Article by Alexander van Deursen, published in Journal of Medical Internet Research
The World Health Organization (WHO) stresses that public health is an important topic on policy agendas in most Western countries. Considerable effort is directed to offering health information and services aimed at the general population online. Such efforts potentially support people in improved outcomes regarding their knowledge of health issues, health communication with professionals, decision-making about health issues, proper use of health services, and improved ways of taking care of themselves. However, when health information and services are moved online, issues of equality need to be considered. Online information and services can also disempower marginalized people by violating their rights and autonomy, further entrenching their position. Digital inequality research typically considers how specific populations can benefit from access to online services and has shown that those most likely to experience health-related issues are also less likely to benefit from the internet in general. In this respect, most attention has focused on, for example, age, racial and ethnic, and socioeconomic differences in access to online health. Actual well-being in terms of personal health is far less studied as a determinant of internet access in digital inequality research. When considered, it is often simplified in binary terms or by a single self-rated health scale. In this study, we focus on the general population and take as a point of departure the way people with different health statuses—pertaining to general functioning and well-being—use the internet to obtain positive health outcomes, for example, in determining a medical condition from which one might suffer or making better health-related decisions. We attempt to provide an in-depth picture by focusing on different health statuses in relation to stages of internet access and online health outcomes. The paper is structured around 3 goals.
The first goal was to reveal to what extent the process of internet access is important to obtain health outcomes. Internet attitude increases the likelihood of improving material access, the development of internet skills, and internet health use, suggesting that making online health apps attractive for larger segments of the population is an important objective. Material access, considered in this study as the diversity of the devices used, is highly relevant, as it has significant relationships with internet skills and internet health use. Individuals with different devices to connect to the internet everywhere and at all times of the day have more opportunities to develop internet skills and use online health apps. Internet skills are, in turn, required to use online health apps. The sequential nature of the access stages does not suggest that improving material access will automatically result in better internet skills or that a high level of internet skills will automatically result in a large variety of health-related internet use; all stages are, however, necessary conditions. The results furthermore revealed that all 4 access stages directly contribute to obtaining positive health outcomes, suggesting that to make online health care attainable for the general population, interventions should focus simultaneously on all stages. For example, attitudes might be improved by considering issues of accessibility and usability of online health information and services, material access by offering schemes such as device donation, internet skills by training programs tailored to the needs of people with different health statuses, and online health apps by awareness programs. Such approaches would require government, public, private, and nonprofit sector organizations to collaborate.
The second goal was to reveal to what extent different health statuses among the general population relate to the internet access stages and thus to internet health outcomes. The results confirmed that digital inequality research would benefit from considering health as a predictor of internet attitude, material access, internet skills, internet health use, and health outcomes. However, a general conclusion is that we should go beyond single self-reported measures of health, as different health statuses among the general population make unique contributions to the different internet access stages:
- Physical functioning contributes to internet attitude, material access, and internet skills, likely because physical limitations impact the process of taking up or learning how to use technologies (eg, in the case of smaller tablets or smartphones). Those with better physical functioning make less use of online health information and services as they have a relatively low need. Similarly, people with specific diseases that hinder physical functioning have less information need about their disease if they experience less limitations (eg, in the case of rheumatoid arthritis).
- Better social functioning contributes to better material access and higher levels of internet skills. The importance of social bonds to use technology has long been established, and support from family, friends, or those that are important to the individual’s life contributes to learning to use a device or improving internet skills. This is further strengthened when mobile phones, tablets, or laptops further enhance social connections and communication. Note that for internet skills, research has shown that informal support mainly works to apply basic skills. The use of online health information and services is higher for those with poorer social functioning. This suggests that those whose health restricts people from visiting friends and family are more likely to seek health information online. This might be the result of a higher need for online health information and services but also of online health information serving as a substitute for information received from peers.
- Concerning mental health, the results revealed a positive contribution to internet attitude but a negative contribution to material access. An explanation might be that those suffering from mental health issues are more likely to experience excessive internet use, which is supported by the use of multiple devices to provide instant access at all times. Furthermore, mental health negatively contributes to internet health use. As mental health is reflective of general distress, it causes people to turn to the internet for health information and services, apparently despite their less positive attitude toward the internet.
- People who perceive their health as higher have greater levels of material access and internet skills. A possible explanation might be that higher health perceptions foster social interactions that are supported by material access and higher levels of internet skills in the case of online social networking. The higher use of online health information and services among those with higher health perceptions seems to be inconsistent with prior research [30]. This discrepancy might be related to the influence of the COVID-19 pandemic in the survey period.
- Like poor physical functioning, physical pain negatively affects internet attitude and material access, suggesting that physical pain limits the use of certain devices and the process of learning how to use the internet.
In relation to our third goal, the general conclusion is that the contributions of the health statuses to the internet access stages differ for age and education. The main findings concerning age are that for seniors:
- internet attitude plays a more important role in obtaining material access than for those aged under 65 years. An important reason for seniors not to go online is a less favorable attitude toward the internet. A positive, guided experience with the internet might motivate seniors to move to the following stages of internet access. Furthermore, seniors are most likely to benefit most from accessible and usable apps.
- mental health plays a larger role in obtaining material access and developing internet skills. This suggests that seniors with mental health issues have a relatively high need for support, a worthwhile finding as online health interventions can reduce their mental health problems.
- perceived poor health hinders material access, suggesting that seniors who believe they are in poor health consider this as a barrier to interact with computer devices. This is a missed opportunity, as smartphones, tablets, or laptops might also be used as tools to enhance their perceived health.
The main findings concerning education are that for those with lower levels of education:
- internet attitude plays a larger role in obtaining material access, consistent with prior research that showed that education positively affects internet attitude [9]. Similar suggestions discussed for seniors apply, although specific approaches will be required.
- physical functioning is relatively important for developing a favorable internet attitude. This might be explained by the fact that lower-educated individuals are more likely to suffer from limitations in physical functioning, which could hinder the process of taking up and learning how to use the internet.
- social functioning plays a relatively important role in the development of internet skills and the use of online health information and services. Unfortunately, lower-educated individuals are less likely to perceive higher levels of support in relation to health, making organizing access to support an important objective.
- perceived health is relatively important for the development of internet skills. This suggests that lower-educated people who believe they are in poor health are more in need for skills training to make use of online health information and services as compared to their higher-educated counterparts.
Conclusion
To obtain positive health outcomes and make online health care attainable for the general population, interventions should focus simultaneously on internet attitude, material access, internet skills, and internet health apps. However, issues of equality need to be considered and digital inequality research would benefit from considering health as a predictor of all 4 internet access stages and health outcomes. Furthermore, studies among the general population should go beyond single self-reported measures of health as physical functioning, social functioning, mental health, perceived health, and physical pain all demonstrated unique contributions to the internet access stages. The general conclusion is that different health statuses affect internet access stages in different ways and, consequently, the health-related opportunities that the internet offers. Further complicating this issue is that such influence is moderated by age and education.
