نظریه پردازی شکاف دیجیتالی:چارچوب هایاستفاده شده فن آوری اطلاعات و ارتباطات استفاده در میان زنان فقیر با استفاده از سیستم پزشکی از راه دور

In this paper, we argue that reconceptualizing the “digital divide” from the perspective of those with the least access requires that the policy concern shift from disparities in access to computers and the Internet toward an examination of how Internet information resources are differentially accessed and used. Drawing on an archive of clinical narrative descriptions documenting training sessions related to eight African American, low-income women involved in a clinical trial of a telemedicine system intervention for monitoring cardiovascular disease risk factors implemented at Temple University; we illustrate the shortcomings of a limited conceptualization of access. Rather, we propose a model that depicts information and communication technology (ICT) access in terms of four interrelated elements: (a) information delivery approaches (how information is shared, disseminated and accessed through the use of e-communication technologies), (b) technology use contexts (what are the specific settings in which technology is accessed), (c) social networks (what is the role of social networks in shaping access to and use of ICTs) and (d) the social policies and institutional mechanisms regulating technology access (specifically targeted to ICT use as well as more generally). This model highlights the embeddedness of ICT use in the geography of people’s daily lives and suggests a number of policy concerns related to how ICTs may mitigate or exacerbate economic and political inequalities in the United States.

Information and communication technologies (ICTs) are radically changing the way that healthcare in the United States is delivered, with the advancement of telemedicine among the most prevalent changes. Telemedicine involves using ICTs to provide health care to patients in settings that are geographically discontinuous from the locus of health care institutions. As such, telemedicine can be seen as an inherently geographic technology. In fact, geographers (and others) have suggested that there is an urgent need to analyze critically the effects of telemedicine systems on health care delivery and outcomes (Cutchin, 2002 and Crampton, 1999; Andrews and Kitchin, 2005). Many people studying telemedicine primarily focus on its potential benefits (Cutchin, 2002). Yet as Crampton (1999) argues, all technologies have both totalizing and democratizing tendencies. A number of researchers note the transformative effects of ICTs for reorganizing institutionalized health care services and health care provider roles while simultaneously creating new cyberspace arrangements that comprise new realms of care (Cutchin, 2002, Halford and Leonard, 2006 and Andrews and Kitchin, 2005). Cutchin (2002, p. 12) argues that the “geography of virtualization” raises ethical concerns related to access and connectivity. In particular, Kim (2005) suggests that there are ethical concerns raised by the potential for telemedicine to widen health disparities given that there are also disparities in people’s access to ICTs. We reflect on these ethical concerns by considering the issue of how society weighs the tensions between the right of people to health care, the costs and benefits of providing care, and people’s right to privacy. Specifically, we argue that this issue can not be adequately addressed without reframing the “digital divide” from the perspective of some of those who not only experience the least access to information and communication technologies, but also experience significant health care disparities – both of which are due to their wider economic, political and social marginalization. The gap between those with the most and those with the least access to information and communication technologies (ICTs) is commonly referred to as the “digital divide.” The digital divide is most associated with other indicators of inequality such as income, gender, race/ethnicity and geographic location. The larger societal concern is that lack of access to the computers and the Internet as well as related information flows will exacerbate other forms of social, economic, and political marginalization. The conceptualization of the digital divide has expanded from an earlier, more limited focus on differential access to computers and the Internet to a broader understanding of access in terms of infrastructure, usage, and information flows (see van Dijk, 2005; DiMaggio et al., 2001, Hargittai, 2003, Lenhart and Horrigan, 2003, Jackson et al., 2003 and De Haan, 2004). However, Servon (2002) notes that policy makers have continued to focus on ICTs in terms of lack of access to infrastructure by concentrating on finding the means to provide individuals and communities with computers and Internet service as well as training in basic computer literacy. But this research is limited in its ability to produce nuanced policy prescriptions because of a lack of geographic analysis. For example, while scholars have agreed that limiting the concept of access to equate solely with location and quality of ICT infrastructure is insufficient (Hargittai, 2002), the geographic dimensions of ICT and social inequality are largely unexamined (Andrews and Kitchin, 2005). A number of geographers have begun to reconceptualize the digital divide in terms of people’s embeddedness in places as well as by exploring how digital divides are uneven across multiple scales (Crampton, 2003 and Warf, 2001). Geographers have also considered the implications of virtual communications for reconfiguring geographies of everyday life (Adams, 1997, Adams, 1998, Dodge, 2001, Dodge and Kitchin, 2005a, Dodge and Kitchin, 2005b and Hillis, 1998). This growing body of work, however, does not focus specifically on how people challenge and alter their strategies with respect to their own purposes for using ICTs. In order to get at these geographic issues, a different scale of analysis is needed. Gilbert and Masucci, 2004 and Gilbert and Masucci, 2006 have shown that examining individual perspectives of poor women who are navigating institutions to gain educational, economic, and health services needed for survival gives insight about their self-efficacy with respect to using geographic information specifically and ICTs more generally. This work underscores the need to differentiate among groups of poor women, whose frameworks are inextricably intertwined with their highly localized circumstances and social contexts (Gilbert and Masucci, 2006, p. 758). In this paper, we intend to explore the spatiality of the digital divide from the perspective of low-income racialized minority women living in inner cities – many of whom are elderly. This is a group that is typically characterized as being the most negatively impacted by the digital divide (NTIA, 2002). Specifically, we want to understand these women’s frameworks for ICT use – that is how their daily experiences, interests, and knowledge shape how they do or would like to use ICTs and the related information flows. Our focus on their use of a telemedicine system reflects the societal trend for many poor, racialized women to encounter ICTs as a part of their negotiation of education, health and social services as well as for elderly women to first encounter ICTs in the context of changing modalities of the delivery of health care (Kreps, 2005). We will draw on an archive of clinical narrative descriptions documenting training sessions related to eight women (ages 37–71) involved in a clinical trial of a telemedicine system intervention for monitoring cardiovascular disease risk factors implemented at Temple University in 2004 (for further discussion see Masucci et al., 2006 and Kashem et al., 2006). The archive of clinical narratives comprises part of the study record for a digital divide sub-study connected with a larger clinical investigation related to the use of an Internet Telemedicine System that monitors risk factors for patients with cardiovascular disease. The objective of the sub-study was to assess the effectiveness of an ICT training process to provide a foundation in basic computer skills and training in the use of the telemedicine system for users with little prior ICT experience. We will examine perspectives related to ICTs found in narrative descriptions of a small cohort of trainees consisting of the poorest and least experienced users in the sub-study to examine the digital divide beyond the facets of access to computers and the Internet and differential usage. We will draw on the archive of clinical narratives among the women to outline an alternative model building on geographical conceptualizations of the digital divide that depicts ICT access in terms of the interconnections among four elements: (a) information delivery approaches (how information is shared, disseminated and accessed through the use of e-communication technologies), (b) technology use contexts (what are the specific settings in which technology is accessed), (c) social networks (what is the role of social networks in shaping access to and use of ICTs) and (d) the social policies and institutional mechanisms regulating technology access (specifically targeted to ICT use as well as more generally). Each of the elements of our reconceptualization of the digital divide is inherently geographical, as we will demonstrate, and points to the importance of understanding the embeddedness of ICTs in daily life. As such, it suggests a number of policy concerns related to how ICTs may mitigate or exacerbate economic and political inequalities in the United States.

In conclusion, we argue that our reconceptualization of the digital divide from the perspective of some of the most marginalized people in our society shifts the policy thrust from simply overcoming delivery barriers to understanding what strategies may work to help empower poor people through the use of ICTs in daily life. It requires us to understand the embeddedness of people in place-based communities and social networks as well as the unevenness of ICT resources and information across space. It is important that public policy invests in strategies that will improve access to computers and the Internet such as investing in community technology centers, donating computers to community organizations, providing training programs for supporting workforce development and creating publicly accessible information resources. There is no question that we need to enhance substantially the ICT resources available in poor communities. However, these approaches have not fundamentally altered the landscape of empowerment among marginalized groups nor have they democratized information resources. We suggest that by learning what strategies are being employed successfully by marginalized populations, both at the individual and collective scales, we can gain a better understanding of how ICTs can be a part of improving quality of life. Our observations show that among the strategies used by the women to overcome digital divide barriers were: sharing computers with place-based social networks, particularly family members, accessing educational programs at local community centers and libraries, and coupling ICT training with engagement of needed services. These experiences provided enough ICT background for nearly all of the women to master the use of the telemedicine system in the digital divide sub-study. This demonstrates that a reconceptualized policy framework for addressing ICT approaches that reflects the perspectives of marginalized populations might link investments in community information needs to the specific challenges faced. For the women in the digital divide sub-study, it is clear that health information needs should be central to policy-making efforts. A number of policy concerns need to be addressed in order to ensure that poor people are not marginalized further by linking community information needs to specific challenges such as health care. First, we need a broader discussion of who has the right to decide what information should be made available in the public domain. Clearly, the implications for privacy are far reaching for everyone. Yet, poor people are monitored extensively through their participation in the social welfare system; and their privacy concerns could be greatly exacerbated as health care delivery is increasingly integrated with the use of ICTs. Second, a re-evaluation of public policies related to the intertwining of technological and basic literacies as prerequisites to accessing health, education, jobs and decision making processes. The use of ICTs has the potential to exacerbate inequalities in the United States so we need to think carefully about how we embed ICT use in public policy. Thirdly, an examination of the costs and benefits of improving information accessibility towards the goals of decreasing health gaps for racialized minority populations and women in the United States. Clearly providing infrastructure is not enough, however costly. But finding better ways to empower marginalized people in relation to their health is likely to have long-term benefits to society in terms of decreased medical costs.