Population and Public Health

Understanding the Digital Divide and Ensuring Access for All

Bridging the digital divide

Madelynn ValuThe term digital divide describes a gap regarding access to and usage of information and communication technology.

Conventional considerations in the mid-1990s around the digital divide often existed to focus on those who have access to the internet and those who do not. In 1999, the National Telecommunications and Information Administration (NTIA) published an in-depth look at the digital divide in the United States, finding striking racial/ethnic, economic and geographic inequalities between those who could get online and those who could not.

Not dissimilar to recent findings on the digital divide, the 1999 NTIA report found that minorities, low-income persons, the less educated, and children of single parent households—particularly when they reside in rural areas—are among the groups that most often lack access to information resources. In this report, it is stated that “ensuring access to the fundamental tools of the digital economy is one of the most significant investments our nation can make”. By the early 2000s more than half of all Americans were online and the use of the internet for households earning less than $15,000 a year was growing at an annual rate of 25%. This significant expansion in access and usage quieted the need to address the issue of digital isolation and instead, resulted in shifting the terminology to digital inclusion.

Although access to computers and the internet continues to soar on a yearly basis among Americans, within the U.S. and globally, the digital divide continues to widen at an alarming rate as unrelenting technological advances often aim to serve the elite and already technologically savvy. As technology itself becomes more complex, the capabilities and intricacies of its applications become more elaborate and wide-reaching, requiring higher skill levels for efficient use. With a global reach of 3.8 billion smartphone users worldwide in 2021, the conventional considerations of the past in assessing mere access to the internet and internet-capable devices are not and were not sufficient. While access to the internet remains a pervasive issue across the globe and particularly in regions of Africa and Asia, the digital divide is no longer simply defined by the “haves and have nots” and now encompasses every technical and financial requirement to optimizing computer and internet use, as well as the economic, linguistic and generational barriers associated with this. While these barriers have been well-experienced by certain populations since the internet’s inception, they have never been as acutely painful as during the COVID-19 pandemic. 

As COVID-19 began rapidly spreading across the globe, many of the world’s major industries, as well as routine aspects of daily life, pivoted to digital technologies to ride out the storm. From working, to learning, to socializing, to accessing vital healthcare services, people are living virtual lives in more ways than could have been imagined prior to the pandemic. But where does this transition leave those who do not have the skills, socioeconomic privilege or tools to use digital technologies? 


The Pandemic’s Impact on the Digital Divide

People of all ages facing barriers to optimal internet use are being left behind academically and economically. Now, as telemedicine and virtual healthcare delivery platforms have become the default for in-person primary care, many of these same people are being withheld their right to health. According to the Center’s for Disease Control and Prevention, use of telemedicine has increased by more than 50% in the first quarter of 2020 compared to the same period in 2019. While telemedicine provides convenience and serves as a critical mechanism to ensure patient safety, these benefits are not shared equally. A study found that during the early phase of the pandemic, persons who were older, insured by Medicaid or did not speak English as a primary language had completed fewer telemedicine visits. Additionally, older, female, Black, Latinx and individuals of low socioeconomic status were all less likely to use video for telemedicine visits, which requires more digital bandwidth than audio alone. Cost, relevancy and digital literacy are cited as primary drivers of inadequate digital access. Globally, the fast implementation of telemedicine is still laborious and even impossible for several countries, many of which carry a disproportionate burden of vulnerable communities who are at risk due to COVID-19.

With the development and distribution of three U.S. Food and Drug Administration-approved COVID-19 vaccines, concerns regarding the broadening requirements for adequate digital access are focused beyond access to primary care and now center on vaccination efforts. In the absence of a federal vaccine management system, states are relying on an array of ad-hoc approaches to meet demand, manage allocation and schedule appointments. In many states, elderly populations have been among the first eligible for the vaccine, but with registration largely taking place online, some are faced with multiple barriers including comfort level and familiarity with technology and therefore, are forced to rely on others with more digital know-how to register. The online registration processes rolled out state by state are too difficult for most people to handle on their own and as a result, vaccine rates are unsettlingly low among those that need it the most.

As vaccine distribution accelerates and more people become eligible to make an appointment in the coming months, inequities in online registration are likely to remain—even among those with smartphones, computers and internet access. The process of making an appointment to be vaccinated requires substantial time, technology and trust. Many lower-income individuals, including essential workers, lack the time and flexible schedules required to continuously check for appointments or hold on the phone for hours. Additionally, the ability to travel, mostly by personal vehicle, and trust in the healthcare system are strong contributing factors to whether or not a person is able to seek and obtain a COVID-19 vaccine. 

These challenges, many of which are driven by structural determinants of health—cultural norms, policies, institutions and practices that define the distribution or maldistribution of social determinants of health—will require focus, sustained attention and dedication on the part of health professionals and digital health innovators to overcome. Three examples outlined in a recent article clearly depict the need to look beyond the bounds of device and internet access when considering challenges and solutions to the worsening digital divide. These examples provide missing context needed to call for innovation that tailors equitable digital health solutions to patient context and communication preferences. 

The Biden Administration’s national COVID-19 response strategy outlines equity as a key priority, including part of vaccine distribution efforts. When it comes to the critical timing of the continued vaccine rollout, health officials should consult with health equity experts in the design, building and maintaining of vaccine registration systems and to better understand the barriers faced by communities highly impacted by the COVID-19 pandemic. Health departments should elevate the voice of community partners that are trusted by populations who the healthcare system has not yet earned the trust of due to generations of mistreatment. For example, the Colorado Vaccine Equity Task Force (CVET) is utilizing civic organizations, faith communities and healthcare settings to host education and outreach seminars. The CVET has also launched a website in both English and Spanish to provide information about the currently available COVID-19 vaccines, highlight stories and testimonials from people in the community who have received a vaccine and take questions from community members. In Ohio, virtual town halls have been hosted that will be replayed weekly on television to combat COVID-19 vaccine misinformation. The town halls are focused on addressing questions and concerns of Black, Hispanic, Asian, Pacific Islander and rural residents.

Finding Solutions to Fill the Gap

Culturally aware, multilingual, offline options should be available (and reliable) for vaccine registration. State and local governments are engaging in a range of strategies to increase the availability and accessibility of vaccines for underserved populations. These strategies must ensure that appointments can be booked by phone, via text or in-person. Mississippi and Alabama have set up a hotline for appointment scheduling meant to serve residents who cannot or do not want to use online systems. In Connecticut, officials have worked with United Way to implement the “Vaccine Appointment Assist Line” that takes phone calls 12 hours per day, seven days a week to set up appointments (up to 10,000 per week). The Dallas, Texas Democratic Party, has implemented phone-banking and gone door-to-door in an effort to register as many seniors as possible. Some states are using text-based approaches to send notifications of when vaccine appointments may be available. Oklahomans are able to sign up for text messages to alert them when new vaccine appointments are available. While most websites utilize a translation software or provide translated materials through downloadable resources, recent reporting finds that many COVID-19 vaccination registration and information websites at the federal, state and local levels violate disability rights law, hindering the ability of blind people to sign up.

Lastly, in the digital era, the ability to continuously check websites and respond immediately to surprise alerts has created an unfair advantage for certain people with these freedoms. Available appointments for vaccines should be released at multiple times of the day and night to accommodate those with alternative working schedules. These times should be consistent and made public knowledge. In an attempt to build equity into the process, a new system rolled out by D.C. Health will give qualified residents 24 hours to schedule their vaccine appointment online once they have been notified of availability. 

Continuing to face the digital challenges of the COVID-19 pandemic will take an innovative and cutting edge approach, as well as a realization that technology, by itself, does not level the playing field. As vaccine rollout continues across the U.S. and globally, digital equity should seek to ensure that all people have the access, resources, tools and literacy needed for civic and cultural participation, opportunities to advance employment and learning, and utilization of essential services. 

Social Determinants of Health Task Force

Explore the opportunities that exist in the meaningful integration of social determinants of health (SDOH) data to properly inform care delivery and improve individual and population health. Members seek to provide expert guidance to drive SDOH-related efforts in healthcare information and technology forward, specifically anchored in standardization, implementation and policy development.

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