Consumer Health Digital Divide: A Research Agenda for Studying Inequality in Online Health Information Access and Use Jing Chong School of Information Sciences and Technology Penn State University University Park, PA 16802 [email protected] Driven by social, economic, academic and technological forces, the new field of E-health has been developing quickly in recent years. Many E-health applications are Internet-based and therefore have the potential to help people throughout the world. However, this high dependence on the Internet also raises sobering questions about a health digital divide, i.e. unequal access and use as well as unequal rights to gain benefits of online information among health consumers. In this paper, we discuss social, cultural and economic factors which shape a research agenda for examining health digital divide issues. These factors are derived by means of a literature review. Future research questions include how to solve the discrepancies between health digital divide and digital divide among the general population, what is the role of content prejudice in health digital divide, and what is the status quo of health digital divide in developing countries, et al.

Introduction Since 1990s, the Internet has never stopped its step progressing into every aspect of our daily life and every corner of the world. Nowadays, we can shop online, receive education online, date online, and also take care of our health online. There are an estimated more than 70,000 websites featuring health information (Grandinetti, 2000) and the number is constantly on the rise (Nielsen//NetRatings, 2002). The most recent survey shows that the number of online healthcare users increased about 20% in one year, adding up to 93 million, which is 80% of all the adult Internet users in the US (Fox & Fallows, 2003), and there shows no sign of ceasing this trend (Cotten, 2001; Fattah, 2000; Taylor, Alman & Manchester, 2001). Looking for medical information online has become a preference for both healthcare consumers and practitioners or providers (Eysenbach, Ryoung & Diepgen, 1999; Riegelman & Persily, 2001; Suarez-Amazor, Kendall & Dorgan, 2001). Multiple social, economic, academic and technological forces are behind such growth. The privacy, anonymity, time flexibility and information variety that are essential for health information searching can be realized online (Fox & Rainie, 2000; Marton, C., 2001; Skinner, Biscope & Poland, 2003), which is the biggest attraction for health consumers. The phenomenal achievements made in biological and medical research compel healthcare providers to resort to the Internet to keep them updated. The growing number of aging population, the increasingly popular healthcare model of patients’ participation, the more and more focus of public healthcare awareness on disease prevention instead of mere curing accelerate consumers’ online health behaviors. Furthermore, the economic pressures on healthcare institutions to reduce costs and the monetary lure offered by health insurance companies also have encouraged consumers to go online. (Anderson, Rainey& Eysenbach, 2003; Shelia & Gupta, 2004). A new discipline of E-health is emerging. In this paper, E-health is defined as “studying applications of the Internet and global networking technologies to medicine and public health, examining the impact and implications of the Internet, and evaluating opportunities and the challenges for health care (Eysenbach et al., 1999). Being the fastest growing category regarding Internet use with a rate of 34% per year, even faster than the Internet itself (Cyber Dialogue, 2000), makes E-health promising to be “the hub of health care” (Coile, 2001). However, since E-health unavoidably depends heavily on the Internet, it can not overcome the social problems intrinsic in this information technology, one of which is the digital divide. Although the Internet is believed to be able to bring equality to healthcare by disseminating health information among traditionally underrepresented consumers (Brodie, et al., 2000; Zarcadoolas, Blanco, Boyer & Pleasant, 2002), it is at least not now considering the fact that the digital divide among the general population is arguably still not eliminated in spite of the increased

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Internet access and use (Lenhart et al, 2003), just as what Bolt and Crawford (2000) have found, “health information is not equally accessible with less educated, economically disadvantaged, and socially marginalized persons least likely to access health information on the Internet”. The purpose of this paper is then, by means of a comprehensive literary review, to investigate to what extent, on what scale and in what sense this health digital divide exists, as well as what needs to be explored in the future by comparing with the research results in digital divide.

Digital Divide Digital divide has received a lot of attention in the past decade by researchers and policy-makers. However, there is still controversy over whether or not this gap has been bridged. Even its definition has not been quite agreed upon. In general, the focus of any definition invariably falls into one or more of the following three dimensions: aspect, stakeholder and dimensions. There are two aspects concerning digital divide: access (Anthony, 2000) and use (NTIA, 1998). The stakeholders involved can be categorized as regions, countries and areas (Mendoza, 2001; Norris, 2001; Simpson, Daws & Pini, 2004); communities and organizations (Johnson, 1998; Rooney, 2002); and groups of people (Millward, 2003). The dimensions can be demographical (Brinson, 2002; Losh, 2004), economic (McLaren & Zappalà, 2002), political (Hung, 2004) and cultural (Press et al., 2002). As far as demographical factors are concerned, age, gender, income, race and education are the most important ones, with younger, richer, more educated white males being more likely to use the Internet (Hargittai, 2002; Miller, 2001). Income is more decisive because it is found that racial divide is less obvious if income is controlled (Brodie et al., 2000). Disability can also be a hindrance to the Internet use (Horrigan, 2004). We contend that these debates about the existence of the digital divide may result from a rather narrow treatment of a complex social phenomenon. In fact, many of the newer studies in this genre call for a rethinking of the digital divide (Gurstein, 2003; Hacker & Mason, 2003; Kvasny & Truex, 2001; Payton 2003; Warschauer, 2002). Common among research in this genre is a call for shifting from demographic statistics around technological access to a socially-informed research on effective uses of technology. Computer and Internet access are insufficient without the requisite skills and competencies to leverage the technology to meet selfdetermined needs and goals (Mossberger, Tolbert & Stansbury, 2003). Groups that are historically underserved in their quality of employment, their level of qualifications, their level of income, their quality of education, and their consumption opportunities tend to also be marginalized in their access to and use of the Internet. The digital divide, therefore, is a political outcome rooted in these historical systems of power and privilege, and not simply a gap in access to technological artifacts. Promoting access and basic training to improve the computer skills of individuals is warranted, but may do little to redress the social forces that may limit these actions in the first place. From this perspective, the divide is about disparities in what individuals and groups are able to do with their access. Gurstein (2003) contends that effective use of the Internet occurs when people are able to use this technology purposively and independently to improve life chances in culturally relevant domains such as economics, employment, health, education, housing, recreation, culture, and civic engagement.

Online Consumer Health Information Health is one of the most important domains for studying digital divide issues because it is fundamental to life itself. Countries throughout the world provide some basic level of health care to their populations. More recently, governments and health care providers are placing increasing amounts of consumer health information on the Internet. Consumer health information can be defined as messages that help consumers “understand their health”, “make health related decisions for themselves and their families” (USDHHS, 2000), and “construct a social and personal sense of health” (Tardy & Hale, 1998, p. 338). Information is deemed as the most important resource in health condition improvement because it is “the first step to every healthy choice” (Gann, 1986) and it is “on a continuum between health education and health promotion” (Rolinson, 1998). Among the many benefits that online health information can bring about to consumers, peer support and empowerment are the two most important ones.

Peer Support In E-health, there is a special group of people online. They are patients, but at the same time they are “consumer specialists” (Calabretta, 2002) or “patient helpers” (Ferguson, 2000). They are quite knowledgeable in certain aspects of healthcare based on their own experiences, and, equally importantly, they have warm hearts, willing to help others in similar health conditions by organizing online discussion groups, running websites, and

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sharing health information as well as offering psychological consultation. They are not competitors, but complements to the health providers (Ferguson, 2000). The online health communities thus formed have become major sources for consumers to seek peer support (Eysenbach et al., 1999; Skinner et al., 2003)

Empowerment Before the widespread use of the Internet, healthcare providers had the exclusive privilege and access to obtain, interpret and convey health information, which resulted in their more advantageous status in their interaction with patients or health consumers (Giddens, 1991; Goldsmith, 2000; Hardey, 1999). In this sense, healthcare consumers going online is not just a transition in the pattern of information seeking behaviors or just a success in getting what previously could not possibly be got, but a major process of empowerment and control gaining (Cotten, 2001; Diaz, 2001), as they are more able to “actively understand and influence their health status”(D’Alessandro & Dosa, 2001), “assume more responsibility for their own health, and participate in health care decisions” (Anderson et al., 2003)

Consumer Health Digital Divide Unfortunately, the potentially huge benefits of online consumer health information are not evenly distributed among people who need them, resulting in a “consumer health digital divide”. Hardly any paper has explicitly mentioned that term, although some have discussed about the influence of digital divide in the general population on the differences in online health information access and use (Cotten, & Gupta, 2004; Kalichman, Weinhardt, Benotsch & Cherry, 2002). In this paper, we define consumer health digital divide as a form of health disparity in healthcare consumers’ access to and use of both the information technologies, the Internet in particular, and health information online. In this section, two most researched dimensions in consumer health digital divide, i.e. demography of healthcare consumers and the Internet itself will be conceptualized. The contributing factors in each of those two categories will be addressed in detail. The methods that have been used in studying consumer health digital divide and the measures taken to deal with it will be summarized. Last but not least, conditions of consumer health digital divide in developing countries will also be discussed. Together, these provide a useful but limited set of approaches for examining consumer health digital divide issues.

Demography ! Gender There are two different views concerning the role of gender in health digital divide. Most studies show that women are more likely than men to use the Internet for health information (Hern, Weitkamp, Hillard, Trigg & Guard, 1998; Miller, 2001) and girls are more likely than boys to do so (Brodie, et al., 2000). As to the reasons for this phenomena, Pandey, Hartb and Tiwaryc (2003) argue that “Internet has become such an integral part of daily life that health-conscious women use the Internet in a pro-active manner for health promotion”. Two most recent studies reveal the opposite scenario. Swartz, Cowan and Batista (2004) find that no gender differences exist in the use of practice Web sites. Hanauer, Dibble, Fortin & Col (2004) survey the students in a community college about online health information search and find that almost the same number of men and women use the Internet for health information.

! Age Age is another key contributing factor to health digital divide (Swartz et al., 2004). Based on the relationship between age and Internet use, healthcare consumers can be divided into three groups: adolescents, the seniors and the others whose ages are in-between. The third group is the backbone of online health information consumers with the average age of 40.The seniors, with average age 11 years older, are “non-Internet health information seeking group” (Shelia & Gupta, 2004), despite the fact that they obviously are in greater need and have as much positive attitude and acceptance(Gustafson, et al, 2001). However, some studies find that there is a trend that the seniors are increasingly using the Internet to search for health information (Fox, 2001).Chances are that in the future, this age gap may be not be as evident as today and may be no longer “a key discriminating factor in where individuals seek health information” (Shelia & Gupta, 2004). Adolescents are another group of people who are not much of online health information consumers. Rolinson (1998) finds that among 635 13–16-year-olds in England, there are only 3% who have used the Internet for health information. He thinks the reason lies in the fact that adolescents don’t think it “cool” to be seen doing this and they are not willing to devote too much effort in this “active” searching behavior. Gray (1999) is surprised at the low rate of online health related behavior among university students in UK, who turn to the Internet only when

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encountering unusual diseases, even though they are quite comfortable with online activies. In Gray, Klein, Cantrill and Noyce (2002)’s study, “only a minority of adolescents seem to use the Internet for health information”. The Internet is the last channel they would think of when they need health information. It is valuable only if the information they need is “too embarrassing for discussion with a family member”.

! Literacy/ Education For online health information behavior, literacy is composed of general literacy, computer and online literacy, and health literacy. General literacy is the very basic of the other two, thus undoubtedly is a fundamental source of health digital divide, reading level in particular. According to Berland et al. (2001)’s study, “the average sampled health information in English is on a Grade 13 reading level, while the reading level for Spanish materials is at Grade 10”. For neurology brochures and Websites, most of the content is “written at Grade 9 level or above” (Murphy, Chesson, Berman, Arnold & Galloway, 2001). Health consumers with lower level of reading skills will certainly find it hard to enjoy the benefits of online information. Computer and online literacy, the prerequisite for online health information seeking, is another source of health digital divide. Since it has been much dealt with in literatures about the digital divide among general population, it will not be addressed in detail here in this paper. However, there is one aspect worthy of being mentioned here. Users more experienced with the Internet are more likely to use it for health information search (Fox & Fallows, 2003). Health literacy, or biomedical literacy (Miller, 2001), is the capacities, skills or confidence to obtain, interpret, understand and use health information and service in order to enhance decision-making and promote health (USDHHS, 2000). Obviously, health literacy depends on “more general levels of literacy”, but is “more than being able to read pamphlets and make appointments” (WHO/HPR/HEP, 1998). It is one of the most important distinguishing elements in health digital divide and the “strongest predictor of looking for health information on the Web” (Miller, 2001). One component of health literacy is the ability to judge and assess the applicability and credibility of online health information (Jadad & Gagliardi, 1998). More often than not, health-related websites are full of incomplete, outdated, misinforming, inaccurate and biased information mostly written by non-professionals (Culver, Gerr & Frumkin, 1997). Therefore, online health consumers may become victims of fraud and false information which “at worst can undermine patient care and frustrate treatment progress” (Gustafson, Robinson, Ansley, Adler & Brennan, 1999) if they don’t have the necessary evaluating and discriminating skills. However, the potential risk should not be a reason for “denying or limiting access to the Internet” (Kalichman, Weinhardt, Benotsch & Cherry, 2002) Although literacy is closely and positively related to education, it does not necessarily be achieved through education and education does not necessarily result in literacy. Therefore, education should be treated separately from literacy as a dimension in health digital divide. As Shelia and Gupta (2004) indicate, 48% of the online health information users have a bachelor’s degree or the above, while only 18% offline users have. When combined with gender, it is found that women with more education tend to use the online health information more (Pandey et al., 2003).

! Race Consistent with studies in the digital divide among the general population, minority groups still can’t overcome the disadvantageous conditions when it comes to health information access and use. The Center for Studying Health System Change has found that Spanish-speaking Latinos in the US are about half as likely to go online for health information as their English speaking counterparts (Center for Studying Health System Change, 2003). For African Americans, although they have as much interest in using the Internet for health information as the white and tend to think of it as appealing (Gustafson, et al., 2001; Fox & Rainie, 2000), the actual use among them is still low, being two times less likely than the white to do healthcare related research online (Fox, 2004). Besides the well-known reason of their low income and literacy level, Brodie et al.(2000) finds that “blacks are more likely than whites to distrust Internet information and to have concerns about Internet privacy”. This holds true even after income is controlled.

! Income Still in agreement with studies in digital divide, income continues to be a key factor in health digital divide. Online health consumers tend to have relatively higher income than their offline counterparts (Shelia & Gupta, 2004; Pandey et al., 2003). Fox (2004) finds that only people living in higher-income households ($50,000+ annually) are more likely to have made medical purchases online. One new finding is that consumers with health insurance are more likely to search health information online (Swartz et al, 2004)

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! Place The gap in online healthcare is not all the same in different places. It is found that health digital divide is not as pervasive in California as in the rest of the country. Lower-income Californians are found to be more likely than other lower-income Americans to go online and search for health information. Once online, their behaviors are similar to those with higher income, despite the fact they are often less educated, only 12% having a college degree while most health websites require college level reading skills. The fact that makes California stand out is that it has been the center of the “.com” boom that has introduced the Internet. (Fox, 2003) Apart from geographical difference, the place where health consumers have the Internet connection also matters. It is found that users with home access to the Internet have more experience with it (Kalichman, et al, 2002), which is also the case with online health consumers, especially considering the fact that privacy is a quite sensitive issue in healthcare and “public Internet access, such as libraries, community centers and schools, which, more often than not, do not provide the privacy necessary for personal health searches” (Fox, 2003)

! Health Regarding the relationship between health conditions and use of the Internet, there are opposite findings on whether online health consumers are healthier than their offline counterparts. According to Swartz et al (2004), people with diagnoses of “acute and chronic” diseases and visit clinics more frequently tend to use online health information more, which echoes some of the earlier studies (Fox et al, 2000). That is the proof of the health needs model developed by Pandey, Hart and Tiwary (2002). On the other hand, Shelia and Gupta (2004) find that online health consumers are healthier than their offline counterparts according to their self-reports of health conditions, which means healthier people are more likely to use the Internet for health information. The authors explain this by saying that people in poorer health conditions are physically barred from accessing and using the Internet, or online consumers have already benefited from the health information obtained from the Internet in the sense of “maintaining good health”. Unfortunately, causal relationship can not be determined due to the nature of the available data. There is still a third voice. Fox (2004) finds that there is only a slight difference between those in excellent health and those in poor health (including disability) in the behaviors of searching online for information about prescription drugs.

Internet The innate properties of the Internet determine its role as a two edged sword, which facilitates the spread of health information as well as its potential benefits, and at the same time does harm to disadvantaged consumers’ right to access E-health. Health digital divide is caused by two main factors in this respect: connection quality and access control.

! Connection Quality Basically, there are two kinds of Internet connection: broadband and dial-up. The key difference is speed, which is closely related to the gap in users’ experiences with the Internet. “A person’s relationship to the Internet changes when they get that high-speed connection…Broadband users are more likely to go online on a typical day” (Fox, 2004). As searching for health information is not the very basic function and most direct way of usage of the Internet, speed has a great influence on whether an Internet user would become a health consumer or not. Having had pleasant experiences with the speedy connection, broadband users more tend to go beyond simple and common online behaviors and begin to sample health-related websites (Fox, 2004). Not having high-speed Internet connection is largely an economic issue. A study shows that in rural area, only 25% Internet users have broadband connection at home, while the percentages are 44% for urban users and 47% for suburban ones respectively (Horrigan, 2004)

! Access Control Access control or gate-keeping is to block certain websites and to restrict certain types of use (Robert Wood Johnson Foundation, 2001). Gray et al. (2002) have done a research on access control of online health information by schools. Pupils are automatically prevented by software installed on school computers from visiting websites related to certain health subjects that are deemed inappropriate. Although this measure is taken out of good intention, it in fact deprives the pupils of their accessing education-oriented content online which they really need, such as information on reproductive health and drug misuse.

Method The research methods used in current literatures on health digital divide are short of variety. Reports from the Pew Internet & American Life Project, a rich source of most updated data, almost completely rely on telephone interview (Fox et al, 2000; Fox & Rainie, 2002; Fox, 2003; Fox & Fallows, 2003), which is also used in other

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studies (Brodie et al., 2000; Pandey et al., 2003). Other qualitative methods applied include focus group (Gray et al., 2002; Skinner et al., 2003) and secondary data from surveys done by authorities (Cotton & Gupta, 2004). Just as what Shelia and Gupta (2004) have implied, most studies are “descriptive in nature”, thus make it difficult to draw up causal relationships. Therefore, they suggest replacing “cross-sectional data” with “longitudinal studies” to track changes over time. The scale of samples should also be larger, even extended across national borders so as to find out the generalizability of the research results. There is also a need for intensive research to increase understanding of the perspectives and practices of disadvantaged groups (Kvasny, forthcoming). Only then can we develop online consumer health information that meets the distinct cultural needs of underserved groups.

Measures Measures mentioned in the literatures address health digital divide in the following aspects: • Developing interactive computer technology-based interventions to increase Internet access has demonstrated positive outcomes (Bjornsdottir, 1999; Jones et al., 2000; Turnin et al., 1992). One example is the Computer-Based Health Enhancement Support System for people living with HIV/AIDS includes “an instant library, question and answer resources, means for gaining support, a referral directory, health risk assessments, strategies for managing medical decisions, and personal stories of peers experiencing similar problems” (Kalichma, Benotsch & Weinhardt, 2003). • The government should also take on its responsibility in ensuring access to online health information in order for more consumers to benefit from it. Health InfoNet of Jefferson County is just a collaborative consumer health information service by the Jefferson County public libraries and the UAB Lister Hill Library of the Health Sciences to people “on the other side of the ‘digital divide’” (Smith, 2001). In California, one of the statewide initiatives is Health-E-App, which targets lower-income families’ ability to access health care services online. Since 2001, lower-income families have been able to enroll children and expectant mothers in California’s public health insurance programs, using an online application that is available statewide in English and Spanish. They can even choose health providers and plans from online lists. Another statewide initiative provides online enrollment for publicly-funded breast and cervical cancer screening and treatment (Fox, 2003). • Training can be used to help consumers build skills in online health information handling, which include content quality assessment, source credibility evaluation, and translation of information into behaviors (Kalichma et al., 2003). • To deal with the negative effect of access control, “promoting parental and teacher involvement and discussion” is much better than filtering software to protect adolescents from harmful health information (Gray et al., 2002)

In Developing Countries The potential capabilities of information technology in bridging health digital divide by improving the delivery of health services to poor and remote areas (Chandrasekhar & Ghosh, 2001; Sood, 2004) have been recognized in some developing countries. Although there are already a few successful projects in this respect, such as the national telemedicine network in Mali initiated in 2001, which used “Internet-based technologies for distance learning and teleconsultations” (Geissbuhler, Ly, Lovis & L’Haire, 2003), awareness is still far away from actual realization and application (Kim, Eng, Deering & Maxfield, 1999). The major obstacles include problems with infrastructure, hardware availability, and computer and online skills (Chandrasekhar & Ghosh, 2001). Like in developed countries, the quality of health information online is also a problem in developing countries. The information is inconsistent in quality and only a few websites can be graded (Edejer, 2000).

Discussion This paper provides a survey of digital divide and E-health scholarship, and begins to articulate a set of factors which may be useful for future research. Based on these factors, several potential research questions come to surface, which need to be dealt with by researchers in this field.

Demography By comparing the demographic dimensions of consumer health digital divide and digital divide, the two are consistent in income, education and race (Brodie et al, 2000; Shelia & Gupta, 2004). In other words, these factors continue to play their similar roles in consumer health digital divide. From digital divide, we can predict to certain extent what may influence the differences in consumers’ online health information access and use. However, it doesn’t mean that health digital divide is too consistent with digital divide to be worthy of being explored any further given the already prolific research into digital divide. There still are discrepancies between

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them. Women are at least as likely as men, or even more likely than men, to use the Internet for health information, although women account for smaller percent of online users in general population. The reason for this has not been well explained in available studies. For age, middle-aged consumers use online health information more than those at the other two ends of the spectrum: the youth and the old. However, in general population, there is no significant difference in using the Internet between the middle-aged and the youth. Why the youth don’t take at least a medium portion of their overall large amount of time online needs to be further explored. In addition, it is also unknown whether the seniors would become frequent consumers of online health information if the “grey digital divide” (Millward, 2003) regarding access and literacy can be bridged. For digital divide in general population, being white means being more likely to go online, which is mainly due to advantages in income and education. However, for health digital divide, although income and education still count much, black people’s privacy concern is a new raised issue, in which more research effort should be made. Place is much mentioned in digital divide with people in remote or poor areas using the Internet less. Whether place still matters much in health digital divide if economic influences are controlled remains a question. A seldom written-on dimension in digital divide among general population is that parents with children living at home are more wired than non-parents or sole parents (Cullen, 2001), which is expected to still hold true for health digital divide, although few literatures have explored this before. Health conditions have been roughly dealt with in digital divide. For health digital divide, one question here is what the relationships are between income and the possibility of having health insurance as well as the percent of income allocated to health insurance. The other question is what the true relationship between consumers’ health conditions and their possibilities of going online for health information. Still another dimension worthy of more research is culture, which is expected to be a more relevant issue in health digital divide than in digital divide among general population. One case in point is homosexual people. The Internet has become a more useful tool for them than for others in countries whose dominant cultures are typically more conservative. In Taiwan, for example, homosexual people are more active online than in real life regarding sharing information and seeking emotional support. In this way, they don’t have to worry about “the disclosure of their sexual preferences and causing unwanted negative consequences” (Yang, 2000). Although their health information behaviors online haven’t been much studied, it is justifiable to hypothesize that culture bias or prejudice is also a contributing factor to health digital divide.

Internet An important aspect of the Internet is largely neglected in the studies of health digital divide: content. For digital divide among the general population, a lack of relevant content is a major reason for some groups to choose not to access the Internet, especially “cultural or ethnic groups outside the predominantly Western culture of the Internet” (Brodie, et al., 2000; Cullen, 2001). Apart from the potential content prejudice, language monopolization should not be overlooked as well in health digital divide.

In Developing Countries In developing countries, identified dimensions of health digital divide are almost the same as those of digital divide among the general population there, with economic incapability being the most determinant one. The factors unique to health digital divide per se have not been much addressed. The reason could presumably be that healthcare is still a luxurious consumable in developing countries where possessing basic living necessities still remains a problem, let alone E-healthcare. Besides, studies on health digital divide within the developing countries themselves are very rare. Whether the situations there would be similar to those in developed countries is still unknown. Last but no least, like the digital divide in the general population, future studies in consumer health digital divide should also be more oriented towards political and historical perspectives instead of simply focusing on demographical and technological aspects. Apart from healthcare consumers, health digital divide among other relevant stakeholders, such as doctors and healthcare institutions in various geographical areas, should also be paid attention to.

Conclusion Health digital divide has been largely existent ever since the Internet was introduced into healthcare. Bridging health digital divide is generally believed to be a significant task worthy of great efforts because of the huge benefits online health consumers can get and their offline counterparts are potentially be deprived of. In order to eliminate this gap, the contributing factors to health digital divide need to be identified first. It is generally found

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that middle-aged, health literate, better-off white women with broadband Internet connection at home are the group of consumers who tend to use online health information most. Research methods ever applied need to be further improved and diversified, and focus more on finding causal relationships. Studies on developing countries should be strengthened. More measures to bridge health digital divide can be expected to be taken in the years to come. For example, the goal of AMIA 2003 Spring Congress entitled "Bridging the Digital Divide: Informatics and Vulnerable Populations", was to “develop a framework for a national agenda in information and communication technology to enhance the health and health care of underserved populations” (Chang et al, 2004).

ACKNOWLEDGEMENTS Many thanks to my advisor, Dr Lynette Kvasny, for her insightful advice on revision.

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