The Healthcare Information Gap: A Global and National Perspective
by Mary Ann Coverdell RN, CCRN and Rose Utley RN, PhD
Coverdell, M. & Utley, R. (February, 2005). The Health Care Information Gap: A Global and National Perspective. Online Journal of Nursing Informatics (OJNI), Vol. 9, No. 1 [Online]. Available at http://ojni.org/9_1/coverdell.htm
The development of computer technology has created an information gap that has grown faster and wider over recent years. As healthcare systems and providers rely more on information from the Internet to guide day-to-day care, the disparity between the information “haves and have nots” expands. Awareness of the disparity and its impact on healthcare is the first step in narrowing the information gap.
Reasons for the gap are complex and multi-factorial, as are the solutions. In the United States, age, race, gender, education, domicile, and income influence the ability to access and sustain computer technology. Across the globe, technologically poor nations lack the infrastructure to support computer technology. For these countries, meeting basic needs, such as food, water, and shelter, takes priority. Once basic needs are met, a shift of focus to one that supports the use of computer technology can occur.
Information gap, Information divide, Information technology, Digital divide, World Wide Web
In 1989, Tim Berners-Lee, a scientist working for a Swiss research laboratory, revolutionized the world of information communication. He developed a model that could link and transfer information between computers (World Wide Web Consortium, 2004). This was the beginning of what is known as the World Wide Web [WWW] (Englebardt & Nelson, 2002, p.254; WWW Consortium, 2004).
Since that time, the WWW has dramatically changed how health related information is accessed. Today, healthcare practitioners in technologically rich countries rely more on the WWW to provide the latest health information and research. Hard copies of reference books are being replaced by online, electronically updated reference books. We are notified immediately of new journal articles via email and we access copies online instead of waiting for a paper copy to arrive via mail. Instead of searching a text book for information on a clinical topic we now can search the Internet for recent print or multimedia information on the topic. Healthcare information access for the public also has changed dramatically. No longer do internet connected individuals need to rely on brief television or news reports, or on printed books and magazine articles for the latest healthcare information. Through internet access the public easily can obtain recent and detailed healthcare information. Yet within this rapid evolution of information there exists a chasm of information “haves” and “have nots”. The disparity between these groups, variously referred to as the information gap, information divide, or digital divide, cuts between age, race, gender, income, education, and geographic area.
Initially, it was hoped that the WWW would be a great equalizer, enabling everyone to share immediate access to the same information. For healthcare providers this would mean the ability to share information about new drugs, new treatments, and the latest research, as well as provide immediate awareness of outbreaks in communicable disease. Unfortunately, this has not proved to be the case. Today, the information gap within the United States (US) and across the globe is as wide as ever. This paper will focus on understanding the gap between information technology “haves and have nots” and how this contributes to disparities in healthcare in the United States and around the world.
The Information Gap in the U.S.
In 1994, the Department of Commerce conducted a study on the information gap and published their recommendations (US Department of Commerce, 1995). Not surprising, they found that information technology was not easily accessed by individuals in rural areas or central cities and that household connectivity to the internet was low. Native Americans and rural Blacks lagged the furthest behind, with only 4.5% reporting computer ownership. Interestingly, in 1994, minority groups surpassed Whites in percentage of those searching classified ads, taking on-line classes, and accessing government reports (US Department of Commerce, 1995, p. 4).
In addition , several demographic factors such as place of residence, age, and income, were found to be related to the development of the information gap (US Department of Commerce, 1995). Rural and central city households in the US had the lowest percentage of computer ownership, whereas rural southern and northwest central cities had the highest rates of access and online searching. Those 55 and over in the rural and central cities had the lowest percentage of computer use, 11% and 12 % respectively.
In a later survey, connectivity of rural and urban households remained close with rural households earning between $5,000 and $10,000 per year having the lowest rates of online access at around 2%, and urban areas and central cities at around 4% (National Telecommunications and Information Administration [NTIA], 1997). This fact is more significant considering that the lowest phone penetration rate was not in the rural areas but in the central cities (US Department of Commerce, 1995). It was anticipated that as the cost of purchasing computer hardware decreased and online services become more widely available, the information gap would narrow even further.
Unfortunately, over recent years, not much improvement has been noted in the information gap; however, some of the earlier trends have shifted. Although computer ownership in the US grew to 51.9% and e-mail access grew by 397.1%, the disparity of computer ownership between Blacks and Hispanics compared to Whites increased (NTIA, 1997). White households reported 41% computer ownership, and Black and Hispanic households reported 19% (p.3). The racial divide persists between high income households with Blacks and Whites earning $75,000 or more reporting computer ownership at 64% and 76%, respectively (NTIA, 1997). Though all income groups reported an increase in computer ownership, those at higher income levels reported a greater increase, that has widened the information gap even further.
Education and marital status also have contributed to the information gap. According to the NTIA, “Those with a college education were nearly ten times as likely to own a computer as those without any high school [63.2% versus 6.8%]” (1997, p. 4). Fifty- seven percent of married couples with children were computer owners, whereas 25 % of unmarried women and 30 % of male head-of-households owned computers. Combined, the factors of income, education, and marital status play an important role in the development of the information gap.
The person’s age also seems to contribute to the information gap. In 1997, those with the highest percentage of computer ownership were adults ages 35-44 (NTIA, 1997). Though seniors reported the highest percentage of telephone penetration, they had the lowest percentage of online access (8%), followed by adults under 25 years old (17%) (NTIA, 1997).
Into the morass of numbers and statistics, researchers at Vanderbilt University began a project to further explore reasons behind the information divide (Hoffman & Novak, 1999). As of 1999, over 43 million hosts worldwide were connected to the Internet and between 40 to 80 million adults had access to the Internet. As of September, 2004, the number of users had grown to an estimated 453.9 million worldwide, of which nearly 200 million were in the US (Nielsen, 2004). Hoffman and Novak (1999) concluded that by making computer ownership more affordable and making Internet access easier to obtain, increased home usage would follow.
The Global Information Gap
Attempts to bridge the information gap in the US have been challenging, but according to the Digital Divide Network, our obstacles pale in comparison to much of the rest of the world (“International Issues,” n.d.). The burden of poverty, low literacy levels, and the inability to meet basic needs, such as access to clean water and food are formidable barriers poor countries must scale in order to enjoy the benefits of information technology (“U.N. Forum”, 2004).
Compared to the high percentage of Internet users in the US and Canada (27.3% of the world wide total) many other countries lag significantly behind. The Middle East, for example, shares only 2.1% of the global internet. In Africa, the situation is even worse with only 1.6% of their population online (Internet World Stats, 2004). The Internet Society of South Africa estimates that only one in ten South Africans will have internet access by 2006 (ISOC-ZA, 2004). Although China saw the number of internet users jump from 22.5 million to 56.6 million users between 2001 and 2002, this represents a mere 5.5% of the total population of China (Greenspan, 2002). These statistics point to how wide the information gap is globally, between the “haves and have nots”.
Narrowing the Information Gap
Several initiatives are currently in place to address the problems contributing to the digital divide. One initiative, developed by the United Nations (UN), under Secretary General Kofi Annan, has employed a task force to study the dearth of technological access across the globe (Millennium Project, 200 4) . During the 2000 UN Millennium Summit, task forces were created to determine millennium development goals (MDGs) in 10 different focus areas. Realizing that access to information is a tenet of a developing nation, Task Force 10 was created to deal with the status of science, technology, and information in developing nations (Juma & Yee-Cheong, 2004). Since that time, the MDGs developed by the task force have been accepted by the international community as standards for monitoring technology and its influence on the human condition in developing countries.
One important consideration for increasing information technology identified by Task Force 10 is the development of an adequate infrastructure (Juma & Lee-Cheong, 2004). Factors such as the lack of reliable “transportation, water, sanitation, energy, and telecommunications,” are a hindrance to the alleviation of poverty and to the dissemination of information (p. 5). Lack of electricity, inability to protect computers from dust or moisture, and lack of technicians to repair computers, are just a part of the problem (Kagan, 1998). In addition, illiteracy (“UN Forum”, 2004) and in some places, an unstable government, complicate the growth of a solid infrastructure.
In their interim report, Task Force 10 calls on the global community to assist developing nations to achieve stability by promoting foreign direct investment, international trade, higher education, and by encouraging policies that support business development (Juma & Yee Cheong, 2004). An international collaboration, referred to as the Digital Opportunity Task Force (DOT Force), is doing just that. The task force, which was spearheaded by the G 8 Heads of State at the Kyushu-Okinawa Summit in 2000, has combined businesses and non-profit organizations to promote the development of technology infrastructure and create digital opportunities for developing nations (“Digital Opportunities”, 2001). An example is Satellife, a Massachusetts based organization, that is leading a project to put personal handheld computers or PDAs into the hands of healthcare workers in Ghana, Uganda, and Kenya. Healthcare workers are able to obtain information quickly and easily using these relatively inexpensive, portable computers (Evaluation, 2002).
According to Task Force 10, once a society is stable, special attention can be given to science education, which is foundational for the development and use of computer technology. To enhance science education, they suggest placing universities at the center of the development process. Within the university framework, scientists can profit from shared knowledge and prosper in an environment that serves as a “business and technology incubator” for the larger community (Juma & Yee Cheong, 2004, p.8).
The reality, however, is that many countries that fall into the information gap struggle to meet their basic survival needs. According to Safran (2002), “ Many believe that families who live on the far side of the so called “digital divide” have other pressing health and social problems that need to be addressed before providing them with internet access” (p. 4) . For many countries, access to food, clean water, and shelter must take priority. Librarians, who deal with information access on a daily basis, have long voiced similar concerns. K.J. Mchombu, a librarian from Africa, echoed this sentiment:
In the underdeveloped countries the common man [sic] is poor, illiterate, and concerned with the basics of survival. More than four fifths of his [sic] income is spent on food alone. He [sic] is hungry, undernourished, and diseases such as malaria, sleeping sickness, and cholera are his [sic] constant companions. Children suffer more than adults; kwashiorkor and parasitic diseases claim many of their lives before they reach the age of ten. Only about 40% of the children complete primary school (Mchombu, 1982, p 242).
Instead of narrowing, the information gap continues to widen as poor countries struggle with basic services and wealthy countries continue to progress. A recent summit of UN delegates pointed out that the only way for developing nations to acquire technical information is to obtain access, yet this simple ideal is difficult to attain (“UN Forum”, 2004). The Intermediate Technology Development Group (ITDG), a British-based charity, believes that helping struggling communities develop their own technology is more helpful (“Information and Technology”, n.d). For example, villagers in Kenya have received assistance to develop power sources by tapping into streams to power turbines and generators, and Sudanese farmers have been helped to make plows from scrap metal to replace their primitive hoes (“Where We Work”, n.d.; “UN Forum”, 2004). On the surface, these efforts may not appear to be related to improving information technology, but they do strengthen the community by increasing self-sufficiency, reducing poverty, and helping the community meet some of its basic needs. In essence, these efforts strengthen the community’s infrastructure so it may eventually support the development of information technology. Supplying information technology is a moot point if those given access to it are struggling to meet basic needs, unable to read, or have no access to electricity (Kagan, 1998).
Where Are We Today?
Faced with an information divide with global and national implications, the UN continues its world-wide campaign to eradicate illiteracy and bring under-developed nations into the Internet age (Juma & Yee Cheong, 2004). Progress has been made in addressing the infrastructure changes outlined by Task Force10, but there is still a long way to go. The timeline for achieving the goals of Task Force 10 is the year 2015. However in the US, governmental efforts to explore the reasons between the information “haves” and “have nots” have recently stalled. However, private enterprises, such as libraries, universities, and foundations, have taken up the gauntlet and continue to seek ways to narrow the gap (Hoffman & Novak, 1999). For example, grants from the Bill and Melinda Gates Foundation have been used to bring computers and Internet access to libraries in many underserved areas of the US (“Equal Access,” n.d.; Lohr, 2004). In 2003, the Foundation helped install more than 47,000 computers in nearly 11,000 libraries across all 50 states (“Global Library”, n.d.). Now, 95 % of libraries offer Internet access. As a result, the Gates Foundation is focusing on grants to help libraries stay connected (“Global Library”, n.d.; Lohr, 2004). Unfortunately, charitable foundations, government programs, and economic development can not abolish all of the barriers of poverty, illiteracy, and lack of infrastructure overnight.
Methods of storing and distributing information have changed dramatically since the development of the Internet and the WWW. Books that were once rare and limited to the province of Kings are now the stuff of yard sales. More than ten years after the advent of the WWW, we still struggle to disseminate information much the same as Gutenberg struggled to spread the word of God.
Unfortunately, being connected, having access to Internet technology, and appreciating the benefits of the Internet remain beyond the reach of many. Although certain populations embrace the Internet and the information it provides, age, race, education, and marital status, compounded by geographic and economic dynamics, continue to limit Internet access of many individuals.
Clearly, whenever one segment of the population is less proficient or has less technology available than another, disparities will exist. The information gap will likely remain wherever there is poverty, illiteracy, or indifference. In terms of healthcare, this can mean disparity in information available to healthcare providers and the continuation of outdated, less effective treatment approaches. Healthcare providers who are connected to the Internet will have increasing access to the latest healthcare information, as well as electronic consultation, internet meetings, and educational teleconferences, all of which can enhance healthcare delivery. According to Fowler (2003), “The feedback loop between research and practice will become smaller, tighter, and faster” (p. 11), resulting in healthcare providers having greater and quicker access to the latest healthcare information. For the disconnected public, it can mean less awareness of health problems and how to manage them, and less self-empowerment.
As nurses, we are the main link for our “disconnected” patients to the wealth of healthcare information on the Internet. By staying connected, nurses can enable disenfranchised patients to reap the benefits of the latest healthcare knowledge and healthcare developments through us. Until the information gap narrows, it is important that nurses accept responsibility for sharing healthcare information with disconnected patients, and continue to access the latest information online to provide safe, effective, research-based care.
About the millennium project. (n.d.). Retrieved July 23, 2004, from http://www.unmillenniumproject.org/html/about.shtm Digital opportunities for all: Meeting the challenge . (2001). Retrieved July 23, 2004, from the G8 Genoa Summit 2001: http://www.g8italia.it/_en/docs/STUWX141.htm
Englebardt, S. P. & Nelson, R. (2002). Health care informatics an interdisciplinary approach . St Louis, MO: Mosby.
Equal access to technology: Libraries help close the gap. (n. d.). Retrieved July 23, 2004 from The Bill and Melinda Gates Foundation: http://www.gatesfoundation.org/StoryGallery/Libraries.htm
Evaluation of the Satellife PDA project. (2002). Retrieved November 12, 2004 from http://www.bridges.org/satellife/index.html Fowler, J. (2003, Winter). Beyond the digital divide. Health Forum Journal, p. 9-13.
Global library program fact sheet. (n.d.). Retrieved July 23, 2004 from The Bill and Melinda Gates Foundation: http://www.gatesfoundation.org/MediaCenter/Publications/LibraryFactsheet-040224.htm
Greenspan, R. (2002). China pulls ahead of Japan. Retrieved November 16, 2004 from http://www.clickz.com/stats/big_picture/geographics/article.php/1013841
Hoffman, D.L., & Novak, T.P. (1999). The growing digital divide: Implications for an open research agenda. [Electronic Version]. In B. Kahn & E. Brynjolffson, eds. Understanding the digital economy: Data, tools and research . Cambridge: MIT
How many online? (n.d.). Retrieved July 23, 2004, from the NUA: http://www.nua.com/surveys/how_many_online/index.html
Information and Communication Technologies Research. (n.d.) Retrieved July 23, 2004 from Intermediate Technology Development Group http://www.itdg.org/
International issues. (n.d.). Retrieved July 23, 2004, from the Digital Divide Network: http://www.digitaldividenetwork.org
Internet World Stats. (2004). Usage and populations statistics. Retrieved December 16, 2004 from http://www.internetworldstats.com/
ISOC-ZA trying to lower broadband costs. (2004) Retrieved November 16, 2004 from http://allafrica.com/stories/200408250855.html
Juma, C. & Yee-Cheong, D. I. L. (2004). Interim report of task force 10 on science, technology and innovation (Executive summary). Retrieved July 23, 2004, from the MilleniumProject: http://www.unmillenniumproject.org/html/tf10docs.shtm
Kagan, A, (1998). The electronic information gap. Retrieved July 23, 2004, from International Federation of Library Associations and Institutions: http://www.ifla.org
Lohr, S. (2004, April 22). Libraries wired, & reborn. Retrieved December 16, 2004, from http://tech2.nytimes.com/mem/technology/techreview.html?oref=login&res=9C0CE4D7163AF931A15757C0A9629C8B63
Mchombu, K. J. (1982). On the Librarianship of Poverty, Libri 32, 3, p 241-250.
Millennium project. (2004) Retrieved June 18, 2004, from http://www.unmilleniumproject.org/documents/Millennium%20Project%20Information%20Material%20May%2013-04.pdf
National Telecommunications and Information Administration. (1997). Falling through the net II: New data on the digital divide. Retrieved July 23, 2004, from the National Telecommunications and Information Administration: http://www.ntia.doc.gov/ntiahome/net2/falling.html
Nielsen//NetRatings. (2004). Retrieved November 12, 2004 from, http://www.nielsen-netratings.com
Safran, C. (2002). The collaborative edge: Patient empowerment for vulnerable populations. International Journal of Medical Informatics, p. 1-6.
U.N. forum delegates cite technology gap. (n.d.).Retrieved July 23, 2004 from The New York Times: http://www.nytimes.com
U.S. Department of Commerce. (1995). Falling through the net: A survey of the “have nots” in rural and urban America. Retrieved July 23, 2004 from the National Telecommunications and Information Administration: http://www.ntia.doc.gov/ntiahome/fallingthru.html
Where we work. (n.d.). Retrieved July 23, 2004 from Intermediate Technology Development Group: http://www.itdg.org/
World Wide Web Consortium. (2004). Tim Berners-Lee. Retrieved July 23, 2004 from World Wide Web Consortium: http://www.w3.org/People/Berners-Lee/
Mary Ann Coverdell RN, CCRN
Ms. Coverdell is a staff nurse at Ozarks Medical Center in West Plains, MO. She is currently enrolled in the BSN program at Southwest Missouri State University and is pursuing a Master’s Degree .
Rose Utley RN, PhD
Dr. Utley is an Associate Professor of Nursing at the Southwest Missouri State University in Springfield, Missouri. She is the Program Director for the Nurse Educator Graduate Programs and teaches a variety of courses in both the graduate and undergraduate nursing programs, including an online course in Healthcare Informatics.