Including everyone in the digital agenda Nicholas Hardiker Reader, School of Nursing & Midwifery Professor (Adjunct), University of Colorado-Denver, USA.

Including everyone in the digital agenda

Nicholas HardikerReader, School of Nursing & MidwiferyProfessor (Adjunct), University of Colorado-Denver, USAConsultant, International Council of Nurses

Overview• Findings and recommendations arising

from a literature review component of the ‘Including everyone in electronic health information services’ project, funded by NHS Connecting for Health

Aims• To examine literature relating to the use

of eHealth services

• To identify and explore factors (barriers and facilitators) that may influence engagement with those services by the public

Methods• Search terms harvested from exemplar

articles

• Search of MEDLINE, CINAHL, EMBASE – no date restrictions to January 2009

• 2622 unique abstracts returned

• 70 articles obtained, 50 of which met inclusion criteria

Inclusion criteria• Named or identifiable examples of

eHealth services

• Used by the public

• Barriers or facilitating factors influencing use

• Readily and freely available online

• Published in English

eHealth services• Health information on the Internet

• Bespoke online health information e.g. CD ROM

• Online support e.g. online coaching, email lists and online communities

• Telehealth services

Barriers and facilitators• Characteristics of users• Technological issues• Characteristics of eHealth services• Social aspects of use• eHealth services in use

Characteristics of usersBarriers

• Increasing age• Asian/non-white• Not in paid employment• Living in rented accommodation• No access to a PC at home• Lower socio-economic groups• Semi- and unskilled occupations• Lower level of education• Low literacy• Lack of interest or curiosity• Lack of engagement with own health• Poor computer skills and information

literacy

Facilitators/motivators

• White• Professional and managerial

occupations• Higher levels of income• Higher level of education• Longer education• Higher educational attainment• Employed in a health-related

occupation• High literacy• Faith in content• Openness• Engagement and health literacy• Exposure, prior use and familiarity

Technological aspectsBarriers

• No PC at home• Lack of continuity in discussion• High volume of content• Lack of relevance• Security and privacy concerns

Facilitators/motivators

• Internet access• Use of internet at home• Tangible benefits• Fast connection speed• Short log in time

People with potentially stigmatising conditions e.g. epilepsy believe that the potential benefit of having an accessible health record in the event of a seizure outweighs the risk of a third party obtaining unauthorised access to their health record

Few studies identified security and privacy concerns as barrier

Characteristics of eHealth servicesBarriers

• Issues with content – too complicated, too distressing, culture-specific, misleading, etc.

• Mistrust of commercial sites

Facilitators/motivators

• Educational sites• Tailoring of information• Anonymity• Safe, comfortable, non-judgemental,

supportive environment• Empowerment

The lack of a physical presence makes it easier to start discussions on difficult and painful subjects

In one un-moderated list only 10 postings out of a total 4600 postings were either misleading or false. 7 of these were identified and corrected by other participants, typically within less than 5 hours

Social aspects of useBarriers

• Differing opinions (cyber bullying)

Facilitators/motivators

• Part of a community/shared responsibility

• A sense of belonging• Shared experience• Personalised case histories• Social interaction• Emotional support• Reassurance

Reticence in sharing experiences because of not wanting to dwell on illness, nor cultivate a ‘victim-like or competitive environment’ of sharing

eHealth services in useBarriers

• Lack of time• Lack of equipment• Costs• Lack of fit• Lack of usefulness

Facilitators/motivators

• Ease of use• Motivation

Who do we include?• Young, rich, white, highly-educated,

literate, knowledgeable and skilled

Who do we exclude?• Old, poor, non-white, poorly-educated,

illiterate, unknowledgeable and unskilled

How do we exclude people?• Limited exposure and restricted access to

poorly-implemented and difficult to use applications that have no relevance and do not fit with daily life

How could we include people?

• Exposure and ready access to well-implemented and easy to use applications that have relevance and fit well with daily life

Leveller or divider?• Access to health information via the Internet does not

guarantee equity in the use of the Internet to complement the use of health services– For participants adept at using computers and with high expectations

about good outcomes for information utilisation, Internet information enabled them to negotiate better and optimise their contact with services; it empowered them by representing a form of authority

– For participants with less confidence, services were viewed as predetermined and they felt unable through Internet information to alter negotiations or health matters. For this group, information was anxiety-promoting and a source of interference with established ways of coping

Rogers, A. and N. Mead, More than technology and access: primary care patients' views on the use and non-use of health information in the Internet age. Health & Social Care in the Community, 2004. 12(2): p. 102-110.

Recommendations• There should be targeted efforts to engage those who

are underserved by eHealth services due to age, ethnicity, educational attainment and socioeconomic status

• Attempts should be made to maximise exposure to eHealth services across all sections of society, in order to increase familiarity and improve perceptions of usefulness and relevance, thereby maximising potential use

• Maximising exposure to eHealth services includes improved access to computers and the Internet

• There should be a continued focus on the appropriate design and delivery of eHealth services in terms of ease of use and fit with everyday life i.e. time and cost

• Efforts should be made to ensure that the content of eHealth services meets the needs of the target audience for those services (perhaps through a balance between quality criteria for content and information skills training for users). Content should be understandable, relevant and trustworthy to a wide variety of potential users

• eHealth services should capitalise on the continued public interest in social computing and allow users of those services to reap the benefits of online community engagement

• The role of health workers in the delivery of eHealth services, including endorsement and facilitation, should be clarified

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