Progress towards enhanced access and use of technology during the COVID-19 pandemic: A need to be mindful of the continued digital divide for many rural and northern communities.

The COVID-19 pandemic produced unprecedented adoption and deployment of technology in rural and northern areas; however, this expansion widened the digital divide for many. Evidence shows that older adults' use of technology has increased. Coupled with an increasing number of available technologies to enhance healthcare delivery, social engagement, meaningful activities, and support to carers, we are at a crossroads for change. Emerging strategies used by organizations to promote technology and support efforts to bridge and close the digital divide are discussed. In a post-pandemic society, policy-makers can play a critical role to ensure that improvements, efficiency gains, and lessons learned are fully leveraged to reap the benefits of technology use by older adults, care partners, and the healthcare system. Recommendations are given for policy-makers to capitalize on this opportunity to narrow the digital divide for those in rural and northern communities.

Falling down the digital divide: A cautionary tale.

The disruptions of the coronavirus pandemic have enabled new opportunities for telehealth expansion within movement disorders. However, inadequate internet infrastructure has, unfortunately, led to fragmented implementation and may worsen disparities in some areas. In this Correspondence, we report on geographic and racial/ethnic disparities in access to our center's comprehensive care clinic for people with Parkinson's disease. While both in-person and virtual versions of the clinic enjoyed high patient satisfaction, we discovered that participation by Black/African-American individuals was cut in half when we shifted to a virtual delivery format in April 2020. We outline potential barriers in access using a socio-ecological model.

Digital Divide in Perceived Benefits of Online Health Care and Social Welfare Services: National Cross-Sectional Survey Study.

BACKGROUND: The number of online services in health care is increasing rapidly in developed countries. Users are expected to take a more skilled and active role in taking care of their health and prevention of ill health. This induces risks that users (especially those who need the services the most) will drop out of digital services, resulting in a digital divide or exclusion. To ensure wide and equal use of online services, all users must experience them as beneficial. OBJECTIVE: This study aimed to examine associations of (1) demographics (age, gender, and degree of urbanization), (2) self-rated health, (3) socioeconomic position (education, experienced financial hardship, labor market position, and living alone), (4) social participation (voting, satisfaction with relationships, and keeping in touch with friends and family members), and (5) access, skills, and extent of use of information and communication technologies (ICT) with perceived benefits of online health care and social welfare services. Associations were examined separately for perceived health, economic, and collaboration benefits. METHODS: We used a large random sample representative of the Finnish population including 4495 (56.77% women) respondents aged between 20 and 97 years. Analyses of covariance were used to examine the associations of independent variables with perceived benefits. RESULTS: Access to online services, ICT skills, and extent of use were associated with all examined benefits of online services. ICT skills seemed to be the most important factor. Poor self-rated health was also consistently associated with lower levels of perceived benefits. Similarly, those who were keeping in touch with their friends and relatives at least once a week perceived online services more often beneficial in all the examined dimensions. Those who had experienced financial hardship perceived fewer health and economic benefits than others. Those who were satisfied with their relationships reported higher levels of health and collaboration benefits compared with their counterparts. Also age, education, and degree of urbanization had some statistically significant associations with benefits but they seemed to be at least partly explained by differences in access, skills, and extent of use of online services. CONCLUSIONS: According to our results, providing health care services online has the potential to reinforce existing social and health inequalities. Our findings suggest that access to online services, skills to use them, and extent of use play crucial roles in perceiving them as beneficial. Moreover, there is a risk of digital exclusion among those who are socioeconomically disadvantaged, in poor health, or socially isolated. In times when health and social services are increasingly offered online, this digital divide may predispose people with high needs for services to exclusion from them.

Evaluating critical success factors in implementing E-learning system using multi-criteria decision-making.

Learning using the Internet or training through E-Learning is growing rapidly and is increasingly favored over the traditional methods of learning and teaching. This radical shift is directly linked to the revolution in digital computer technology. The revolution propelled by innovation in computer technology has widened the scope of E-Learning and teaching, whereby the process of exchanging information has been made simple, transparent, and effective. The E-Learning system depends on different success factors from diverse points of view such as system, support from the institution, instructor, and student. Thus, the effect of critical success factors (CSFs) on the E-Learning system must be critically analyzed to make it more effective and successful. This current paper employed the analytic hierarchy process (AHP) with group decision-making (GDM) and Fuzzy AHP (FAHP) to study the diversified factors from different dimensions of the web-based E-Learning system. The present paper quantified the CSFs along with its dimensions. Five different dimensions and 25 factors associated with the web-based E-Learning system were revealed through the literature review and were analyzed further. Furthermore, the influence of each factor was derived successfully. Knowing the impact of each E-Learning factor will help stakeholders to construct education policies, manage the E-Learning system, perform asset management, and keep pace with global changes in knowledge acquisition and management.

Beyond broadband: digital inclusion as a driver of inequities in access to rural cancer care.

PURPOSE: Rural cancer survivors have worse quality of life than their urban counterparts. Telemedicine is a potential solution to connecting rural residents with specialized cancer providers during the survivorship period, but limitations in broadband may stifle the impact. Using data from a feasibility study evaluating a telemedicine intervention aimed at connecting rural Virginia cancer survivors with their care team located at a cancer center associated with an academic medical center, we sought to evaluate the ability of rural survivors to access the intervention and suggest strategies for improving access to rural cancer survivorship care. METHODS: We used a descriptive design with geospatial and quantitative methods to understand broadband access, driving time to a satellite telemedicine site, and ability to utilize a borrowed cellular-enabled tablet to participate in the intervention for cancer survivors living in Central Virginia. RESULTS: Our study participants resided in census tracts where an average of 58% of households have adequate broadband access necessary to support a telemedicine videoconferencing intervention. Average driving time to the nearest telemedicine site was 29.6 min. Those who utilized the borrowed tablet experienced considerable difficulty with utilizing the technology. CONCLUSIONS: Rural cancer populations do not have equal access to a cancer survivorship telemedicine intervention. IMPLICATIONS FOR CANCER SURVIVORS: Telemedicine interventions aimed at connecting cancer survivors with their academic medical center-based cancer providers may be ineffective if survivors do not have access to either fixed broadband or a satellite clinic. Future research needs to evaluate other sites from which rural survivors can connect, such as rural public libraries.

Gender and the Digital Divide Across Urban Slums of New Delhi, India: Cross-Sectional Study.

BACKGROUND: Disparities in access to specific technologies within gender groups have not been investigated. Slum settings provide an ideal population to investigate the contributing factors to these disparities. OBJECTIVE: This study aimed to examine gender differences in mobile phone ownership, internet access, and knowledge of SMS text messaging among males and females living in urban slum settings. METHODS: A convenience sampling approach was used in sample selection from 675 unnotified slums. A total of 38 slum sites were then selected across four geographic zones. Of these, 10% of the households in each slum site was selected from each zone. One household member was interviewed based on their availability and fulfillment of the eligibility criteria. Eligible individuals included those aged 18 years and above, residing in these slums, and who provided voluntary consent to participate in the study. Individuals with mental or physical challenges were excluded from the study. RESULTS: Our results showed that females were half as likely to own mobile phones compared with males (odds ratio [OR] 0.53, 95% CI 0.37-0.76), less likely to have internet access (OR 0.79, 95% CI 0.56-1.11), or know how to send text messages (OR 0.93, 95% CI 0.66-1.31). The predictors of mobile phone ownership, internet access, and text messaging between males and females included age, individual education, housing type, and the number of earning members in a household in the adjusted analysis. Among males, the number of earning members was a predictor of both mobile phone ownership and text messaging, whereas household education was a predictor of both internet access and text messaging. Age and individual education only predicted internet access, whereas housing type only predicted text messaging. Among females, household education was a predictor of all the technology outcomes. Age and type of toilet facility only predicted mobile phone ownership; housing type only predicted internet access whereas television ownership with satellite service and smoking behavior only predicted text messaging. CONCLUSIONS: Our study findings showing disparate access to technology within gender groups lend support for further research to examine the causal mechanisms promoting these differences to proffer significant solutions. Specifically, our study findings suggest that improving household education is crucial to address the disparate access and usage of mobile phones, the internet, and text messaging among women in slum settings. This suggestion is due to the consistency in household educational level as a predictor across all these technology indicators. In addition, the mechanisms by which the number of household earning members influences the disparate access to technology among men call for further exploration.

Closing the Digital Divide in Speech, Language, and Cognitive Therapy: Cohort Study of the Factors Associated With Technology Usage for Rehabilitation.

BACKGROUND: For stroke, traumatic brain injury (TBI), and other neurologic conditions associated with speech-language disorders, speech and language therapy is the standard of care for promoting recovery. However, barriers such as clinician time constraints and insurance reimbursement can inhibit a patient's ability to receive the support needed to optimize functional gain. Although digital rehabilitation has the potential to increase access to therapy by allowing patients to practice at home, the clinical and demographic characteristics that impact a patient's level of engagement with technology-based therapy are currently unknown. OBJECTIVE: This study aimed to evaluate whether the level of engagement with digital therapy differs by various patient characteristics, including age, gender, diagnosis, time from disease onset, and geographic location (urban vs rural). METHODS: Data for patients with stroke or TBI that initiated the use of Constant Therapy, a remotely delivered, cloud-based rehabilitation program for patients with speech-language disorders, were retrospectively analyzed. Only data from therapeutic sessions completed at home were included. The following three activity metrics were evaluated: (1) the number of active weeks of therapy, (2) the average number of active therapy days per week, and (3) the total number of therapeutic sessions completed during the first 20 weeks of program access. An active day or week was defined as having at least one completed therapeutic session. Separate multiple linear regression models were performed with each activity measure as the dependent variable and all available patient demographics as model covariates. RESULTS: Data for 2850 patients with stroke or TBI were analyzed, with the average patient completing 8.6 weeks of therapy at a frequency of 1.5 days per week. Contrary to known barriers to technological adoption, older patients were more active during their first 20 weeks of program access, with those aged 51 to 70 years completing 5.01 more sessions than patients aged 50 years or younger (P=.04). Similarly, patients living in a rural area, who face greater barriers to clinic access, were more digitally engaged than their urban counterparts, with rural patients completing 11.54 more (P=.001) sessions during their first 20 weeks of access, after controlling for other model covariates. CONCLUSIONS: An evaluation of real-world data demonstrated that patients with stroke and TBI use digital therapy frequently for cognitive and language rehabilitation at home. Usage was higher in areas with limited access to clinical services and was unaffected by typical barriers to technological adoption, such as age. These findings will help guide the direction of future research in digital rehabilitation therapy, including the impact of demographics on recovery outcomes and the design of large, randomized controlled trials.

Older Adults' Internet Use for Health Information: Digital Divide by Race/Ethnicity and Socioeconomic Status.

Building upon literature suggesting low Internet use among racial/ethnic minorities and socioeconomically disadvantaged groups, this study examined how race/ethnicity and socioeconomic status (SES) influence the Internet use for health information, addressing both independent and interactive effects. Using data from 17,704 older adults in the California Health Interview Survey, logistic regression models were estimated with race/ethnicity (Whites, African Americans, Latinos, and Asians), SES index, and the interaction between race/ethnicity and SES index. Overall, approximately 40% of participants were Internet-users for health information. Direct effects of race/ethnicity and SES-and their interactions-were all found to be significant. Minority status combined with the lowest levels of SES substantially reduced the odds of using Internet for health information. Findings suggest the combination of racial/ethnic minority status and low SES as a source of digital divide, and provide implications for Internet technology training for the target population.

Profiles of a Health Information-Seeking Population and the Current Digital Divide: Cross-Sectional Analysis of the 2015-2016 California Health Interview Survey.

BACKGROUND: Internet use for health information is important, given the rise of electronic health (eHealth) that integrates technology into health care. Despite the perceived widespread use of the internet, a persistent "digital divide" exists in which many individuals have ready access to the internet and others do not. To date, most published reports have compared characteristics of internet users seeking health information vs nonusers. However, there is little understanding of the differences between internet users seeking health information online and users who do not seek such information online. Understanding these differences could enable targeted outreach for health interventions and promotion of eHealth technologies. OBJECTIVE: This study aims to assess population-level characteristics associated with different types of internet use, particularly for seeking online health information. METHODS: The 2015-2016 California Health Interview Survey datasets were used for this study. Internet use was classified as never used the internet (Never use), ever used the internet but not to search for health information in the last 12 months (Use not for health), and ever used the internet and have used it to search for health information in the last 12 months (Use for health). Weighted multinomial logistic regression was used to assess sociodemographic and health characteristics associated with types of internet use. Findings are reported as odds ratios (ORs) with 95% CIs. RESULTS: Among 42,087 participants (weighted sample of 29,236,426), 19% reported Never Use of the internet, 27.9% reported Use not for health, and 53.1% reported Use for health. Compared to Never Use individuals, Use for health individuals were more likely to be younger (OR: 0.1, 95% CI 0.1-0.2 for ≥60 years vs <60 years), female (OR: 1.6, 95% CI 1.3-1.9 compared to males), and non-Hispanic white (OR: 0.54, 95% CI 0.4-0.7 for Latinos and OR: 0.2, 95% CI 0.2-0.4 for African Americans) and have a higher socioeconomic status (>400% of Federal Poverty Guidelines; OR: 1.3, 95% CI 1.4-2.4). Overall, characteristics for the Use not for health and Use for health groups were similar, except for those with lower levels of education and respondents not having visited a physician in the last year. For these two characteristics, the Use not for health group was more similar to the Never Use group. CONCLUSIONS: Our findings indicate that a digital divide characterized by sociodemographic and health information exists across three types of users. Our results are in line with those of previous studies on the divide, specifically with regard to disparities in use and access related to age, race/ethnicity, and socioeconomic status. Disparities in online health-seeking behavior may reflect existing disparities in health care access extending into a new era of health technology. These findings support the need for interventions to target internet access and health literacy among Never Use and Use not for health groups.

Trends of online patient-provider communication among cancer survivors from 2008 to 2017: a digital divide perspective.

PURPOSE: In the past decade, online patient-provider communication (OPPC) has emerged as a viable avenue for cancer survivors to communicate with their providers. However, little is known about the patterns of OPPC among cancer survivors. Thus, the current study aims to explore the trend of OPPC used by cancer survivors, and the influence of digital divide on OPPC in the past decade. METHODS: Data from the 2008, 2011, 2013, and 2017 iterations of the nationally representative survey of Health Information National Trends Survey (HINTS) were analyzed. Only cancer survivors were included in the analyses. Descriptive analyses and multivariate regressions were performed. RESULTS: Email has been the most typical means of OPPC; its adoption rate has increased from 9.7 to 36.6% in the past 10 years. More options for OPPC (e.g., mobile app, social medial, video conferencing, electronic health records) have been adopted since 2013. Physical Internet access was a significant predictor of OPPC over the four iterations, while cognitive access failed to predict OPPC in all the four waves. The effect of socio-demographic access varied vastly across iterations, with greater influences in 2017. CONCLUSIONS: This study illustrates an increasing trend in OPPC use among cancer survivors. Significant digital divide barriers also exist in the adoption and diffusion of OPPC. IMPLICATIONS FOR CANCER SURVIVORS: OPPC is an important communication channel for cancer survivors and will become more important in the digital era. Targeted interventions to address the digital divide barriers affecting OPPC could be developed to benefit underserved cancer survivors and to bridge health disparities.

Persistent digital divide in access to and use of the Internet as a resource for health information: Results from a California population-based study.

OBJECTIVES: Access to the Internet has grown dramatically over the past two decades. Using data from a population-based survey, we aimed to determine the prevalence and predictors of (i) access to the Internet, and (ii) use of the Internet to search for health information. METHODS: We analyzed data from the 2011-12 California Health Interview Survey (CHIS) and included all individuals 18 years of age and older. Our outcomes were (i) prior use of the Internet, and (ii) use of the Internet to find health or medical information within the past year. We performed survey-weighted logistic regression models on our outcomes to adjust for potentially confounding demographic and socioeconomic factors. RESULTS: Our study included an unweighted and survey-weighted sample of 42,935 and 27,796,484 individuals, respectively. We found that 81.5% of the weighted sample reported having previously used the Internet. Among Internet users, 64.5% stated that they used the Internet within the past year to find health or medical information. Racial/ethnic minorities, older individuals, and those who lived in lower income households and rural areas were less likely to have access to and use the Internet to search for health information. Conversely, English-proficiency and increasing levels of education were positively associated with online health information-seeking. CONCLUSIONS: We found that most Californians have access to and use the Internet to search for health information, but still noted a persistent digital divide. Interventions to narrow the divide are needed, otherwise this may lead to a continued widening of existing healthcare disparities.

La sociedad red y la información en salud digital / Digital health information

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Health Literacy and Health Information Technology Adoption: The Potential for a New Digital Divide.

BACKGROUND: Approximately one-half of American adults exhibit low health literacy and thus struggle to find and use health information. Low health literacy is associated with negative outcomes including overall poorer health. Health information technology (HIT) makes health information available directly to patients through electronic tools including patient portals, wearable technology, and mobile apps. The direct availability of this information to patients, however, may be complicated by misunderstanding of HIT privacy and information sharing. OBJECTIVE: The purpose of this study was to determine whether health literacy is associated with patients' use of four types of HIT tools: fitness and nutrition apps, activity trackers, and patient portals. Additionally, we sought to explore whether health literacy is associated with patients' perceived ease of use and usefulness of these HIT tools, as well as patients' perceptions of privacy offered by HIT tools and trust in government, media, technology companies, and health care. This study is the first wide-scale investigation of these interrelated concepts. METHODS: Participants were 4974 American adults (n=2102, 42.26% male, n=3146, 63.25% white, average age 43.5, SD 16.7 years). Participants completed the Newest Vital Sign measure of health literacy and indicated their actual use of HIT tools, as well as the perceived ease of use and usefulness of these applications. Participants also answered questions regarding information privacy and institutional trust, as well as demographic items. RESULTS: Cross-tabulation analysis indicated that adequate versus less than adequate health literacy was significantly associated with use of fitness apps (P=.02), nutrition apps (P<.001), activity trackers (P<.001), and patient portals (P<.001). Additionally, greater health literacy was significantly associated with greater perceived ease of use and perceived usefulness across all HIT tools after controlling for demographics. Regarding privacy perceptions of HIT and institutional trust, patients with greater health literacy often demonstrated decreased privacy perceptions for HIT tools including fitness apps (P<.001) and nutrition apps (P<.001). Health literacy was negatively associated with trust in government (P<.001), media (P<.001), and technology companies (P<.001). Interestingly, health literacy score was positively associated with trust in health care (P=.03). CONCLUSIONS: Patients with low health literacy were less likely to use HIT tools or perceive them as easy or useful, but they perceived information on HIT as private. Given the fast-paced evolution of technology, there is a pressing need to further the understanding of how health literacy is related to HIT app adoption and usage. This will ensure that all users receive the full health benefits from these technological advances, in a manner that protects health information privacy, and that users engage with organizations and providers they trust.

Digital divide and information needs for improving family support among the poor and underserved.

Despite of its emotional benefits, communication with family members who live abroad can present a large financial burden for low-income foreign-born individuals. The aims of this study were (1) to explore the current technologies available for low-cost communication with family living abroad and (2) to assess the level of awareness and use of low-cost technologies for family communication as well as related information needs among low-income foreign-born individuals. This mixed-methods study included an environmental scan, survey, and focus groups with low-income foreign-born individuals living in East Harlem in New York City. Low-income individuals who have family members living abroad face financial stress with complicated technology choices for communication with family living abroad and they have many information needs. They would welcome interactive and convenient educational tools that (1) build skills for utilization of various technologies and (2) provide decision support to simplify choosing among the vast array of available communication options.

Ocio entre pares en la era digital: percepción del ocio conectado juvenil / Leisure between the digital age pair: perception youth connected leisure

Las herramientas de comunicación online han modificado sustancialmente las prácticas de ocio juvenil en los últimos años. Mediante la incorporación de dispositivos digitales portátiles, muchas actividades de ocio tradicionales se han visto transformadas, mientras que la conexión a Internet se convertía, en sí misma, en un espacio de ocio. No abundan los estudios de corte cualitativo que se ocupen de las percepciones de los jóvenes en torno a estas nuevas formas de ocio. Este estudio quiere explorarlas a través de las técnicas del grupo de discusión y la entrevista en profundidad, aplicadas a una muestra de un total de 88 estudiantes de primero y segundo de Bachillerato de Bizkaia. Los resultados confirman la presencia cotidiana del ocio digital en la vida de estos jóvenes, pero presentan ciertas dudas respecto de su valoración, mostrando incluso su asociación con expresiones de connotación negativa

Online communication tools have substantially modified leisure practices among young people in the last years. Many traditional leisure activities have been transformed by the effect of digital mobile devices, while Internet connectivity became a leisure space in itself. Qualitative studies dealing with how young people perceive these new forms of leisure are scarce. The present study intends to explore these perceptions by means of focus groups and in-depth interviews, which were administered to 88 students of first and second grade of Bachillerato in the province of Bizkaia. Results confirm the everyday presence of digital leisure in the lives of young people, but also present some doubts regarding their appreciation of it, showing even how it is associated with terms with a negative connotation

Health literacy and the digital divide among older Americans.

BACKGROUND: Among the requirements for meaningful use of electronic medical records (EMRs) is that patients must be able to interact online with information from their records. However, many older Americans may be unprepared to do this, particularly those with low levels of health literacy. OBJECTIVE: The purpose of the study was to quantify the relationship between health literacy and use of the Internet for obtaining health information among Americans aged 65 and older. DESIGN: We performed retrospective analysis of 2009 and 2010 data from the Health and Retirement Study, a longitudinal survey of a nationally representative sample of older Americans. PARTICIPANTS: Subjects were community-dwelling adults aged 65 years and older (824 individuals in the general population and 1,584 Internet users). MAIN MEASURES: Our analysis included measures of regular use of the Internet for any purpose and use of the Internet to obtain health or medical information; health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) and self-reported confidence filling out medical forms. KEY RESULTS: Only 9.7% of elderly individuals with low health literacy used the Internet to obtain health information, compared with 31.9% of those with adequate health literacy. This gradient persisted after controlling for sociodemographic characteristics, health status, and general cognitive ability. The gradient arose both because individuals with low health literacy were less likely to use the Internet at all (OR = 0.36 [95% CI 0.24 to 0.54]) and because, among those who did use the Internet, individuals with low health literacy were less likely to use it to get health or medical information (OR = 0.60 [95% CI 0.47 to 0.77]). CONCLUSION: Low health literacy is associated with significantly less use of the Internet for health information among Americans aged 65 and older. Web-based health interventions targeting older adults must address barriers to substantive use by individuals with low health literacy, or risk exacerbating the digital divide.