Experts now say digital access can determine a person’s health — here’s why that matters to social purpose organizations

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Like most health and care providers, the West Elgin Community Health Centre in Ontario pivoted to offering online services at the beginning of the pandemic. It wasn’t long before they realized the impact that had on clients with disabilities, and older adults. Quickly, two groups who needed their services the most were not only cut off from a physical health centre, but many also lacked the digital literacy to be able to access online health services.  Using a grant from the Ontario Trillium Foundation, West Elgin staff launched an iPad loan program. They purchased tablets and data packages, as well as funded an administrative role to both manage the initiative and coach clients on how to use the devices.  According to one home-bound client who was interviewed about the loan program, having access to an iPad during the pandemic – where otherwise she would rely on libraries for internet access – “changed her life”.  For Brian Sankarsingh, the communication and engagement liaison at the Alliance for Healthier Communities, these sorts of disparities – namely who has access to a connected device, and who is able to use the device to complete crucial life tasks – will continue to exist beyond the pandemic. In fact, this inaccessibility is likely to become exacerbated if health and community services organizations don’t address just how much of their service provision has shifted online, and who is being left out as a result.  In October, the Alliance for Healthier Communities hosted Digital Equity Week, which recounted patients’ and service users’ lived experiences of inaccessibility to health services in an online setting. It also highlighted the need for funding that addresses digital inequity, as is currently happening in the US and the UK, Sankarsingh added.  The Alliance is increasingly focusing on digital access and literacy as a social determinant of health. It is encouraging health, wellbeing and care organizations to be cognizant of how people who are unable to afford a device, don’t have access to a stable internet connection, or don’t know how to use the internet are cut off from health services, thus impeding their human rights to health.  Digital accessibility and affordability also needs to be considered a social determinant of health. Social determinants of health refer to any non-medical issues that impact a person’s overall sense of health and wellbeing. This could include economic factors such as poverty, unemployment or underemployment, as well as social and community factors, such as isolation, living in unstable housing, or not being able to speak the dominant language in a country.  Since a lot of these critical social services – that can lift people out of poverty or precarious housing – are increasingly moving online, a lack of digital access and literacy can prevent people from accessing assistance in a timely manner. That, in turn, can impact people’s sense of health and wellbeing. Digital access should be thought of as a ‘super-determinant’ of health, according to Sonia Hsiung, director of the Canadian Institute for Social Prescribing.  

Towards a nuanced understanding of whose health is impacted by digital inequity 

The Alliance for Healthier Communities had embedded digital equity into its health equity charter in 2019, helping Ontario-based primary health organizations to shift service provision in light of this growing digital inequality. The pandemic only heightened the urgency for health and care providers.  Not only were online appointments out of reach for certain subsets of the population, but places like libraries and Tim Hortons, where people could usually access the internet free of charge, were suddenly closed, Hsiung points out. So for those who couldn’t afford to pay for a device or internet connection in their homes, certain vital services became unavailable.  It’s no surprise that GIS (Geographic Information Systems) mapping carried out by the University of Guelph found that those bearing the brunt of digital inaccessibility are also facing other systemic barriers, Sankarsingh adds.  Health organizations must also be aware of nuances in digital literacy and access, rather than painting certain demographics with one broad brush stroke, says Dr Carmen Logie, the Canada Research Chair in Global Health Inequity and Social Justice with Marginalized Populations. She suggests asking a number of questions about the quality and consistency of an individual’s internet access in order to then be able to tailor health and care services to their needs.  ‘What kind of phone does someone have? Is it a smartphone? How much data do they have, and who pays that bill? How consistently do they use that phone? Is it a shared phone, and to what extent can you share information on it? Are people experiencing extreme poverty and thinking of selling their phones?’  For example, women often aren’t factored in as a social group that is affected specifically by digital inequity, Dr Logie says. But for those in abusive or controlling relationships, their technology access is hindered, preventing text or internet-based interventions from domestic abuse shelters.  Sankarsingh points to a case study of a member organization of the Alliance in Northwest Ontario, where a number of people use drugs and want to stay safe when they do so. Drug users began using an app called Lifeguard to let others in their social circle know that they were going to be using. If they didn’t use the app after a certain time, emergency services would be called immediately.  However, an app doesn’t take into account the nuance of a lot of drug users often also living in poverty, and therefore not being able to afford a smartphone at all. Even if an individual has a phone, Sankarsingh says, they might not have bandwidth from where they are using it to be able to access the service in an emergency.   

Why the digital equity solution includes both more and less technology 

While the internet has certainly helped health organizations expand their services out to hard-to-reach communities, Dr Logie warns that “Technology has a lot of potential, but it will not erase social inequality. Instead, it will exist alongside social inequality.” As the Alliance for Healthier Communities points out in its Digital Equity Strategy, health and care providers need to be able to facilitate both ‘inclusive access’ and ‘meaningful adoption.’ Meaningful adoption means meeting service users where they are, rather than trying to insert overcomplicated technology into an otherwise simple process. It means co-designing a user experience with the people who are most at risk of being left out of digital services.  For instance, as the West Elgin Community Health Centre found, addressing digital inequity is about much more than handing out physical hardware. Funding is also required to support people who can coach and guide people to use those devices meaningfully. The Community Health Centres of Northumberland, who also received a grant from the Ontario Trillium Foundation, put funding towards devices and a project coordinator, discovering that a number of older patients needed personal assistance with how to use the device.  In both of these cases, it became clear that digital access programs also had to factor in users’ existing literacy levels. Only then could health organizations holistically help those struggling to access online services. At the London InterCommunity Health Centre, on the other hand, access and literacy needs go hand-in-hand: the Centre has launched device-lending programs and improved access to lower-priced laptops and computers, as well as becoming a hub for digital literacy and public wifi to facilitate internet access.   

Taking a systematic approach to digital health inequalities 

Hsiung also highlights the work of the Art Gallery of Ontario, who pivoted to offer a telephone walk-through of the gallery during lockdown, to continue tackling social isolation. Although not an organization that is directly involved in the health sector, this is an example of a low-tech solution that can improve service users’ wellbeing regardless.  Health and community organizations certainly cannot bridge the digital divide alone, Sankarsingh emphasizes. “Health organizations can start initiatives to move the needle on digital equity, but they’ll then have to look to partner organizations within the community,” he says. “That could be public libraries, literacy agencies, immigrant agencies, and various other non-profits that have nothing to do with health.”

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