Digital Inclusion is a Social Determinant of Health

Efforts to improve digital literacies and internet access are valuable tools to reduce health disparities. The costs of equipping a person to use the internet are substantially lower than treating health conditions, and the benefits are multiple.

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Digital Disparities: Understanding the Need

Thirty-seven million people in the U.S. do not have a computer and internet access needed for video-based telehealth1.  Most e-health appointments require home broadband, yet the American Community Survey shows that 40% of low-income households lack a broadband subscription to the internet, requiring them to use limited cell plan data or local public wifi hotspots2. Cell phone options may appear accessible and practical but costs are high and the user's privacy is limited.    

Those who do not have access to affordable broadband internet services, digital devices, digital literacies training, and technical support, face numerous challenges video-conferencing with their doctor,  checking test results, filling prescriptions, and much more.  Many individuals require significant support developing the digital literacies needed to engage in telehealth with the greatest need among older individuals, racial/ethnic minorities, and low-income communities. Taken in context, the costs of equipping a person to use the internet are substantially lower than treating health conditions, and the benefits are both persistent and significant.2 

“Super” Social Determinants of Health

Digital literacies and internet connectivity have been called the “super social determinants of health” because they encompass all other social determinants of health (SDOH).  Access to information, supports, and services are increasingly, and sometimes exclusively, accessible only online.

The social determinants of health shown in Figure 1. Digital Literacies & Access, include the neighborhood and physical environment, economic sustainability, healthcare system, community and social context, food, and education.4  Together these factors impact an individual's ability to access healthcare services, education, housing, transportation, online banking, and sustain relationships with family members and friends.  Digital literacies and access impacts all facets of a person's life and affects behavioral and environmental outcomes such as shopping choices, housing, support systems, and health coverage. 

Figure 1. Digital Literacies & Access. 

Recommendations for Healthcare Systems 

Healthcare systems play a crucial role in eliminating health disparities and should screen patients in need of support digital literacies skills. Our recently published paper3 highlights the hidden aspects of the digital divide and provides three recommendations healthcare systems can take to decrease health disparities stemming from a lack of digital access and digital literacies. 

  • Adopt a digital inclusion-informed strategy
  • Systematically assess individual patients’ digital literacies, learn about their internet access, and work to address their needs 
  • Partner with community-based organizations (CBO’s) with expertise in digital literacies training 

When digital literacies and connectivity gaps are assessed systematically and universally, healthcare  systems can document overall population-level metrics, examine disparities, implement solutions, and track changes over time. Having data to work from heightens awareness and bolsters efforts to improve digital literacies and reduce disparities. Understanding the nuances of access in the communities they serve can help healthcare systems implement more inclusive strategies.  

Healthcare systems need to actively partner with community organizations with expertise in digital literacies training. Community-based organizations can provide resources for technical support for those most in need. Libraries not only offer the Internet but also provide a spectrum of training services including basic and digital literacies and skills required for using specific devices and applications for multiple purpose. Some communities have partnered with community health workers and patient navigators to screen and refer patients for support in addressing gaps in basic digital literacies and internet connectivity5,6.

Get Involved

Immediate action must be taken to address the barriers to accessing healthcare services. Organizations like the National Digital Inclusion Alliance (NDIA) have taken action to support practitioners on the ground who are working directly with the communities and national, local, and state-based organizations to develop solutions that address digital inequities.  

NDIA amplifies the efforts of organizations that offer digital technology training, subsidized internet, and computers.  Visit NDIA's website to access free resources, connect with partners, and network with others who are implementing innovative programs in communities across the country.  

References

1. Benda, N. C., Veinot, T. C., Sieck, C. J., & Ancker, J. S.  Broadband Internet access is a social determinant of health! American Journal of Public Health 110(8):1123-1125.  (2020). doi: 10.2105/AJPH.2020.305784.

2. Schartman-Cycyk, S., Meisser, K. Bridging the gap: what affordable, uncapped internet means for digital inclusion. In Beacon M., (Ed.) (2017).

3. Sieck, C.J., Sheon, A., Ancker, J.S. et al. Digital inclusion as a social determinant of health. NPJ Digital  Medicine. 452 (2021). https://doi.org/10.1038/s41746-021-00413-8

4. Gibbons, C. Digital Access Disparities: Policy and Practice Overview. Panel Discussion, Digital Skills and Connectivity as Social Determinants of Health. Sheon, A. Conference Report: Digital Skills: A Hidden “Super” Social Determinant of Health: Interdisciplinary Association for Population Health Science. (2018).

5. Sheon A., Carrol L. How can health systems leverage technology to engage patients?. in (ed Marx E. W.) Voices of Innovation: Fulfilling the Promise of Information Technology in Healthcare. (Taylor and Francis, Washington, DC, 2018).

6. McAlearney, A. S. et al. High touch and high tech (HT2) proposal: transforming patient engagement throughout the continuum of care by engaging patients with portal technology at the bedside. JMIR Res. Protoc. 5, e221 (2016).

Jill Castek

Associate Professor , University of Arizona