Category: Health and Healthcare

The UK Rural-Urban Digital Health Divide: Research Trends 

15/05/2023 

Background
This article explores research literature that relates digital exclusion to developments in digital health and healthcare access in rural communities, including remote intensive care units (Schulte et al., 2019), telehealth and telemedicine, and eHealth (Peck, Jackson and Marshall, 2015). Ever since the Covid-19 pandemic – with governments enforcing strict lockdowns – digital alternatives have developed at an unprecedented rate within the broader health industry (Devon Communities Together, 2022; World Health Organization, 2020). Research literature indicates the potential benefits that technologies may have for improving health and healthcare access throughout the UK. Yet, there is a scarcity of research on the specific needs of rural communities for successfully implementing digital healthcare solutions.

Research Trends on the Rural-Urban Digital Healthcare Divide 
Current research indicates a variety of ways in which digital healthcare solutions may benefit rural communities (Schulte et al., 2019) They can aid in overcoming transportation barriers, track the vital signs of those with chronic conditions, support remote examinations, reduce costs, and make possible preventative, predictive, and personalised care (DHSC, 2018; Deloitte, 2015).

Digital health, or eHealth, is an evolving term, but typically refers to the following services (Deloitte, 2015, pp. 3-4). 1) Telecare, which involves using communication and information technologies to deliver care at distance, as well as offering ways of supporting self-management and individualised feedback (McLean et al., 2013). 2) mHealth or telehealth, which is related to telecare, but designates the specific usage of mobile technology to achieve improved health, enhance communication between carers and patients, monitor health conditions in real-time, and reduce isolation (Deloitte, 2012). 3) Data analytics, which can be used for predictive purposes, such that electronic patient records are analysed to “generate risk scores to highlight those that are likely to be re-admitted in the near future” (Imison et al., 2016, p. 11).

While acknowledging the concerns regarding confidentiality and privacy in eHealth solutions (the sharing of medical records, e-referrals, etc), Peck, Jackson and Marshall (2015) have identified several benefits of telecare and telehealth. These virtual health solutions provide a viable option to those that are unable to travel long distances for medical appointments – often due to the limitations of public transportation (Peck, Jackson, and Marshall, 2015). However, many of the positive contributions that such digital technologies could provide to healthcare in rural areas will remain hypothetical without sufficient digital infrastructure. Peck, Jackson, and Marshall outline several potential barriers to a successful digitalisation of healthcare in rural areas. Telemedicine necessitates the “existence of an appropriate digital infrastructure and removal of social and technical barriers that might deter users from accessing such services” (2015, p. 3). Telehealth requires higher levels of digital expertise of both patients and medical practitioners. Many assistive technologies – for example, community alarms – may not only require sufficient infrastructure, but also personal income to fund the installation and maintenance of such equipment in the home. The sharing of patient records electronically raises important issues about data security, and appropriate measures need to be implemented to reassure both medical professionals and patients that data security is safeguarded.

Devon Communities Together (2022, p. 10) has identified several barriers to successful digitisation in rural communities, taking into account specific rural experiences of digital healthcare solutions:

• A lack of IT support
• Concerns about confidentiality
• Being unused to and unfamiliar with technology

The group also identified several solutions to combat said barriers, including but not limited to:

• Support older people with technology, including those with dementia
• Utilise local resources to widen digital access (village halls, libraries, etc.)
• Identify the digital capability of patients (for example through surveys and interviews)
• Provide computers, tablets, and other devices

From these findings, it is clear that although digital health solutions and implementations can improve access to healthcare and widen the range of healthcare solutions for those in rural areas, this research demonstrates the need for improved digital infrastructure, digital literacy, and accessibility – especially among those aged 50+. This is confirmed in a paper by Lindberg and Lundgren (2022), which focuses on rural communities in Northern Sweden. This study consists of semi-structure interviews with persons aged 61-85. Not only do older people struggle to navigate emerging eHealth applications, but they also expressed “resignation” and even “defiance” towards increased digitalisation. Many felt that they were being forced to engage with eHealth solutions given the decrease in local healthcare services. This also included a sense “of reduced citizenship in relation to urban populations” (2022, p. 81).

A study by Currie, Philip, and Roberts (2015) regarding attitudes to eHealth among older adults living with chronic pain highlighted how digital solutions have the potential to overcome traditional challenges of providing healthcare in rural contexts. Yet, several challenges were also noted. “Ergonomic challenges” were discussed, including difficulties caused by eyesight, hearing impairment, becoming tired easily, and a lack of concentration (2015, p. 7). Infrastructure challenges were also discussed, given the lack of quality of broadband services. One interviewee said that “a problem here is that the internet is so slow so you’ve got to have time to sit and let it – it can take two or three minutes for a page to load” (2015, p. 8). The study further indicates that the willingness to engage with digital healthcare largely depends on individual preferences and whether the patient is motivated and willing to learn: “not all personality types are likely to benefit equally from using eHealth technologies” (2015, p. 9).

Socio-cultural factors play a significant part in whether such digital transformation will be successful. This insight is echoed by Costas and Smith (2020), which indicates that a stigma surrounding mental health may prevent some people in need for seeking help before getting to the “desperate stage”. However, some research has showed that Telehealth may, in fact, aid in reducing the risks of stigma associated with physically attending mental healthcare premises (Nelson et al., 2023, p. 6).

Nelson et al. (2023) identified three major gaps in knowledge that is currently hindering a successful implementation of digital mental care solutions in rural settings. First of all, the lack of research in this area poses a problem, which has been dominated by an urban focus. There is a major risk that the uniqueness of the rural context is forgotten in these discussions. Second, a lack of digital infrastructure. The authors highlighted the risks that technological development will “be centred on large urban centres and rural areas will continue to experience” poor digital connectivity compared to their urban counterparts. Third, a lack of digital expertise and literacy among healthcare professionals means that it will be more difficult to deliver telehealth services. Rural health professionals face significant challenges when it comes to “accessing education targeted to their needs and locality” that would serve rural patients’ needs.

More research is also needed on the availability and reliability of digital infrastructure in rural communities. A 2021 study by Broadband Savvy sought to understand the extent to which consumers were able to find broadband deals that met their specific needs. It showed that broadband deals were typically slower than what they needed given the household’s internet usage. Alarmingly, the study also found that rural households pay, on average, 76% more for broadband deals than urban residents, and those living in rural areas “receive speeds 28 percent slower than the advertised typical download speed” (Paton, 2022). The most expensive broadband deals are in the North East, Northern Ireland, and Scotland, whereas London, Wales, and the South East have the UK’s cheapest broadband deals. The conclusion of this study is that this digital divide “boils down to infrastructure failings”. Many rural households still rely on copper cabling for internet access provision, but this is unable to facilitate fast broadband speed. 4G and 5G may be able to combat this problem. However, only 7% of rural households are able to use 4G/5G compared to 17% of urban households (see also Ofcom 2022, p. 13).

A lack of digital skills, and data literacy, also impacts access to digital healthcare in rural communities. According to NHS Digital (2021), 22% of the UK population lacks the digital skills necessary for navigating, sharing, and appraising digital information. As Stephens and Mankee-Williams note (2021), rural communities, which often lack digital training hubs, are on average more likely to experience a lack in digital literacy. The lack of digital training hubs is exacerbated by a lack of digital infrastructure. Those that are less digitally literate are more likely to come from low-income groups, are less educated, and of older age (Honeyman et al., 2020, p. 13).

Recommendations for Future Research

• More research is needed to answer the question why it is that the implementation of digital infrastructure in rural communities is less successful compared to their urban counterparts (e.g. with slower digital services), and what the implications may be for combating the rural-urban digital divide in the long term.
   
  
• A “one size fits all” approach to combating the digital divide is not feasible – be it in healthcare or beyond. There is a notable scarcity of research pertaining to rural service delivery, telehealth, eHealth, and other technological implementations, and we need a deeper understanding of the uniqueness of the rural context.
  
  
• Progress has been made in terms of implementing new digital mental health services in rural and urban communities. However, the current “mental health stigma” in many rural communities risks undermining these efforts, and we need a deeper understanding of this phenomenon and the implications that it may have for overcoming the digital health divide.
   
  

References

Costas, M., and Smith, O. (2020). Unseen and Unheard:  Tacking Inequality in Rural Mental Health. Centre for Mental Health, 8 December. Available at: https://www.centreformentalhealth.org.uk/blogs/unseen-and-unheard-tackling-inequality-rural-mental-health

Deloitte. (2012). The four dimension of effective mHealth: People, places, payment, and purpose. Available at: https://www2.deloitte.com/content/dam/Deloitte/sg/Documents/life-sciences-health-care/sg-lshc-mhealth-noexp.pdf.

Deloitte. (2015). Digital Health in the UK: An industry study for the Officer of Life Science. Available at: https://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/digital-health-in-the-uk.html.

Department of Health and Social Care. (2018). The future of healthcare: our vision for digital, data and technology in health and care. https://www.gov.uk/government/publications/the-future-of-healthcare-our-vision-for-digital-data-and-technology-in-health-and-care/the-future-of-healthcare-our-vision-for-digital-data-and-technology-in-health-and-care 
 
Devon Communities Together. (2022). Rural Digital Health Inequalities. Devon: Devon Communities Together. Available at: https://www.devoncommunities.org.uk/sites/default/files/users/SarahNewman/Rural%20Digital%20Health%20Inequalities%20final%20report%20FINAL-compressed_1.pdf

Honeyman, M., Maguire, D., Evans, H., and Davies, A. (2020). Digital technology and health inequalities: a scoping review. Cardiff: Public Health Wales NHS Trust.

Imison, C., Castle-Clarke, S., Watson, R. and Edwards, N. (2016). Delivering the benefits of digital health care. The Nuffield Trust. Available at: https://www.nuffieldtrust.org.uk/research/delivering-the-benefits-of-digital-health-care.

McLean, S., Sheik, A., Cresswell, K., Nurmatov, U., Mukherjee, M., Hemmi, A., and Pagliari, C. (2013). The impact of telehealthcare on the quality and safety of care: a systematic overview. PLoS One, 19(8): e71238. https://doi.org/10.1371/journal.pone.0071238.

Nelson, D., et al. (2023). Mental health professionals and telehealth in rural settings: a cross sectional survey. BMC Health Services Research, 23(200): 1-10.

Ofcom. (2022). Digital Exclusion: A review of Ofcom’s research on digital exclusion among adults in the UK. https://www.ofcom.org.uk/__data/assets/pdf_file/0022/234364/digital-exclusion-review-2022.pdf 
 
Peck, F., Jackson, K. and Marshall, A. (2015). Digital health and its application in rural areas: a review of international experience. Available at: https://www.cumbria.ac.uk/media/university-of-cumbria-website/content-assets/public/researchoffice/documents/cachet/strategy-for-digital/Report_on_international_learning.pdf 
 
Schulte, A., Majerol, M. and Nadler, J. (2019) Narrowing the rural-urban health divide : Bringing virtual health to rural communities. Deloitte Centre for Government Insights. Available at: https://www2.deloitte.com/content/dam/insights/us/articles/6307_Virtual-health-in-rural-communities/DI_Virtual%20health%20in%20rural%20areas.pdf   

Stephens, M., and Mankee-Williams, A. (2021). The sickening truth of the digital divide: Digital Health Reforms and digital inequality. Journal of Social Inclusion, 12(2): 1-10.

Paton, T. (2022). Study: Rural UK Pays 76% More For Slower, Less Reliable Broadband. Broadband Savvy. https://broadbandsavvy.com/rural-broadband-survey/

The Tinder Foundation. (2016). Improving Digital Health Skills in Communities: Findings from the Evaluation of Years 1 and 2 of the Widening Digital Participation programme. Available at: https://nhs.goodthingsfoundation.org/wp-content/uploads/2016/07/Improving_Digital_Health_Skills_Report_2015.pdf

World Health Organization. (2020). Digital technology for COVID-19 response. Available at: https://www.who.int/news/item/03-04-2020-digital-technology-for-covid-19-response.