Digital inclusion: The concept and strategies for people with mental health difficulties

Within five years, digital exclusion will rival all other social and economic determinants, and may become the major social justice challenge of our time.

Perlgut (2011)

Widespread use of mobile and wireless technologies has the potential to transform health care. Increasingly, digital technologies such as smart phones, the Internet and digital TV are becoming an important way to gain access to the social determinants of health including employment, education and social networks. The use of smart phones has rocketed, with over 11 million Smartphone users in Australia in 2013, up 29% compared to 2012 (Australian Communication and Media Authority, 2013). However, the quantity and quality of access to these technologies and the possible effects of this on people from socially disadvantaged groups especially for those experiencing mental health problems have rarely been considered. Perlgut (2011) has put it succinctly in the context of digital inclusion in Australia as ‘the concept of—digital divide has slipped from the public radar in recent years under the onslaught of smart phones, iPads, other—tablets and the bewildering and growing collection of digital devices …’

The concepts of digital divide and digital inclusion are used interchangeably to describe the access or lack of access to the digital technology for the population. While the digital inclusion is hotly debated in social and information technology (IT) sectors, there is almost complete lack of debate about the digital inclusion in mental health. We will argue that digital inclusion will become the most important determinant of social inclusion and wellbeing, and will suggest measures to enhance digital inclusion for those suffering from mental illness.

Digital inclusion is the ability of individuals and groups to access and use information and communication technologies (ICTs). This includes access to the Internet, suitable hardware and software and training for the digital literacy skills (Perlgut, 2011). Better access to these technologies results in wider choice and empowerment, with better integration in society. Much of social inclusion is now created and nurtured online. Lack of access to or the knowledge of how to use ICT results in digital exclusion which is considered as an important indicator of economic inequity (Norris, 2001).

Socially disadvantaged people not only lack in access to digital technologies, they are also falling further behind the rest of society who use technology to their advantage. This increases both width and depth of the digital exclusion. Digitally excluded people are increasingly at risk of becoming ‘invisible’, as the key platforms for discussion and social participation (e.g. e-petitions) are also digitally driven. This leads to a vicious cycle in which those excluded from the digital advantage suffer from higher costs of living and often restriction to access from services. Disability groups and patients remain key groups who experience digital exclusion. In Australia, 28% of those suffering from a disability have broadband access compared to 48% of people who do not need assistance (Perlgut, 2011). As a result, those who lack digital access and are unable to use the technology effectively are likely to suffer from increasing health inequities. Most importantly, perhaps in future, large number of interventions will be based on digital platforms (see, for example, www.marketwired.com/press-release/wellframe-expands-partnership-with-mclean-hospital-deliver-pioneering-support-model-1955815.htm). Therefore, digital exclusion may limit potential treatment options for patients with mental illness in the future.

Although the effects of digital exclusion on mental health are not studied, the social exclusion and its relationship with poor mental health is well known. For example, a recent study based on a large dataset from 26 European countries found that both ‘economic/employment’ and ‘social/welfare’ dimensions of social exclusion significantly influenced suicide mortality among male patients (Yur’yev et al., 2013). Existing literature on the use of Internet and mobile technologies in the assessment and treatment of psychiatric disorders is limited to cross-sectional surveys based on convenience samples from outpatient populations without comparison groups. A relatively larger US study found that only one-third of those with serious mental health difficulties reported having used the Internet and less than one-third of Internet users had ever searched for health information. This was in stark contrast to the Internet use by chronic condition groups, where half went online regularly, and the majority were avid consumers of online health information (Borzekowski et al., 2009).

The acceptability, motivation and attitudes toward the use of digital devices by people suffering from mental health difficulties are also poorly understood. The distressing experiences of unusual beliefs and delusions associated with psychotic disorders, possible interference with patient–clinician communication and anxiety associated with using digital devices can result in distorted perceptions and suspiciousness regarding computers and mobile phones.

The interventions to enhance the digital inclusion should focus on individual, institutional and professional levels. Most programs to help service users have focused on providing IT training and computer literacy. Anecdotally, these do not seem to work and instead can create more anxiety and skepticism around technology. Predictors of what encourages people to become online users can be very personal. It is important to assess the individual interests of people and demonstrate how ‘going online’ could further enhance areas they already enjoy. Such a personalized approach can help individuals to train in ICT. Different incentives could be provided to encourage patients to visit health websites with reliable and up-to-date information.

Digital exclusion should also be considered at institutional and professional levels. Increasingly, services require patients to participate in digitally mediated communications. It is, therefore, the responsibility of the health professionals and the institutions serving patients that they provide support, skills and technology in order to avoid exacerbating health inequities and promote the benefits for health of digital inclusion. Clinicians would benefit from developing insights into digital interaction and the effects on mental wellbeing, and this must become part of routine clinical discourse.

At institutional level, lack of a presence or inadequate participation in the virtual community means that mental health professionals are missing out on an opportunity to help facilitate social inclusion and fight the stigma of mental health difficulties. The organizations such as the Royal College of Psychiatrists need to develop policies and advocate for the digital inclusion. Availability of a suitable infrastructure for disadvantaged groups is a major obstacle that needs to be addressed. User interfaces will require adaptation for people with learning disabilities, older people and those with cognitive impairment. Initiatives to promote uptake might involve subsidizing access to broadband for patients and mental health services. Mental health centers could be benchmarked and rated for their access to broadband and whether these are ICT friendly, in an effort for this to become adopted by services.

Digital inclusion cannot be considered separately from economic and social inclusion. As digital technologies rapidly evolve and have much greater impact on our lives, it is likely that socially disadvantaged and mentally ill people will lag much behind the rest of the population, if digital inclusion is not addressed as a priority issue. There is need for concerted efforts by all stake holders, especially the clinicians and institutions involved in mental health care. Studies examining the nature and degree of digital inclusion are urgently required to inform the policy and clinical practice in this rapidly changing area.