The paradox of rural digital exclusion

By: Barbara Fersch, Associate Professor and Project Manager of the REACT project, Annette Aagaard Thuesen, Associate Professor, and Egon Noe, Professor, Danish Centre for Rural Research, University of Southern Denmark

For many years, digitalisation has been hailed as an essential part of the solution to many of the welfare state's challenges. During the coronavirus pandemic, we have learnt that it is indeed possible for services to be delivered and used digitally. Since then, a wealth of online and e-health options have emerged, such as apps and screen-based services that can be used to monitor health and communicate with welfare professionals, among other things.

The new apps and screen-based services are particularly obvious in rural areas, where distances to health centres, doctors and hospitals are greater. Research points to the potential of these digital offerings to be more than just "poor substitutes". If implemented with a focus on social aspects, they can contribute to a strengthened offer that can improve the relationships between citizens and welfare professionals.

The very accelerated digitalisation of the public sector that we are experiencing in Denmark, however, carries a significant risk of new forms of exclusion of a group of citizens who can be described as digitally challenged or who have chosen not to adapt to a digital everyday life with smartphones and internet.

So far, the exclusion discussion has mostly been based on citizens' digital access to the public sector through MitID, which "by default" should preferably be paperless and automated. Opting out of digital must be an active choice, which has led to a grey area of MitID users who are officially digital but have problems using the MitID platform. The consequences of this grey area have been that citizens have, for example, lost unemployment benefits because they have not been able to respond to letters in their e-Boks within the response deadline. And even though there is a formal right to decline MitID and digital access, in practice this proves to be very difficult within a system that is not set up for non-digital citizens.

Looking at the development of municipal health and welfare departments, one might be concerned that similar dynamics will apply to digitised health and welfare services in the future. This raises some fundamental questions about the fairness of services in the digitalised welfare state: How do we ensure that there is equal access for all?

So far, most digital health and welfare services are voluntary and co-exist alongside non-digital services. But in a situation where there is a shortage of labour for virtually all health and welfare tasks, there is a trend towards a massive expansion of digital, for example in home care. A recent report from the Region of Southern Denmark shows a high risk of exclusion in the region. 20 percent of the population in the region do not have sufficient digital health skills to actively use digital health services, i.e. to use them in a way that they can really help and fulfil their potential.

In the REACT project, which aims to develop a solution to create more inclusion in digital health and welfare services in rural areas, we have been in contact with welfare professionals on the municipal frontline in recent months. They tell us that the challenges are diverse and complex. The challenges relate to, for example, citizens not owning the required electronic devices, citizens having trouble accessing apps through MitID, and citizens having trouble clicking in the right place at the right time. As one of the welfare professionals puts it, their experience is that "anything can happen" and that things can go wrong in many different ways.

The report from the Region of Southern Denmark also shows that the risk of exclusion is particularly high in rural areas. In the most densely populated urban areas, 11 percent of the population does not have sufficient digital health skills, while in the most sparsely populated areas in the Region of Southern Denmark, 28 percent of the population does.

Older age and lower educational background play a role in digital health literacy - and herein lies the reason for the differences. The demographic profile of the rural population (which is older and less educated than the average urban population) means that a larger proportion of the population is at risk of digital exclusion.

The situation is almost paradoxical - those who could potentially benefit the most from digital services due to infrastructure and distance are also the part of the population most at risk of exclusion. This has the potential to further exacerbate social inequality between rural and urban areas.

To prevent and avoid the new forms of exclusion, it is firstly necessary to take the challenge seriously. This means that the challenge must be considered already in the design and roll-out of new digital offerings. It's important to focus on ensuring that digital welfare and health services are inclusive and that there are real opportunities for people to be trained in the skills they need to participate.

For some, training is an option, but there will still be a portion of the population that will be digitally challenged for one reason or another. It is important that the digital systems and the actors in and around them adapt to these citizens - and not the other way around.

Secondly, the right to be non-digital must be taken seriously and not just be a pro forma option. Healthcare professionals must have the tools to identify the digitally challenged, and they must be able to offer real alternatives.

If not, we will see many more serious consequences of digital exclusion. 

This op-ed is based on the research project REACT - Rural e-Health Facilitators, which has received funding from the EU's Erasmus+ education programme. Read more about the project on REACT's website.

The op-ed was published in Jysk Fynske Medier in Erhverv+, Thursday 31 August 2023.