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What is the nature of the digital health divide in the UK?

Background
In the UK there is considerable effort being put into enhancing digital services for healthcare. Digital first describes a commitment by NHS England to prioritising the uptake of digital solutions in healthcare (Young and Wilkins 2013). There is a similar commitment in Wales with the development of Health services for a digital age (NHS Wales Informatics Service 2013). Much of this is driven by a belief that the use of technology will help , as described in the Welsh Primary Care Strategy paper Setting the Direction, citizens to develop confidence in their ability to manage their own health through improved information, knowledge and self-care (Jones 2010). But is this belief justified? As a practicing GP changes in the use of technology to support healthcare will impact on my daily practice, and as a medical educator, we must consider how to prepare medical students and other health professionals to work in these ways this is of particular concern to me. The health burden is not distributed evenly throughout the population. Those who are poorer, with lower levels of education, and living in deprived areas are significantly more likely to have chronic diseases such as diabetes and hypertension (Mackenbach, Looman et al. 1996, Power and Matthews 1997, Frohlich and Potvin 2010). Chronic conditions are also more likely with increasing age (Freid, Bernstein et al. 2012). So to make most impact, digital health interventions would need to be well used by older populations, and those in poorer socio-economic circumstances. However, when the use of digital health services is examined the opposite is more likely to be found. For example, the service Renal PatientView, an online portal for UK patient with kidney disease, has disproportionately higher access by younger and more highly educated patients (Bartlett, Simpson et al. 2012). Similarly in the North West of the United States, poorer patients were less likely to use an online electronic health record. In California, analysis of the use of a patient portal to improve the care of patients with diabetes found that those with no college degree were more than twice as likely to never log on that those who did have a degree (Sarkar, Karter et al. 2011); leading the authors to conclude that most at risk for poor diabetes outcomes may fall further behind as health systems increasingly rely on the internet and limit current modes of access and communication. Differential access to the benefits of online communication and tools has been called the digital divide. Initially perceive as being a divide in internet access (Hoffman, Novak et al. 2000), the divide is now more likely to also be constructed in terms of skills and usage of the Internet to enhance everyday life. If patients who have the greatest burden of ill-health do not engage as much online, will expectations of initiatives such as Digital First be delivered? Fifteen years ago it was suggested that those most likely to have preventable health problems are least likely to have access to information and communication technologies (Eng, Maxfield et al. 1998). The authors called for reducing the information divide then so that we might be closer to the health equity in this century.

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So far I have discussed the evaluations of digital health projects which seem to show that this digital health divide still exists. Several population studies have also been published exploring who is online and seeking health information. These include studies from France (Renahy, Parizot et al. 2008), Italy (Siliquini, Ceruti et al. 2011), seven European countries (Andreassen, Bujnowska-Fedak et al. 2007), and the United States (Rice 2006, Lustria, Smith et al. 2011). In general higher levels of education , income and younger age is associated with increased likelihood of Internet access (Dutton, Blank et al. 2013, White and Selwyn 2013). In a population study in Paris it was found that after adjusting for these factors having a current health problem made Internet access less likely(Renahy, Parizot et al. 2008). For those who are online, the strongest predictors of seeking health information are being female (Rice 2006, Andreassen, Bujnowska-Fedak et al. 2007, Renahy, Parizot et al. 2008, Atkinson, Saperstein et al. 2009, Lustria, Smith et al. 2011, Siliquini, Ceruti et al. 2011), higher levels of education (Rice 2006, Andreassen, Bujnowska-Fedak et al. 2007, Renahy, Parizot et al. 2008, Lustria, Smith et al. 2011, Siliquini, Ceruti et al. 2011), and having a chronic condition or current health condition (Rice 2006, Andreassen, Bujnowska-Fedak et al. 2007, Renahy, Parizot et al. 2008, Siliquini, Ceruti et al. 2011). Although general Internet access in the UK is well studied through the biennial Oxford Internet Study (Dutton, Blank et al. 2013) in particular, I could not identify any UK population study which looked at accessing online health information. A web-based study of the users of NHS Choices ( a general health information website) found that they were younger, more likely to be female and have higher levels of education that the UK population in general (Powell, Inglis et al. 2011) In the absence of a published population study addressing them I would like to use an existing UK dataset to answer the following two research questions. 1. What is the association between socio-economic and demographic factors (age, sex, education, and household income), health status and using the Internet? 2. For those who have used the Internet in the last 3 months what is the association between socio-economic and demographic factors (age, sex, education, and household income), health status and using the Internet to seek health-related information? In their Parisian study Renahy, Parizot et al. (2008) describe a double divide in health information seeking on the Internet whereby the socio-economic factors which predict Internet access, are also associated with accessing health information when online. This paper will explore whether parts of the UK population also face a double whammy digital divide.

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Methods Choice of Data Set

To explore internet use in the UK and particularly engagement with online health information several datasets are available. The Opinions and Lifestyle Survey, formerly known as ONS Opinions Survey or Omnibus, is a monthly survey carried out across Great Britain of those ages 16 and older(UK Data Service 2013). In the months of January, February and March it includes a module on internet access. Since 2008 this has included a question about whether or not in the past 3 months the respondent has used the internet to obtain health information. In total 2925 interviews were conducted in 20143 with response rates of 57%, 53% and 51% in January, February and March respectively. The Oxford Internet Survey is a biennial survey carried out by the Oxford Internet Institute since 2003. All but the most recent dataset is available to researchers who wish to access it. At the time this essay was commenced only the 2009 dataset was available. This interviewed 2013 respondents with a 62% response rate (Dutton and Blank 2011). I decided to use the ONS Opinions and Lifestyle Survey as it was the most up-to-date dataset which was available to address the research question. As this is an individual level analysis weighting (Wta) has been applied.

Outcome variables
Two outcome variables have been explored. The first is internet use within the last 3 months. The original survey questions asked When did you last use the Internet?. Possible responses were within the last 3 months, between 3 months and a year ago, more than a year ago and never. A preliminary analysis established that less than 3% of responses were between 3 months and a year ago or more than a year ago. Responses were then recoded in to a new dichotomous variable Have you used the Internet in the last 3 months? The second outcome variable constructed was the dichotomous variable In the last 3 months have you used the Internet to see health-related information? This was recoded from a multiple response variable asking about purposes for which the Internet had been used in the last 3 months, including seeking health-related information.

Independent Variables Socio-economic and demographic

The following variables were used: Age : In the descriptive analysis, the relationship of age and smoking will be examined by using grouped age bands . In the multivariate analysis it will be assessed as a continuous variable. Sex Education Highest education qualification has been grouped in to degree or equivalent, below degree level, other qualification (including foreign qualification below degree level and non (no formal qualifications). Income Gross household income was originally categorised in to 38 bands which were not evenly divided. These bands were then recoded into a new variable with 8 categories. Bands 1-5

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were the 1st category, bands 6-10 the 2nd, and so on, with bands 36-38 forming the 8th category. This new variable was used in the analyses.

Health status
The ONS Lifestyle and Opinions survey asks two questions relating to self-reported health status. The first How is your health in general? There are 5 possible responses very good, good, fair, bad and very bad. These were not recoded. This question has been asked in surveys since the 1950s and poor self-reported health status has been shown to correlate with mortality(Guimares, Chor et al. 2012), although the mechanism is not understood (Jylh 2009). It is also used to calculate healthy life expectancy(Smith, Evans et al. 2012), a measure which is increasingly being used globally (Stiefel, Perla et al. 2010). The second variable concerned the presence of a chronic condition. Have you any long-standing illness, disability or infirmity? is again widely in surveys in part to calculate disability free life expectancy (Smith, Olatunde et al. 2010).

Analysis Descriptive
Unadjusted odds ratios are given for each of the socio-demographic variables- age group, sex, education and income, and the two health status variables with the outcome variables. Confidence intervals were calculated for odds ratios with SPSS v20, by using the enter procedure with individual logistic regressions.

Multivariate
For the two outcome variable, having used the Internet in the past 3 months or not, and having used the Internet in the past 3 months to see health information or not, stepwise logistic regressions using the forward conditional mode of variable selection in SPSS v20 were performed. The models included the three categorical socio-economic variables (sex, income and education, the two categorical health status variables and age as continuous variable. 95% confidence intervals for the odds ratios are given. .

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Results Use of Internet in Last 3 months Descriptive Statistics Overall prevalence of internet use in the last 3 months
When asked when they had last used the Internet, 83% responded that they had done so in the last 3 months. This compares to 78% who described themselves as current Internet users in the 2013 Oxford Internet Study (Dutton, Blank et al. 2013) of the UK population, and 85% of US adults this year (Zickuhr 2013).
Frequency No Valid Missing Total Yes Total System 608 2305 2913 7 2920 Valid Percent 17.2 82.8 100.0

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 1 Have you used the Internet in the last 3 months?

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Age
Figure 1 shows that the likelihood of using the Internet in the last 3 months is strongly inversely correlated with increasing age. This is in keeping with previously reported studies in the UK (Dutton, Blank et al. 2013).
Figure 1: Proportion who have used the Internet in the last 3 months by age group

100 90 80 70 60 50 40 30 20 10 0 16 to 24 25 to 44 45 to 54 55 to 64 65 to 74 75 and over Grouped age %

Table 2 gives frequencies and unadjusted odds ratios for using the Internet in the last 3 months , and shows that the strong linear relationship between age and online access. Those over 75 have less than 1/50 the odds of being an Internet user compared to the reference group of 16-24 year olds. The largest differences are between those of working age and those who have retired. This is possibly in part related to having access to the Internet at work, or having to use it as part of routine work.

Have you used the Internet in the last 3 months? No Yes % Yes Grouped age 16 to 24 25 to 44 45 to 54 55 to 64 65 to 74 75 and over 2 33 47 82 185 259 216 852 422 412 286 117 99 97 91 84 64 34

Total

Exp(B)

95% C.I.for EXP(B) Lower

Upper

218 885 469 494 471 376

1.00 0.25 0.09 0.05 0.01 0.00

0.07 0.02 0.01 0.00 0.00

0.90 0.31 0.16 0.05 0.02

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented Table 2 Frequencies and unadjusted odds ratios for internet use in the last 3 months by age group

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Sex
Figure 2 Proportion who have used the Internet in the last 3 months by sex

100 90 80 70 60 50 40 30 20 10 0 Male Sex of Respondent Female %

Figure 2 and Table 3 show that there is no significant difference in Internet use in the past 3 months between males and females.
95% C.I.for EXP(B) Lower

Have you used the Internet in the last 3 months? No Yes % Yes Sex of Respondent Male Female 253 355 1035 1270 84 82

Total

Exp(B)

Upper

1288 1625

1.00 0.88

0.72

1.07

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 3 Frequencies and unadjusted odds ratios for internet use in the last 3 months by sex

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Education
Figure 3 shows a linear relationship between highest educational qualification and Internet use within the last 3 months. Those with no qualifications have 1/30th the odds of those with a degree level education of being an Internet user (Table 4). As the Oxford Internet Survey this year found this year, it is only those with no educational qualifications at all *who+ tend to be left out (Dutton, Blank et al. 2013;21)
Figure 3 Proportion who have used the Internet in the past 3 months by highest level of qualification

100 90 80 70 60 50 40 30 20 10 0 Degree or equivalent Below degree Other None (no formal level qualifications (inc. qualifications) foreign quals below degree level) What is the highest level of qualification?

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Have you used the Internet in the last 3 months? No Yes % Yes What is the highest level of qualification?

Total

Exp(B)

95% C.I.for EXP(B) Lower

Upper

Degree or equivalent Below degree level Other qualifications (inc. foreign quals below degree level) None (no formal qualifications)

23 139

654 1108

97 91

677 1247

1.00 0.28 0.17 0.46

100

287

77

387

0.09

0.05

0.16

346

256

48

602

0.03

0.02

0.04

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 4 Frequencies and unadjusted odds ratios for internet use in the last 3 months by highest level of qualification

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Income
The relationship between income and Internet use is not straightforward. Those with lowest income had high levels of internet usage. This is in part because they are disproportionately younger than the higher income groups. The highest income band had significantly lower odds of using the Internet than the reference group which was a very low income of less than 50/week. This is not in keeping with the Oxford Internet Study which found a linear relationship with increasing Internet use with higher income (Dutton, Blank et al. 2013). They found that 99% of those with a household income over 40000 were Internet users compared to only 86% of those with a household icome of over 46799 here.
Figure 4 Proportion who have used the Internet in the past 3 months by gross annual income

100 90 80 70 60 50 40 30 20 10 0 0- 2599 2600 - 5200 - 10400 - 15600 - 20800 - 33800 - 46800 5199 10399 15599 20799 33799 46799 Gross annual income

Have you used the Internet in the last 3 months? No Yes % Yes Gross annual income 0- 2599 2600 5199 5200 10399 10400 15599 15600 20799 20800 33799 33800 46799 46800 5 61 230 135 46 33 2 96 72 166 354 374 288 434 196 421 96 75 66 78 90 93 99 86

Total

Exp(B)

95% C.I.for EXP(B) Lower

Upper

77 227 584 509 334 467 198 517

1.00 0.14 0.09 0.16 0.41 0.66 4.32 0.28 0.05 0.03 0.06 0.15 0.23 0.81 0.10 0.39 0.24 0.44 1.14 1.84 22.94 0.74

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 5 Frequencies and unadjusted odds ratios for internet use in the last 3 months by gross annual income

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Health Status
Figure 5 Proportion who have used the Internet in the past 3 months by presence of long-standing illness, disability or infirmity

100 90 80 70 60 50 40 30 20 10 0 Yes No Have any long-standing illness, disability or infirmity? %

Those with chronic health conditions or disabilities are significantly less likely to have used the Internet in the previous three months than those who have not (Figure 5 and Table 6). This is in keeping with the findings of the Oxford Internet Study which found that 51% of those who said they were disabled compared to 84% of non-disabled were Internet users (Dutton, Blank et al. 2013). A Pew Study in the US (Fox 2011) found that 64% of those who had at least one chronic condition had Internet access compared to 81% of those who had none. Again this may be explained by the well established relationships between chronic conditions and lower socio-economic status (Mackenbach, Looman et al. 1996, Smith 1999).

Have you used the Internet in the last 3 months? No Yes % Yes Have any longstanding illness, disability or infirmity?

Total

Exp(B)

95% C.I.for EXP(B) Lower

Upper

Yes No

408 199

776 1517

70 90

1184 1716

1.00 4.02

3.28

4.92

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 6 Frequencies and unadjusted odds ratios for internet use in the last 3 months by presence of long-standing illness, disease or infirmity

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Figure 6 Proportion who have used the Internet in the past 3 months by general health status

100 90 80 70 60 50 40 30 20 10 0 Very good Good Fair Bad Very bad How is your health in general? %

Those who rate their health as very good have significantly more likely to be using the Internet than those who say their health is good(Table 7), and those who say it is fair/bad or very bad are significantly lower again. This may be because self-reported health is known to be positively correlated with higher levels of education (Subramanian, Huijtsb et al. 2010) and inversely correlated with age (Eriksson, Undn et al. 2001).

Have you used the Internet in the last 3 months? No Yes % Yes How is your health in general? Very good Good Fair Bad Very bad 88 208 212 77 22 904 975 311 83 20 92 86 63 55 57

Total

Exp(B)

95% C.I.for EXP(B) Lower

Upper

992 1183 523 160 42

1.00 0.49 0.14 0.10 0.11

0.37 0.11 0.07 0.05

0.65 0.19 0.15 0.21

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 7 Frequencies and unadjusted odds ratios for internet use in the last 3 months by general health status

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Multivariate Logistic Regression

Six variables were entered into the model using forward conditional mode of variable entry. Five of these are individual categorical socio-economic and health status variables (sex, education level, household income, presence of longstanding disability, illness or infirmity and general health status) and with age entered as a continuous variable. The results are shown in Table 8. Only four of the variables were found to be significant. Sex was not significantly associated with Internet usage in the univariate analysis and this is not changed by adjusting for the other factors. In contrast the presence of long-standing illness, disability or infirmity had also been found to be negatively associated with Internet usage, but after adjusting for the other factors this relationship is not present. Age remains strongly predictive of the likelihood of using the Internet. For each additional year of age, the odds of being online decreases by 7%. The relationship between education and Internet access is only slightly attenuated by adjusting for the other factors. After adjusting for age, income and general health status the odds of someone with no qualifications using the Internet is 1/15th that of someone with a degree level education. With regards to general health status only those with self-reported fair or poor health are significantly less likely to have used the Internet than those who have very good health when the other factors are adjusted for. In the univariate analysis income was not strongly related to Internet use, but the highest income band had significantly reduced odds of using the Internet compared to the lowest income group. After adjusting for age, education level and health status the highest income band now has nine times the odds of the lowest income group. The high levels of Internet access in the lowest income group were thought to be due to confounding by age but the relationship is still U-shaped rather than linear after adjusting for age.

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Variable

Exp(B)

95% C.I.for EXP(B) Lower Upper 0.92 0.94

Age What is the highest level of qualification?

0.93

Degree or equivalent
Below degree level

1.00
0.29 0.17 0.50

Other qualifications (inc. foreign quals below degree level) None (no formal qualifications)

0.15 0.07

0.08 0.04

0.26 0.12

How is your health in general?

Very good Good Fair Bad Very bad 0- 2599 5200 - 10399 10400 - 15599 15600 - 20799 20800 - 33799 33800 - 46799 46800 -

1.00 0.85 0.53 0.34 0.44 1.00 0.55 0.61 0.88 1.46 1.28 9.52

0.60 0.37 0.20 0.19

1.19 0.77 0.57 1.02

Gross annual income

0.34 0.41 0.58 0.88 0.76 2.17

0.89 0.89 1.33 2.44 2.16 41.80

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 Table 8 Logistic regression of using the Internet in the last 3 months (showing odds ratios and 95% CI)

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Using the Internet to seek health-related information in the last 3 months Descriptive Statistics Overall prevalence
Of the 82% of those who have used the Internet in the previous three months, just fewer than 50% have used it to see health-related information (Table 9). This is much lower than the level found in the Oxford Internet Survey (Dutton, Blank et al. 2013). In this 69% of Internet users look for health information online, but this is not within a specific time-frame, as various categories have been merged. This is the group who have not said that they never seek online health information. A recent Pew Survey (Fox and Duggan 2013) found that 72% of US internet users say they looked online for health information of one kind or another within the past year. A study of 7 European countries in found 71% of Internet users had accessed online health information (Andreassen, Bujnowska-Fedak et al. 2007). As can be seen from these other studies, the level of reported access of health information is lower than in other studies. I attempted to validate this result by accessing the 2008 ONS Lifestyle survey as this was the first to contain the question on seeking health information in the Internet access module. I constructed a variable for using the Internet to seek health information as in this current dataset. In the 2008 42% of those who had used the Internet in the previous 3 months had used it to access health-related information. This is in contrast to the 2007 and 2009 Oxford Internet surveys which both found 68% of Internet users looking online for health information. It may be that the framing of the Oxford Internet Survey questions How frequently do you use the Internet to access health or medical information? daily/weekly/monthly/less than monthly/never is less likely to receive a never response than no as a response to In the past 3 months have you use the Internet to access health-related information in the ONS Opinions and Lifestyle Survey.
Frequency No Valid Missing Yes Total System 1163 1149 2310 608 Valid Percent 50.2 49.8 100.0

Total 2920 Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 9 Have you used the Internet in the last 3 months to see health-related information?

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Age
Amongst Internet users only 25-44 year olds are more likely than the reference group to access health-related information (Figure 7 and Table 10). A recent Pew study found that younger, rather than older people, were much more likely to look for health information online, but that this may have been related to compensation for lack of medical insurance (Fox and Duggan 2013). As the UK has universal healthcare this may explain the different pattern.
Figure 7 Proportion who have used the Internet in the last 3 months to seek health-related information by age group

100 90 80 70 60 50 40 30 20 10 0 16 to 24 25 to 44 45 to 54 55 to 64 65 to 74 75 and over Grouped age %

In the last 3 months have you used the Internet to seek health-related information? % No Yes Yes Grouped age 16 to 24 25 to 44 45 to 54 55 to 64 65 to 74 75 and over 117 348 245 212 168 73 99 506 178 201 120 45 46 59 43 49 41 41

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper 2.20 1.20 1.54 1.17 1.30

216 854 423 413 288 118 1.69 0.90 1.15 0.84 0.82 1.30 0.67 0.85 0.60 0.52

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 10 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information by age group

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Sex
Women are more likely to access health-related information. This has been found repeatedly in studies of online health information seeking in France (Renahy, Parizot et al. 2008), United States ((Rice 2006, Lustria, Smith et al. 2011), and Italy (Siliquini, Ceruti et al. 2011).
Figure 8 Proportion who have used the Internet in the last 3 months to seek health-related information by sex

100 90 80 70 60 50 40 30 20 10 0 Male Sex of Respondent Female

In the last 3 months have you used the Internet to seek health-related information? % No Yes Yes Sex Male Female 587 576 451 698 44 55

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper 1.82

1038 1274

1.00 1.55 1.32

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 11 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information by sex

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Education
The finding that higher levels of educational qualification are significantly related to increased likelihood of seeking online health information (Figure 9 and Table 12) is also consistent with other studies (Rice 2006, Andreassen, Bujnowska-Fedak et al. 2007, Renahy, Parizot et al. 2008, Lustria, Smith et al. 2011, Siliquini, Ceruti et al. 2011).
Figure 9 Proportion who have used the Internet in the last 3 months to seek health-related information by highest level of qualification

100 90 80 70 60 50 40 30 20 10 0 Degree or equivalent Below degree Other None (no formal level qualifications (inc. qualifications) foreign quals below degree level) What is the highest level of qualification?

In the last 3 months have you used the Internet to seek health-related information? % No Yes Yes What is the highest level of qualification? Degree or equivalent Below degree level Other qualifications (inc. foreign quals below degree level) None (no formal qualifications)

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper

253 556

403 554

61 50

656 1110

1.00 0.62 0.51 0.76

165

123

44

288

0.50

0.38

0.66

189

69

26

258

0.22

0.16

0.31

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 12 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information by highest level of qualification

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Income
In this univariate analysis there is no discernible relationship between income and likelihood to seek online health information (Figure 10). None of the income bands has significantly different odds of using the Internet to access health-related information from the reference category (Table 13).
Figure 10 Proportion who have used the Internet in the last 3 months to seek health-related information by gross annual income

100 90 80 70 60 50 40 30 20 10 0 0- 2599 2600 - 5200 - 10400 - 15600 - 20800 - 33800 - 46800 5199 10399 15599 20799 33799 46799 Gross annual income

In the last 3 months have you used the Internet to seek health-related information? % No Yes Yes Gross annual income 0- 2599 2600 - 5199 5200 - 10399 10400 15599 15600 20799 20800 33799 33800 46799 46800 34 93 192 215 154 187 86 202 38 73 164 160 134 248 111 221 50 49 45 43 48 55 59 51

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper

72 166 356 375 288 435 197 423

1.00 0.98 0.83 0.75 0.92 1.25 1.43 1.06 0.60 0.53 0.48 0.58 0.80 0.87 0.68 1.62 1.31 1.19 1.47 1.96 2.34 1.65

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 13 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information

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Health Status
Those with a chronic condition- a long-standing illness, disability of infirmity are significantly more likely to access health information than those who do not (Table 14). This has also been found in other studies (Rice 2006, Andreassen, Bujnowska-Fedak et al. 2007, Renahy, Parizot et al. 2008, Siliquini, Ceruti et al. 2011). With regards to general health status those who state their health is very good are significantly less likely to use the Internet to seek health-related information than those who consider their health to be good or fair (Table 15). .
Figure 11 Proportion who have used the Internet in the last 3 months to seek health information by presence of long-standing illness, disability or infirmity

100 90 80 70 60 50 40 30 20 10 0 Yes No Have any long-standing illness, disability or infirmity? %

In the last 3 months have you used the Internet to seek health-related information? % No Yes Yes Have any longstanding illness, disability or infirmity?

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper

Yes No

358 798

419 725

55 47

777 1523

1.00 0.72 0.61 0.86

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 14 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information by presence of long-standing illness, disability or infirmity

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Figure 12 Proportion who have used the Internet in the last 3 months to seek health-related information by general health status

100 90 80 70 60 50 40 30 20 10 0 Very good Good Fair Bad Very bad How is your health in general? %

In the last 3 months have you used the Internet to seek health information? % No Yes Yes How is your health in general?

Total

Exp(B)

95% C.I.for EXP(B) Lower Upper

Very good Good Fair Bad Very bad

481 474 151 39 11

427 503 160 44 10

46 52 53 55 55

908 977 311 83 21 1.28 1.32 1.41 1.36 1.07 1.02 0.88 0.58 1.52 1.71 2.28 3.20

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 *Weighted % and unweighted sample N are presented. Table 15 Frequencies and unadjusted odds ratios for using the Internet in the last 3 months to seek health-related information by general health status

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Multivariate Logistic Regression

Again six variables were entered into the model using forward conditional mode of variable entry. Five of these are individual categorical socio-economic and health status variables (sex, education level, household income, presence of longstanding disability, illness or infirmity and general health status) and with age entered as a continuous variable. The results are shown in Table 16. All six variables were significant in the model. After adjusting for all the other variables with each year of increase in age, the odds of seeking online health information reduces by 1%. No relationship was found between income and accessing online health information in univariate analysis. Once the other variables are adjusted for there is the suggestion of a U-shaped curve relationship. Only one category had significantly decreased odds than the reference range, and another (the highest income band) was significantly increased. With regards to education those with no formal qualifications have of the odds of those with degree level education. The odds of women, compared to men, seeking health information online are increased when other variables are accounted for. Both health status variables are significant. Those with chronic conditions are more likely to use the Internet to see health-related information, and those who state they have good or fair health are more likely than those who say their health is very good.

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Variable

Exp(B)

95% C.I.for EXP(B) Lower Upper 0.98 0.99

Age

0.99

What is the highest level of qualification?

Degree or equivalent Below degree level Other qualifications (inc. foreign quals below degree level) None (no formal qualifications) 0.61 0.50 0.75

0.49 0.22

0.37 0.16

0.67 0.32

Have any longstanding illness, disability or infirmity?

Yes No Very good Good Fair Bad Very bad Male Female 0- 2599 2600 - 5199 5200 - 10399 10400 - 15599 15600 - 20799 20800 - 33799 33800 - 46799 46800 -

0.64 1.00 1.37 1.69 1.60 1.64 1.00 1.73 1.00 0.83 0.91 0.77 0.67 0.90 1.14 1.43

0.52

0.80

How is your health in general?

1.13 1.24 0.94 0.64

1.66 2.31 2.73 4.18

Sex

1.45

2.06

Gross annual income

0.52 0.64 0.57 0.50 0.66 0.87 1.01

1.32 1.31 1.03 0.89 1.22 1.50 2.03

Source: Opinions and Lifestyle Survey, Internet Access Module, January, February and March, 2013 Table 16 Logistic regression of using the Internet in the last 3 months to see health-related information (showing odds ratios and 95% CI)

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Discussion and Conclusion

This study shows that there is evidence of a digital divide in accessing health information in the UK. Those who are younger, have higher levels of education and higher income, are more likely to have online access, and to be using it to seek health information. This reflects the discrepancy in uptake of new digital health technologies such as Renal PatientView, and threatens initiatives such as Digital First unless ways can be found of addressing this digital divide. Of note, self-reported health status is negatively associated with the likelihood of being online after adjusting for income, age and education. This was also found in the Parisian population study (Renahy, Parizot et al. 2008). It may be because those with poor self-reported health have physical or psychological problems which make it difficult for them to physically use a computer, or they may lack motivation. This is an area which would benefit from further exploration. However it is also clear that the health digital divide is not just about access. Selwyn (2004)is critical of the narrow focus where one is considered to be on one side of the divide or not depending on whether or not one has access. This is reflected in government policy aiming to reduce the digital divide by increasing access to broadband (Wilkinson 2010). Instead Selwyn argues that we should consider access a staged progress moving from formal access through engagement to meaningful outcomes. He suggests that the digital divide could be considered in terms of access to different forms of technological capital economic, cultural and social. Let us consider educational attainment. Higher qualifications in particular are associated with higher levels of internet access and higher levels of accessing health information. This quantitative analysis does not help us to understand why higher levels of education are associated with increased use of the Internet for health information, and it cannot tell us that higher education causes increased use of online health information. However, the fact that this relationship has been found in studies across the world over different periods of time makes it interesting to explore further. It may represent what Lee (2009) describes as the health-knowledge gap. This suggests that those with higher levels of education can more quickly acquire knowledge from a given medium than those with lower levels of education. Or education may be giving access to the various forms of capital that Selwyn (2004) considers are important. Neter and Brain (2012) consider the health digital divide in terms of eHealth Literacy. This may also be a pathway mediating the relationship between education and online information seeking. There is still much work to be done in identifying and addressing these roots of the digital divide. Even if we had full understanding of what predicted seeking online health information and were able to find measures which would address the digital divides I have described here, other factors would still need to be addressed before some of the more ambitious plan for the use of technology in healthcare which initiatives such as Digital First envisage could be realised. Qualitative research such as that of Kerns, Krist et al. (2013) which investigated how patients want to engage with a personal health record shows the complexity of these adoptions. Beyond the motivation and skills of individual patients, how the technology is embedded in existing practices and the relationships between staff and patients is key to success. In the meantime, this analysis of a large UK dataset reminds us that without addressing and considering some aspects of the digital divide described here, the increased use of online technologies may increase health inequalities (Jones 2013).

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