Transforming lives: Combating digital health inequality

Abstract

For those who are connected digitally, the digital health revolution is an enormous opportunity for patient empowerment. However, half the world’s population are not online. Those who are least likely to be online are exactly those who experience the greatest burden of ill health. As information about health and illness is increasingly (and often exclusively) available in digital form, we face a new public health challenge – digital health inequality. Libraries are ideally placed to reach these population groups who may be hardest to reach. The IFLA (2017) Statement on Digital Literacy recognises that with libraries’ mission to help all their users access and apply the information they need for personal and community development, digital inclusion is an important part of the practice of librarianship. Successful interventions to improve digital inclusion involve targeting connecting, and transforming lives. This article focuses on initiatives to combat digital exclusion in England and Wales.

Keywords

Consumer health information digital inclusion digital literacy health inequalities health literacy library outreach social deprivation

Introduction

A revolution in digital health is going on all around us. 80% of Internet users regularly search for health information (Amante, 2015; Fox, 2011). One in 20 Google searches are for health content (Gibbs, 2015). Over 300,000 apps are available to support self-diagnosis and self-management (Pohl, 2017) – 47,000 health apps are available in the Apple App Store (Statista, 2018) with even more for Android.

Patients are being helped to make decisions and navigate healthcare systems through apps and decision aids. Electronic transactions such as appointment bookings, repeat medication and access to online personal health records are increasingly the norm in developed healthcare systems. Remote consultations using Skype and other video technologies are improving access and convenience, particularly for those less able to travel. Artificial intelligence is driving increasingly sophisticated symptom checkers and diagnostic advice tools. Consumer technologies and networks are being used to encourage healthy behaviours and long-term lifestyle change through coaching, motivational reminders, and communities of like-minded people (Topol, 2012).

Access to consumer health information online has been associated in a number of studies with a range of positive health outcomes, including empowerment of people in their own healthcare and greater involvement in shared decision making (Pluye, 2019).

The World Health Organization recognises the potential of digital technologies to advance sustainable healthcare development, and in particular to support health systems in all countries in health promotion and disease prevention, and by improving the accessibility, quality and affordability of health services.

In May this year, the World Health Assembly adopted a Resolution on Digital Health (WHO, 2018) with 11 actions to drive forward digital health adoption. It is encouraging that WHO sees digital inclusion of citizens as central to achieving the benefits of digital health. One of the 11 actions urges member states to:

Improve the digital skills of all citizens, including through working with civil society to build public trust and support for digital health solutions, and to promote the application of digital health technology in the provision of, and access to, everyday health services.

Leaving nobody behind

The US institute Pew Research sought the views of 2500 experts and members of the public on what our digital life would be like in in 2025 (Anderson and Rainie, 2014). They concluded:

In ten years the internet will be readily available, everywhere, at low cost – embedded in people’s lives for good & ill. The greatest impact will be on personal health. Health care will become self-administered. We will detect, monitor, diagnose, get advice & treatment, through mobile, wearable & implanted network devices.

But despite these exciting opportunities there is a significant challenge:

We risk a dangerous divide between the digital haves & have-nots. Networked transactions may benefit smaller & smaller segments of the global population.

The challenge for healthcare services in the 21st century is to ensure that nobody is left behind in this digital health revolution. Of EU citizens 76% go online weekly – but this still means a quarter of the European population do not. In Europe 63% of disadvantaged people use the Internet weekly, with older people (53%) and less educated (55%) still further behind. Lack of use and access to digital resources (often called digital exclusion) is closely related to social deprivation and health inequalities. Among Europeans 47% have insufficient digital skills to make best use of websites, apps and tools. Amongst socially disadvantaged people this rises to 64% (European Commission, 2017).

In the USA, 89% of the population are online, and 11% are not. Age is the most likely indicator for people not using the Internet. Use of the Internet is almost universal in the young population (98% of 18–29 year-olds) but falling to 66% of over 65s. Household income and education are also indicators of a person’s likelihood to be offline. Roughly one in three adults with less than a high school education (35%) do not use the Internet. Adults from households earning less than $30,000 a year are far more likely than the most affluent adults to not use the Internet (19% vs. 2%). Rural Americans are more than twice as likely as those who live in urban or suburban settings to never use the Internet. Racial and ethnic differences in Internet use are becoming less significant, and today, whites, blacks and Hispanics are all equally likely to be offline (Anderson et al., 2018).

Worldwide, the United Nations has a sustainable development goal of affordable Internet access for all by 2020. The UN’s Broadband Commission for Sustainable Development predicted in 2014 that half the world would be online by 2017. In fact, the pace of digital adoption has slowed so that this will not be reached until the middle of 2019 (Sample, 2018). Not only is half the world not online, but there are stark variations: 98% of the population of Iceland have accessed the Internet but only 1.2% in Eritrea and 1.9% in Somalia. Women in low income African countries are the least likely people in the world to be online – yet women are traditionally the main caregivers in families, responsible for everyday healthcare of children and older relatives, as well as for their own health (Alliance for Affordable Internet, 2018).

Those who are least likely to be online are exactly those who make the most use of health services and experience the greatest burden of ill health (older people, people with low incomes, people with long term conditions and disabilities). The rapid growth in digital technologies brings transformative opportunities. Benefits to patients and to health care systems include more involvement of patients in their own care, more convenience and time savings, reduced costs, and better health outcomes (Imison, 2016). But this transformation also threatens to deepen the digital divide between the active users capable of exploiting ever improving technologies, and those who struggle to overcome the barriers to getting online. These digitally excluded people are in danger of being left behind in society, as more and more services, including healthcare services, go online.

The inverse care law was set out by Tudor Hart (1971), who argued that the availability of good health care varies inversely with need. The inverse care law was proposed in the pre-digital world. Today, as healthcare systems progress their digital transformation agenda, there is a real danger of a new digital inverse care law whereby those citizens most in need of accessing new digital services will be left behind again, due to their lack of digital skills and access.

With information about health and illness increasingly (and often exclusively) available in digital form, digital literacy is a key precondition of health literacy. Increasingly this is a public health challenge: low health literacy is closely linked to poor health outcomes and mortality (Kickbusch et al., 2013). Libraries are ideally placed to lead the response to this challenge

Digital inclusion and digital literacy

‘Digital inclusion’ is the term most commonly used in the UK for people being able to use digital technologies, particularly the Internet, in ways that enhance their lives and help them overcome disadvantage. The term is often used interchangeably with digital skills, digital participation, digital competence, digital capability, digital engagement, digital literacy, etc.

IFLA uses the term ‘digital literacy’ to describe the ability to harness the potential of digital tools. IFLA promotes an outcome-orientated definition – to be digitally literate means one can use technology to its fullest effect – efficiently, effectively and ethically – to meet information needs in personal, civic and professional lives (IFLA Statement on digital literacy, 2017).

The three main barriers to digital inclusion are:

Lack of skills

Lack of access

Lack of motivation

Today many more people are using digital technologies, helped by cheaper equipment, easier to use touch-screen interfaces and faster broadband speeds. This is leading to a reappraisal of what we mean by these barriers.

Where once by ‘digital skills’ we meant the basic skills of carrying out a search or setting up an email account, we are now more likely to mean information literacy skills – being able to distinguish good quality health information from ‘fake news’. Where once by ‘access’ we meant owning or being able to use a device, we are now more likely to mean having sufficient data on a mobile phone contract, access to free wi-fi or high-speed broadband.

These barriers of skills and access still exist for significant numbers of people, preventing them from participating with the digital world. But today lack of motivation, confidence and trust can be the most significant factor preventing a person moving from a reluctant, single-purpose user to someone who truly reaps the benefits of being online.

Data from the Lloyds Bank (2018) Consumer Digital Index in the UK suggests that for the core of those who are not online, lack of interest in what the Internet can do for them is now the major barrier. It seems that too often digital services are not sufficiently compelling and meaningful for them to overcome concerns including privacy and security. See Table 1.

Table 1.

Reasons for not using the Internet.

Source: Lloyds Bank (2018) Consumer Digital Index.

Challenging assumptions

In the UK over 11 million people lack the basic digital skills they need to use the Internet effectively. And over 4 million people never go online at all (Lloyds Bank, 2018). Some sections of the population are more likely to be digitally excluded than others. These are:

older people – 51% of digitally excluded are over 65;

people in lower income groups – 45% of digitally excluded earn less than £11.5k a year;

people without a job – 19% of digitally excluded are unemployed;

people in social housing – 37% of digitally excluded are social housing tenants;

people with disabilities – 56% of digitally excluded have a disability or long-term condition (and 22% of adults with a disability have never been online);

people with fewer educational qualifications – 78% of digitally excluded left school before 16;

people living in rural areas;

homeless people;

people whose first language is not English.

These characteristics of an older, poorer, less educated, rural population who are offline are still predominantly true but the picture is beginning to change. Our assumptions about who is, and is not, online have been challenged in the UK by a timely blog by Scobie and Schlepper (2018) for the Nuffield Trust which tests some of the received wisdom about digital exclusion and health against available data for the UK.

Assumption: Older people do not use digital technology

Facts

Older people are less likely, but the gap is narrowing (although less so in over 75s). Awareness of online primary care services, such as the ability to book an appointment or order repeat medication, is actually highest in the 64–75 age group. And over a fifth of people in this older age group do order repeat medication online – the age group most likely to.

Assumption: Digital services are less accessible to people with complex needs

Facts

Awareness and use of online primary care services by people with disabilities and long-term conditions is similar, or higher depending on the condition, than for people without. But there are important exceptions, including people with learning disabilities, dementia or sight impairment for whom both awareness and use of online services are lower.

Assumption: Ethnic groups are digitally excluded

Facts

Among younger age groups, Internet use is similar between different ethnic groups. Non-white groups have lower rates of use for people over 65. However overall use of the Internet is actually lowest among white people, reflecting the older age profile of this group.

Assumption: Internet access is worse in rural areas

Facts

There are certainly low levels of digital inclusion in rural areas, due particularly to poor broadband infrastructure and older populations. But some of the worst digital exclusion is still in some urban areas, reflecting worse levels of deprivation.

In July 2018, the Centre for Ageing Better published an important and thought-provoking report on new approaches to supporting people in later life to get online (Mouland, 2018). People in later life stand to benefit hugely from being online – to improve health and wellbeing, save money and keep in touch with family and friends. However, there remains a core of people in later life who are not online and have no intention of getting online. When asked what would prompt them to go online, 74% of people over the age of 65 responded ‘nothing’.

Ageing Better funded Good Things Foundation to conduct research to understand what enables and prevents people in later life from getting online – focusing specifically on people in later life who have never used the Internet, those who used to but have now stopped or those who have limited usage. The report concluded:

Not using the Internet and being digitally excluded are not the same thing. Some people make a reasoned decision not to be online;

We need to move on from a focus on basic digital skills to building confidence and motivation to do things online that matter to people;

We must measure success by outcomes (including health outcomes) rather than just numbers of people attaining basic digital skills.

Digital inclusion for health: National programmes in UK

England

There have been consistent policy commitments to digital inclusion in England for several years, as set out most recently in the Government Digital Inclusion Strategy (UK Government, 2014). The Department of Health and Social Care’s (2018) vision for digital health, The Future of Healthcare recognises the challenge of delivering an equitable service through digital channels:

Health and care services are for everyone. We need to design for, and with, people with different physical, mental health, social, cultural and learning needs, and for people with low digital literacy or those less able to access technology. We must acknowledge that those with the greatest health needs are also the most at risk of being left behind and build digital services with this in mind, ensuring the highest levels of accessibility wherever possible.

Furthermore, the new NHS Long Term Plan (2019) sets out the vision:

People will be empowered, and their experience of health and care will be transformed, by the ability to access, manage and contribute to digital tools, information and services. We will ensure these technologies work for everyone, from the most digitally literate to the most technology averse, and reflect the needs of people trying to stay healthy as well as those with complex conditions.

And the recent review by Topol (2019: 23) of the digital skills of the healthcare workforce reminds us that digital inclusion is a vital equalities issue:

The NHS is founded on a commitment to the principles of equal and equitable access to healthcare for all UK citizens. Yet use of digital healthcare technologies could undermine these principles by exacerbating inequalities, unless consideration is given to how they affect equality and equity, including the risk that vulnerable groups might be excluded or exploited.

With the rapid growth in digital health products and services, particular attention is now being given to the quality and evidence base of digital technologies. The National Institute for Health and Care Excellence (NICE, 2019) has produced Evidence Standards Framework for Digital Health Technologies. The aim of the standards is to make it easier for innovators and commissioners to understand what good levels of evidence for digital healthcare technologies look like, while meeting the needs of the health and care system, patients, and users.

For the past five years in England a National Health Service (NHS) programme called Widening Digital Participation has been mobilising libraries and other community organisations in socially deprived communities to teach digital skills for health, supporting people who may never have used the Internet to get online to take more control of their own health.

NHS England has worked in partnership with a social enterprise, Good Things Foundation, which specialises in supporting digital inclusion and the development of digital skills for socially deprived people. Good Things Foundation coordinates a network of Online Centres where people who lack digital skills or confidence in using online resources can use computers in a supported environment and gain online skills: 96% of public libraries are part of the Online Centres network, which also includes community centres, health centres, sheltered housing schemes – even a fish and chip shop.

Through the Widening Digital Participation programme, two simple online courses have been developed on the LearnMyWay platform (www.learnmyway.com/what-next/health). The first introduces people with limited digital skills to health information using the NHS website (www.nhs.uk). The second covers online health transactions including booking a doctor’s appointment or requesting repeat medication online.

Over the three period 2013–2016, 400,000 people were engaged in the programme through events, workshops and online access to health information resources. Of these 220,000 have been trained in using digital health resources with support in a library or other community setting.

Following the success of the initial three-year Widening Digital Participation programme from 2013–2016, the NHS committed to further action to combat digital inequality in the period to 2020. At the end of 2015, the Secretary of State for Health in England asked the Internet pioneer, digital champion and Twitter board member Martha Lane Fox to advise on next steps to accelerate digital take-up and reduce digital exclusion. Her recommendations (Department of Health, 2015) called on the NHS to:

Provide accessible, free of charge, infrastructure (wi-fi) throughout all NHS premises to enable patients and carers to access digital tools and technologies at point of care;

Build the digital skills capability of the NHS workforce at all levels (from leadership to front-line) so staff have the knowledge and motivation to act as digital champions, supporting and encouraging take-up of digital services;

Embed digital inclusion in all areas of NHS work, nationally and locally, with ‘reaching the furthest first’ a core principle of all we do. If we can get digital health services right for the hardest to reach groups they will be right for everyone.

Following these recommendations, the Widening Digital Participation programme was extended in 2017, again working with Good Things Foundation. In this second phase there has been a shift away from a focus on digital skills to a discovery and service design approach, which aims to build a better understanding of the barriers to digital inclusion, and to co-design and test solutions with service users.

To provide evidence for the second phase of the programme, a data driven mapping exercise was undertaken. Using the Digital exclusion heatmap (Tech Partnership, 2017) areas of the country with the highest levels of digital exclusion were identified. These were then mapped against data on health inequalities and deprivation (Public Health England, 2017). This enabled prioritisation of localities with both high levels of digital exclusion and health inequalities. On the whole there is a strong correlation between the two – but not always. For example, inner city London has high health inequalities but digital inclusion is good with a young population and good broadband connections. On the other hand, some rural areas have poor broadband and an older population but often better health status.

The data mapping provided the evidence base for identification of sites for Widening Digital Participation Pathfinders. These have now been developed with the involvement of local health and care organisations. The Pathfinders involve working intensively with particular user groups in socially deprived localities to investigate their use of digital health services and information, and how they can best be supported. Up to 20 Pathfinders will be funded, with 11 live to date:

North London – young people with mental health issues;

Sheffield – using social prescribing to refer patients to digital training;

North Somerset – developing a high street healthy living hub;

Stoke – people with long-term conditions;

Bradford – young people as carers;

Wakefield – hearing and visually impaired people;

Hastings – homeless and insecurely housed people;

Sunderland – isolated older people

Thanet – people in social housing;

Dorset – maternity care, particularly with traveller families;

Blackpool – users of accident and& emergency services.

The Pathfinder work is carried out transparently and can be followed on the programme’s Digital Health Lab (Good Things Foundation, 2018a) which includes blogs, case studies, reports of design sessions, and practical how-to-guides capturing learning. Emerging findings include:

Although young people are generally digitally confident and use digital tools in their everyday lives, they do not always find digital health resources relevant and meaningful. They are more likely to use health information, apps, etc. if they are involved in their design and development.

Today older people are often using digital channels such as Skype and Facebook to keep in touch with friends and family. They can be surprisingly ready to use these channels for virtual consultations if they provide convenience (e.g. avoiding need to travel).

Homeless people often have devices (particularly mobile phones) and often have the skills to use them. Their needs can be more basic – a dry, safe, non-judgemental place where they can charge their phone and get online using free public wi-fi.

The Widening Digital Participation programme has also produced a Guide to Digital Inclusion (Gann, 2018a) for local health and care organisations. The Guide provides practical advice on establishing the extent of digital inclusion locally, commissioning and evaluating digital inclusion support, benefits and business case, and partnership working. The content of the Guide was researched through a programme of engagement with health and care organisations, and an agile approach was taken to development with user feedback on alpha and beta versions before the Guide was published online in May 2018.

Wales

Wales has an impressive record in tackling digital exclusion, both in policy and practical action. The Welsh Government’s (2016) Delivering Digital Inclusion: A Strategic Framework for Wales has an ambitious 15-point delivery plan, and a Digital Inclusion Charter. A dedicated national digital inclusion programme, Digital Communities Wales, is being delivered by the Wales Co-operative Centre. A new Digital Competence Framework (Welsh Government, 2018b) is in place in all schools, equipping pupils with the skills they need to be digital citizens in the modern world. Superfast Cymru is bringing broadband access to rural communities which would otherwise miss out.

There are many examples of digital inclusion good practice and innovation in health and care settings, particularly through Digital Communities Wales (Welsh Government, 2018a). In particular, Wales is leading the way in intergenerational support. Through the Digital Heroes initiative, schoolchildren befriend older people in care homes and introduce them to digital technology, often with inspiring and transformative results.

More than 75% of women and a third of men over 65 in Wales live alone, and a quarter say they are lonely. The cost of social isolation and disconnected communities in Wales has been calculated at £2.6bn per annum (National Assembly for Wales, 2017). Through Digital Communities Wales, people who would otherwise be lonely and isolated are being supported to get online so that they can keep in touch with friends and family. Under the Ffrind i mi (or Friend of mine) initiative, Community Connectors befriend anyone who feels lonely or isolated so they can reconnect with their communities

Technologies (including VR headsets) are being used to enable people with dementia to connect with positive memories). Reminiscence sessions in care homes for staff, families and people with dementia, are using digital media (Internet, tablet computers) to help people compile their own life stories.

Digital Communities Wales has also recognised a powerful link between people’s motivation to improve both their digital skills and their physical activity. People in a number of settings (housing association tenants, women’s fitness group, stroke survivors, workforce) have been loaned Fitbits and shown how to use technology in a fun and informal way.

Remote health care through Skype and online consultations has particular potential in Wales, saving people journeying to hospital where there is often poor rural transport. Digital inclusion support has been shown to create the right conditions for frail older people to use virtual consultations in rural areas (Williams et al.,2017).

A recent report on Digital Inclusion in Health and Care in Wales (Gann, 2018b) reviews good practice in Wales, and makes recommendations for future action. In response the Welsh Government has made a new allocation of £3m for a new digital inclusion for health and social care programme from 2019.

In England and Wales we have driven forward digital inclusion through:

Targeting: using evidence-based, data mapping approaches to identify localities with the greatest health deprivation and low digital adoption so we can focus our efforts;

Connecting: working with some of the most digitally excluded people in their own spaces, including homeless people and people in long stay mental health units;

Transforming: carrying out qualitative and quantitative evaluation with compelling case studies showing the transformative impact of gaining digital skills for individuals, and evidence of significant benefits and cost savings to the health care system.

The role of libraries

Despite the adverse impact of widespread public library closures – 499 libraries closed in the UK between 2012 and 2017 (Onwuemezi, 2017) – libraries remain a crucial community asset for both health promotion and digital inclusion. Libraries are trusted community spaces, whose unique benefits include assisted digital access, health information resources and services, and the volunteering and recreational opportunities they provide. They can deliver a range of health and wellbeing benefits to local communities including those who may not normally access other services.

In August 2017, IFLA issued a Statement on Digital Literacy. As the Statement asserts, digital technologies have dramatically transformed our lives but not all can take full advantage of the opportunities created to receive, apply, share and create information. Just as basic literacy – the ability to read and assimilate information – is essential for individuals to participate and flourish in society, realising the potential of digital technologies for personal and community development requires everyone to have the necessary knowledge, skills, attitudes and behaviours.

Given libraries’ mission to help all their users access and apply the information they need for personal and community development, this is an important part of the practice of librarianship. The Statement sets out the case for action, defines digital literacy, and makes recommendations to governments and other stakeholders. It also includes examples of library programmes supporting digital literacy in Tampere, Finland; Melbourne, Australia; San Antonio, USA; and Western Cape, Australia.

The American Libraries Association has held a Digital Inclusion Summit leading to the report After Access: Libraries and Digital Empowerment (Clark and Perry, 2015). The report recognises the central role of libraries in building digitally inclusive communities, ensuring that nobody is left behind in the digital revolution. The report includes valuable summaries of activities carried out by libraries in partnership with other community organisations.

England

The Society of Chief Librarians (now Libraries Connected) has developed a set of Universal Offers, including a Universal Health Offer and a Universal Digital Offer. The Universal Health Offer (Libraries, 2017b) includes a commitment for public libraries to provide a range of services including:

Creating Reading Well self-help reading lists and book collections in libraries covering key areas of health and wellbeing such as mental health, dementia and long-term conditions;

Signposting and referring the public to information and local services who can provide advice and support;

Providing creative and social reading activities for a range of targeted groups such as dementia sufferers, teenagers and older people.

The Universal Health Offer includes the Reading Well programme, developed with the Reading Agency. Reading Well promotes the benefits of reading for health and wellbeing, and includes Books on Prescription and Mood Boosting books.

The Universal Digital Offer (Libraries Connected, 2017a) aims to narrow the digital divide between those who regularly access information online and those who do not by:

Ensuring that all public libraries offer a basic level of digital service to the public, to include free wi-fi, computers and online information about library services;

Working to develop staff so that they have the skills to help customers who do not normally access information and services online;

Identifying significant digital developments and highlighting how public libraries and their leaders should respond.

Libraries have been key partners in supporting digital inclusion through the NHS Widening Digital Participation programme. In Southampton, the city library service worked with Macmillan Cancer Support to improve the digital and information literacy skills of people with cancer, and introduce them to high quality cancer information resources. (Tinder Foundation, 2015).

NHS library and knowledge services, while primarily focused on the knowledge and information needs of healthcare professionals, have also recognised their vital role in supporting patients, carers and the general public. Knowledge for Healthcare (2018) has produced a vision statement which includes:

Healthcare library and knowledge services…work in partnerships with key stakeholders to enrich the information offered to patients and carers, to enable people to better manage their health and wellbeing and make fully informed decisions about their treatment and care.

Knowledge for Healthcare has also produced an Ideas Bank with practical examples of how healthcare libraries can contribute to patient information activities.

Wales

The quality framework for Welsh public library standards, Connected and Ambitious Libraries (Welsh Government, 2017), introduced a specific quality indicator for health and wellbeing. Libraries must ensure that the following are offered in all static service points open for 10 hours a week:

Books on Prescription Wales;

Better with Books Scheme;

Designated health and wellbeing collection;

Information about healthier lifestyles;

Signposting to health and wellbeing services.

And must report on the number of service points where the following are available:

Macmillan Cancer or other health information partnerships;

Dementia friendly services;

Mental health awareness services.

Public libraries in Wales have been working with Digital Communities Wales to provide digital skills training and support information literacy. A half-day digital inclusion training course has been developed for staff and volunteers in libraries, as well as a fuller two-day digital champions course. Many libraries in Wales are now holding Digital Fridays, where users are introduced to digital technology and tools.

For example, during 2018 Newport Libraries delivered two health-related pilot projects, in partnership with a social housing association and the mental health support organisation MIND. Tea & Tech sessions for social housing residents were based around using the Internet to look at ways of improving health and wellbeing, visiting recognised safe sites for support and guidance. Users had the opportunity to complete an online health assessment form and to be signposted to support groups that could give information on their condition. The project with MIND started in August 2018, encouraging the use of apps to support health and wellbeing. As apps are becoming more popular the Library Service is beginning to promote their use within the digital literacy support programme.

Kenya: UK partnership

In addition to working in the UK, specialist digital inclusion organisations are helping to support digital literacy in other countries. Digital health in Kenya is in its infancy. High costs of digital health systems, poor infrastructure in rural areas and low digital literacy of the population are all barriers to digital health adoption. However, submarine fibre optic cables and connection of major towns to broadband has led to marked improvements in infrastructure.

The real game changer is mobile. Mobile subscriptions in Kenya have surged from 330,000 in 2001 to 38 million in 2016, in a country with a population of nearly 45 million. Many Kenyans have skipped a technological generation, with mobile bringing many online who have never had access to desktop machines or fixed-line broadband (Mutiga and Flood, 2016).

The Kenya National e-Health Policy 2016–2030 aims to ensure that health services are electronically accessible to patients at all levels of the economy, with objectives which look familiar to healthcare systems in other countries:

Ensure that health information on the eHealth platforms for patients and physicians is multilingual, multicultural, multi-professional, and multijurisdiction;

Ensure affordable broadband Internet connectivity to all parts of the country to enable online access to eHealth services and information;

Ensure that services are offered across a variety of eHealth access platforms including but not limited to mobile devices and community digital centres;

Facilitate the use of telemedicine by caregivers in geographically isolated communities to provide healthcare services;

Promote cross-border sharing of health information about the medical incidences and history of a particular patient by healthcare professionals without compromising his/her privacy.

Last year, a new project to help develop digital literacy was launched by the UK-based Good Things Foundation in partnership with the Kenya National Library Service. Digital Life: Kenya (Good Things Foundation, 2017) has been working with librarians to develop their digital skills, which were often low, so that they could act as digital champions with library users. Libraries are now providing outreach sessions to teach digital skills, with over 60 libraries in the scheme.

At Kinyambu Library, over 50 library users have registered on the Learn My Way online digital skills learning platform. The library now runs a Community Digital Club on Saturdays. Some library users have successfully found jobs after completing Learn My Way.

The Kenya National Library Service has been sponsored by a development corporation to provide laptops and wi-fi, with 640 new devices provided along with local cabling. There are also successful partnerships with international agencies including Book Aid International and EIFL (Electronic Information for Libraries).

Measurable benefits of digital inclusion

Digital inclusion is a social and moral imperative, but there are also compelling economic reasons. Evaluation of the Widening Digital Participation programme in England has produced very encouraging results with people trained in digital skills through libraries in socially deprived communities showing greater confidence in managing minor ailments, reduced dependence on health services and improvements in lifestyles (Tinder Foundation, 2016).

Results include

82% of learners were socially disadvantaged and likely to be experiencing health inequalities;

41% of learners learned to access health information online for the first time;

54% of learners would now go online for non-urgent medical advice;

52% of learners now feel less lonely or isolated.

The impact on primary care services was particularly encouraging. One in five of people trained can now book appointments with their general practitioner (GP) online and one in five now order their medication online, saving time and cost for themselves and the NHS. And one in five (21%) say that because they now know how to access online health advice, they now make fewer visits to their GP for minor ailments: 6% say the same about fewer visits to hospital accident and emergency departments. Good Things Foundation has calculated that this represents an annual cost saving to the NHS of £6m in avoided GP and A&E visits – paying for the £1m annual cost of the Widening Digital Participation programme six times over.

The level of savings for the NHS has now been revised in a report from Cebr: Centre for Economics and Business Research, The Economic Impact of Digital Inclusion in the UK (Good Things Foundation, 2018b). Cebr calculate savings to the NHS through individuals learning digital skills and so being able to use the NHS website for self-care advice, as well as booking appointments and requesting prescriptions online. These amount to savings of £141m by 2028 through reduction in GP visits and reduction in use of offline services. Reduction in avoidable GP consultations alone could save £10m within a year.

Of course, increasing digital inclusion has benefits for society as a whole as well as for the NHS. It is important to take these benefits into consideration when considering the impacts for public health. Analysis of Scottish data carried out by Ipsos MORI for Carnegie UK Trust (White, 2016) illustrates the wider societal benefits how Internet use is associated with better health and wellbeing. Those who use the Internet are more likely to have:

been to a cultural event;

visited outdoors for recreation;

taken part in sport;

volunteered.

Conversely those who are not online are more likely to have visited their doctor once a month or more.

There is a particularly strong benefits opportunity in digital inclusion relieving loneliness and isolation. The National Assembly for Wales (2017) Inquiry into Loneliness and Isolation includes powerful evidence on the impact:

There is a strong link between loneliness and depression. 60% of older people who report being depressed also say they are lonely.

Lonely and isolated people tend to smoke and drink more, have a poorer diet, and skip medication.

Falls among lonely and isolated people tend to go unnoticed and unreported.

Lonely and isolated older people are at an increased risk of dementia.

The cost of social isolation and disconnected communities in Wales has been estimated as £2.6bn per annum, which included:

£427m – demand on health services;

£10m – demand on policing;

£8m – cost of stress and low self-esteem

Disconnected communities are linked to a loss of productivity, with a net cost to the Welsh economy of over £1bn every year. Economic modelling of the cost effectiveness of actions to reduce loneliness to promote better mental health carried out for Public Health England and submitted as written evidence to the National Assembly for Wales (2018) Inquiry into Loneliness and Isolation ‘concludes conservatively that substantial costs to health and social care systems potentially may be avoided if poor health associated with loneliness can be avoided’. This modelling suggests that these costs conservatively may be in the region of £1700 to £6000 per case of loneliness avoided over a 10-year period for people aged 65–75.

If people are online they have better opportunities to keep in touch with friends and family, so reducing loneliness and isolation. The Widening Digital Participation evaluation in England showed 52% of people provided with digital inclusion support felt less lonely and isolated. Work in Wales to combat loneliness through improved digital adoption, including Digital Heroes, is demonstrating a significant return on a very small investment.

Conclusion

Universal access to digital health tools and services, with the skills to use them, has the potential to be one of the great public health advances of the 21st century. The great public health advances of the 19th century came not from medicine but from infrastructure improvements in housing, water supply and sewers. In the 21st century, those who lack access to the public utility of the Internet will, like those who lacked access to the public utility of clean water and sanitation in the 19th century, be at risk of increasing inequality and poorer health status. Libraries are on the front line in combating digital health inequality. In an era of austerity, libraries are having to justify their role. Today, they are showing the way as agents of equality – bridging the gap between the digital haves and the digital have-nots.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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