What do we mean by digital exclusion?

An internet non-user is someone who hasn’t used the internet in the past 3 months, or ever (ONS Internet Users, 2020), but for someone to be completely digitally included they must have both the capability to get online and be able to make the most out of the internet (Citizens Online). Those who are already at a disadvantage, such as individuals with learning disabilities, or those living below the poverty line, are more likely to be digitally excluded.

Digital exclusion is therefore a social issue, and one we have been thinking a lot about in recent months. As more services become digitised, individuals who are digitally excluded are at higher risk of missing out on resources such as important healthcare advice, and sites to find cheaper goods, perpetuating the inequalities they already face.

Is there a link between digital inequality and health inequality?

Unfortunately, there are currently no national datasets that look at the direct link between digital exclusion, access to digital healthcare, health outcomes and health inequalities (Good Things Foundation, 2020). There is, however, evidence that being digitally excluded is correlated to poverty, disability, unemployment and low educational attainment (Ofcom, 2020), all of which are linked to a lower life expectancy (Tinson, 2020). For example, only 51% of households earning £6-10k per year had household internet access, compared to 99% of households earning above £40k (Local Government Association, 2021).

Here are some of the ways that digital inclusion could support better health outcomes:

1. Using the internet can support better mental wellbeing, if it is used in the right way

The field of research looking into the link between internet use and mental wellbeing is a relatively recent one - however, the key lesson that we can take from current studies is that the answer to whether use of the internet increases wellbeing is a far from binary one.

It has been suggested that how and why an individual uses the internet is what impacts wellbeing, as opposed to general use; one study (Verduyn et al., 2015) suggested that passive use of social media, such as scrolling through a feed, could negatively impact wellbeing, but that active use, such as talking to friends, could improve psychological wellbeing. In line with this, Good Things Foundation reported that 51% of those who had completed Learn My Way courses (to improve digital skills to get online) felt less lonely and isolated, and 65% said they had increased social contact due to being online and felt happier as a result. However, not all individuals report the same mood increase; NHS Digital (2017) found that the mood of adolescents with a mental illness was more likely to change as a result of ‘likes’ and ‘comments’ on posts, compared to those without a mental illness, and Nowland, Necka and Cacioppo (2017) suggested that using social technologies can perpetuate loneliness when used to escape from the social world. We know that there are also several risks that are associated with being online, from increased likelihood of scams and the promotion of misinformation, to being groomed (Online Harms White Paper, 2019), all of which could negatively impact mental wellbeing.

2. There is some suggestion that use of digital tools can support improved health outcomes

It is easier now more than ever to get healthcare advice at the click of a button; from the NHS online symptom checker, to apps enabling individuals to speak to a healthcare professional within hours.

Totten et al. (2016) suggest that using telehealth for communication or remote monitoring of chronic conditions leads to improved quality of life and fewer hospital admissions. There is provisional evidence that the use of health apps and online services can provide better support for patients outside of a clinical setting; for example, a systematic review by Alessa et al. (2018) looked at apps that support patients to monitor their hypertension (high blood pressure). They found that 71.4% of the studies they reviewed, covering 3112 patients, reported significant decreases in blood pressure through the use of apps. However, the authors stress that these findings should be interpreted cautiously as several of the studies had a risk of high bias.

Whitehead and Seaton (2016) conducted another systematic review looking at the use of mobile apps to manage three long-term conditions: diabetes mellitus, cardiovascular disease and chronic lung disease. They found interventions that involved, in some way, the use of an app significantly improved the primary measure of the patients’ clinical outcome in 6/9 studies - though this fell to 3/9 when only an app was used. The authors suggested that the positive outcomes were due to enhanced symptom control, though the longer-term results are currently unclear as the longest study was a year.

Anecdotally, the Widening Digital Participation programme (NHSD and Good Things Foundation) has suggested that using Alexa to support carers gives practical, social, emotional and wellbeing benefits to both carers and their patients; one carer described how she could set reminders for medication, physio exercises and more on Alexa for her dad, who has Alzheimer’s, throughout the day.

Digitally excluded individuals may not have the skills, internet access or devices to access these benefits, excluding them from these innovative health services and potentially leading to poorer health outcomes.

Conclusion

It is clear that more evidence is needed to fully understand the link between being digitally included and health outcomes - including mental wellbeing and the management of long-term conditions. Current studies are small and there has been little research into longer-term impacts. However, there is certainly promising potential for digital inclusion to produce both patient-level physical and mental health benefits.

Want to find out more about the benefits of digital inclusion? Be sure to read out our blog post 'Could increasing digital inclusion in the UK deliver financial benefits for the NHS?' and give our podcast 'Could digital and data save the NHS' a listen.