMJ found that differences in care may restrict black patients’ access to supplemental oxygen and other intensive treatments. Researchers also found pulse oximetry devices overestimate arterial oxygen saturation levels in Covid-19 patients of racial and ethnic minority groups, detrimentally impacting their eligibility for treatment therapies.

“Some wearable devices perform very well for healthy, light-skinned individuals, but the performances may be substantially different for older, less active or darker-skinned individuals,” says Woolley. 

As the sector continues to grow at a rapid pace, calls for technology innovators, manufacturers, researchers, and the broader healthcare industry to focus on overcoming current inequities and biases in medical wearables are loudening.

“Developing low-cost wearable devices and subsidising the cost for low-income individuals can help address financial barriers to adoption,” says Litwin. “Education and high-touch methods, including in-person help setting up a new device, may be needed to reduce inequities in using and accessing fitness trackers and other wearable devices.”

Woolley says that enabling improved diversity of performance will require additional investments in technology sensing and calibration and much-improved diversity reporting in the clinical and health technology literature. “Ultimately, if improvements are not forthcoming, regulation will be needed.”