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Communicating Health: Priorities
and Strategies for Progress

Office of Disease Prevention and Health Promotion logo

Objective 11-1. Internet Access in the Home

Drafters
Robert Gold, Ph.D., Dr.P.H., University of Maryland

Nancy Atkinson, Ph.D., University of Maryland

Small Group Participants
Rachel Anderson, Benton Foundation

Stephen Downs, U.S. Department of Commerce (at the time of the meeting)

Keith Fulton, AOL Time Warner Foundation

Brian Komar, Leadership Conference on Civil Rights

Frank Principi, National Governors Association (at the time of the meeting)

Elisabeth Stock, Computers for Youth

Note taker: Sara Coggins, National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services

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Text of Objective
Increase the proportion of households with access to the Internet at home.

Scope
The objective is intended to represent an important aspect of Internet access but cannot encompass all issues raised by and related to the subject. The objective means to serve the specific purpose of providing data on progress for Internet connections in the home and the general purpose of stimulating discussion about a wide range of Internet access issues.

Measurement
2000 Baseline: 26 percent of households

2010 Target: 80 percent of households

The objective is measurable. It seeks to determine how many households have established an Internet connection. Data are collected as part of the Computer and Internet Use Supplement to the Current Population Survey, U.S. Census Bureau. The supplement is fielded every 2 to 3 years, subject to funding availability.

There is a new strategy emerging in terms of measurement that may affect the long-term tracking of the objective. The most recent U.S. Department of Commerce study, A Nation Online: How Americans Are Expanding Their Use of the Internet, focuses on individual rather than household access. The report cites several reasons for this subtle but important change. As stated in the report:

  • Focusing on individuals permits the study of such factors as age, gender, education, and employment status in determining computer and Internet use.
  • Internet access occurs frequently outside the home, at such locations as work, schools, and libraries.
  • A small but growing number of Internet connections are increasingly occurring over personal mobile devices, such as wireless phones and personal digital assistants, in addition to traditional desktop computers.

The most recent data indicate that Americans' use of information technologies has grown in all locations—home, workplace, school, and community settings. As of September 2001, 60.2 million U.S. homes (or 56.5 percent) had a personal computer. Seven of every eight households with computers (88.1 percent) also subscribed to the Internet. As a result, more than half of U.S. households (53.9 million homes, or 50.5 percent) had Internet connections.

Table 1 shows the baseline data and updates for the objective with household as the unit of measure. The National Center for Health Statistics, U.S. Department of Health and Human Services, is working with the Department of Commerce to determine if data are or will be available for the categories in the reporting template currently labeled "data not collected" or "data are statistically unreliable."

Table 1. Internet Access: September 2001 (2000 Update) and
August 2002 (2001 Update)
  1998
Baseline (Percent)
2000
Update (Percent)
2001
Update (Percent)
TOTAL 26 42 51
Race and ethnicity      
AI/AN DSU DSU DSU
A/PI 36 57 68
Asian DNC DNC DNC
NHOPI DNC DNC DNC
Black 11 24 31
White 30 46 55
Hispanic 13 24 32
Not Hispanic 28 43 52
AI/AN DSU DSU DSU
A/PI 36 57 68
Black 11 24 31
White 30 46 55
Gender      
Female 15 30 40
Male 20 36 45
Education level      
Less than high school 5 12 23
High school graduate 16 30 40
At least some college 31 48 58
Geographic location      
Urban 28 42 51
Rural 22 39 49

Legend:
AI/AN—American Indian/Alaska Native
A/PI—Asian/Pacific Islander
NHOPI—Native Hawaiian or Other Pacific Islander
DSU—Data Statistically Unreliable
DNC—Data Not Collected

Source: U.S. Department of Commerce. Computer and Internet use supplement to the current population survey, September 2001. Available online at www.bls.census.gov/cps/computer/computer.htm.

Inclusion of the Internet items on the Current Population Survey, however, cannot be guaranteed because of funding and space constraints on the questionnaire. Action needs to be taken to ensure that the current items plus additional items remain part of the survey or become part of a comparable data collection instrument.

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Issues Pertaining to Measurement
The objective assesses Internet connection rates. Although Internet service providers can now provide "dial-up" service (via a standard telephone line) to virtually every home in the United States, not all homes currently have telephone access; in some rural areas, the cost of dial-up Internet connectivity may be prohibitive. In addition, recipients need some sort of client-side device (e.g., computer, television, or personal digital assistant [PDA]) to make use of the Internet service, and, for some families, the cost of these devices may be prohibitive. Future data collection should be oriented toward the assessment of "meaningful access," which is more than an Internet connection. Meaningful access encompasses all the factors that make an Internet connection valuable, such as basic computer literacy, ongoing technical support, and Web content of interest. Information about meaningful access would provide a more complete picture of the circumstances surrounding Internet connection rates and the types of interventions that have the greatest impact.

In addition, one cannot presume that an Internet connection in a household means that everyone in the home has access to it. Parents who are computer owners may not allow their children to use the computer. Or parents who are loaned a computer for work may keep it for their own use only. New items to assess household access might include questions about

  • Who owns the devices connected to the Internet and who pays the connection fees (e.g., head of household, local school district, or employer)
  • The amount of time users spend on personal or business use of the Internet
  • The type of Internet connection (e.g., dial-up, digital subscriber line [DSL], cable modem, new options as they emerge)
  • Households' access to technical support and any subsidies to sustain Internet connections over time.

Public policy has played a part in shaping perceptions of what constitutes "access" and its assessment as the basis for policymaking. Past and current public policy is based on the assumption that whatever needs individuals have for the Internet can be satisfied with public (community) access or purchase of a household connection at whatever price the market will bear. With few exceptions, such as very underserved rural and inner-city urban areas, public policy has not focused on making Internet connections easier and more affordable for households. Internet connections in the home have been cast as a personal decision related to households' ability to pay monthly connection fees. Consequently, public policy has been oriented toward ensuring access to computers and the Internet in public places, such as schools, public libraries, hospitals, and community centers. Not surprisingly, the government has paid much less attention to funding interventions to promote household connections than to funding interventions to promote community-level access.

The situation may change with broadband technologies. Corporate interest in mass diffusion of broadband technologies to support the delivery of multimedia content may prompt new debate on the public policy mechanisms needed to increase and sustain Internet connection rates. Typically, the economics of the "last mile" and the perception that some types of household connections, such as cable television and the Internet, were discretionary and nonessential made unlikely a workable policy for wired connections in the home other than telephone service. Telephone service was the exception and has been protected by the presumption of "universal service"; that is, all who want to should be able to connect to the telephone network, and basic service fees should be subsidized if necessary. However, dial-up connections to the Internet, which currently are the overwhelming majority, are unlikely to be included in any policy efforts.

A related policy and programmatic matter concerns the lack of attention to household Internet connections as a matter of health policymaking and program planning. Healthcare and public health professionals have been virtually silent on the importance of household Internet connections for access to health information and services. As of 2002, 110 million U.S. Internet users had searched for health information online on average three times a month (HarrisInteractive 2002). The inclusion of Internet access as a Healthy People 2010 objective is an important first step to draw attention to the issue. The next step is for health policymakers and program directors to make household connections to the Internet part of their models, programs, and activities and to support meaningful access for everyone, especially the most underserved populations. Without this level of attention across the health sector, progress on the objective is likely to be slow for those populations with the greatest health risks.

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State of Knowledge About Issues Represented by the Objective
The primary set of knowledge about Internet access and connections to the home comes from public debate and research of a phenomenon commonly referred to as "the digital divide." "Digital inclusion" has been proposed as an alternative framing of the issues. The Benton Foundation, which sponsors a Web site devoted to digital divide issues (www.digitaldividenetwork.org/content/sections/index.cfm), defines the digital divide as the "gap between those who can effectively use new information and communication tools, such as the Internet, and those who cannot. While a consensus does not exist on the extent of the divide (and whether the divide is growing or narrowing), researchers are nearly unanimous in acknowledging that some sort of divide exists at this point in time." The main issue of digital divide debates has been the unequal distribution of technology and technical skills in a society. The digital divide is conceptualized as both a national and global phenomenon.

Although the healthcare sector lags behind other sectors in the adoption of digital technologies, the Internet and related technologies and applications are becoming an increasingly important part of the way health and health care are managed in the United States. The text accompanying Objective 11-1 suggests that many healthcare organizations and public service agencies already use the Internet as one of their main channels for information dissemination. Access to the Internet and subsequent technologies is likely to become essential to gain access to health information, contact healthcare organizations and health professionals, receive services at a distance, and participate in efforts to improve local and national health.

As noted above, Objective 11-1 could potentially provide a basis for public policy to promote sustainable household connections to the Internet. Community settings, which in the past afforded some segments of the population greater access to computer technologies and the Internet, perhaps were sufficient for some types of information retrieval activities; however, they may be inadequate for the types of 24/7, highly personal health management functions that are emerging. On-demand, private, and secure connections are important so individuals can access the full range of health information and services available to them online. Because of the sensitivity of much health information for and about individuals and because of the added value of a person being able to pick up where they left off, such access can best occur in the home or on personal devices.

Not enough is known about how to make home Internet connections a reality and to sustain them beyond the initial investment. Assessments of consumer knowledge about how to buy computers or other Internet devices and how to acquire Internet connections are scarce, and little information is available on what types of training and other essential support are necessary to maintain Internet connections from the home. Some programs, such as Computers for Youth in New York City, have made training and technical support a cornerstone of their operations; as a result, they have experienced success in helping families maintain Internet connections. We also know that important financial barriers exist to acquiring Internet services. These barriers extend beyond the purchase of Internet-enabled devices. Many Internet service providers insist that customers have credit cards to pay for the service or pay a steep premium on monthly service charges if customers do not have reliable credit.

Several studies provide insight about individuals' motivations and interest in Internet connections at home (Ipsos-Reid, 2001; Lenhart, 2003; U.S. Department of Commerce, 2002; 2000). The discussion below focuses on reasons people offer to explain why they don't have Internet connections in their homes or don't use the Internet.

Don't Want Internet. Several studies have documented that large numbers of people who are not connected to the Internet believe they don't want to be connected. The latest Pew Internet and America Life report on the digital divide found that 52 percent of respondents not currently connected to the Internet said they don't want or need to go online (Lenhart, 2003). In the Falling Through the Net report by the U.S. Department of Commerce, not wanting Internet access is the most common reason why households with computers have never been connected. Nearly one-third of respondents (30.8 percent) cite this as the most common reason. This reason is more important for seniors age 55 and older than for younger respondents. Another survey done by Ipsos-Reid found that not wanting Internet access is an important reason people do not intend to use the Internet. Among Internet "nonintenders," 40 percent say they have "no need for it," and 25 percent report they are "not interested in it." These findings suggest that attitudes, lack of Internet experience, and perhaps age are important factors related to Internet connections.

Computer Equipment Issues. Each of the studies reported here identify similar percentages of households that no longer own any computers (17 to 21 percent). Findings from the Falling Through the Net survey suggest that some people rely on Internet access outside the home. "Can use elsewhere" is the primary reason given by 10 percent of households with computers that have never been online and by 13 percent of households that have discontinued Internet use. The most recent Department of Commerce data show that slightly fewer households had discontinued Internet use (11 percent) because of being able to access the Internet elsewhere (2002). Work or other locations outside the home, however, may be unreliable places of access. Among Internet dropouts in the Pew study, 5 percent cite a change in job as the reason they are no longer online (Lenhart, 2003). Parenthood is one factor that seems to encourage people to think about getting Internet access in the home. Among Pew study respondents, 56 percent of parents who aren't online report that they probably or definitely will go online, while only 34 percent of non-parents predict they will go online at some point (Lenhart, 2003).

Financial Barriers. Although not wanting an Internet connection is the most common reason for not using the Internet, cost is a more important factor for some. A Nation Online findings from the Department of Commerce show that 26.9 percent of households making $50,000 or less annually rank cost as the number one reason. Household heads under age 45, female-headed families, and those with less education identified cost as an important reason they do not have an Internet connection. Cost was also a primary concern for 12 percent of Internet "nonintenders" responding to the Ipsos-Reid survey. As noted above, a lack of credit is also a financial barrier to getting Internet service. Customers without credit may find it difficult to get even a low-cost loan to purchase equipment, and customers without credit cards may be charged a steep premium every month to purchase an Internet connection.

Knowledge and Skill Barriers. Technology literacy appears to be a factor in deciding whether or not to go online. A total of 16 percent of Internet nonintenders responding to the Ipsos-Reid survey say that the biggest reason for not using the Internet is that they "don't know how to use it." Almost 30 percent of Pew respondents who are non-users say that the Internet is too complicated and hard to understand (Lenhart, 2003). People with a high school education or less are most likely to feel that the Internet is hard to use.

Attitude Barriers. A number of different attitudinal factors appear important to understand Internet connection rates, as discussed below.

  • Not Interesting or Useful. The primary attitude (up to 60 percent of Internet nonintenders) mitigating against going online is respondents' perception that the Internet is not interesting or useful enough to use.
  • Not Enough Time. Two of the surveys show that respondents do not use the Internet because of time constraints. In the Falling Through the Net survey, 9 percent of those who have never used the Internet and 10 percent of discontinued users with computers report "not enough time" as the main reason for not going online. In the Ipsos-Reid survey, 8 percent of Internet nonintenders also report this as a factor in their decision not to have an Internet connection.
  • Dangers in Going Online. Being concerned about children's access was related to discontinuing Internet use among 3 percent of respondents in the A Nation Online survey. Among households with children, 68.3 percent were more concerned about the kind of material children may be exposed to on the Internet than on television. This concern, however, did not translate into lower rates of Internet access in the home. Among those who thought the Internet was a source of concern, 51.8 percent had Internet in the home. Further, parents responding to the Pew study indicated that being parents encouraged them to think about getting Internet access in the home (Lenhart, 2003). A Nation Online found that there is more concern about confidentiality over the Internet than with the telephone. In the Pew study, more than 40 percent of Internet nonusers report that they are worried about online pornography, credit card theft, and fraud (Lenhart, 2003).

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Stakeholders
As referred to here, a stakeholder is considered to be any contributor to efforts implied by or related to this objective, although the stakeholders identified in the paper are principally the drivers of efforts to increase Internet access and connections, even if their efforts do not reference the objective. Many groups and organizations have examined the issues related to increasing Internet access and closing the digital divide. They have also funded programs and made recommendations about how to close the divide. These include the U.S. Department of Commerce, the U.S. Department of Housing and Urban Development, the Federal Communications Commission, the Leadership Conference on Civil Rights, the Benton Foundation, the National Governors Association, the Children's Partnership, the Web-based Educational Commission, and many States and local school districts, among others.

Given the broad use of "stakeholder," all the following groups are included for consideration:

  • Consumers
  • Content providers or publishers
  • Education associations and coalitions
  • Educators
  • Families
  • Federal, State, local, and tribal governments
  • For-profit corporations
  • Hardware or telecommunications providers
  • Investors
  • Journalists
  • Nonprofit, business, or trade associations and coalitions
  • Foundations
  • Public or private-sector organizations that provide technology training
  • Research organizations
  • Schools and universities
  • Small businesses
  • Unions

In terms of e-health, other stakeholders would include patients, public health agencies and organizations, healthcare professionals, and organizations that provide all types of health services. The Appendix presents a beginning list of stakeholders who could be organized to work on the objective.

Table 2. Examples of Stakeholder Activities
 
Activity Computers for Families
(www.sbcff.org)
Organization Santa Barbara Partners in Education and Santa Barbara County Education Office
Mission Santa Barbara Computers for Families is placing 4,000 computers into the homes of Santa Barbara County schoolchildren whose parents cannot afford to purchase computers. The program will also provide training resources to the students, teachers, parents, and administrators who will use them. Support comes from Santa Barbara area businesses, foundations, and individuals as well as grants from the U.S. Department of Education.
 
Activity Computers for Homebound and Isolated Persons
(www.korrnet.org/chips/model.html)
Organization Knoxville-Oak Ridge Regional Network (KORRnet), Knoxville-Knox County Community Action Agency
Mission This network, funded by the U.S. Department of Commerce's Technology Opportunities Program, provides computers to eligible persons in their homes to allow them to stay connected to families and other sources of support.
 
Activity Computers for Youth
(www.cfy.org)
Organization Computers for Youth Foundation, Inc. (CFY)
Mission CFY has developed and tested a comprehensive and community-centric program in New York City Project Patchwork. All recipients receive a home computer, training, technical support, tailored Web content, and e-mail accounts on a community-wide system.
 
Activity Computers In the Hood
Organization 13 Scribes Inc.
Mission This project provides low-cost financing for families to buy low-cost computers, with installation and training included.
 
Activity Indiana Legislative Agenda
(http://ideanet.doe.state.in.us/legwatch/2001/
05.html
)
Organization Indiana Department of Education Legislative Agenda
Mission The Indiana Legislative Agenda supports the Realizing Equitable Access to Computers in Homes (REACH) program at $7.5 million per year. This program would have enabled thousands of low-income ninth-graders to have Internet access at home through their schools as well as additional learning capabilities. Funding was not supported for FY 2002 but will be sought again.
 
Activity One Economy Corporation
(www.one-economy.com)
Organization One Economy Corporation
Mission One Economy Corporation increases access to the Internet in low-income homes, aggregates the economic power of low-income households, helps low-income households accumulate assets in the form of social and economic capital, and fosters civic engagement.
 
Activity Technology Goes Home
(www.techboston.org)
Organization Boston Digital Bridge Foundation
Mission This project prepares adults for employment opportunities and helps children improve academic performance by bringing technology to the homes of low-income families.

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Status of Selected Stakeholder Activities
Table 2 provides an overview of illustrative activities that organizations and groups are undertaking to bring technology and Internet connections to populations that would not otherwise have them. These activities range from policy and regulatory initiatives to specific financial assistance to acquire technologies and Internet connections.

Government. In the public sector, several organizations at the Federal, State, and local levels are interested in increasing home Internet access. They come from a range of agencies, including commerce, education, and health departments. Most government operations are becoming computerized, and government workers are increasingly dependent on computers. For example, Healthy People 2010 contains another objective on Internet access for public health employees.

  • Objective 23-1: Increase the proportion of Tribal, State, and local public health agencies that provide Internet and e-mail access for at least 75 percent of their employees and that teach employees to use the Internet and other electronic information systems to apply data and information to public health practice.

In addition, government is moving in the direction of

  • Providing public access to government services through the Internet (e.g., bill payment, tax collection)
  • Creating legislative agendas providing incentives to companies and end-users to access information and services online
  • Creating legislative agendas to generate incentives for getting connected.

Although many of the initiatives that address digital inclusion have begun in schools and community centers, several groups have changed their focus to the home as the optimal Internet access point. The Web-based Education Commission (2000) examined home Internet access and came to the following conclusions:

Home access is important for students doing research, taking online courses, and communicating with teachers and other learners. For parents, online access means new kinds of communication with their children's schools, with their children's teachers, and with other parents. For all households, Internet access is another way to connect with their communities and government services. Home access helps to advance economic opportunities: low-income users were the most likely to report using the Internet to look for jobs.

State governments have actively promoted the deployment of Internet technologies, particularly broadband technology, to resident businesses and the citizens of their States. State governments accomplish their vision of widespread deployment through a variety of means including loans, loan guarantees, State-match funding, subsidies, right-of-way initiatives, deregulation, and encouragement of a competitive telecommunications environment. Some State and local governments offer broadband as a service directly to their citizens.

For example, in California, the Riverside Computer Investment Program has helped 145 low-income households get computers, free training classes, free bilingual phone technical support, and Internet access. This public-private partnership's $20,000 capitalization provides a $225 subsidy per qualified low-income family to purchase their personal computer and keep monthly loan repayments below $20. In Texas, the Dallas County Workforce Board and the nonprofit Enterprise Foundation are supplying 1,000 low-income households in Dallas County with hardware, Internet access, and computer training through "Program @chieve" (NGA Center for Best Practices, 2001).

Despite recent events, including a downturn in the economy and the reordering of public policy priorities following September 11, 2001, States continue to promote broadband deployment. Michigan, for example, announced an initiative, "LinkMichigan," that will provide a statewide financing authority and a one-stop right-of-way authority to providers to assist with funding and to expedite deployment (http://medc.michigan.org/news/reports/economic/combo.asp?
ContentId=94595AF5-BAE2-4BEE-856A-22DA8A130538
).

As the primary regulatory body for telecommunications policy, the Federal Communications Commission (FCC) is an important stakeholder. Even though the FCC does not regulate the pricing of Internet access services directly, it has a broad policy interest and monitors developments related to Internet technologies and access. The FCC continues to examine barriers to more rapid diffusion of broadband services. The agency is also an entity that could extend the principle of "universal service" beyond telephony to encompass Internet access as a basic service for every household in the United States.

Business Community. Some employers have helped make home computer and Internet access available to their employees. In some cases they have provided access to low-cost systems and Internet service providers; in other cases they have provided the systems or Internet access. These employer initiatives have arisen for several reasons. Government incentives, such as tax breaks, have encouraged businesses to invest in their employees in new ways. Some employers may find it more cost-efficient to have an employee work at home rather than onsite where the business would have to furnish an office. With changes in work patterns, the shift to "information work," and increasing acceptance for telecommuting, employers have provided support for home-based workstations connected to the Internet. This delivers technology, access, and capability to the household and provides a very powerful model to develop a populace comfortable with information technologies in the home, not just at work. Other employers may see home Internet access as an employee benefit to boost morale and retention.

An important segment of the business community is vendors of technology, bandwidth, and improved applications. They are playing a key role in the deployment of access at the household level by providing hardware, software, Internet access, and technical assistance in ways that keep the issue on the public agenda and drive demand for new services and technologies. These vendors recognize the importance of these activities to their own business futures and are often willing to subsidize or provide seed money for demonstration projects. They also have played key roles on decisionmaking boards and task forces at every level of government and the public and private sector. Finally, to some extent their own research and development budgets contribute to the realization of the objective by continuing the process of technology development, which can contribute to enhanced accessibility and utility.

Other Intermediaries. Many other potential intermediaries can influence the achievement of Healthy People Objective 11-1. Nongovernment organizations, foundations, voluntary health associations, and healthcare systems have all played a role. As evidenced from the list of projects in the Appendix, many organizations are invested in closing the digital divide. Some are providing grant support to digital divide projects focused on the home, but these are minor in comparison to the school and community initiatives they fund. Other organizations do not provide funding but rather conduct research, raise public awareness, or lobby other agencies. Their work often keeps others apprised of the ever-shifting boundaries of the digital divide.

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Factors That Can Influence Change
Given the current state of knowledge and the scope of current initiatives, a number of factors may be considered as principal facilitators of or barriers to change. Generational differences in familiarity and comfort with use of technology have been noted. As the population ages, household decisionmaking and resources will be shifted to those more likely to be comfortable with and interested in use of the Internet in the home. Improvements in technology and applications may make the Internet more user-friendly, attractive, and tailored to individual needs and wants, individual comfort, and perceived need, which could increase demand for access. Employers and school systems recognize the importance of home Internet access to improve the knowledge and skills of their employees and students. Table 3 summarizes these and other factors likely to influence change. At least three different frames of reference are necessary to understand the multiplicity of factors that will influence progress on Internet connection rates.

Table 3. Factors Able To Influence Change
Demand Side Supply Side Policy
Skills and training Technology improvements Investment tax credits and loan guarantees
Technology improvements Economic and market innovations Subsidies
Public awareness and perception Lower costs of Internet connections and appliances Regulation or deregulation
Increased importance to employers and educators Improvements in telecommunications infrastructure Public awareness and public perception
Increased credit card, electricity, and phone access Predatory or fraudulent practices Encouragement of new suppliers of Internet access
Public awareness and public perceptions Comprehensive technology services (now fragmented)
 
Generational influences Consumer education  
Marketing campaigns Availability of content that users want  
Concerns over privacy and safety    
Trust    
Economic conditions (e.g., slow down or recession)    
Changing priorities (unforeseen historical events)    

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Strategies and Solutions
Looking at household penetration of communication and information technologies reveals at least three broad categories of decisionmakers in households: (1) those who have never used such technologies, (2) those who have tried and discontinued their use of such technologies, and (3) those who are currently using these technologies. These groups are not homogenous with respect to the motivations of individuals. For example, among those who have never tried these technologies at home, lack of awareness, fear of the unknown, and cost are relevant barriers, among others. At the same time, some barriers may be relevant at different times. For example, cost may be a barrier to initiating use, or it may be a reason someone decides to discontinue use. Each of these groups will need attention, and the strategies will need to be consistent with the reasons that individuals and households give for not having Internet connections at home.

The size and composition of the groups of household decisionmakers are likely to be influenced by a number of factors.

The passage of time, perhaps a generation, will likely result in an increase in Internet penetration in the home, as the most reluctant users (aging baby boomers and senior citizens) are replaced by the now young, technology-savvy generations. Internet access has demonstrated rapid penetration compared with other major technologies such as telephones and color televisions. Whereas the telephone reached half of American homes after 71 years and color TVs took 18 years, according to the Electronic Industry Alliance, the Internet took only 10 years to reach 50 percent of homes in the United States.

The latest research from the Pew Internet and American Life project indicates that Internet access is not a static state (Lenhart, 2003). The population moves online and offline for a variety of reasons—economic and social. The Pew project estimates that only 24 percent of Americans are completely disconnected from the Internet, that is, they have no direct or indirect experience with the Internet, and moreover, are unlikely to have an Internet connection. The rest of the population either has a regular Internet connection or once had a connection and may have one again in the future. Of particular relevance for the target of the Internet access objective is the Pew finding that Internet penetration rates have remained steady since late 2001 at about 60 percent. Although there may have been some optimism a few years ago that the Internet would follow a steadily increasing diffusion curve, this outcome may no longer be likely, particularly at the subpopulation level.

The leveling off of Internet connections occurs at a time of declining prices for devices to connect to the Internet. The costs of computer hardware and software are declining; for example, Internet-ready computers have fallen in price from $1,700 in 1996 to a few hundred dollars in 2003. Declining prices on entry-level computers and other Internet-ready devices may motivate some people to connect to the Internet, but declining prices alone are unlikely to motivate the 40 percent of the population that does not have a household Internet connection. Widespread availability of broadband services through local Internet service providers may bring new users to the Internet but, with the cost of broadband service remaining relatively static and about twice as much as dial-up service, it is equally likely to be an upgrade for those who already have dial-up service. Application developers are continuing to identify ways to attract new users with more attractive content and features. More widespread use of tailoring technologies may make content more attractive and draw new users to the Internet, and current users might increase their interest in being online and the time they spend online.

Along with the increasing speed and power of existing hardware, software, and bandwidth comes the emergence of Internet appliances that will change the way people view technology. As the elements of television, telephone, PCs, game consoles, and entertainment centers begin to merge into multifunctional, single devices, household consumers are likely to view these technologies differently. Those who have an innate fear of computers may connect to the Internet through television or cell phone. Those who cannot afford a stand-alone computer may use game consoles to connect to the Internet. Many of the advances in technology penetration can be linked to new entertainment options, so game consoles that allow multiuser games across the Internet may serve as the impetus for some households to finally get online.

These trends, however, will not necessarily mean access for all. Household penetration does not always provide access for all household members. Nor does it reflect how such access is being used and what benefits or risks result from such use. The following general strategies provide an outline for progress toward meaningful access.

  • Establish and support an ongoing research and evaluation agenda. There is a need to continue to collect data that will enable us to understand the forces influencing achievement of the objective. Among the factors that should be examined are geographic differences, income, race, gender, and other population characteristics that we may not even know about yet. As we learn more about the factors that influence interest in the Internet, should 80 percent be the universal target? Is it better to try to achieve a national average of 80-percent penetration or to aim for 80-percent penetration for each type and location of household, defined according to relevant characteristics? Targets should continually be monitored and revisited over the next 7 years to ensure that the objective is consistent with technology opportunities and availability. Such a research agenda will guide our capacity to customize solutions to overcome barriers specific to each target audience segment that stand in the way of accomplishing the objective.
  • Develop public and private policies. An expansion of the principle of universal service to include Internet access to homes would provide important impetus. As currently defined, universal service applies to residential telephone services and select community services. According to the FCC, "the goals of Universal Service, as mandated by the 1996 Act, are to promote the availability of quality services at just, reasonable, and affordable rates; increase access to advanced telecommunications services throughout the Nation; advance the availability of such services to all consumers, including those in low-income, rural, insular, and high-cost areas at rates that are reasonably comparable to those charged in urban areas" (www.fcc.gov/wcb/universal_service/welcome.html).
  • Implement programmatic initiatives. Continued support is essential for programmatic initiatives directed at overcoming attitudinal, knowledge, skill, and other predisposing factors that represent barriers to acquisition of equipment and connections. Initiatives with demonstrated success should be supported at a level that enables them to grow to scale and serve many more people. Many years have already been spent testing small pilot programs. It is time to take the lessons learned and put them to work. For example, one of the lessons learned is that to make a home access program work, technical support and training for end-users must be addressed. Successful home-access programs also usually engage community-based, trusted intermediaries to organize distribution and technical assistance efforts. Trusted intermediaries are much more likely to persuade people that the Internet is useful, entertaining, and not too difficult to use than are general appeals to the civic, educational, or commercial virtues of the Internet.

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Action Steps
Establish and support an ongoing research and evaluation agenda.

  • Review and reassess data collection strategies annually.
  • Identify appropriate mechanisms for audience segmentation for delivery of programs and incentives.
  • Focus on understanding relevant population differences.
  • Identify a lead agency with oversight responsibility to coordinate an action plan.
  • Identify healthcare providers, businesses, social service agencies, and other public and private-sector entities that
    would benefit from having their customers or clients connected to the Internet.
  • Identify communities in need and their trusted intermediaries who are already using the Internet.
  • Identify those individuals and households that are ready to use the Internet and the assistance they need to make it happen.
  • Use data from the Health Literacy Component of the 2003 National Assessment of Adult Literacy to identify collaborative strategies to address Internet use and health literacy issues.

Develop public and private policies.

  • Identify and analyze Federal, State, and local policies that act as incentives or disincentives.
  • Identify and analyze related educational and economic development goals that act as local incentives and disincentives.
  • Create model policy guidelines for public and private concerns interested in pursuing such opportunities.
  • Engage appropriate intermediaries to influence policy analysis and modification.
  • Identify technology champions in the public sectors.
  • Provide incentives to homebuilders of public and low-income housing to include infrastructure for Internet access.
  • Identify incentives for refurbishing and repurposing computers and other donated equipment.
  • Provide incentives for those who are ready and able to acquire access to the Internet from the home.
  • Promote discussion about expanding the definition of residential universal service to include Internet service.

Implement programmatic initiatives.

  • Identify and analyze Federal, State, and local activities that have been successful in increasing home Internet connection rates.
  • Identify and analyze related educational and economic activities to facilitate or provide Internet access.
  • Use the literature on help-seeking behavior, diffusion of innovations, stages of change of the Transtheoretical Model, and other related theories as the basis for program activities.
  • Convene an ongoing forum for stakeholders to develop a national action plan on home digital inclusion.
  • Create model health communication and outreach programs promoting household Internet access.
  • Develop a coalition of public groups, government agencies, and the private sector to implement the action plan.
  • Support training initiatives that increase skills.
  • Use community centers to provide training and model Internet use behaviors that allow potential users to become more familiar and comfortable with technology in the home.
  • Examine mechanisms for increasing opportunities for content syndication.
  • Identify communities and their connected intermediaries.

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Lead Organizations and Responsibilities
Suggested leads for the research agenda include

  • Summarize existing literature (Office of Disease Prevention and Health Promotion [ODPHP]).
  • Convene a working group (representative of all stakeholders) to determine new data collection efforts (ODPHP, National Cancer Institute, and Centers for Disease Control and Prevention).

Timeframe for Action Steps
Phase I: Address research issues.

  • Within 6 months, re-examine data collection and analysis strategies systematically.
  • Within 6 months, develop an evaluation plan for monitoring the effectiveness of activities to influence this objective.
  • Within 12 months, develop strategies for population segmentation.

Phase II: Promote discussion about expanding the definition of universal service.

  • Within 6 months, develop a plan to promote discussion of residential universal service to include Internet access in the home.

Phase III: Package programmatic initiatives.

  • Within 18 to 36 months, identify strategies for leveraging support and building incentives.
  • Within 18 to 36 months, focus on sustainable economic and fiscal policies to saturate communities with initial Internet connections.

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References
Eng TR. The ehealth landscape: a terrain map of emerging information & communication technologies in health and healthcare. Princeton, NJ: The Robert Wood Johnson Foundation, 2001. Available online at www.rwjf.org/publications/publicationsPdfs/eHealth.pdf.

HarrisInteractive. Cyberchondriacs update. May 2002. Available online at www.harrisinteractive.com/harris_poll/index.asp?PID=299.

Harris LM, ed. Health and the new media: technologies transforming personal and public health. Mahwah, NJ: Lawrence Erlbaum Associates, 1995.

Ipsos-Reid U.S. Market Research. The face of the Web. Washington, DC, 2001.

Lenhart A. The ever-shifting Internet population: a new look at Internet access and the digital divide. Washington, D.C.: The Pew Internet and American Life Project, 2003. Available online at www.pewinternet.org/reports/toc.asp?Report=88.

NGA Center for Best Practices. "Digital divide" being creatively bridged in several states. 2001. Available online at http://www.nga.org/center/
frontAndCenter/1,1188,C_FRONT_CENTER^D_2188,00.html
.

Roberts DF, Foehr UG, Rideout VJ, Brodie M. Kids media @ the new millenium. Pub #1536. Menlo Park, CA: Kaiser Family Foundation, November 1999. Available online at www.kff.org/content/1999/1535/KidsReport%20FINAL.pdf.

Science Panel on Interactive Communication and Health. Wired for health and well-being: the emergence of interactive health communication, Eng TR, Gustafson DH, eds. Washington, DC: U.S. Department of Health and Human Services, U.S. Government Printing Office, April 1999.

UCLA Center for Communication Policy. UCLA Internet report 2001—surveying the digital future year two. November 2001. Available online at http://ccp.ucla.edu.

U.S. Department of Commerce. Computer and Internet use supplement to the current population survey, September 2001. Available online at www.bls.census.gov/cps/computer/computer.htm.

U.S. Department of Commerce. Falling through the net: toward digital inclusion. Washington, DC: U.S. Department of Commerce, October 2000. Available online at www.ntia.doc.gov/ntiahome/fttn00/contents00.html.

U.S. Department of Commerce. A nation online: how Americans are expanding their use of the Internet. Washington, DC: U.S. Department of Commerce, February 2002. Available online at www.ntia.doc.gov/ntiahome/dn/index.html.

Wartella E, O'Keefe B, Scantlin R. Children and interactive media. New York: Markle Foundation, May 2000. Available online at www.markle.org/news/digital_kids.pdf.

Web-based Education Commission. The power of the Internet for learning: moving from promise to practice. Washington, DC: Web-based Education Commission to the President and the Congress of the United States, 2000. Available online at http://interact.hpcnet.org/webcommission/index.htm.

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Contents
Introduction to the Health Communication Action Plans
Objective 11-1. Internet Access in the Home
Objective 11-2. Improvement of Health Literacy
Objective 11-3. Research and Evaluation of Health Communication Programs
Objective 11-4. Disclosure of Information To Assess the Quality of Health Web Sites
Objective 11-5. Centers for Excellence in Health Communication
Objective 11-6. Healthcare Providers' Communication Skills
Acknowledgments/
Credits
Appendix. Examples of Stakeholders Involved in Technology Diffusion and Internet Access Initiatives