Week 10 Learning Goals and Objectives ....................................................................................................... 1
Week 10 Introduction ................................................................................................................................... 2
Week 10 Readings ......................................................................................................................................... 6
Week 10 Independent Learning Activities .................................................................................................... 7
Week 10 Forum Discussion ........................................................................................................................... 7

Explore and discuss the phenomenon known as the digital divide.

Define and characterize the factors and issues that are inherent in the digital divide.

Explore causes and consequences of the digital divide including who may be impacted and why.

Consider and discuss the digital divide from the consumer health informatics perspective.

Explore and describe how and to what extent technology access issues impact on the delivery of health care and health information, and on overall quality-oflife.
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Welcome back from Spring Break! AND, Welcome to our last full Module, Module
D: Challenges and Issues of CHI !
Module D lasts for three weeks (weeks 10 - 12):
Week 10: The Digital Divide
Week 11: The Law in Consumer Health: Ethics, Privacy and Confidentiality
Week 12: The Patient Record and Online Health Information Security
During Module D, we will explore contemporary trends in consumer health informatics and information seeking, identifying a variety of challenges and issues that impact on the technology-based delivery of healthcare.
This week, we begin with a discussion about the digital divide and its impact on healthcare and health information resources.
Digital divide is a term used to describe the inequality between technology and information
‘haves’ and ‘have not’s.
The digital divide is so LARGE that it has actually been categorized into multiple digital divides, but interestingly, different sources give different definitions of what the 2nd, 3rd, and 4th digital divides actually ARE.
1 st digital divide: is about access to computers: those who have a computer with
Internet access vs. those who do not.
2 nd digital divide:
The 2nd digital divide is, primarily, about information usage skills including computing literacy, information literacy and health literacy. Those who have sophisticated information skills are the haves ; and those who lack these skills are the have not’s
.
3 rd digital divide:
There are also varying definitions of what constitutes the 3rd digital divide.
Some say that it is about policies that block or limit access to quality information.
This 3 rd digital divide is often created by security issues that then lead to prohibitive regulation, policies, and procedures.
We see this 3 rd digital divide fairly frequently in hospital libraries in which information technology/information services policies dictate the use of firewalls that effectively prohibit hospital libraries from accessing valuable Internet resources. We also see this in public libraries that use filters to block sexually explicit content. Although the goal of filters in these organizations is to block pornography or protect children, an Internet filter
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will also block legitimate health content like breast cancer , for example.
Others define the 3rd digital divide in terms of Internet access among developing nations -- third world countries.
Regardless of what constitutes the 1 st , 2 nd , or 3 rd digital divides, however, the complexity and confusion around these issues illustrate the general complexity of these issues!
The Numbers, and Causes of Digital Divides
Let’s look at some of the statistics:
Disparities definitely exist, broken down along many demographic and socioeconomic factors . These are overviewed here:
According to a report from the National Telecommunications and Information
Administration, computer and Internet use correlate with family income , employment status, and educational levels attained. There is a significant divide along racial lines, with African Americans, Native Americans, and Latinos/Latinas having much lower rates of computer ownership than Caucasians and Asian Americans.
Interestingly, according to the National Institutes of Health, African Americans are more likely to have a smart phone than a home computer. So, when we are building consumer health resources for these populations, the resources should probably be on a mobile app.
Whites and Asian Americans are also more likely to use the Internet at non-home locations such as home, school or work than are minority groups in the U.S.
Age is a major factor, with half of the non-online population over the age of 50 years. In fact, rates of computer and Internet use fall sharply for people over 55. This disparity holds true across income brackets and geographic locations.
Estimates from the Current Population Survey (CPS) indicate that 95.2% of children who have home computers are enrolled in school, whereas only 85.4% of children who do not have home computers are enrolled in school.
Slightly more than half of all African American and Latino children have access to a home computer, and approximately 40% have access to the Internet at home
(compared to 85.5 and 77.4% of white, non-Latino children).
Ethnic and racial disparities in home computer and Internet access rates are larger for children than for adults. This plays out negatively for children when teachers and schools require Internet usage for homework.
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Estimates from the CPS and the National Longitudinal Survey of Youth indicate that teenagers who have access to home computers are 6 to 8 %age points more likely to graduate from high school than teenagers who do not have home computers after controlling for individual, parental, and family characteristics.
We also find evidence of similarly strong relationships between home computers and educational outcomes using several estimation strategies and even after controlling for detailed home environment and extracurricular activities. Home computers appear to increase high school graduation partly by reducing non-productive activities, such as school suspension and crime, among children.
Roughly 1 out of 7 blacks and 1 out of 8 Latinos subscribe to broadband at home, compared to 26.1% of whites. One third of Asians and roughly 1 out of 8 Native
Americans have broadband at home. Because Native Americans are so underserved, the National Institutes of Health (NIH) through the National Library of Medicine (NLM), and the Patient-Centered Outcomes Research Institute (PCORI) have put a LOT of money into funded projects for this population.
Until about 2005, Indiana had a major digital divide problem because of the lack of
Broadband -- many of you may remember the days no so long ago when your only
Internet options were dial-up!
At the same time, more recent data show that this disparity does not extend to mobile technologies such as iPhones. As I mentioned above, research illustrates that African
American communities are just as likely to have these mobile technologies as are
Caucasians.
The Digital Divide is large and does not appear to be disappearing soon. A report for the
Leadership Conference on Civil Rights Education Fund presents a similar picture of the technology divide:
Blacks and Latinos are much less likely to have access to home computers than are white, non-Latinos (50.6 and 48.7% compared to 74.6%). They are also less likely to have Internet access at home (40.5 and 38.1% compared to 67.3%).
Asians have home computer and Internet access rates that are higher than white, non-
Latino rates (77.7 and 70.3%), and Native Americans have lower rates (51.6 and
40.9%).
Among Latino groups in the United States, Mexicans have the lowest home computer and Internet access rates followed by Central and South Americans who have the next lowest rates. Although Cubans, Puerto Ricans and other Latinos have higher rates, all
Latino groups are less likely to own a computer or have Internet access at home than are Caucasian, non-Latinos.
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Income differences are partly, but not entirely responsible for ethnic and racial disparities in computer and Internet access. Even among individuals with family incomes of at least $60,000, African Americans and Latinos are substantially less likely to own a computer or have Internet access at home than are Caucasians.
Relatively lower levels of income among Latinos also contribute to why their rates of computer ownership and Internet use are lower than non-Latinos (these factors explain
26.6 and 21.0% of the gaps, respectively).
Latinos have substantially lower levels of education than Caucasians, and this is assumed to be one of the major causes of this digital divide: These lower levels of education presumably account for 22.5% of the white/Latino gap in home computer rates and 36.4% of the gap in Internet use rates.
The explanations for low rates of computer and Internet use among Mexicans are similar to those found for all Latinos, however, the explanations differ somewhat for
Cubans and Puerto Ricans. Education and income may explain less of the Cuban/white gap in computer ownership, and education and income may explain nearly 75% of the gap between Puerto Ricans and white, non-Latinos.
Low levels of income might explain 36.2% of the gap in computer ownership and 33.0% of the gap in home Internet use between Native Americans and whites.
Low levels of education also explain a sizeable portion of the gaps (13.3 and 24.5%, respectively). Another factor that explains part of the gaps (4.2 and 4.7%) is the higher likelihood of Native Americans living in rural areas than whites.
Sixty% of all workers in the U.S. use some form of computing at work, and 46% use the
Internet at work. Among jobs that require a college degree, 85% of workers use a computer at work and 74 % use the Internet at work.
Language is an important determinant of computer ownership and Internet use even after controlling for education, family income and immigrant status. Spanish-speaking
Latinos, especially Mexicans, have strikingly low rates of computer ownership and home
Internet use. And as we know, there are many fewer Spanish-language sites than
English-language health sites and sources available on the web, for example.
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…..SO, while these statistics are bleak, we are still plowing ahead with our efforts to deliver healthcare to the masses via technology – the web, smart phones, telehealth, etc.
Think about what these statistics mean in real, practical terms for consumer health informatics; for patients and their families!
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We may assume that the bulk of our patients and clients have access to the Internet, but this may not be an accurate assumption.
If they DO have access, they may not possess the literacy and health literacy skills required to effectively USE the information they find.
In fact, most of the health information on the web is written at a college level, but the average American adult reads at/or below the 9th grade level. This renders most of the information unusable to the average adult in this country! Canada fares no better, by the way
– their health literacy and general literacy rates are as dismal as those in the
U.S.
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Again, what do these data mean in terms of CHI?
How can we deliver healthcare to folks who have no phone? No email? No Internet access? …To those who cannot read or write above a 9 th grade level? … To those who do not have strong health literacy skills or health information literacy or numeracy skills?
What kinds of visible or invisible digital divides and barriers might your clients and patients face?
How can technologies overcome or improve the digital divide?

Nielsen-Bohlman, pp. 256 - 266, 302 - 322

Lewis, Chapters 11 and 20

Consumers' perceptions about and use of the internet for personal health records and health information exchange: analysis of the 2007 Health Information
National Trends Survey. Wen KY. Kreps G. Zhu F. Miller S. Journal of Medical
Internet Research. 12(4):e73, 2010.

eHealth literacy: extending the digital divide to the realm of health information.
Neter E. Brainin E. Journal of Medical Internet Research. 14(1):e19, 2012.

Matrix analysis of the digital divide in eHealth services using awareness, want, and adoption gap. Liang TH. Journal of Medical Internet Research. 14(1):e11,
2012.

Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities. Lopez L. Green AR. Tan-McGrory A.
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King R. Betancourt JR. Joint Commission Journal on Quality & Patient Safety.
37(10):437-45, 2011 Oct.
A. Take some time to explore the A.D.A.M. application and talk about it with classmates.
A.D.A.M. is a simple health information tool created by Ebix Health
( http://www.adam.com/healthsolutions.aspx
), a dot-com. The tool is then marketed to hospitals and other organizations. For example, the University of Southern
California (USC) health system uses A.D.A.M. (as do many others).
Check out the USC A.D.A.M.: http://keckmedicine.adam.com/content.aspx?productId=65&pid=65
How does A.D.A.M. help patients deal with digital divide issues?
This week’s framing questions:
Define and characterize the specific factors and issues that are inherent in the digital divides from the CHI perspective.
Who are the visible and invisible have-nots in your professional community?
How do digital divides impact on the 'havenots’ abilities to find and use healthcare information?
What kinds of disparities in healthcare might be created by or worsened by the digital divides?
What disparities are improved by or made worse by the availability of informatics applications? What are the corresponding social responsibility issues?
What skills, equipment or materials, or motivators are necessary to bridge the digital divides?
How can librarians, nurses, doctors and other information and healthcare experts work to bridge the digital divides?
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