The digital divide used to be about who had internet access and who didn’t, with broad implications for every aspect of life — especially health care. But digital health innovation is growing rapidly, with projections showing a $536.6 billion market by the end of 2025 compared to the $179.6 billion market at the end of 2016. So, what does that mean for the digital divide? We believe the digital divide no longer just refers to access, but to the level of understanding and ability to comfortably use digital health technology. Unfortunately, older adults seem at risk for being on the wrong side of this split.

In the U.S., roughly 80 percent of older adults have at least one chronic condition and more than two-thirds have two or more chronic diseases. Regular exercise is an effective strategy for chronic condition prevention and management and can safely be incorporated into the lives of older adults. However, less than 16 percent of older adults meet the weekly guidelines for aerobic and muscle-strengthening activity set forth by the Centers for Disease Control and Prevention (CDC) in the 2008 Physical Activity Guidelines for Americans. Digital health innovations such as wearable technologies can help people consistently track their physical activity and lead to improved health outcomes and may serve as a means for older adults to safely incorporate exercise into their daily routines.

However, it’s evident that older adults are not a target population for activity tracker vendors, as ads tend to showcase younger and healthier adults, who are in fact the highest purchasers of these devices. To counteract this problem, in 2015, we started RecycleHealth based on the hypothesis that people who may be least likely to purchase wearable activity trackers may be the ones who benefit the most from their use. Since then, we have received over 3,000 donated trackers, which we refurbish and provide to underserved populations, mostly in Greater Boston, all while studying the effects on health, well-being, and fitness. While results have been quite positive – improved health outcomes, positive behavior change and increased acceptance — we stumbled upon a new digital divide, one that is keeping older adults from accessing digital health.

In recruiting participants (age 50-75) at senior centers, a primary care practice and a church, mostly in lower-income areas around Greater Boston, we’ve observed that cost and difficulty with setup are just two barriers to adoption, but the issues of access go well beyond these.

For example, to take advantage of tracker features and be part of our studies, potential participants are required to have smartphones, but we have found that ownership is not enough and there exist several other barriers to engagement. In some cases, the phones may be a few generations old, which can lead to compatibility issues when downloading a required app or connecting an activity tracker to a phone.

The set-up, design, and implementation of these apps can be challenging for seniors. What’s considered intuitive for a millennial is anything but for many older adults. For example, the default step goal is often 10,000 steps per day, yet this is often more than older adults can physically manage. It’s also more than what the CDC physical activity guidelines would equal in number of steps. In working with older adults, we try to understand their current activity levels, provide guidance on a more realistic starting point and show them how to change the default setting.

Other features are designed in ways that inadvertently make people feel old, like dials to set date of birth. When setting the year, several people have said to us, “I have to spin that a lot!”

Furthermore, devices typically come with minimal guidance on setup and ongoing use. Some apps during setup use jargon-heavy language, such as “sync with Bluetooth,” or direct users to the vendor’s website. The idea of helping consumers through setup and use of a product is not novel. Think about what you receive when you buy a car or a printer. There’s often a thinner overview guide and then a thicker, more detailed manual.

While barriers to adoption and use clearly exist, we are also interested in understanding potential facilitators to engagement, so we can better help older adults to comfortably and adeptly use and benefit from digital health technologies.

One facilitator that we’ve been exploring is access to individual hands-on training. When we give someone a tracker, we sit with them and walk them through the setup process and help them configure the device to meet their unique needs. This not only helps improve an individual’s digital literacy but also helps the individual feel more comfortable using the technology on their own. The challenge is how we bring this high-touch support to scale. We have found that often you only get “one shot” at this. If the technology fails once, many people will give up on it.

Integration of digital health technologies in the lives of older adults will also require more attention to the design of apps and devices to ensure they are both appealing and usable by older adults. This includes looking at fine motor skills (or dexterity) of older adults and the type and frequency of messages that the devices send to users.

With the number of adults age 65 and older projected to make up 20 percent of the U.S. population by 2030, it seems imperative for clinicians, researchers, digital health manufacturers and developers to work together with older adults to combat this new digital divide.

Lisa Gualtieri is founder and program director, RecycleHealth, can be reached on Twitter @lisagualtieri. Jeff Phillips is a family physician and wellness leader, RecycleHealth, and can be reached on Twitter @DocJeffPhillips. Sandra Rosenbluth is program coordinator and communication specialist, RecycleHealth and can be reached on Twitter @sanrosenb. Steph Synoracki is a RecycleHealth volunteer and strategic health communication consultant. She can be reached on Twitter @stephsynoracki.

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