The digital health paradox in Primary Care: A cluster analysis of user profiles and equity determinants.

Abstract

Digital health platforms are intended to democratize healthcare, yet they often encounter the "digital health paradox," where tools primarily benefit those with high digital literacy. In the Principality of Asturias (Spain), the Mi asturSalud portal was implemented to foster patient co-responsibility, but its actual usage patterns and equity determinants remain under-researched. To identify distinct behavioral user profiles and analyze the sociodemographic determinants of portal adoption, as well as the predictors of perceived digital barriers, in a Primary Care setting. A multicenter cross-sectional study was conducted (N=384) across four health districts. Predictors of portal adoption and digital barriers were analyzed using mixed-effects logistic regression models, with the health center as a random effect to account for data nesting. Among active portal users (n=138), hierarchical cluster analysis was performed to identify distinct engagement patterns, utilizing the elbow method for cluster selection and Pearson's chi-square tests for profile comparison. Two distinct user profiles emerged: "Comprehensive clinical users" (72.5%), who autonomously access clinical data, and "Limited administrative users" (27.5%), whose interaction is confined to basic transactional tasks. Mixed-effects models revealed that adoption is primarily driven by individual sociodemographic factors, particularly educational attainment and age, rather than geographic or institutional context (ICC = 0.026). Education proved to be a more potent predictor than household income. Significant barriers to engagement included credential complexity and a lack of functional literacy regarding clinical features, disproportionately affecting users with lower educational attainment. A significant "functional divide" exists, where a segment of the population remains limited to superficial administrative interactions. Digital inequality is a transversal issue rooted in individual capabilities and social support structures. Achieving digital equity requires moving beyond mere technical access toward personalized interventions, with Primary Care nursing serving as a critical mediator for fostering functional health literacy.