Internet divide: Implications for implementing internet-based pediatric preventive screening in an urban population

Background: Internet-based technology can be used to tailor well-child encounters by allowing families to conduct pre-visit work such as developmental screening. The applicability of such technology to families of low socioeconomic status is unknown. Our objective was to use both qualitative and quantitative tools to define access to digital technology in such a population. Methods: Setting and Population: Children and families in four clinics within a safety-net health care system. Study Design: 1) Parental surveys (n = 205) of a convenience sample of parents whose children were seen for primary care in one of the four clinics; 2) focus groups (n = 7) with parents from the clinics; 3) In-depth interviews during home visits with 5 families from the clinics. Analysis: We used chi-square analyses to compare computer and internet access in English and Spanish speaking families. We used standard qualitative methods to code focus group texts and identify convergent themes. Results: English speaking parents (n=103), compared to Spanish speaking parents (n=102), reported far greater access to computers (72% vs 30%, p<0.01), use of the internet or e-mail (72% vs 29%, p<0.01) and sending or reading e-mails (69% vs 26%, p<0.01). In focus groups, the concept of parental pre-well child visit work, such as developmental screening tests, was viewed favorably by all groups. However, many parents expressed reservations about doing this work using the internet or e-mail, and stated a preference for either paper or telephone options. Many Spanish speaking families discussed lack of access to computers and printers. The concept of conducting an “e-visit” with a health care provider was rejected by all groups. In the 5 home visits, we found that even families that reported they had internet access might simply have a laptop computer with which they tried to access unprotected wireless internet connections in the neighborhood. Conclusions: In this economically disadvantaged population, language is a strong predictor of access to computers and the internet. This “digital divide” suggests that the use of internet-based technology to tailor well-child encounters, which has been successfully employed in a non-safety net setting, may not yet be suitable in practices that serve low-income, multi-ethnic, and multi-linguistic families. Given the potential power of pre-visit work to tailor well child visits to the needs of individual families, alternative strategies to the internet need to be explored for populations without reliable internet access.