No. 4, October 2004
SPECIAL TOPICS IN PUBLIC HEALTH
What Do We Mean by Internet
Access? A Framework for Health Researchers
Nigel E. Bush, PhD, Deborah J. Bowen, PhD, Jean Wooldridge, MPH, Abi
Ludwig, Hendrika Meischke, PhD, Robert Robbins, PhD
Suggested citation for this article: Bush NE,
Bowen DJ, Wooldridge J, Ludwig A, Meischke H, Robbins R. What do we mean by
Internet access? A framework for health researchers. Prev Chronic
Dis [serial online] 2004 Oct [date cited]. Available from: URL:
Much is written about Internet access, Web access, Web site
accessibility, and access to online health information. The term access
has, however, a variety of meanings to authors in different contexts when
applied to the Internet, the Web, and interactive health communication. We
have summarized those varied uses and definitions and consolidated them into
a framework that defines Internet and Web access issues for health
researchers. We group issues into two categories: connectivity and human
interface. Our focus is to conceptualize access as a multicomponent issue
that can either reduce or enhance the public health utility of
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The Internet and World Wide Web (Web) have rapidly become ubiquitous in
the lives of the majority of Americans. By March 2004, three fourths of
Americans were able to use the Internet from home (1). Americans routinely
turn to the Web for information, entertainment, merchandise, and
communication. In particular, the Internet has become a prime source of
health information for consumers (2,3). Although the Internet has potential
as a tool for health improvement, its impact hinges on issues of access.
Access is an issue that affects people at home, at school, and in the
community at large (4). Even where access to basic Internet
infrastructure exists or is provided, further access to Internet use is
often limited by other factors (5). A more global concept of Internet
access encompasses a spectrum of narrower, interrelated factors described by
Eng et al as “the ability to access, comprehend, and utilize information and
support appropriate to one’s personal characteristics” (6).
In this article, we document the myriad uses and definitions of Internet
access from a wide variety of sources and consolidate them into a single,
comprehensive, cohesive framework suitable for health research and practice.
We believe the proposed framework will provide researchers a clearer and
more thorough understanding of Internet access, whether they design
Web-based interventions, implement electronic outcomes assessments, develop
online educational resources, or otherwise incorporate interactive health
communications (IHC) components in their research endeavors.
Need for clarifying and specifying terms
Our own research experience illustrates the difficulties of the issues of
access. We recently conducted pilot research on
communicating breast cancer risk to low-income,
predominantly African American, elderly, inner-city women. As part of this
research, we tested a computer and Internet education and training program in local
church community centers among a sample of our target audience. One of our
first steps was to identify a group of Web nonusers, or novices,
through telephone questionnaires. We had to revise our initial questionnaire
several times before we were able to define and isolate our target group.
Who exactly was a nonuser? Was a nonuser someone who had never used the
Internet or Web, someone who may have used it occasionally but not recently,
or someone who used it frequently but stopped? What did we mean by
occasionally or recently? What degree of use determined a user? Did
occasional e-mailing with help from another person constitute Internet
experience? Should we include women who were computer users but who had
little or no Internet experience? Was a nonuser also someone who had no
access to an Internet connection? By “no access” did we mean no easy or
convenient access? If so, how did we define ease or convenience and what was
our cut-off criterion? Was it availability in the home only or availability
within easy walking distance from the home (e.g., church, community center)?
The permutations were endless.
The details of our final framework are based both on our own experience
and on the findings of other Web-based health research projects (7,8) and
are described below.
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Distinguishing between the Internet and the Web
Within the technology community, a clear demarcation exists between the
Internet and the Web. In common usage, however, the two are often confused,
with Internet and Web frequently used interchangeably as if they were the
same entity. Motive, a New Zealand-based Internet communication design
company, defines the Internet in relatively lay terms as “a global network of
interconnected computers. This is the infrastructure through which
applications such as e-mail, chat rooms and instant messaging operate” (9).
Motive goes on to distinguish the Internet from the Web: “Thus, the Web is
an example of an Internet application. The Web is accessed through a browser
which can display text, images, and time-based media and allow a user to
access applications” (9). December Communications, a Web-based
communications company, reminds us in more technical terms that “[t]he Web
is not the Internet itself. The Web is not a proprietary system like AOL.
Instead, the Web is a system of clients (Web browsers) and servers that uses
the Internet for its data exchange” (10). Foldoc, an online dictionary of
computing, similarly describes a Web browser: “The client program (known as
a browser), e.g., Netscape Navigator, runs on the user’s computer and
provides two basic navigation operations: to follow a link or to send a
query to a server” (11).
We explored three overlapping information sources that cover the various
uses of Internet and Web access: 1) the academic, medical, and health
literature, 2) the Web itself, including recent Internet usage surveys, and
3) seminal reports on eHealth and online health consumers. Searches of
Medline and PubMed for the words “Internet” and “Web” in any field each
yielded more than 3000 articles, and more than 1500 hits resulted when we
combined the two search terms. Searches for “World Wide Web” produced more
than 500 results. These three searches produced results that were beyond the
scope of this summary paper, so we then narrowed our search to articles
published in the last five years with the words “Internet” or “Web and
Access” in their titles and abstracts. This more focused search generated a
more wieldy 200 articles. We also searched the Web for definitions and
examples of Web access, Internet access, and variations on those themes in
the commercial and private sector using search engines such as Google (12)
and WebFerret (13). In addition, we reviewed recent Internet communication
and survey sites including the Pew Internet and American Life Project (14),
Nielsen//NetRatings (15), Harris Interactive (16), and Nua Internet Surveys
(17). Finally, for definitions, uses, and terminology, we inspected a selection of recent seminal reports on
e-health, online health, and the “digital divide,” including Healthy People
2010 (18), The eHealth Landscape (5), Wired for Health (19),
Online (20), Falling through the Net (21), and The UCLA Internet Report
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A health researcher’s framework of Internet and Web access
Figures 1 and 2 present our proposed framework for describing Internet
and Web access. In the process of consolidating results from our search of
the literature, Web, and other sources, we sorted the disparate and varied
uses and definitions of access into coherent unifying clusters, or
collective grouping, based on similar meanings and usages. Initially, we
created a relatively large number of small clusters, with individual
examples often allocated to more than one cluster. We then progressively
combined clusters that we judged to share similar overriding characteristics
into fewer, more broadly descriptive and exclusive groupings. Finally, we
assigned our final clusters to one of two global categories. We propose that
issues of Internet and Web access can be catalogued as either connectivity
(Figure 1) or human interface (Figure 2) issues. These global categories are
not mutually exclusive, and many of the examples within each category
interact and co-vary with others to different extents; we believe, however,
the two global categories offer a simple and convenient descriptive
Computer, Web appliance, personal digital assistant, cell phone,
pager, tablet, kiosk
RAM, Video RAM
Hard drive, flash card
Display size, video colors, resolution
Operating system Windows95/98/2000/NT/XP, Macintosh, Unix,
Browser type/version Netscape 3/4/5/6, Opera
Accessory applications, plug-ins, and settings
Adobe PDF, MacroMedia
Flash, RealPlayer, Windows Media Player, cookies
(Quality, Speed, Bandwidth)
Depth of Connection
Internet only (without Web)
Internet and Web
Restrictions to specific Web sites, Web pages, and
components (firewalls, filters, passwords)
Work or school
Community (public library, church, community center)
Commercial (Internet café)
Degree of Availability/Convenience
Full, easy, convenient availability
Shared with one or more others
Shared with voice communications
Shared with other (device) applications
Inconvenient (e.g., distant) location
Figure 1. Examples of elements of connectivity, which is defined as “connecting
or being connected to the Internet, the Web, a Web site, Web page, or Web
subcomponent; having the functionality and content of the Internet and/or
Web physically available.” The categories above provide
noninclusive lists of examples.
(Ability to read/understand content)
Content in reader’s native language
Completely fluent in content language
Can read and write in content language
Completely unable to understand content language
(Ability to understand content)
Do not have high school diploma
High school graduate or GED
2-year college degree or trade degree
4-year college degree
(Ability to read content)
Unable to read
3rd grade reading level
6th grade reading level
12th grade reading level
Value of face-to-face communication vs impersonality of computer
Sensitivity or appropriateness
Ability to afford access device such
Ability to afford Internet Service Provider subscription
Ability to afford high-bandwidth access
Ability to afford “connected” school
Disability and Age
Experience and Familiarity
How often do you use a computer?
at least once/day
1–2 times ever
never (complete novice)
How often do you use the World Wide Web?
at least once/day
1–2 times ever
never (complete novice)
How would you rate your computer skills?
Professional (e.g., programmer)
How would you rate your skills as a Web user?
Professional (e.g., programmer)
Figure 2. Examples of elements of human interface, which is defined as “those factors
relating to user demographics and characteristics, such as literacy,
language, education, race, ethnicity and culture, income, disability and
age, experience and familiarity, and skill and training, which determine or
restrict level of access to Internet/Web and content.” The categories above
provide noninclusive lists of examples.
We broadly define connectivity as “connecting or being
connected to the Internet, the Web, a Web site, Web page, or Web
subcomponent; having the functionality and content of the Internet and/or
Web physically available.” A number of sources in the academic literature describe access
simply as being connected to the Internet or Web (23-54). We found, for
example, references to free Internet access (49), access to the Internet
during dentist visits (55), Internet access through an employer (41), use of
touch-screen kiosks to provide Internet access (56,57), degree or quality of
connectivity (e.g., Broadband service) (24), and common places of access,
such as home (58,59) or work (43). Predominantly commercial Web sites and
Web surveys also focused primarily on this kind of basic connectivity. SearchVB.com* described access in this way: “Web access means having a
connection to the World Wide Web through an
access provider or an
online service provider such as America Online” (60). In addition,
theDirectory.org* described Internet access providers as “companies that
provide connections to the Internet for businesses and individuals”
(61). Nielsen//NetRatings Audience Measurement Service reports Internet
usage estimates based on a sample of households that have access to the
Internet. The Nielsen//NetRatings Internet universe is defined as all
members of U.S. households (aged two years or older) that currently have access to
the Internet (62). Harris Interactive seems to define access as “computer
users who are online.” For example, “Two-thirds (66%) of all adults are now
online. This includes more than half (55%) of all adults who access the
Internet from home, almost a third (30%) who access it from work, and almost
one in five adults who go online from a school, library, cyber café or other
location” (63). In addition, Systems Computing Services distinguishes
between connection and access: “When connected to the Internet, you have
access to several kinds of resources” (64).
Other varied references to access as basic connectivity included:
- “Internet access from home: To reach the Internet the user needs
service from 1) a communications company (i.e., a telephone, cable
television, or wireless company) providing a transport service to
physically transmit data to and from the consumer’s home and 2) an ISP
[Internet Service Provider] providing access to the Internet” (65).
- “80 percent of Americans access the Internet through dial-up service,”
and “Internet access is more frequently occurring outside the home, at
such locations [defined] as work, school, public libraries, community
centers, someone else’s house, and somewhere else” (20).
- “Americans bought home computers and hooked them up to the Internet at
a remarkable rate between December 1998 and August 2000. Virtually every
group has participated in the sharp upward trend of Americans connecting
their homes to the Internet” (66).
- “Interactive health communication (IHC): the interaction of an
individual — consumer, patient, caregiver, or professional — with or
through an electronic device or communication technology to access or
transmit health information, or to receive or provide guidance and support
on a health-related issue” (19).
Browser — a software application used to find and display Web pages.
Kiosk — a stand-alone booth providing a computer-related service.
Kiosks must be easy to use (without training or documentation), and the
hardware must be capable of operating unattended for long periods of
time. Examples of kiosks include automated teller machines and tourist
Firewall — a barrier designed to protect a private network from
unauthorized access. Information going through the firewall in either
direction is examined to make sure it meets security criteria. Firewalls
can be implemented in hardware, software, or both.
Plug-in — a piece of hardware or software that adds a specific
feature or service to a larger system. The idea is that the new
component simply plugs into the existing system, but it must be
installed separately from the existing system.
Intranet — a private network that operates like the Internet but is
accessible only to a limited group of users, such as a company’s
employees. Many intranets are also connected to the Internet, but they
are protected by a firewall.
Functionality — what the features of hardware or software enable a
user to do.
Application — software applications are the programs (or groups of
programs) that enable users to accomplish tasks. Examples include word
processing and spreadsheet programs as well as e-mail programs and Web
Networking — connecting two or more computers together so they can
communicate with each other.
Bandwidth — the amount of data (pieces of information) that can be
transmitted in a fixed amount of time.
Coding — writing the instructions for a computer program.
There are many different types of code as well as computer languages in
can be written.
RAM (Random Access Memory) — the type of memory, or data storage,
used for storing data temporarily while working on a computer. RAM is
volatile, which means that when the power is turned off, the contents
stored in RAM are lost. Computer memory can be thought of as boxes, each
of which holds a single byte of information. If a computer has 8MB RAM,
then eight million bytes of memory are available for programs to use.
The majority of sources in the academic literature also describe Web or
Internet access as opening, using, or getting to content, documents, and
applications and collecting data (31,36,37,48,67–110). This description is
necessarily broad and encompasses a variety of types of access and types of
content accessed. General examples include access to patient/medical records
and clinical information (111–125); a variety of online databases (126–148),
including blood bank (149) and sperm bank (150) information; teaching and
education syllabi (151,152); other computer systems (153,154), such as
libraries (155); continuously acquired physiological patient data (156) or
real-time diagnoses (157) by physicians; medical expertise (88,158,159);
online patient decision-support tool (160); specific, sometimes
difficult-to-find populations (75); and populations for online surveys
Availability. We first qualify connectivity in terms of its
availability. The location and availability of the connection device are
important in determining degree, ease, and convenience of access. For
example, we may describe a group of users as having home Internet access
because a survey tells us that each individual within the group has a home
computer connected by telephone modem to an ISP. The single question, “Do
you have a computer at home connected by telephone modem to an ISP?,”
however, tells us little about the availability of Internet access. In one
home, a single occupant may be the sole user of the Internet connection. In
another home, availability of the home Internet connection may be much more
restricted — use may be shared, regulated, severely limited or even denied,
perhaps by some other person in the house. Both examples depict home
Internet access but vary considerably in degree.
Also critical in determining access is the availability of local ISPs
(not requiring a long-distance call), and, more frequently, adequate quality
of connection (bandwidth and choice of medium). Both factors vary greatly
with geography, especially between urban and rural areas. For example, a
potential user in a more remote rural area simply may not have available
high-speed Internet service (21,162).
The location of the connection device must also be considered when
defining availability of access. Connections to the Internet are commonly
made from the home, from work or school, or from local communal points such
as community centers, church halls, public libraries, or Internet cafés.
Internet users without home connections may also connect from other people’s
homes, an option often forgotten in access surveys. And the Internet now can
be reached via mobile or portable devices without fixed locations.
Connection at and between each location varies in the degree of
availability, convenience, and ease of access. Availability might be
restricted because of multiple users (i.e., the obligation to share the
connection with one or more other users). Availability might also be
restricted if the connection uses the only telephone line available at that
location (i.e., sharing a voice line). At work, the connection device might
be located in an office with restricted physical access. At school, the
device might be in a computer lab with availability rigorously scheduled
(i.e., limited times and hours). Finally, the connection location itself
might be inconvenient. In some urban areas, a connection location outside of
the home, work, or school can often be found within a few blocks; in other
locales, the nearest place to go online may be preclusively distant.
The implication of describing Web site availability is that some
restriction may prevent users from opening or using the site. For example,
describing a Web site as “publicly accessible” (163) implies that other
sites may not be accessible by the general public but are limited to
designated users; security measures may be employed to limit access to a
site or to specific site content (164) or to a computer system (154). One of
the most common examples in this context is the privileged (restricted to
authorized users only) access to medical records
(90,113,121,122,125,141,165). Alternately, a site, or information within
it, may be inaccessible because of design or coding issues; for example,
specific content or sites may be inaccessible to search engines (166,167).
Access and use also may be hindered by navigational challenges due to
numerous design features (e.g., disorganization, technical language, lack of
permanence , or simple download time ).
Capability. We further qualify connectivity in terms of
capability. The capability (and configuration) of both hardware and software
determines how efficiently the content and functionality of the Internet or
Web is accessed and how comprehensively the content and functionality are made available. With lesser capability, some content or functionality
will not be accessible or available.
Hardware capability and configuration can determine how much of a Web
page is visible, the quality or resolution of that view, or how many Web
pages can be opened at one time. For example, a PDA (personal digital
assistant) with 8MB (megabytes) of RAM and small monochrome display is considerably less
capable of opening, displaying, and manipulating a typical Web page than is
a late-model desktop computer. Hardware capability also determines to some
extent software capability. More powerful and fully featured software
applications typically require more RAM, larger hard-drive storage capacity,
and faster computer processing speed and power to function optimally. Less
capable hardware can diminish software performance. Additionally, Internet and Web content and
functionality may be optimized for, or even require, specific versions and
types of software. For example, many multimedia Web pages can only be
optimally opened, viewed, and manipulated using a recent-version Web browser
of a specific brand and third-party software plug-ins.
The capability of the connection between the access device, such as a
computer, and the Internet and/or Web is also critically important to
overall access. Most home Internet users connect from a desktop computer via
modem and standard telephone line to an ISP. An increasing number of users
connect via faster telephone connections called DSL (digital subscriber
line), which allows data transmission without interfering with telephone
voice service, while a few home users and many people at work use much
faster dedicated cable or T1 lines. The bandwidth of the connection and/or
the speed of the modem determine how quickly Web content and other data
download from the Internet to the user device. For example, a Web page
containing large files such as graphic elements or audio-video features,
because of prohibitive download times, may be largely inaccessible to a user
with a slow telephone connection.
We distinguished previously between the Internet and the Web. Some
Internet users do not connect to or use the Web; instead, they use non-Web
networking to access and transmit data. Examples include Pine®, an
electronic messaging program that does not use the Web, but connects to the
Internet, and FTP (file transfer protocol), which allows users to transfer
files over the Internet without using the Web. Internet users may also use private or
proprietary sets of networked tools and they may share
applications. These users may have Internet access, but not Web access. Most
home consumers, however, do connect to the Internet and to the special
Internet application known as the Web. There are, therefore, varying degrees
of network connectivity, including 1) intranets shared
by or accessible to only a limited groups of users, 2) restricted or relatively
unrestricted use of the Internet, and 3) the Web. We can specify degree of
network connectivity more precisely by assessing availability of specific
Web sites or even components of Web pages. Connections to both the Internet
and the Web and their various components frequently are restricted by
firewalls, ISP limitations and policies, content filters, passwords, and
other boundaries. Availability of some Web sites may also be limited by
their obscurity to search engines. Thus, Internet or Web access is related
to the type and degree of network availability. When we say someone has
“full Web access,” we mean it only in the most generic terms. We assume that
the user has functionality as well as availability to general Web content,
but we also presume that specific sites and content are unavailable on a
case-by-case basis or by type (e.g., pornography filtered by ISP or public
We define the human interface category of Internet access as
“those factors relating to user demographics and characteristics, such as
literacy, language, education, race, ethnicity and culture, income,
disability and age, experience and familiarity, and skill and training, which determine or restrict level of
access to Internet/Web and content” (5,169). Again, many of these factors
are not mutually exclusive but interact and covary with each other. Not
surprisingly, our various sources contained frequent references to the
relationships among Internet/Web access, health disparities, and individual,
personal, or demographic limitations — the digital divide.
To some extent, our human interface factors encompass, but are not
confined to, issues commonly considered when assessing usability. Usability
of a product or application typically refers to the quality of a user
experience when interacting with the product or application, with an
emphasis on behavior rather than opinion or recollection. Usability measures
learnability, memorability, efficiency, frequency and severity of errors,
and user satisfaction. Having evolved from observational methodology and
ergonomics, the study of Web site usability has focused increasingly on
human limitations, such as disability and literacy (170–174). We list and
describe below human interface accessibility factors.
Literacy. For the content of a Web site to be accessible, it must
be readable. A health-related Web site written at a college-graduate–level
of literacy is inaccessible to a reader with a sixth-grade reading level
Language. The ability to read content is also determined by the
user’s language skills. A site written in English obviously is inaccessible
to a monolingual native-French speaker, however rudimentary the written
literacy level (48,168).
Education. For the content of a Web site to be accessible, it must
also be understandable once it is read. We suggest that educational level
may be the closest analog of the ability to understand information,
especially health-related material (179).
Race, ethnicity, and culture. The content of a Web site may be
both readable and understandable to a user, but at the same time it could
also be culturally or ethnically insensitive, inappropriate, or irrelevant
to the user and, therefore, relatively inaccessible. For example, a
cancer-prevention–related Web site might illustrate quite vividly a cervical
screening procedure that white individuals may deem acceptable, but that
other readers (e.g., women with a traditional southeast Asian background)
might find offensively candid (4,5,48,162,178,180).
Income. Income appears to predict Internet access even more than
race and ethnicity (39). People of lower income are less likely to be able to
afford either a home Internet connection device such as a computer or the
regular subscription costs to an ISP. Lower-income people who connect to the
Internet from home are less likely to afford a higher (faster) bandwidth
connection or live in an area where it is available. Although other avenues
of access are available in the community, they are less convenient than the
home and, consequently, less often used. And the workplaces and schools of
lower-income people are less likely to provide Internet connectivity
Disability and age. We take for granted many of the skills and abilities necessary to access the Internet. We turn on a computer
and manipulate a pointing device such as a mouse to open a connection to an
ISP. We recall our private password and user name, type a Web address on the
keyboard, and open a Web page. We read the text, look at the images, perhaps
listen to audio; these tasks are denied to users with certain disabilities.
And while these disabilities may be due to non-age–related causes,
they most commonly are associated with advancing age. Thus, physical disability might restrict mobility (reaching the computer) or
dexterity (accurate or speedy use of keyboard and mouse). Visual impairments
such as myopia or color-blindness affect easy reading of text, which may
vary in font size or color, or viewing of images. Hearing deficiency further
restricts access to multimedia. Cognitive disability such as problems with
memory and concentration limit the effectiveness of training, recall of
passwords and educational content, navigation, and so on (21,170,184).
Experience and familiarity. A primary factor determining the level
or degree of access to Internet and Web content and functionality is the
user experience and familiarity with all the various aspects of connecting
to the Internet and Web and navigating, manipulating, and otherwise using
the Internet and Web once connected. We further distinguish between
experience and familiarity with the connection device, usually a computer,
and experience and familiarity with the Internet and Web once connected. By
experience and familiarity, we mean how often and for what duration the
individual has been exposed, either by personal use or vicariously, to the
device and the Internet. Device experience and Internet experience are
frequently but not necessarily related. A computer novice is unlikely to be
an experienced Internet user; however, an individual may be a relatively
experienced computer user but quite unfamiliar with the Web and largely
unable to avail himself or herself of its features (18,48,182–185).
Skill and training. The issue of perception of skill often, but
not necessarily, overlaps with experience and familiarity in affecting
levels of Internet access. Our own anecdotal evidence suggests that some
individuals may report considerable computer experience but judge themselves
to be only moderately computer literate or skillful. We believe that
technical knowledge and skills determine to some extent the degree of access
to the Internet and Web. For example, a good working knowledge of computer
and Web applications might better enable routine maintenance of the
connection device or the installation of third party plug-in software when
required for Web site access. Again, we relate skill separately to the
connection device and to the Internet and Web.
Applying the framework
In our introduction, we described briefly our recent pilot research on
communicating breast cancer risk. The initial difficulty in defining nonuser
in our screening questionnaire was one of the factors that stimulated the
writing of this paper and the development of our framework. Subsequently, we
applied the framework as a guide to designing our final project procedures
and the breast cancer risk Web site itself. Our target audience was
low-income, predominantly African American, elderly, inner-city women in Seattle, Wash, who, to be eligible, had no Internet access and who were computer and
Internet novices. Referring to our framework in our approach phone calls and
screening questionnaires, we first considered connectivity. Because
we were looking for nonusers, the capability of any connectivity was less
relevant than availability, and we chose the general infrastructure
of our target location to be urban-underserved and therefore unlikely to be
“wired.” We first ascertained that each candidate had no home or convenient
local availability of a computer or Internet connection (locale and
degree of availability). We then turned to human interface
factors and concurrently determined that each candidate had little or no
experience and familiarity or skill with computers and the Web.
We ensured that each candidate could minimally read and write in English (language).
We then tailored our church-based training program and test Web site
functionality and content to participant literacy, education,
race/ethnicity/culture, and disability/age.
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This paper has focused exclusively on a discussion of access, including
access to the Internet and Web, content accessibility, and restrictions to
access. We are well aware that the complexities of IHC go beyond mere
access; they include the countless ways people use, interact with, and
potentially benefit from new media. Established models of information
processing, such as cognitive style preferences for perceiving,
remembering, organizing, processing, thinking, and problem solving (186), are being
newly applied to emerging technology applications such as the Web but are
beyond the scope of this paper. In future papers, we will delve deeper into
the intricacies of usability, learning style, and other issues (170-174).
Before we conclude, however, there is one factor relating to access that
is often ignored: the possibility that many people do not use the Internet
not because they lack access but simply because they do not want to use it
or do not see a need to use it. This has serious implications for health care infrastructure spending, especially
among the underserved. Current efforts on the digital divide have focused
largely on providing access to computers and the Internet and to hardware
and software training. One of the most popular access enhancement models is
the establishment of community computer/Internet centers in lower-income
neighborhoods, which have been supported by various foundations,
corporations, local businesses, and government agencies (5). Yet despite
gains in computer and Internet access reported early in 2002 by the
Department of Commerce (20), a significant divide continues based on income,
education and literacy, race and ethnicity, age, gender, geography, and
disability (177,187,188). What remains unclear is to what extent the divide
is due to poor access to information technology and how much it is due to
low adoption of the technology where access exists. Conventional wisdom
suggests that disparities in Internet use emanate from inequalities in
infrastructure access, primarily in connectivity, and that providing access
to the underserved alleviates the inequality. However, in many cultures,
computers are simply not valued and may be resisted as poor alternatives to
face-to-face communication (177). In our own city (Seattle), 82% of
residents have access to the Internet, and yet adoption or use remains low, especially in some
underserved communities (187). Although there are still local disparities in
access, apparent lack of interest or perceived need is often cited as one of
the highest barriers to Internet use (22,95), which may be mediated by
ignorance of what the Internet has to offer (8).
We have described in significant detail a range of definitions for, myriad
determinants of, and restrictions to Internet and Web access. We do not
claim to have constructed the definitive taxonomy; in fact, that may be a
futile goal given the rapid and unpredictable progress of IHC. We hope our
efforts may, however, make health researchers more aware of the need for
specificity and consistency in their reporting of Internet access-related
topics and provide them with some choices.
Back to top
This activity was supported, in part, by National Cancer Institute grants
#CA070866, #CA78164, #CA82894, and #CA82569.
Back to top
Corresponding author: Nigel E. Bush, PhD, Fred Hutchinson Cancer Research
Center, 1100 Fairview Ave N, M3-B232, Seattle, WA 98109-1024. Telephone:
206-667-5688. E-mail: email@example.com.
Author affiliations: Deborah J. Bowen, PhD, Jean Wooldridge, MPH, Abi
Ludwig, BS, Robert Robbins, PhD, Fred Hutchinson Cancer Research Center,
Seattle, Wash; Hendrika Meischke, PhD, University of Washington, Seattle, Wash.
Back to top
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