Skip Navigation Links
Centers for Disease Control and Prevention
 CDC Home Search Health Topics A-Z

Preventing Chronic Disease: Public Health Research, Practice and Policy

View Current Issue
Issue Archive
Archivo de números en español

Emerging Infectious Diseases Journal


Volume 1: No. 4, October 2004

What Do We Mean by Internet Access? A Framework for Health Researchers


Print this article Print this article
E-mail this article E-mail this article:

Send feedback to editors Send feedback to editors
Download this article as a PDF Download this article as a PDF (478K)

You will need Adobe Acrobat Reader to view PDF files.

Navigate This Article
Author Information

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 electronic communications.

Back to top


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. 

Back to top


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).

Information source

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), A Nation Online (20), Falling through the Net (21), and The UCLA Internet Report (22).

Back to top


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 framework.

Connection Device
Computer, Web appliance, personal digital assistant, cell phone, pager, tablet, kiosk
Hardware Capability

RAM, Video RAM
Hard drive, flash card
Display size, video colors, resolution
Software Capability
Operating system
Windows95/98/2000/NT/XP, Macintosh, Unix, Linux
Browser type/version Netscape 3/4/5/6, Opera
Accessory applications, plug-ins, and settings
Adobe PDF, MacroMedia Flash, RealPlayer, Windows Media Player, cookies
Arrow leading to next section
Connection Quality
(Quality, Speed, Bandwidth)

T2, T1, Cable, DSL, 56K modem,
28.8K modem
Arrow leading to next section
Depth of Connection
(Network Level/Type)
Intranet only
Internet only (without Web)
Internet and Web
Restrictions to specific Web sites, Web pages, and components (firewalls, filters, passwords)
General Infrastructure
Arrow leading to next section
Own home
Others’ home
Work or school
Community (public library, church, community center)
Commercial (Internet café)
Arrow leading to next section
Degree of Availability/Convenience
Full, easy, convenient availability
Shared with one or more others
Shared with voice communications
Shared with other (device) applications
Restricted location
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)
Language levels
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)
Education levels
Do not have high school diploma
High school graduate or GED
2-year college degree or trade degree
4-year college degree
Post-graduate degree
(Ability to read content)
Literacy levels
Unable to read
3rd grade reading level
6th grade reading level
12th grade reading level
Race, Ethnicity, and Culture
Value of face-to-face communication vs impersonality of computer
Sensitivity or appropriateness
Income levels
Ability to afford access device such as computer
Ability to afford Internet Service Provider subscription
Ability to afford high-bandwidth access
Ability to afford “connected” school
Disability and Age
Experience and Familiarity

With Connection Device

How often do you use a computer?

4–8 hrs/day
at least once/day
1–4 times/week
1–4 times/month
4–5 times/year
1–2 times ever
never (complete novice)

With Internet/Web

How often do you use the World Wide Web?

4–8 hrs/day
at least once/day
1–4 times/week
1–4 times/month
4–5 times/year
1–2 times ever
never (complete novice)

Skill and Training

With Connection Device

How would you rate your computer skills?

Professional (e.g., programmer)
Advanced amateur

With Internet/Web

How would you rate your skills as a Web user?

Professional (e.g., programmer)
Advanced amateur

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.* 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,* 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 information booths.

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 browsers.

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 which they 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 (161).

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 [70], or simple download time [168]).

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 library). 

Human interface

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  (168,175–178).

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 (38-40,48,181-183).

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.

Back to top


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

Author Information

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:

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


  1. Nielsen//NetRatings. Three out of four Americans have access to the internet [Internet]. New York: Nielsen Media Research; 2004 [cited April 27, 2004]. Available from:*.
  2. WebMD Corporation. Research reveals that Internet has become primary means by which consumers access health information [Internet]. San Diego (CA): The Corporation; 2003 [cited April 29, 2003]. Available from: 2003/02/021003_pr.htm*.
  3. Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for health care information: results from a national survey. JAMA 2003;289(18):2400-6.
  4. Digital Divide Network. Digital Divide Network [homepage on the Internet]. Newton (MA): The Network; 2004 [cited October 10, 2002]. Available from:*.
  5. Eng TR. The eHealth landscape: a terrain map of emerging information and communication technologies in health and health care. Princeton (NJ): The Robert Wood Johnson Foundation; 2001.
  6. Eng TR, Maxfield A, Patrick K, Deering MJ, Ratzan SC, Gustafson DH. Access to health information and support: a public highway or a private road? JAMA 1998;280(15):1371-5.
  7. Bowen DJ, Ludwig A, Bush N, Unruh HK, Meischke H, Wooldridge J, et al. Early experience with a Web-based intervention to inform risk of breast cancer. J Health Psychol 2003;8:175-86.
  8. Bush NE, Wooldridge J, Foster V, Shaw K, Brown P. Web site design and development issues: the Washington State Breast and Cervical Health Program Web Site Demonstration Project. Oncol Nurs Forum 1999;26(5):857-65.
  9. Motive Ltd. The Motive Internet glossary [Internet].  Wellington South (New Zealand): Net Communications with Intent; 2002 [cited October 14, 2002]. Available from:*.
  10. December Communications Inc. Introduction to Internet WWW: Definitions [Internet]. Milwaukee (WI): The Company; 2002 [cited October 14, 2002]. Available from:*.
  11. Foldoc. Foldoc Free Online Dictionary of Computing [Internet]. London (England): Imperial College Department of Computing; 2002 [cited October 14, 2002]. Available from:*.
  12. Google Inc. The Google Search Appliance [Internet]. Mountain View (CA): Google Inc.; 2002 [cited October 10, 2002].  Available from:*.
  13. ZD Inc. FerretSoft. WebFerret [Internet]. San Francisco (CA): CNET Networks; 2002 [cited October 10, 2002]. Available from:*.
  14. Pew Research Center for People and the Press. Pew Internet and American Life Project [Internet]. Washington (DC): The Center; 2002 [cited October 10, 2002]. Available from:*.
  15. Nielsen//NetRatings. Neilsen//NetRatings [homepage on the Internet]. New York: Nielsen Media Research; 2002 [cited October 10, 2002]. Available from:*.
  16. Harris Interactive. Harris Interactive [homepage on the Internet]. Rochester (NY): Harris Interactive; 2002 [cited October 10, 2002]. Available fom:*.
  17. NUA. NUA Internet surveys [Internet]. Bradenton (FL): Scope Communications USA Limited; 2002 [cited October 10, 2002].  Available from:*.
  18. U.S. Department of Health and Human Services. Healthy People 2010: understanding and improving health. Washington (DC): U.S. Government Printing Office; 2000 [cited September 23, 2002]. Available from:
  19. US Department of Health and Human Services. Wired for health and well-being: the emergence of interactive health communication [Internet]. Washington (DC): Science Panel on Interactive Communication and Health, U.S. Government Printing Office; 1999 [cited September 23, 2002]. Available from:
  20. National Telecommunications and Information Administration.  A nation online: how Americans are expanding their use of the Internet [Internet]. Washington (DC): U.S. Department of Commerce; 2002 [cited April 15, 2002]. Available from: anationonline2.htm.
  21. National Telecommunications and Information Administration. Falling through the net: toward digital inclusion [Internet]. Washington (DC): U.S. Department of Commerce; 2000 [cited April 15, 2002]. Available from:
  22. UCLA  Center for Communication Policy. The UCLA Internet report: surveying the digital future year two [Internet]. Los Angeles (CA): The Center; 2001 [cited September 23, 2002]. Available from:*.
  23. RNdex case management offers Internet access. Comput Nurs 1997;15(1):5,11,3.
  24. Demiris G, Speedie SM, Finkelstein S. Change of patients' perceptions of TeleHomeCare. Telemed J E Health 2001;7(3):241-8.
  25. Bell DS, Kahn CE Jr. Health status assessment via the World Wide Web. Proc AMIA Annu Fall Symp 1996:338-42.
  26. Anthony D. Immediate access. The clinical nurse needs the Internet just as much as any academic. Nurs Stand 2000;14(43):27.
  27. Biro G, Bukovinszky A, Martin D. [Dr. Quiz: a program of medical question-data bank with access to Internet]. Orv Hetil 1999;140 (33):1847-50.
  28. Carnall D. NHS librarians cannot access the internet. BMJ 1999;319(7201):10.
  29. Durkin C. Accessing the Internet. Researching rare diseases and genetic disorders on the Internet. Nat Netw 2000;24(2):22-3.
  30. Flatley-Brennan P. Computer network home care demonstration: a randomized trial in persons living with AIDS. Comput Biol Med 1998;28(5):489-508.
  31. Gee PM. The Internet. Part-II. A home care nursing clinical resource. Home Healthc Nurse 1997;15(3):175-80.
  32. Giedd JN, Allen AJ, Behr R. Opportunities on the Internet for child and adolescent psychopharmacologists: net access and mailing lists. J Child Adolesc Psychopharmacol 1996;6(2):147-50.
  33. Harrison J, Morris-Docker S, Tod A. Internet access: the impact on nurses and PAMs. Nurs Stand 2000;15(7):33-4.
  34. Jones CM. The Internet access breakthrough. Bringing healthcare home. Healthc Inform 1997;14(7):62,64.
  35. Kaiser F. Maximizing Internet access. Mich Health Hosp 1998;34(5):28.
  36. Lipp ER. Web resources for patients with prostate cancer: a starting point. Semin Urol Oncol 2002;20(1):32-8.
  37. London JW, Morton DE, Marinucci D, Catalano R, Comis RL. Cost effective Internet access and video conferencing for a community cancer network. Proc Annu Symp Comput Appl Med Care 1995:781-4.
  38. Lyon BJ, Stavri PZ, Hochstein DC, Nardini HG. Internet access in the libraries of the National Network of Libraries of Medicine. Bull Med Libr Assoc 1998;86(4):486-90.
  39. Mandl KD, Feit S, Pena BM, Kohane IS. Growth and determinants of access in patient e-mail and Internet use. Arch Pediatr Adolesc Med 2000;154(5):508-11.
  40. Mandl KD, Katz SB, Kohane IS. Social equity and access to the World Wide Web and E-mail: implications for design and implementation of medical applications. Proc AMIA Symp 1998:215-9.
  41. Matarrese P, Helwig A. The development and assessment of Web-based health information for a corporate Intranet--a pilot study. Proc AMIA Symp 2000:551-5.
  42. Mihaescu T. The Internet. Access is now available in Romania. BMJ 1996;312(7036):978.
  43. Nylenna M, Aasland OG. [Nine out of ten Norwegian physicians have access to the Internet]. Tidsskr Nor Laegeforen 2000;120(27):3280-2.
  44. Patrikios H. Global health research. Internet access is not yet universal. BMJ 2001;322(7279):173.
  45. Pealer LN, Weiler RM, Pigg RM Jr, Miller D, Dorman SM. The feasibility of a web-based surveillance system to collect health risk behavior data from college students. Health Educ Behav 2001;28(5):547-59.
  46. Peckham B. Internet access for ESRD patients gives new meaning to "Sleepless in Seattle". Northwest kidney centers wire all stations at newest unit. Nephrol News Issues 1999;13(1):18-9.
  47. Price WS. Superhighway: NMA's access to the Internet. J Natl Med Assoc 1996;88(1):15-6.
  48. Uhlenhopp MB, Fliedner MC, Morris P, Van Boxtel T. A global perspective on nurses' Internet access and information utilization. Oncol Nurs Forum 1998;25(10 Suppl):27-32.
  49. Usatine RP, Lin K. Free Internet access for community preceptors. Acad Med 1999;74(3):204-5.
  50. Walker TJ. Authors willing to pay for instant web access. Nature 2001;411(6837):521-2.
  51. White H, McConnell E, Clipp E, Branch LG, Sloane R, Pieper C, et al. A randomized controlled trial of the psychosocial impact of providing internet training and access to older adults. Aging Ment Health 2002;6(3):213-21.
  52. Wilkins AS. Expanding Internet access for health care consumers. Health Care Manage Rev 1999;24(3):30-41.
  53. Williams A. Surfing over sixty. Making Internet access available helps residents stay connected. Provider 1999;25(8):69, 71-2.
  54. Wirtz P. Costs and benefits of Web access to museum data. Trends Ecol Evol 2000;15(9):374-5.
  55. Anderson CV. Office web site. Patients can access the Internet during their dentist visits. Mo Dent J 1996;76(5):19-21, 3-4.
  56. Jones RB, Balfour F, Gillies M, Stobo D, Cawsey AJ, Donaldson K. The accessibility of computer-based health information for patients: kiosks and the web. Medinfo 2001;10(Pt 2):1469-73.
  57. Nicholas D, Huntington P, Williams P. Comparing Web and touch screen transaction log files. J Med Internet Res 2001;3(2):E18.
  58. Ikemba CM, Kozinetz CA, Feltes TF, Fraser CD Jr, McKenzie ED, Shah N, et al. Internet use in families with children requiring cardiac surgery for congenital heart disease. Pediatrics 2002;109(3):419-22.
  59. Smith-Barbaro PA, Licciardone JC, Clarke HF, Coleridge ST. Factors associated with intended use of a Web site among family practice patients. J Med Internet Res 2001;3(2):E17.
  60. definitions [Internet]. Needham (MA): TechTarget; 2002 [cited October 10, 2002]. Available from: 0,,sid8_gci211510,00.html*.
  61. theDirectory of Internet Service Providers and Web Hosting Companies. theDirectory definitions [Internet]. 2002 [cited October 10, 2002]. Available from:*.
  62. Nielsen//NetRatings. Average Web usage [Internet]. New York: Nielsen Media Research; 2002 [cited October 14, 2002]. Available from: NRpublicreports.usageweekly*.
  63. Harris Interactive. Internet penetration at 66% of adults (137 million) nationwide [Internet]. Rochester (NY): The Company; 2002 [cited October 14, 2002]. Available from: index.asp?PID=295*.
  64. System Computing Services. Tutorial for newcomers to the Internet [Internet]. Las Vegas (NV): University and College System of Nevada; 1999 [cited October 10, 2002]. Available from:*.
  65. United States General Accounting Office. Report to the Ranking Minority Member, Subcommittee on Telecommunications, Committee on Energy and Commerce, House of Representatives. Characteristics and choices of Internet users [Internet]. Washington (DC): United States Department of Commerce; 2001 [cited September 23, 2002]. Available from:
  66. Patients justified in their concern about privacy of health Web sites, study finds. Health Care Strateg Manage 2000;18(3):9-10.
  67. Internet surfing for ease of access to AHCPR-clinical practice guidelines. Home Healthc Nurse 1996;14(7):560.
  68. How the Internet can be used to access current information for use in nursing practice. AARN News Lett 1997;53(3):24.
  69. WHO and six publishers launch Access to Research, internet initiative for developing countries. Ann Oncol 2002;13(5):641.
  70. Cline RJ, Haynes KM. Consumer health information seeking on the Internet: the state of the art. Health Educ Res 2001;16(6):671-92.
  71. De Ruiter HP, Larsen KE. Developing a transcultural patient care Web site. J Transcult Nurs 2002;13(1):61-7.
  72. DiGiorgio CJ, Richert CA, Klatt E, Becich MJ. E-mail, the Internet, and information access technology in pathology. Semin Diagn Pathol 1994;11(14):294-304.
  73. Doyle MD, Ang CS, Martin DC, Noe A. The visible embryo project: embedded program objects for knowledge access, creation and management through the World Wide Web. Comput Med Imaging Graph 1996;20(6):423-31.
  74. Duffy M. Web-based research: an innovative method for nursing research. Can Oncol Nurs J 2000;10(2):45-9.
  75. Duffy ME. Methodological issues in Web-based research. J Nurs Scholarsh 2002;34(1):83-8.
  76. Durkin C. Government Web sites facilitate access to a wealth of medical information. Natl Netw 1997;22(1):10.
  77. Gilchrist L. Internet access to dental register. Br Dent J 2001;191(3):117.
  78. Gomella LG. The wild, wild Web: resources for counseling patients with prostate cancer in the information age. Semin Urol Oncol 2000;18:167-71.
  79. Gomez E. Web sites help oncology nurses to strengthen leadership positions, easily access resources. ONS News 1998 Dec;13(12):11.
  80. Grannis FW, Jr. The Lung Cancer and Cigarette Smoking Web page: a pilot study in telehealth promotion on the World Wide Web. Can Respir J 2001 Sep-Oct;8(5):333-7.
  81. Graves GR. Costs and benefits of Web access to museum data. Trends Ecol Evol 2000 Sep;15(9):374.
  82. Gupta SC, Mehl DC, Verdi MG, Barker JH, Klein SA. Simplified access to medical resources on the Internet. How to get clinicians on the Web. Stud Health Technol Inform 1996;29:630-41.
  83. Guttmacher AE. Human genetics on the Web. Annu Rev Genomics Hum Genet 2001;2:213-33.
  84. Hay SI, Rogers DJ, Toomer JF, Snow RW. Annual Plasmodium falciparum entomological inoculation rates (EIR) across Africa: literature survey, Internet access and review. Trans R Soc Trop Med Hyg 2000 Mar-Apr;94(2):113-27.
  85. Hoffman-Goetz L, Clarke JN. Quality of breast cancer sites on the World Wide Web. Can J Public Health 2000 Jul-Aug;91(4):281-4.
  86. Holbrooks MZ. An introduction to minority health resources on the World Wide Web. Med Ref Serv Q 2000 Spring;19(1):59-71.
  87. Lindberg DA. Internet access to the National Library of Medicine. Eff Clin Pract 2000 Sep-Oct;3(5):256-60.
  88. Madan S, Bodagh IY. Dedicated to elderly care: geriatric medicine on the internet. Age Ageing 2002 Jan;31(1):70-4.
  89. Mascarini C, Ratib O, Trayser G, Ligier Y, Appel RD. In-house access to PACS images and related data through World Wide Web. Eur J Radiol 1996 Jun;22(3):218-20.
  90. Masys DR, Baker DB. Patient-Centered Access to Secure Systems Online (PCASSO): a secure approach to clinical data access via the World Wide Web. Proc AMIA Annu Fall Symp 1997:340-3.
  91. McColligan EE, Samuell RL 3rd, Jones WT, Moon WA, Pretnar SZ, Johns ML. Providing access to healthcare information resources using Internet Gopher technology as a part of a state-wide medical information network. Proc Annu Symp Comput Appl Med Care 1994:990.
  92. McCormick KA, Cohen E, Reed M, Sparks S, Wasem C. Funding nursing informatics activities. Internet access to announcements of government funding. Comput Nurs 1996 Nov-Dec;14(6):315-22.
  93. McGinty P. Internet access to nursing and related health associations, Part 2: International. Int J Trauma Nurs 1998 Jul-Sep;4(3):98-9.
  94. McGinty P. Internet access to nursing associations, Part 1: United States. Int J Trauma Nurs 1998 Apr-Jun;4(2):52.
  95. Murphy MA, Joyce WP. Information for surgical patients: implications of the World Wide Web. Eur J Surg 2001 Oct;167(10):728-33.
  96. O'Kane KC, McColligan EE. A Web access script language to support clinical application development. Comput Methods Programs Biomed 1998 Feb;55(2):85-97.
  97. Patterson J, Hakkinen PJ, Wullenweber AE. Human health risk assessment: selected Internet and World Wide Web resources. Toxicology 2002 Apr;173(1-2):123-43.
  98. Ralston MD, Coleman R, Scrutchfield KM. An organized pilot program promoting web access to picture archiving and communications system data: emphasis on offices outside the host institution. J Digit Imaging 2002;15 Suppl 1:162-5.
  99. Rhodes E. Consumer informatics: helping patients to access health information via the Internet. Nursingconnections 2000 Spring;13(1):33-42.
  100. Rideout V. Generation What are young people really doing online? Mark Health Serv 2002 Spring;22(1):26-30.
  101. Ruskin KJ. How to access Journal of Clinical Monitoring abstracts on the Internet. J Clin Monit 1994 Nov;10(6):371-2.
  102. Stein LD. Internet access to the C. elegans genome. Trends Genet 1999 Oct;15(10):425-7.
  103. Steuer J. How to access images on the Internet. J Nucl Med 1995 Jul;36(7):24N.
  104. Tabozzi M, Osele S. [The internet and public health: access to information]. Sante Publique 1999 Sep;11(3):363-7.
  105. Teasdale K, Teasdale S. Nursing on the Internet. Prof Nurse 1996 Dec;12(3):181-4.
  106. Thoma GR, Long LR, Berman LE. A client/server system for Internet access to biomedical text/image databanks. Comput Med Imaging Graph 1996 Jul-Aug;20(4):259-68.
  107. Unsworth J, Boon H. Access all areas: wound care resources on the Internet. J Tissue Viability 1999 Oct;9(4):117-9.
  108. Voge S. NOAH--New York Online Access to Health: library collaboration for bilingual consumer health information on the Internet. Bull Med Libr Assoc 1998 Jul;86(3):326-34.
  109. Winker MA, Flanagin A, Chi-Lum B, White J, Andrews K, Kennett RL, et al. Guidelines for medical and health information sites on the internet: principles governing AMA Web sites. American Medical Association. JAMA 2000 Mar;283(12):1600-6.
  110. Wootton JC. The quality of information on women's health on the Internet. J Womens Health 1997 Oct;6(5):575-81.
  111. Chadwick DW, Crook PJ, Young AJ, McDowell DM, Dornan TL, New JP. Using the Internet to access confidential patient records: a case study. BMJ 2000 Sep;321(7261):612-4.
  112. Cimino JJ, Li J, Mendonca EA, Sengupta S, Patel VL, Kushniruk AW. An evaluation of patient access to their electronic medical records via the World Wide Web. Proc AMIA Symp 2000:151-5.
  113. Cimino JJ, Sengupta S, Clayton PD, Patel VL, Kushniruk A, Huang X. Architecture for a Web-based clinical information system that keeps the design open and the access closed. Proc AMIA Symp 1998:121-5.
  114. Cross MA. Provider automation. Using the Internet to access records. Health Data Manag 1997 Nov;5(11):56,58.
  115. Eysenbach G, Kohler C, Yihune G, Lampe K, Cross P, Brickley D. A framework for improving the quality of health information on the World-Wide-Web and bettering public (e-)health: the MedCERTAIN approach. Medinfo 2001;10(Pt 2):1450-4.
  116. Goldberg HI, Tarczy-Hornoch P, Stephens K, Larson EB, LoGerfo JP. Internet access to patients' records. Lancet 1998 Jun;351(9118):1811.
  117. Hinds A, Greenspun P, Kohane IS. WHAM!: a forms constructor for medical record access via the World Wide Web. Proc Annu Symp Comput Appl Med Care 1995:116-20.
  118. Kelly B. Cutting ties with phone lines. Delivery system's physicians remotely access its hospital information system via the Internet, saving thousands of dollars. Health Data Manag 2002 Mar;10(3):32-3.
  119. Klimczak JC, Witten DM 2nd, Ruiz M, Mitchell JA, Brilhart JG, Frankenberger ML. Providing location-independent access to patient clinical narratives using Web browsers and a tiered server approach. Proc AMIA Annu Fall Symp 1996:623-7.
  120. Kushniruk AW, Patel VL, Cimino JJ. Evaluation of Web-based patient information resources: application in the assessment of a patient clinical information system. Proc AMIA Symp 2000:443-7.
  121. Masys D, Baker D, Butros A, Cowles KE. Giving patients access to their medical records via the internet: the PCASSO experience. J Am Med Inform Assoc 2002 Mar-Apr;9(2):181-91.
  122. Masys DR, Baker DB, Barnhart R, Buss T. PCASSO: a secure architecture for access to clinical data via the Internet. Medinfo 1998;9(Pt 2):1130-4.
  123. Sherter AL. Internet/intranets. Providing easier access to clinical data. Health Data Manag 1997 Aug;5(8):33-4, 7.
  124. Tarczy-Hornoch P, Kwan-Gett TS, Fouche L, Hoath J, Fuller S, Ibrahim KN, et al. Meeting clinician information needs by integrating access to the medical record and knowledge resources via the Web. Proc AMIA Annu Fall Symp 1997:809-13.
  125. Walker SN. Using Internet to access confidential patient records. Information about NHSnet was incorrect. BMJ 2001 Mar;322(7288):731.
  126. Chen X, Liu M, Gilson MK. BindingDB: a Web-accessible molecular recognition database. Comb Chem High Throughput Screen 2001 Dec;4(8):719-25.
  127. Lenert LA. The reliability and internal consistency of an Internet-capable computer program for measuring utilities. Qual Life Res 2000;9(7):811-7.
  128. Yan Q, Sadee W. Human membrane transporter database: a Web-accessible relational database for drug transport studies and pharmacogenomics. AAPS PharmSci 2000;2(3):E20.
  129. Allen GK, Patrick TB, Murtaugh MP. World Wide Web-based access to heterogenous information resources for cytokine research and education. Proc AMIA Annu Fall Symp 1996:393-7.
  130. Angood PB. Telemedicine, the Internet, and World Wide Web: overview, current status, and relevance to surgeons. World J Surg 2001 Nov;25(11):1449-57.
  131. Balbach ED, Gasior RJ, Barbeau EM. Tobacco industry documents: comparing the Minnesota Depository and Internet access. Tob Control 2002 Mar;11(1):68-72.
  132. Baur C, Kranawetter M, Weiss-Kubat S, Georgieff M, Lehmann-Horn F, Schiebe M. [A remote access system for inquiry of centrally stored data on patients suspected of malignant hyperthermia . A prototypical development for the Internet]. Anasthesiol Intensivmed Notfallmed Schmerzther 1998 Apr;33(4):232-7.
  133. Bazzoli F. The data has left the building. Software vendors hope physicians will turn to the Internet to access applications and store information. Health Data Manag 1999 Oct;7(10):34-6,38-9.
  134. Bergh B, Thomsen J, Felix R. World Wide Web based access to clinical and radiological patient data. Stud Health Technol Inform 1998;56:170-6.
  135. Besson A. Document access over the Web--an intranet solution. Health Libr Rev 1998 Mar;15(1):63-7.
  136. Blythe J, Royle JA, Oolup P, Potvin C, Smith SD. Linking the professional literature to nursing practice: challenges and opportunities. AAOHN J 1995 Jun;43(6):342-5.
  137. Bowles KH, Naylor MD, Peng T, Qian R. Informatics application provides instant research to practice benefits. Proc AMIA Symp 2001:66-70.
  138. Bradley SW, Rosse C, Brinkley JF. Web-based access to an online atlas of anatomy: the digital anatomist Common Gateway Interface. Proc Annu Symp Comput Appl Med Care 1995:512-6.
  139. Brown KM. Using the Internet to access oral health information. J Dent Hyg 2001 Winter;75(1):39-44.
  140. Bult CJ, Krupke DM, Naf D, Sundberg JP, Eppig JT. Web-based access to mouse models of human cancers: the Mouse Tumor Biology (MTB) Database. Nucleic Acids Res 2001 Jan;29(1):95-7.
  141. Duncan RG, Saperia D, Dulbandzhyan R, Shabot MM, Polaschek JX, Jones DT. Integrated Web-based viewing and secure remote access to a clinical data repository and diverse clinical systems. Proc AMIA Symp 2001:149-53.
  142. Harper R. Access to DNA and protein databases on the Internet. Curr Opin Biotechnol 1994 Feb;5(1):4-18.
  143. Kempner ME, Felder RA. LabAutomation 2002: Internet access to health data: elder-care, home-care, and self-care programs--Part 4. Am Clin Lab 2002 Jun;21(5):8-12.
  144. Kindler H, Fliedner TM, Densow D. Internet access to a medical case repository for teaching and analysis. Proc AMIA Annu Fall Symp 1997:543-7.
  145. Nguyen A, Wu S, Jalali M, Uthman M, Johnson K, Banez E. A Web-based database for diagnosis of haematologic neoplasms using immunophenotyping by flow cytometry. Med Inform Internet Med 2001 Oct-Dec;26(4):309-23.
  146. Sanders NW, Mann NH 3rd, Spengler DM. Web client and ODBC access to legacy database information: a low cost approach. Proc AMIA Annu Fall Symp 1997:799-803.
  147. Scoble MJ. Costs and benefits of Web access to museum data. Trends Ecol Evol 2000 Sep;15(9):374.
  148. Tamaoka K, Kirsner K, Yanase Y, Miyaoka Y, Kawakami M. A Web-accessible database of characteristics of the 1,945 basic Japanese kanji. Behav Res Methods Instrum Comput 2002 May;34(2):260-75.
  149. Afrin LB. Web access to the American Society of Hematology slide bank. Blood 1999 Apr;93(7):2425-6.
  150. Aiton JF, McDonough A, McLachlan JC, Smart SD, Whiten SC. World Wide Web access to the British Universities Human Embryo Database. J Anat 1997 Jan;190( Pt 1):149-54.
  151. Hardison RC, Chui DH, Riemer CR, Miller W, Carver MF, Molchanova TP, et al. Access to a syllabus of human hemoglobin variants (1996) via the World Wide Web. Hemoglobin 1998 mar;22(2):113-27.
  152. Patrick TB, Worth ER, Hardin LE. Using concept maps on the World-Wide Web to access a curriculum database for problem-based learning. Proc AMIA Annu Fall Symp 1996:32-6.
  153. Turisco F. Using Internet technology to extend access to legacy systems. Healthc Financ Manage 1999May;53(5):86.
  154. Vazquez-Naya J, Loureiro J, Calle J, Vidal J, Sierra A. Necessary security mechanisms in a PACS DICOM access system with Web technology. J Digit Imaging 2002;15 Suppl 1:107-11.
  155. Rousseau GK, Jamieson BA, Rogers WA, Mead SE, Sit RA. Assessing the usability of on-line library systems. Behaviour & Information Technology 1998;17:274-81.
  156. Nenov V, Klopp J. Remote access to neurosurgical ICU physiological data using the World Wide Web. Stud Health Technol Inform 1996;29:242-9.
  157. Pan CC, Liang WY, Huang CW, Chiang H. Diagnosing minimal adenocarcinoma on prostate needle biopsy by real-time dynamic telepathology through the internet: evaluation of an economic technology for remote consultation. Hum Pathol 2002 Feb;33(2):242-6.
  158. Sargsyan AE, Doarn CR, Simmons SC. Internet and World Wide Web technologies for medical data management and remote access to clinical expertise. Tex Med 1998 Feb;94(2):75-80.
  159. Sargsyan AE, Doarn CR, Simmons SC. Internet and World Wide Web technologies for medical data management and remote access to clinical expertise. Aviat Space Environ Med 1999 Feb;70(2):185-90.
  160. Scott GC, Cher DJ, Lenert LA. SecondOpinion: interactive Web-based access to a decision model. Proc AMIA Annu Fall Symp 1997:769-73.
  161. Houston JD, Fiore DC. Online medical surveys: using the Internet as a research tool. MD Comput 1998 Mar-Apr;15(2):116-20.
  162. Becht D, Taglang K, Wilhelm A. The Digital Divide and the U.S. Hispanic population [Internet]. Newton (MA):  Digital Beat-Benton Foundation; 1999 [cited October 10, 2002]. Available from:*.
  163. Lenert LA. iMPACT3: online tools for development of web sites for the study of patients' preferences and utilities. Proc AMIA Symp 2000:1172.
  164. Marshall WW, Haley RW. Use of a secure Internet Web site for collaborative medical research. JAMA 2000 Oct;284(14):1843-9.
  165. Clark B, Bresee J. Secure Internet access to patient medical information. Healthc Inf Manage 1998 Spring;12(1):69-79.
  166. Greenberg GN. Internet resources for occupational and environmental health professionals. Toxicology 2002 Apr;173(1-2):145-52.
  167. Griffiths KM, Christensen H. The quality and accessibility of Australian depression sites on the World Wide Web. Med J Aust 2002 May;176 Suppl:S97-S104.
  168. Croft DR, Peterson MW. An evaluation of the quality and contents of asthma education on the World Wide Web. Chest 2002 Apr;121(4):1301-7.
  169. Science Panel on Interactive Communication and Health. Wired for health and well-being: the emergence of interactive health communication. [Internet]. Washington (DC): U.S. Department of Health and Human Services, U.S. Government Printing Office; 1999 [cited August 15, 2002]. Available from:
  170. U.S. Department of Health and Human Services. Usability.Gov: your resource for designing usable, useful and accessible web sites and user interfaces [Internet]. Bethesda (MD): The Department, Communication Technologies Branch; 2001 [cited April 15, 2002].
  171. The World Wide Web Consortium (W3C). Web accessibility initiative (WAI) [Internet]. Cambridge (MA): The Consortium; 2003 [cited June 3, 2003]. Available from:*.
  172. Instone K. Usability engineering for the Web [Internet]. World Wide Web Journal 1997 Winter;2(1) [cited April 15, 2002]. Available from:*.
  173. McCray AT, Dorfman E, Ripple A, Ide NC, Jha M, Katz DG, et al. Usability issues in developing a Web-based consumer health site. Proc AMIA Symp 2000:556-60.
  174. Murray G, Costanzo T. Usability and the Web: an overview [Internet]. Ottowa (Canada): National Library of Canada [cited April 15, 2002]. Available from:*.
  175. Wallendorf M. Literally literacy. J Consumer Research 2001;27:505-11.
  176. The Children's Partnership. Online content for low-income and underserved Americans: the digital divide's new frontier finds that the information identified as useful by low-income and other traditionally underserved Americans either doesn't exist or is extremely difficult to find on the Internet [Internet]. Washington (DC): The Partnership; 2000 [cited October 10, 2002]. Available from: low_income/index.html*
  177. Cullen R. Addressing the digital divide. Online Information Review 2001;25:311-20.
  178. Wilson FL, Baker LM, Brown-Syed C, Gollop C. An analysis of the readability and cultural sensitivity of information on the National Cancer Institute's Web site: CancerNet. Oncol Nurs Forum 2000 Oct;27(9):1403-9.
  179. Hoffman DL, Novak TP, Schlosser AE. The evolution of the digital divide: how gaps in Internet access may impact electronic commerce [Internet]. Journal of Computer-Mediated Communication 2000;5.
  180. Anderson R. Native Americans and the Digital Divide [Internet]. Washington (DC): Benton Foundation, Digital Beat; 1999 [cited October 10, 2002]. Available from:*
  181. Robinson C, Flowers CW, Alperson BL, Norris KC. Internet access and use among disadvantaged inner-city patients. JAMA 1999 Mar;281(11):988-9.
  182. Kalichman SC, Weinhardt L, Benotsch E, Cherry C. Closing the digital divide in HIV/AIDS care: development of a theory-based intervention to increase Internet access. AIDS Care 2002 Aug;14(4):523-37.
  183. Kalichman SC, Weinhardt L, Benotsch E, DiFonzo K, Luke W, Austin J. Internet access and Internet use for health information among people living with HIV-AIDS. Patient Educ Couns 2002 Feb;46(2):109-16.
  184. Morrell RW, Mayhorn CB, Bennett J. A survey of World Wide Web use in middle-aged and older adults. Hum Factors 2000 Summer;42(2):175-82.
  185. Buller DB, Woodall WG, Zimmerman DE, Heimendinger J, Rogers EM, Slater MD, et al. Formative research activities to provide Web-based nutrition education to adults in the Upper Rio Grande Valley. Fam Community Health 2001 Oct;24(3):1-12.
  186. Lee Y, Geller J. A collaborative andsShareable Web-based learning system. International Journal on E-Learning 2003;2:33-45.
  187. City of Seattle Information Technology Indicators Program. Residential technology survey [Internet]. Seattle (WA): City of Seattle Community Technology Initiative; 2000 [cited July 29, 2002]. Available from: data20collection.htm*.
  188. Light JS. Rethinking the Digital Divide. Harvard Educational Review 2001;71:709-33.

Back to top

*URLs for nonfederal organizations are provided solely as a service to our users. URLs do not constitute an endorsement of any organization by CDC or the federal government, and none should be inferred. CDC is not responsible for the content of Web pages found at these URLs.



The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.


Privacy Policy | Accessibility

CDC Home | Search | Health Topics A-Z

This page last reviewed March 30, 2012
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
 HHS logoUnited States Department of
Health and Human Services