A study published in JAMA Network Open suggests that lack of internet access was associated with higher Covid-19 mortality rates in the United States.
Radio Advisory episode: Digital inequities (and why you shouldn't call it the digital divide)
For the study, researchers at the University of Chicago conducted a cross-sectional analysis of county-level Covid-19 mortality rates reported by CDC. They looked at 3,142 counties across 50 U.S. states and the District of Columbia from Jan. 22, 2020, to Feb. 28, 2021.
To measure multiple dimensions of social determinants of health (SDOH), they created four indexes: socioeconomic advantage, limited mobility, urban core opportunity, and mixed immigrant cohesion and accessibility. Then, they used spatial regression models to analyze the relationship between SDOH and CDC's county-level Covid-19 mortality rates.
Overall, the relationship between SDOH and Covid-19 mortality rates varied across different racial and ethnic groups and across different community types, such as rural, suburban, and urban communities. In total, 489,254 Covid-related deaths were reported in these counties during the study period.
Among the counties included in the study, 531 were identified as "concentrated longitudinal-impact counties," with a high concentration of a single racial and ethnic population and a high Covid-19 mortality rate. Among these counties, 347 (11%) had a large Black or African American population, 198 (6.3%) had a large Hispanic or Latinx population, and 33 (1.1%) had a large non-Hispanic white population.
Overall, researchers found a connection between several SDOH measures—including income inequality, a lack of health insurance, and limited access to care—and Covid-19 mortality that varied across racial and ethnic groups and community types. Notably, they found that areas with limited internet access had higher mortality rates across all community types, especially in urban areas.
The researchers estimated that for every additional 1% of residents in counties who have internet access, between 2.4 and six deaths per 100,000 residentsare preventable, depending on the makeup of a given region's population.
"We believe this finding suggests that more awareness is needed," the study authors wrote. "Populations with limited internet access remain understudied and are often excluded in pandemic research."
"Future research is needed that explores the different dimensions and regional patterns of SDOH to address health inequity and guide policies and programs," they added.
Although many researchers are aware of the connection between lack of internet access and poor health outcomes, most are unsure whether expanded access would adequately improve health outcomes.
According to Susan Paykin, coordinator and co-author of the study, the researchers weren't surprised when they identified the association between low internet access and high Covid-19 death rates. However, she said they were surprised by the strength of the association, as well as its presence in both rural and urban areas.
Notably, Paykin said that none of the other demographic variables the team examined—including socioeconomic status—were significant factors in all three types of communities.
In addition, Paykin noted that there is currently a lot of research that studies broadband gaps in rural areas, "but I think that misses a lot of what's clearly going on in suburban and urban communities. "The study's findings suggest that there is not only an infrastructure problem in rural areas, but an affordability problem in cities as well.
According to Vox, inequitable access to internet is not new. However, "as Covid-19 pushed routine health care provider visits into the telehealth space, people without internet access—many of them already medically underserved—found health care even harder to access."
Ultimately, the expansion of broadband could provide a natural experiment to determine if improved access results in improved health outcomes, Vox reports.
Improving internet access now would have a positive impact that would last beyond the pandemic, Paykin noted. "This almost surely won't be our last pandemic," she added, nor our last public health emergency.
"Broadband internet access acts as a gateway to information and services," said Natalie Benda, a health care informatics researcher. According to Benda, "Broadband internet access should be a public utility," especially given the research that links internet access to better health outcomes. (Lin et al., JAMA Network Open, 3/4; Landman, Vox, 3/16)
Covid-19 illuminated the overwhelming reliance on internet for our daily lives. This exposed some deep-rooted digital inequity. For many Americans, there has been an outsized impact of a lack of internet access.
To be clear, the consequences of digital inequity existed well before the start of the pandemic—employment opportunities, education, and information access have for years been shifting towards a reliance on the internet. Health care organizations have been on a similar journey. Over the past two years, we have seen calls to consider internet access alongside other social determinants of health due to its influence on education, economic stability, and community.
This study provides some of the clearest evidence yet that internet accessibility impacts health outcomes – that alone should continue to push the health care industry to pay attention. But this study also highlights two more nuanced points on digital equity:
This study found that internet access was linked to Covid-19 mortality across rural, suburban, and urban areas. In fact, the impact of lack of internet access on mortality was greatest in urban areas. The fundamental problem is not rural broadband infrastructure: we must also consider factors that impact access to internet in urban and suburban settings, specifically digital redlining and affordability of services.
Controlling for age, education level, socioeconomic status, and other factors did not remove linkage between internet access and mortality. So while lack of internet access certainly does impact social determinants of health such as education, economic stability, and community, it also impacts health in other fundamental ways, such as access to information.
The internet has become one of our main sources of information (alongside television and radio) as countless publications have shifted towards online-only publication. This can leave those without internet access more likely to exist in an information desert, operating with limited access to timely, credible information. And the connection between a lack of information and health is particularly relevant during a pandemic, where guidelines and recommendations can change at a rapid pace.
The health care industry alone cannot solve the large, structural causes of digital inequity. However, this study provides more evidence that the industry must include digital inequity as a social determinant of health. It also demonstrates why our industry needs to rethink our approach to digital health. Given the level of funding flowing into digital health, we must start designing and implementing digital solutions that work for all patients, not just those with access to and the ability to use reliable broadband. Whether this is providing a tablet and mobile hotspot to patients to allow for video visits and RPM or developing platforms that work in multiple languages and provide accessibility options such as closed captioning, the industry needs to ensure its shift towards digital does not further exacerbate health disparities.
To assist you in your efforts to address digital inequity, here is a list of a few of our curated resources:
The Covid-19 pandemic has led to massive digital investments in the health care industry. In this episode, host Rachel Woods sits down with Advisory Board's Ty Aderhold to talk about these investments, what their impact on equity could be, and why you might want to abandon the phrase "digital divide."
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