Health Communication

ISSN: 1041-0236 (Print) 1532-7027 (Online) Journal homepage: http://www.tandfonline.com/loi/hhth20

Digital Inclusion & Health Communication: A Rapid

Review of Literature

Kim Borg, Mark Boulet, Liam Smith & Peter Bragge

To cite this article: Kim Borg, Mark Boulet, Liam Smith & Peter Bragge (2018): Digital
Inclusion & Health Communication: A Rapid Review of Literature, Health Communication, DOI:
10.1080/10410236.2018.1485077

To link to this article: https://doi.org/10.1080/10410236.2018.1485077

Published online: 11 Jun 2018.

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HEALTH COMMUNICATION
https://doi.org/10.1080/10410236.2018.1485077

Digital Inclusion & Health Communication: A Rapid Review of Literature

Kim Borg , Mark Boulet , Liam Smith , and Peter Bragge
BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University

ABSTRACT
Information and communication technologies can be a valuable tool for enhancing health communica-
tion. However, not everyone is utilising the wide suite of digital opportunities. This disparity has the
potential to exacerbate existing social and health inequalities, particularly among vulnerable groups
such as those who are in poor health and the elderly. This review aimed to systematically identify the
common barriers to, and facilitators of, digital inclusion. A comprehensive database search yielded 969
citations. Following screening, seven systematic reviews and three non-systematic reviews were identi-
fied. Collectively, the reviews found that physical access continues to be a barrier to digital inclusion.
However, provision of access alone is insufficient, as digital ability and attitude were also potential
barriers. Social support, direct user experience and collaborative learning/design were identified as key
strategies to improve inclusion. These review findings provide guidance for health communication
practitioners in designing and implementing effective programmes in the digital environment.

Information and communication technologies (ICTs) can be
a valuable tool for enhancing health communication.
Previous research has found that the benefits of incorporat-
ing ICTs in health communication range from assisting
patients to self-manage their health conditions (Park,
Burford, Nolan, & Hanlen, 2016), improving health literacy
(Tennant et al., 2015) and facilitating communication
between patients and healthcare providers (Prestin, Vieux,
& Chou, 2015). Social networking has also enabled health
communication campaigns to engage with previously
unreachable audiences, further encouraging communicative
behaviours (Shi, Poorisat, & Salmon, 2018; Yoo, Kim, & Lee,
2018). Beyond health, digital services can also yield other
benefits for individuals, for businesses, for not-for-profit
organisations and for governments (Koss, Azad, Gurm, &
Rosenthal, 2013).
In 2005, approximately 18% of households worldwide had
Internet access; by 2016 this figure had increased to over 50%,
and up to 90% in developed countries (International
Telecommunication Union, 2016). Mobile devices are now
the preferred method of connecting—since 2010 the number
of global mobile broadband subscriptions has exceeded fixed
(landline) connection subscriptions (Bold & Davidson, 2012).
Within this context, an Internet connection, and the devices
that facilitate the connection, are now seen as basic utilities,
much like electricity or water (Walton, Kop, Spriggs, &
Fitzgerald, 2013). Many organisations offer their services in
the digital environment, and in some cases these can only be
accessed through the Internet.
Despite this global trend towards increased online connec-
tivity, it is apparent that, even in developed countries,1 there
are certain groups, commonly referred to as the ‘digitally
excluded’, who are not utilising the wide suite of available
digital opportunities (Selwyn & Facer, 2007). The term ‘digital
divide’ was initially coined to describe the difference between
individuals who had, and did not have, physical access to the
Internet and other ICTs (Campos-Castillo, 2015; Rose, Seton,
Tucker, & van der Zwan, 2014). As increases in availability
and affordability began to close the access divide, researchers
began focusing more on how people use, and do not use, ICTs
rather than just on whether they have physical access (Pearce
& Rice, 2013; van Deursen, van Dijk, & Peter, 2015). To this
end, the term ‘digital divide’, is now being replaced with the
more nuanced ‘digital inclusion’, which acknowledges that ‘. . .
the simple binary description of a divide fails to do justice to
the complex reality of various people’s differing access and
usage of digital technology’ (Warschauer, 2003, p. 44). Digital
exclusion does not necessarily come from physical access to
ICTs, but rather from what people are able to do and what
they want to do with these technologies.
It has been found that individuals who have physical access
are not using the Internet in ways which could help foster
social, economic or professional gain (Pearce & Rice, 2013;
van Deursen & van Dijk, 2014). For example, van Deursen
et al. (2015) found that online activities with ‘productive’
outcomes (e.g. using search systems, finding online courses
and training, independent learning) were favoured by those
with higher levels of education and with higher incomes;

CONTACT Kim Borg kim.borg@monash.edu BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Boulevard,
Clayton 3800, Victoria, Australia.
1
According to the Central Intelligence Agency (CIA) World Fact Book, developed countries are also known as the First World, high-income or industrialised
countries. They are comprised of market-oriented economies and are primarily democratic nations in the Organization for Economic Cooperation and
Development (OECD) (https://www.cia.gov/library/publications/resources/the-world-factbook/appendix/appendix-b.html).
© 2018 Taylor & Francis Group, LLC
2 K. BORG ET AL.
whereas online activities with comparatively less productive
outcomes (such as ‘surfing’ without a purpose) were more
common among people with lower education levels and
below-average incomes. The change in focus from physical
access to usage has led some researchers to argue that the
conceptualisation of the digital divide needs rethinking, and
can now be defined by skills and ‘meaningful use’ (Strover,
2014, p. 117).
Generally, those frequently identified as digitally excluded
are more likely to be on low incomes, lack tertiary education,
live in rural or remote communities, live with disabilities, be
from culturally and linguistically diverse backgrounds, be
unemployed or be elderly (Australian Bureau of Statistics,
2014–15; Broadbent & Papadopoulos, 2013; Rose et al.,
2014). In the context of health communication, this disparity
can often exacerbate existing disadvantages already experi-
enced by many of these groups, potentially leading to a cycle
of health inequality. Bell (2014, p. 514) argues that ‘just as
inequalities in health communication can contribute to health
disparities, health disparities might also drive communication
inequalities’.
Using the Internet to manage personal health and well-
being—for example, to seek health-related information, e-mail
healthcare providers or access social media for health pur-
poses—has been recognised as not ‘keeping pace’ with the
increase in Internet penetration (Prestin et al., 2015). This is
especially concerning given that many people experiencing
digital exclusion also have poor health and would greatly
benefit from ‘eHealth’ systems (Robinson et al., 2015).
Meanwhile, those advantaged in society continue to use the
digital environment to further their advantage, thus maintain-
ing the new digital divide (Antoci, Sabatini, & Sodini, 2015;
Robinson et al., 2015; van Deursen & van Dijk, 2015; van
Deursen et al., 2015).
Given the alignment between those who most stand to
benefit from digital health communication services and
those who are digitally excluded, a better understanding of
drivers and barriers for utilisation of online services is needed.
Such an understanding would assist health communication
practitioners in designing and implementing effective pro-
grammes in the digital environment, as well as highlighting
gaps and future research needs. Therefore, the purpose of this
review is to systematically identify the common barriers to,
and facilitators of, digital inclusion with a focus on informing
the design and delivery of online health communication
services.
Method
This review employed a ‘rapid review’ approach. Rapid
reviews are a method of synthesising research where an over-
view of evidence is required in a short time (Wright & Bragge,
2018). Unlike standard systematic reviews (which can take up
to two years to complete), rapid reviews focus on already
synthesised research evidence and, where these are not avail-
able, on high-quality or recent primary studies (Khangura,
Konnyu, Cushman, Grimshaw, & Moher, 2012). Other than
the focus on synthesised (rather than primary) evidence, the
rapid review process follows similar protocols to a systematic
review in establishing a search strategy, setting inclusion and
exclusion criteria for literature screening and selection, data
extraction, quality appraisal and a synthesis of findings.
The rationale for a rapid review of this topic was three-fold.
First, reviews are considered the optimal unit of knowledge
translation, because they are the highest ranked form of pub-
lished evidence—therefore review findings are more robust and
transferable to practice, compared to primary studies
(Grimshaw, Eccles, Lavis, Hill, & Squires, 2012). Second, the
rapid review methodology provides best available research in a
short timeframe. While a definitive systematic review is more
detailed, rapid reviews enable industry, practice and policy
bodies to be informed by research evidence sooner. This is of
particular importance in the field of digital inclusion, given the
rapid advances in ICTs and their use. Third, reviewing reviews
rather than primary studies enables elucidation of a broad
range of behavioural interventions, rather than detailed
description of a narrower range of interventions. While this
does sacrifice depth for breadth, policymakers and practitioners
frequently express a need for a broad overview within a parti-
cular field when deliberating upon a range of possible actions.
Search strategy
A comprehensive search of peer-reviewed journal publications
published from 1 January 2013 until 24 February 2016 was
undertaken of PsycINFO and Web of Science using the search
terms ‘digital inclusion’ and ‘digital divide’. The search was
subsequently updated to 6 April 2018.
Screening and selection
Two reviewers independently screened citations against the inclu-
sion and exclusion criteria outlined below. Discrepancies were
resolved through discussion and consultation with a third inde-
pendent researcher with experience in rapid review methods.
Inclusion criteria
● Primary aim:
○ Identify barriers and facilitators of digital inclusion
(including the digital divide);
○ Evaluate interventions designed to improve digital
inclusion (including those addressing the digital
divide).
● Study settings for included studies in review:
○ Developed countries with modern technology and
infrastructure/digital economies;
○ General reviews of digital inclusion/divide.
● Publication type:
○ Systematic reviews of quantitative or qualitative
studies;
○ Non-systematic reviews.
Exclusion criteria
● Primary studies;
● Technological innovations that do not target human
uptake of IT, e.g. authentication protocols;
● Reviews of observational studies with no behavioural
focus, e.g. Google analytics;
 HEALTH COMMUNICATION 3

● Conference abstracts; behavioural barriers (inhibitors) and enablers (facilitators) of

● Dissertation abstracts or book chapters;
● Discussion/conceptual/protocol papers.
Quality appraisal, data extraction and synthesis
Quality appraisal of the systematic reviews was undertaken by
two reviewers using the AMSTAR, an 11-item tool with well-
established validity and reliability that is extensively used to
evaluate systematic reviews; including design, procedure,
reporting and interpretation (Shea,, Grimshaw et al., 2007).
While the AMSTAR was originally developed for use in
healthcare research, the evaluation criteria pertain to generally
accepted practices for systematic reviews, including a priori
design, duplicate study selection and data extraction; and use
of a quality appraisal tool to evaluate included primary studies
(Shea, Bouter et al., 2007, Shea, Grimshaw et al., 2007, Shea
et al., 2009). Systematic reviews were defined as ‘an overview
of primary studies which contain an explicit statement of
objectives, materials and methods and has been conducted
according to explicit and reproducible methodology’
(Greenhalgh, 1997, p. 672).
Key details from eligible systematic reviews were extracted
as follows: aim, inclusion criteria, number and type of studies,
date of most recent search and key findings/conclusions.
While systematic reviews were the primary target for this
rapid review, only a limited number were identified in our
search. As such, it was decided to include non-systematic
reviews (descriptive or narrative reviews in which there is
no explicit systematic search for, or appraisal of, research
evidence). Although non-systematic reviews lack the rigour
and methodological approach of a systematic review, they
provide useful discussions of the state of a particular field,
often with a strong theoretical framework that can give useful
insights and context to the findings of systematic reviews.
Synthesis of our rapid review results focused on findings
from the systematic reviews. It is not possible to appraise
non-systematic reviews with the AMSTAR because it is not
validated for this purpose.
The findings of the included reviews were narratively sum-
marised with a focus on review findings pertaining to
digital inclusion. Similar thematic approaches have been used
in previously published rapid reviews (Bragge et al., 2015;
Wright & Bragge, 2018).
Results
Screening and selection
The initial search yielded a total of 969 citations and abstracts.
Following initial screening, 544 citations were excluded, leav-
ing 425 for full-text screening. The follow-up search yielded
an additional 77 citations and abstracts, of which 13 were
included in full-text screening. Following full-text screening,
ten reviews were identified, comprising seven systematic
reviews (Abbott, Brown, Evett, & Standen, 2014; Amante,
Hogan, Pagoto, & English, 2014; de Lusignan et al., 2014;
Litt, 2013; Mubarak, 2015; Showell, 2017; Thompson, Reilly,
& Valdez, 2016) and three non-systematic reviews (Litt, 2013;
Satariano, Scharlach, & Lindeman, 2014; Trentham, Sokoloff,
Tsang, & Neysmith, 2015).2
Quality appraisal of included systematic reviews
Results of AMSTAR quality appraisal of the seven systematic
reviews are presented in Table 1. All criteria were considered
of equal importance; however, some articles were rated out of
nine or ten (rather than 11) criteria where an item(s) was not
relevant. The methodological quality of the systematic reviews
varied, with three of the five satisfying the majority of quality
appraisal items:
● One review satisfied nine out of ten applicable review
items (de Lusignan et al., 2014);
● One satisfied six out of nine (Watkins & Xie, 2014);
● One satisfied six out of ten (Amante et al., 2014);
● One satisfied five out of nine (Showell, 2017);
● One satisfied four out of nine (Thompson et al., 2016);
and

Table 1. Results of quality appraisal of included systematic reviews.

Abbott Amante de Lusignan Mubarak Showell Thompson Watkins and
Criterion (AMSTAR) Shea et al. (2007) et al. (2014) et al. (2014) et al. (2014) (2015) (2017) et al. (2016) Xie (2014)
1. Was ‘a priori’ design provided? Yes Yes Yes Yes Yes Yes Yes
2. Was there duplicate study selection and data extraction? No No Yes No No No No
3. Was a comprehensive literature search performed? Yes Yes Yes Yes Yes Yes Yes
4. Was the status of publication (i.e., grey literature) used as No Yes Yes Yes Yes Yes Yes
an inclusion criterion?
5. Was a list of studies (included and excluded) provided? No No Yes No No No Yes
6. Were the characteristics of the included studies provided? No Yes Yes No Yes Yes Yes
7. Was the scientific quality of the included studies assessed No Yes Yes No No No No
and documented?
8. Was the scientific quality of the included studies used N/A No No N/A N/A N/A N/A
appropriately in formulating conclusions?
9. Were the methods used to combine the findings of studies N/A N/A N/A N/A N/A N/A N/A
appropriate?
10. Was the likelihood of publication bias assessed? No No Yes No No No No
11. Was the conflict of interest included? Yes Yes Yes No Yes No Yes
TOTAL ‘yes’/TOTAL applicable items 3/9 6/10 9/10 3/9 5/9 4/9 6/9

2
A copy of the data extracted from the included reviews is available from the corresponding author upon request.
4 K. BORG ET AL.

● Two satisfied three out of nine (Abbott et al., 2014;
Mubarak, 2015).
All seven systematic reviews clearly stated the research
question and performed a comprehensive literature search.
The majority of systematic reviews (six out of seven) included
publication status as an inclusion criteria and declared conflict
of interest. Conversely, only one systematic review undertook
duplicate data extraction (i.e. two researchers extracted rele-
vant data from the reviewed studies) and addressed the like-
lihood of publication bias. As a result, study selection and
interpretation of findings could be compromised in some
reviews and findings should be interpreted in this context.
Given that most systematic reviews satisfied at least half of the
relevant criteria, appraisal results overall indicate that the
reviews are a medium level of quality.
Summary of findings of included reviews
Table 2 provides a summary of the included reviews including
population/setting, review type and key recommendations.

Table 2. Summary of included reviews.

Type of
review
(quality, if
Author (year) Objective Population applicable) Author’s recommendations
Abbott et al. (2014) ‘To build on a previous publications and to Individuals who use Systematic ● Assistive technologies should be more
indicate changes in the scope and trends found assistive technologies (3/9) inclusive to accommodate a wide variety
in assistive learning technologies and related (Europe) of users and users should be involved in
research’ [p. 453] future research and development.
Amante et al. (2014) ‘(1) to examine characteristics associated with Patients with diabetes Systematic ● Provide onsite kiosks to access health
enrolment and utilization of portals among (USA) (6/10) information & design portals to be
patients with diabetes and (2) to identify accessed via mobile devices.
barriers and facilitators of electronic patient ● All users need to be taught how to use the
portal enrolment and utilization.’ [p. 784] required technology.
● Patients (and providers) need to trust that
the online portal is secure and believe in
the benefits of using the portal.
de Lusignan et al. ‘. . .to identify and understand: barriers and Health professionals, Systematic ● Further research is required to develop
(2014) facilitators for providing online access to patients, carers and system (9/10) online medical record access which pro-
[patient] records and services for primary care suppliers (USA & Europe) motes self-management and improves
workers; and their association with health.
organisational/IT system issues.’ [p. 1]
Mubarak (2015) ‘To attain a broad and adequate understanding General population Systematic ● Develop policy initiatives aimed to
of the digital divide by critically examining the (3/9) improve ICT skills.
prior research on the subject.’ [p. 74] ● Design more user-friendly ICT tools.
Showell (2017) ‘. . .to bring to the attention of informatics PHR users and non-users, Systematic ● Develop better understanding of the
practitioners the range of issues and associated patients, one study health (5/9) impact of barriers on users to ensure
barriers which might prevent an equitable professionals (USA, UK & more effective use of resources.
approach to PHR implementation.’ [p. 2] The Netherlands) ● Need better appreciation of how barriers
can affect adoption and use and how it
can be countered.
Thompson et al. ‘This review applied a human factors/ Patients, providers, Systematic ● Pay attention to patients, providers and
(2016) ergonomics (HF/E) paradigm to assess caregivers (USA, Canada, (4/9) caregivers when developing new system
individual, work system/unit, organization, and Norway, The Netherlands) models.
external environment factors generating ● Address low health literacy, access to
barriers to patient, provider, and informal unwanted health information, secure
caregiver personal health record (PHR) use.’ [p. messaging, ease of data entry and
218] interoperability.
Watkins and Xie ‘This review evaluates the research design, Older adults (USA, Australia, Systematic ● Develop high-quality theory-based inter-
(2014) methods, and findings of eHealth literacy England & Ireland) (6/9) ventions to better understand effective
interventions for older adults.’ [p. 1] ways of improving eHealth literacy.
Litt (2013) ‘This article reviews the last decade of literature General population Non- ● Further research into Internet skills to
on measurements of everyday users’ basic systematic help users become more knowledgeable,
internet skills, organizing how scholars have develop more relevant policies and more
defined and measured the construct, and then user-friendly programmes and interfaces.
systematically presenting what these past
assessments tell us about internet skills and
their relationship to other factors.’ [p. 612]
Satariano et al. (2014) ‘To review the range of promising Older adults (USA) Non- ● Further multidisciplinary research to
technologies. . . designed to enhance aging in systematic develop and test effective technologies
place; identify challenges for implementation to meet the needs of an aging
of those technologies; and recommend ways to population.
improve access to technologies in older
populations.’ [p. 1373]
Trentham et al. ‘Determining what is known about the use of Senior citizens (Canada & Non- ● Before addressing access and ease of use,
(2015) social media by senior citizens for the purposes USA) systematic there is a need to address perceived
of social advocacy.’ [p. 558] relevance and trustworthiness of social
media.

The four moderate- to high-quality systematic reviews
were those by de Lusignan et al. (2014), Watkins and Xie
(2014), Amante et al. (2014) and Showell (2017). de
Lusignan et al. (2014) focused on studies pertaining to
the provision of patient access to electronic health
records. Amante et al. (2014) reviewed articles that eval-
uated characteristics, barriers and facilitators associated
with online portal use among patients with diabetes in
the USA. Showell (2017) sought to understand and cate-
gorise the barriers facing various groups (including
patients, healthcare providers and caregivers) in the use
of personal electronic health records (PHRs). These
reviews are of particular relevance in the field of health
communication because, as noted by Amante et al. (2014),
electronic health records play an important role in allow-
ing patients to access health information and communi-
cate with healthcare providers. Watkins and Xie (2014)
reviewed 23 studies involving interventions for older
adults to improve their online skills, specifically eHealth
literacy. This was one of the few reviews to specifically
focus on intervention strategies for improving digital lit-
eracy in the context of health information seeking (these
strategies were primarily from the USA with a smaller
number from Australia, England and Ireland).
The remaining three systematic reviews were of lower
methodological quality. Thompson et al. (2016), like
Showell (2017), examined barriers to use PHRs. Abbott
et al. (2014) focused specifically on the use of assistive
technology in providing digital access, primarily among
the disabled and in Europe. One of the more broadly
focused systematic reviews was conducted by Mubarak
(2015), which addressed the concept of the digital divide
at a general level (not focused on a specific population)
through a critical examination of prior research.
In addition to the systematic reviews, three non-sys-
tematic reviews were identified. Of the non-systematic
reviews, Litt (2013) reviewed 19 studies with a focus on
basic Internet skills among ‘everyday users’ and the rela-
tionship between Internet skills and other factors.
Satariano et al. (2014) focused on technology use among
older people and Trentham et al. (2015) reviewed social
media use by senior citizens for the purposes of social
advocacy.
Taken together, these reviews identified three common
barriers to individuals’ inclusion in the digital environ-
ment; access (connection, speed, coverage), skill (ability to
use ICT hardware and software) and attitude (interest,
motivation, trust). In addition, three common elements
were identified across the reviews as supporting, or
enabling, individuals’ inclusion; social support (e.g.
friends, family, carers and service providers), education
via collaborative learning or direct experience and inclu-
sive design (of technology and interventions). These find-
ings are discussed in detail below, with some
consideration given to the differences between the reviews
included in this study. The implications for digital inclu-
sion generally, and health communication specifically, are
also discussed.
HEALTH COMMUNICATION 5
Discussion
The reviews varied substantially in their population of focus—
from people with a disability (one study), to patients and/or
healthcare providers (four studies), and older adults (three
studies). Two studies did not specify a population as they
were concerned with digital inclusion at a more conceptual
level. Despite these population differences, common barriers
to, and facilitators of, digital inclusion were identified across
the included reviews.
Barriers to digital inclusion
The included reviews identified three primary barriers to
digital inclusion: (1) access; (2) skill and (3) attitude. These
barriers broadly align with the different access categories
described in van Dijk’s (2005) model of digital technology
appropriation:
(1) Motivational access (motivation to use digital
technology);
(2) Material or physical access (possession of device(s)
and Internet connections or permission to use them
and their contents);
(3) Skills access (possession of digital skills: operational,
informational and strategic) and
(4) Usage access (number, diversity and simplicity/com-
plexity of applications—typically a dependent vari-
able) (van Dijk, 2005, p. 21).
Van Dijk argued that individuals must overcome each of
these access issues in order to cross the digital divide. For
example, once they have gained both motivational (attitude
and normative pressure) and material (physical) access, indi-
viduals are then faced with the problem of acquiring the
necessary skills to utilise such technology.
Access
Physical access was identified as a primary barrier across
several systematic reviews (Abbott et al., 2014; Amante et al.,
2014; Mubarak, 2015; Showell, 2017; Thompson et al., 2016)
and one non-systematic review (Satariano et al., 2014). These
reviews reflected a range of populations, including individuals
who use assistive technologies, patients, healthcare providers,
caregivers and older adults. Even among the general popula-
tion, these reviews found that there are certain groups who
continue to experience issues with access, such as the elderly,
the disabled and those living in rural communities. The phy-
sical-access-related issues these groups face include availabil-
ity of usable devices, access to an adequate (and affordable)
Internet connection and access to technology which suits their
needs (e.g. visual impairment). These reviews demonstrate
that physical access continues to affect vulnerable groups in
society who would arguably benefit most from engaging with
ICTs for health-related communication services (such as the
disabled and the elderly). The findings regarding access urge
caution to the emerging belief that the ‘access’ divide has
narrowed or closed. While it may now be the case for many
6 K. BORG ET AL.
that physical access is no longer an issue, this cannot be
assumed for all groups in society.
Skills
In addition to access, several reviews identified a lack of
relevant digital skills as another potential barrier to use. Skill
was not limited to technical literacy, it extended to notions of
digital self-efficacy and topic-specific literacy (e.g. health lit-
eracy). Relevant to health communications, some reviews
specifically highlighted limitations in ‘eHealth’ literacy or
general health literacy for accessing health information, pri-
marily among patients as well as older adults (Amante et al.,
2014; Showell, 2017; Thompson et al., 2016; Watkins & Xie,
2014). Mubarak (2015) argued that while the physical access
gap is narrowing, the ICTs skills ‘divide’ may be widening;
something that Litt (2013) calls a ‘second-level digital divide’.
The review conducted by Litt (2013) also noted that age and
education generally predicted an individual’s digital skills. The
strongest predictor of skill, however, was experience and use
—indicating that Van Dijk’s appropriation of digital technol-
ogy model (2005) is not strictly linear. For example, those
with physical access and skills may subsequently lose motiva-
tion because of a negative experience online.
Attitude
In comparison to access and skill, attitude was less frequently
described among the reviews as a barrier to digital inclusion.
This may reflect the relatively new shift in digital inclusion
research away from physical access towards ‘motivational
access’ which, according to van Dijk (2005), is the first step
towards technology adoption. Amante et al. (2014) found that
while barriers to portal enrolment among patients were largely
related to skill and knowledge (i.e. a lack of ability and lack of
awareness), the barriers to portal use were often attitudinal
(i.e. a lack of desire and previous negative experiences).
Showell (2017) identified several attitudinal-related barriers
including discomfort with computer use, privacy and confi-
dentiality concerns and lack of motivation. In the context of
online health portals, Amante et al. (2014), de Lusignan et al.
(2014) and Thompson et al. (2016) found that patients as well
as healthcare providers were often concerned about privacy
and confidentiality. In some cases, if the provider did not see
the benefits of using the online portal, they instructed patients
not to use it (Amante et al., 2014). Two of the non-systematic
reviews argued that among older adults a lack of familiarity in
combination with poor skills can result in high levels of
anxiety and fear (in addition to low levels of confidence and
trust); showing the inter-dependency of barriers to digital
inclusion (Satariano et al., 2014; Trentham et al., 2015).
These findings imply that attitudinal barriers to digital inclu-
sion may be especially acute in the healthcare context, where
concerns about privacy are often magnified.
Enablers of digital inclusion
Three key enablers to digital inclusion were also identified
across the included reviews: (1) social support; (2) education
via collaborative learning or direct experience and (3) inclu-
sive design.
Social support
Amante et al. (2014) found that patients were more likely to
use online portals if they had sufficient social support; that is,
if their family or caregivers knew how to use the relevant
technology. They argue that, as well as patients, family mem-
bers and healthcare providers also need to know how to use
the required technology. Similarly, Thompson et al. (2016)
suggested that in order to ensure eHealth systems are used by
patients, healthcare providers must actively engage with, and
support known, vulnerable populations. Similarly, Satariano
et al. (2014) argues that end-users, as well as service providers,
family and caregivers, should be involved in researching,
designing and testing digital technologies and interventions.
Several studies identified by de Lusignan et al. (2014) found
that patients wanted the ability to share health records with
family.
Social support may also be an important avenue for
addressing the attitudinal barriers to digital inclusion.
Trentham et al. (2015) argue that in order to make social
media more inclusive for senior citizens, there is a need to
address attitudinal factors of perceived relevance and trust-
worthiness before addressing technical issues of access and
ease of use. Increasing older adults’ use of social media plat-
forms could then increase the potential reach of health com-
munication campaigns. Amante et al. (2014) suggested that
patients and their networks need to be assured that online
interfaces are secure and be persuaded of their benefits if they
are to be adopted in the future. If those providing social
support to Internet users promoted messaging pertaining to
the security and benefits of social media access, this could
influence their attitudes through social norming (that is, use
of a critical mass to normalise a behaviour).
Education
Education and experience were also recognised by several
reviews as potential mechanisms for addressing digital inclu-
sion, particularly as they directly address the skills barrier
already discussed. The review by Watkins and Xie (2014)
found that interventions which applied collaborative learning
strategies among older adults (i.e. learning through interac-
tion with others with commitment to a shared goal) signifi-
cantly improved participants’ computer and Internet
knowledge and skills, self-efficacy and eHealth literacy.
Other reviews highlighted the importance of direct experi-
ences in relation to digital literacy and willingness to partici-
pate, particularly among groups with less exposure to ICTs
such as the elderly (Amante et al., 2014; Litt, 2013). For
example, Litt (2013) found that the more often individuals
reported using the Internet (e.g. how long they have been
using it and how much time they spend on it), the more
skilful they became in its use. The collaborative nature of
the educational interventions highlights the intersection of
this strategy with social support.
Inclusive design
A key finding from Abbott et al. (2014) was that end-users of
assistive technologies (i.e. technologies that enhance the abil-
ity of individuals with disabilities in the completion of day-to-
day tasks) need to be involved in both their research and

design. Similarly, Trentham et al. (2015) argued that an inclu-
sive approach which avoid common assumptions about user-
groups—such as ageist assumptions that senior citizens only
go online for health information rather than using ICT for
other activities such as making appointments or participating
in online consultations. This suggestion is supported by
Satariano et al. (2014, p. p. 1382) who suggested that digital
technologies ‘should be developed from the outset with the
end user and specific environment in mind’. Of relevance to
health communications, Thompson et al. (2016) argues that
individuals should have a say in what information is included
and when it is available, with additional information available
for patients to assist in understanding complex health infor-
mation. While Showell (2017) focused on identifying barriers
(not enablers) of PHR use, they conclude that designers
should take into account known barriers of particular patient
groups when designing and implementing PHRs in the future.
Design of more user-friendly ICT platforms by services and
developers, in addition to policy initiatives, can also contribute
to overcoming issues associated with access and skill (Litt,
2013). For example, health communications should be designed
so that they are compatible with mobile devices, given their
growing popularity and findings that certain groups who are
less likely to use the Internet on a fixed ICT device such as a
desktop computer and are more likely to rely on mobile devices,
specifically smartphones (Abbott et al., 2014; Amante et al.,
2014). In relation to eHealth portals, Amante et al. (2014) also
suggested that physical advancements such as on-site kiosks at
healthcare facilities need to enhance access opportunities.
Synthesis of barriers and enablers to digital inclusion
What was once known as the digital divide, differentiating
those that could physically access the digital environment, and
those that could not, is now seen to be something more
complex. Digital inclusion emphasises not just physical access
to technology but also productive use of the medium for
personal and social benefit. This review, in describing the
barriers and enablers to digital inclusion, sheds light on the
‘more complex reality of various people’s differing access and
Figure 1. Relationships between barriers and enablers of digital inclusion with relevant population groups.
HEALTH COMMUNICATION 7
usage of digital technology’ (Warschauer, 2003, p. 44).
Figure 1 provides a visual synthesis of the review findings,
highlighting relationships between the barriers and enablers
and the populations to which the findings relate. While these
connections need to be tested, they suggest potential inter-
ventions to enhance digital health communications.
The different barriers identified in this review have some
parallel with the key elements of van Dijk’s (2005) digital
technology appropriation model, namely ‘Material or phy-
sical access’, ‘Skills access’ and ‘Motivational access’. These
barriers were more likely to affect particular demographic
groups, such as those with lower education or income levels,
the elderly (Amante et al., 2014; Litt, 2013; Showell, 2017;
Thompson et al., 2016), those from a non-Caucasian ethni-
city (de Lusignan et al., 2014; Showell, 2017), and those
living in rural communities in developed countries
(Mubarak, 2015). Digital take-up may therefore look differ-
ent for certain groups based on the particular barriers they
are facing, and this model may therefore not be universal in
its applicability. These barriers also suggest that Van Dijk’s
model is not linear. For example, those with physical access
may subsequently lose motivation because of a negative
experience online; or new skills might be needed to under-
take more complex and emerging programmes and equip-
ment. Different groups may therefore need to be engaged
‘where they are at’ with regard to the particular issues they
are confronting for greater digital inclusion, rather than
working on the assumption that particular steps need to
be addressed in sequence.
Limitations
Rapid reviews are an emerging method of synthesising
research evidence; however, they lack the depth and
detailed analysis of a traditional systematic review
(Khangura et al., 2012). With this in mind, the conclusions
of rapid reviews have been found to generally align with the
conclusions of full systematic reviews (Watt et al., 2008).
This review also focused on studies from developed coun-
tries because the work was funded by an Australian-based
8 K. BORG ET AL.
organisation committed to pursuing digital inclusion activ-
ities in Australia. This limits the applicability of the findings
outside of developed nations, where additional barriers and
facilitators may influence digital uptake. Similarly, most of
the identified reviews focused on very specific population
groups (e.g. people who use assistive technologies or the
elderly); therefore, it is unclear how directly these findings
would transfer to the general population. In the context of
health communication it is worth recognising that the key
barriers and facilitators were identified among patients and
the elderly.
Conclusion
Health communication increasingly relies on audiences to
be digitally connected for improved health outcomes (Bell,
2014; Jiang & Street, 2017). The barriers identified in this
review show that digital connectivity must encompass all
groups in society to ensure that those who stand to benefit
most are actually able to reap those benefits. Furthermore,
the enablers identified in this review suggest that health
communicators could enhance the outcomes of their ICT
work by ensuring that key audiences are willing and able to
engage with particular programmes. This includes a move-
ment away from simply ensuring physical access towards
providing social support and appropriate skills, and extend-
ing this to support networks of families, friends and health-
care providers. To this end, this review emphasises the
importance of user-focused and collaborative designs to
ensure greater levels of digital inclusion. While this type
of design is already a part of many health communication
programmes (see Jayakar, Liu, Madden, & Park, 2015 for
example case studies), this approach needs to be extended
to ensure that target groups are digitally included in the
first place.
Funding
This work was supported by Australia Post.
ORCID
Kim Borg http://orcid.org/0000-0001-5614-5602
Mark Boulet http://orcid.org/0000-0002-4964-1314
Liam Smith http://orcid.org/0000-0001-7433-364X
Peter Bragge http://orcid.org/0000-0003-0745-5131
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