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Internet Access as a Social Determinant of Health on Tasso Island

By: Elizabeth Chatpar, Ashley Martinez, and Jingyi Zhang

Johns Hopkins Bloomberg School of Public Health

Applied Environmental Health Practice

December 2022

Introduction

2 Education

3 Social Violence Issues

5 Healthcare System | Overview of E-Health | Source of Information 6 Clinical and Public Health Settings

6 E-Health in Gynecological and Pediatric Health

7 Main Takeaways

8 About RowdyOrb.it 8 Introduction to RowdyOrb.it | Community Contributions | Community Economic Empowerment

9 Implementation of Internet in Tasso Island

10 Case Study: Internet Access in Ghana

11 Potential Negative Impacts of Internet Access on Tasso Island

12 Conclusion

13 References

Tasso Island is a developing island approximately 15 nautical miles off the coast of Freetown, Sierra Leone. Home to over 5,000 people, Tasso Island has four major villages: Oku town, Samgblima, Allen, and Tasso (IslandAid, 2022). The Island has a relatively young population, with over 55% of residents being under the age of 20 (IslandAid, 2022). Furthermore, there is little economic activity and nearly the entire island relies on fishing as a source of income (“Tasso Ecotourism Project,” 2020). The Tasso Ecotourism Project also significantly contributes to the island’s economy by employing twenty residents and serving as the main source of non-fishing-related income (IslandAid, 2022).

Tasso Island currently lacks several key resources, including limited electricity and no safe drinking water. Electricity and lighting are only available at the schools, mosques, and churches. Water on the island is mainly sourced from uncovered wells, which largely hold saltwater and are often contaminated. There is currently no available method, aside from boiling, to decontaminate the drinking water (IslandAid, 2022). In terms of education, only three primary schools exist on the island. Tasso Island also lacks access to broadband internet, isolating it from the rest of the world, thus impeding its overall development.

Broadband internet access is known to be a social determinant of health and has the capability to improve living standards (McCall et al., 2022). This paper details the predicted impacts of bringing broadband internet to Tasso Island. These impacts include improved education, a decrease in violence towards women and children, and the advancement of pediatric and gynecologic healthcare.Potential Negative Impacts of Internet Access on Tasso Island.

Unfortunately, Tasso Island has an increasingly high rate of child abuse and domestic abuse, including sexual violence (Island Aid, 2022). Due to the lack of secondary education, students are often sent to mainland Sierra Leone to live with distant relatives to continue their education (IslandAid). In some cases, female students become victims of abuse in these homes, which ultimately negatively impacts, or altogether stops, their education (IslandAid).

According to the African Region of the World Health Organization, children who are abused are at an increased risk for various lifelong social, physical, and mental health impacts (WHO). These impacts include depression, heart disease, cancer, unintended pregnancy, and committing or again becoming a victim of violence. These impacts on individuals ultimately accumulate and can slow the overall development of a nation (WHO). Internet access may not only improve educational opportunities and reduce the number of children having to travel to the mainland for advanced education, but it can also allow them to access domestic violence resources, which can reduce child abuse overall.

According to the United Nations, 53% of women in Sierra Leone have been a victim of domestic or sexual violence (UN Women). In 2007, Sierra Leone introduced the Domestic Violence Act, which codified protective measures against domestic abuse (UN Women). However, despite the introduction of the Act, domestic and sexual violence remain prominent issues in Sierra Leone and on Tasso Island. There are many known negative health outcomes resulting from domestic violence, including chronic pain, insomnia, various psychological impacts, and even death (Alvarado et al., 2018, UN Women). Many survivors often turn to alcohol and drugs to cope, which can have their own health consequences (Guarnotta, 2022). The internet may serve as a tool to address these issues of social violence, thus improving the health and well-being of children and women on Tasso Island.

E-Health is healthcare practice using the internet. It can also be defined as a kind of informatics interchange covering electronic and digital processes in health (International Telecommunication Union, 2008). E-Health includes electronic health records, e-prescribing, telemedicine, and healthcare information systems (World Health Organization, 2019). E-Health

in general, especially telemedicine, is a vital resource in remote regions of emerging and developing countries but is often difficult to establish because of the lack of communications infrastructure (Iluyemi, 2009). The addition of broadband internet in Tasso Island may facilitate this communication and allow for more advanced modes of conducting healthcare.

According to a study from the Journal of the Royal Society of Medicine, surveys consistently show that 60–80% of internet users have utilized the internet to find health information (Powell et al., 2003). The internet is useful for people who are suffering from illness to retrieve quick information and make better health decisions (Ziebland & Wyke, 2012). For medical providers, the internet also provides easier access to up-to-date health information as well as new research (Bujnowska-Fedak, 2019). The Internet can be used on Tasso Island to provide information for the public to prevent illness and live healthier lives and provide professionals updates on diseases.

The internet can also be considered as a tool for delivering healthcare in clinical settings (Powell et al., 2003). Telemedicine, for example, enables patients to access qualified healthcare providers regardless of their location (Benda et al., 2020). While phone conversations are an alternative to video visits, they provide limited possibilities for interactions between patients and healthcare providers because they only allow auditory contact (Benda et al., 2020). Research showed that on-demand telemedicine based on audio and video is more cost-effective in the short-term compared to other expensive care setting alternatives (Nord et al., 2019). Also, using the internet to access and compile health records might offer a physician better information for therapeutic reasons (Benda et al., 2020).

The internet is also valuable in public health settings since public health workers are responsible for preventing and controlling disease and injury. Internet access can enable data collection and health care information delivery (National Research Council (US) Committee on Enhancing the Internet for Health Applications, 2000). For example, during the COVID-19 pandemic, many medical laboratories utilized automatic reporting to inform patients quickly of their test results (Iron Bridge, 2020).

Both clinical and public health settings can benefit from the internet and will be beneficial to Tasso Island. Patients, doctors, and the government will be able to access more medical resources, receive better treatment, and have access to better healthcare systems.

Tasso Island has an increasingly high rate of child abuse and domestic abuse, including sexual violence (Island Aid, 2022). Therefore, this paper also considers how internet access can improve pediatric and gynecological health to aid these populations.

Internet-based interventions may be particularly useful to women preparing for, during, and after pregnancy (Gold et al., 2012). The internet as an informative digital health application in gynecology is used extensively and is widely accepted by patients. Pregnancy-related health decisions are crucial and may have an impact on both the mother’s and the unborn child’s lives (Onuoha et al., 2013).

Online knowledge enables women to identify and reduce pregnancy risks, like iron deficiency and anemia. Additionally, having internet access enables pregnant women to learn about preventive health behaviors, like increasing folic acid and iron intake during pregnancy (Kohan et al., 2007). Research suggests that appropriate online health information can reduce maternal and infant mortality rates (Beigi et al., 2009).

There may also be potential benefits of the internet for finding information about sexually transmitted infections (STIs) (Rietmeijer et al., 2003). A large percentage of STI clinic patients use the internet to look for information about STIs, indicating that the internet plays a significant role in STI and HIV prevention (Rietmeijer et al., 2003). The internet can be useful with regards to testing, follow-up, and treatment adherence of STI patients. As such, patients can access clinical care more efficiently and less expensively (Valentine et al., 2022; Wilson et al., 2017).

Similarly, internet access provides opportunities to improve pediatric health. While the internet certainly opens an avenue to new forms of abuse against children such as online child sexual exploitation; it can also serve as a tool to define abuse more clearly, determine whether assistance is needed, and obtain support (Hirschtritt, 2019, Protecting Children Online, n.d.). For adolescents who are dealing with abuse, such support may come in the form of online help, which may not be available offline due to stigma and other social barriers (Pretorius, 2019). Furthermore, teenagers who are dealing with mental health issues due to abuse may access

online help through social media networks as these platforms are shown to help those with ongoing illnesses, conditions, or disabilities (Chassiakos et al., 2016).

Such examples demonstrate the importance of internet accessibility in improving the healthcare system overall. E-health has the capability to provide users with up-to-date health-related information, deliver care on an online platform, and improve both gynecological and pediatric health outcomes. Given these potential benefits, the addition of broadband internet access in Tasso Island could address issues of violence against women and children and improve pediatric and gynecological health, both of which would enhance the Island’s overall healthcare system.

RowdyOrb.it is a Baltimore-based digital startup for-profit company that believes “broadband infrastructure is an inclusive human right” (Sanders & Scanlon, 2021). It collaborates with government, businesses, non-profits, philanthropies, academia, and other funders to provide affordable connectivity to people living without the internet (RowdyOrb.it, n.d.). RowdyOrb.it started out as an online tutorial series and in November 2016, became a company focused on creating a new curriculum to train workers returning from prison (Higgins, n.d.). The training program focuses on computer data skills, coding, and quality assurance jobs. The company has since expanded, particularly in the Baltimore area (“Building an Internet Oasis in Baltimore’s Black Butterfly,” n.d.).

Investment across Baltimore’s neighborhoods is fragmented by income, race, and geography and this fragmentation does not discriminate when it comes to internet access. The dichotomy of internet access between predominantly African American neighborhoods and their non-African American counterparts perpetuates this idea of the “digital divide (“Baltimore’s Digital Divide,” n.d.).” RowdyOrb.it aims to close this “digital divide” by training young black

and brown people in the Baltimore community to install and maintain Wi-Fi networks. It also provides the South Baltimore community with free access to Wi-Fi internet (“Building an Internet Oasis in Baltimore’s Black Butterfly,” n.d.). In 2020, RowdyOrb.it headed the installation of Wi-Fi technology at New Song Academy, a school in West Baltimore, which now provides free internet access to buildings within a half-mile radius around the school (RowdyOrb.It Will Expand Free Wi-Fi Project to More Underserved Baltimore Neighborhoods, n.d.). Given RowdyOrb.it’s successes in empowering and uplifting under resourced communities in Baltimore, there is confidence that RowdyOrb.it can do the same in communities across the globe, like Tasso Island.

RowdyOrb.it gives communities ownership of internet infrastructure where data can become their own intellectual property (IP) (RowdyOrb.it, n.d.). Putting up community-owned broadband infrastructure and training residents to become community scientists who collect and leverage this data can further provide residents with the tools they need to thrive. Community members are then able to negotiate a price point to use via a data usage agreement or otherwise selling that data, promoting economic development in the community (Moore, 2020). This technology also enables the community to install Internet of Things (IoT) air quality sensors to collect air quality data (Moore, 2020). IoT air monitors allow a community to collect data about environmental factors such as temperature, humidity, pressure, pollutants, carbon monoxide, and other air quality measures, for indoor and outdoor environments (IoT Now, 2021).

According to RowdyOrb.it CEO Johnathan Moore, adding broadband/fiber to a community increases home value by 3.1% (Johnathan Moore). This focus on bringing low-income neighborhoods into the technology industry drives revenue and combats digital poverty. The revenue accumulation from selling data can be circulated back into the community through a ground-up approach, thus promoting generational wealth. Having access to health information empowers individuals to advocate for themselves, promoting RowdyOrb.it’s goal of “tackling [the] social determinants of health” (RowdyOrb.it, n.d.). RowdyOrb.it relies on community members to implement the broadband services and trains community members interested in the tech field in basic information technology, including software skills, hardware skills, how to troubleshoot issues when they arise, and routine maintenance.

The future vision of Tasso Island involves a self-reliant broadband internet system, where residents can access the internet consistently and securely at superior speeds (Hathway, 2019). This involves RowdyOrb.it training Tasso Islanders in basic information technology (IT) so they can manage the internet system, or local internet service provider (ISP), once it is installed. The goal would be to make the community as self-sufficient as possible and to build local and regional capacity, with future training opportunities.

Implementing this type of training program will not only improve local proficiency in IT but will also create jobs in the technology sector and ensure that future generations are well-versed in managing the ISP. Internet access will expand education and healthcare to different parts of the island, ensuring equitability of these resources.

As one of the first countries in Sub-Saharan Africa to be equipped with internet access, Ghana has led the way in the migration of broadband to Africa (Foster et al., 2004). Over the last thirty years, the introduction of internet and wireless technology has enabled the expansion of communication and information in Ghana (Zachary, 2004). In 2020, the percentage of internet users in Ghana was up to 58% as compared to 2010, when it was less than 10% (World Data, n.d.). The addition of internet in Ghana has allowed for research; access to databases and health information; recreation; discussion groups, and expanded educational opportunities (Quaynor et al., 1997). Additionally, it has enabled the community to learn digital literacy skills and facilitated private business sector expansion, both of which are advantages of an “information society” (Ofosu-Adarkwa, 2012).

Tele-centers, or tele-based information centers that exist on a countrywide scale, have increased throughout Ghana, and expanded jobs, improved universal access to the internet, empowered local communities, and increased national wealth (Falch et al., 2003). Tele-communication has become both a major industry in Ghana as well as a source of economic development (Quaynor et al., 1997). As the use of these services has permeated the culture in Ghana, the internet has continued to expand and so has communication through telephone networks; thus, Ghana is no longer experiencing “information poverty” (Quaynor et al., 1997; Zachary, 2004).

f certain technologies, such as automated messages about appointments and patient tracking by providers. It was determined that this technology could save around 56,906 lives, specifically maternal and child, over a period of 10 years (Willcox et al., 2019). Ghana experiences shortages of medical professionals, so the implementation of virtual medical education and telehealth has vastly improved the health of the country’s residents, as it has expanded healthcare access (Tchao et al., 2019). Some providers in Ghana have even begun using a smartphone app known as WhatsApp to stay in contact with their patients, thus benefitting the Ghanaian healthcare system (Young African Leaders Initiative, 2018).

According to a study from the World Wide Web Foundation, women in Ghana are only 6% less likely to use the internet than men, as compared to the global gender gap (21%) (World Wide Web Foundation, 2020). Broadband internet access benefits the women of Ghana because they can learn skills that can be used for educational, social, and economic empowerment online. In Ghana, specific training programs have been implemented to teach young women skills in technology (Kwame Amoh, 2022).

In 2011, a policy introduced technology, such as computers into schools in Ghana and evidence suggests that technical literacy is important, but teachers need adequate training to use these tools (Natia & Al-hassan, 2015). Information and communication technology (ICT) access at home has been shown to decrease likelihood of being educationally disadvantaged in Ghana, since it enhances a child’s ability to learn in their home (Karakara, et. al, 2019). In Ghana, learning and socializing are the most popular activities children partake in online, with 60% using the internet for studying and homework (Global Kids Online, 2017).

The government agency responsible for the regulation of communications in Ghana is the National Communications Authority (NCA), which allocates resources to create communication programs (Vitus Agbenonwossi, 2018). The Wireless Ghana Project is an example of one such program that aims to connect people despite distance, thus eliminating barriers, particularly for children (Vitus Agbenonwossi, 2018). This program, which is managed by community members and United States Peace Corp volunteers, serves as an example of what the future of Tasso Island could resemble with the addition of broadband internet. RowdyOrb.it will pave the way for this vision to come true by laying the groundwork for internet implementation, training residents, and collaborating with local organizations to maintain the internet. This work will expand services in the areas of education, economics, and healthcare on Tasso Island.

Bringing broadband internet access to Tasso Island will improve education, decrease violence towards women and children, and advance pediatric and gynecologic healthcare. However, it is important to consider possible negative impacts resulting from introducing broadband internet to the Island. According to UNICEF, 30–75% of children say they are unable to determine whether information they read online is true (UNICEF, 2019). Since the internet has significant educational benefits, it is important to teach children about misinformation online. One approach to address this issue is by equipping teachers with tools such as critical thinking bootcamps they can use to educate students on how to evaluate the validity of information on the internet (Sage Publishing, 2021).

Internet access can also unfortunately expose children to online predators, and this must be considered when introducing broadband internet to Tasso Island. The wider range of activities a child engages with on the internet, the larger the risk for contact with a predator (UNICEF, n.d.). If the abuse is inflicted in the home environment, teachers should also be equipped with the knowledge to identify signs of abuse in their students (Nworgu et al. 2019). Furthermore, teachers have access to the local government, and in conjunction with the government’s help, they can prevent and intervene in child abuse situations.

Additionally, internet access enables new forms of domestic and sexual violence (National Network to End Domestic Violence, 2017). Changing passwords, cutting off internet access, and location tracking are all ways that perpetrators can use the internet to inflict violence (Internet Safety, n.d.). The NextStep Domestic Violence Project recommends using Google Chrome and clearing browsing history to prevent abusers from monitoring internet usage (Keep Safe Online, n.d.). When implementing broadband internet access on Tasso Island, it is crucial to educate Islanders on how to protect themselves online and where to seek help if needed.

Finally, there can be negative health impacts from the introduction of broadband internet. Health misinformation is most common on Twitter, compared to other social media platforms (Suarez-Lledo & Alvarez-Galvez, 2021). Misinformation is most common in health-related categories including smoking and drug information (Suarez-Lledo & Alvarez-Galvez, 2021). Erroneous information about these topics and other health topics can misguide users and lead to adverse health outcomes for these individuals. In fact, Sierra Leone has previously experienced instances of widespread misinformation. For example, during the Ebola crisis in 2014, there was widespread misinformation regarding methods to cure Ebola (Sowa, 2022). One way to combat potential health misinformation on Tasso Island is by encouraging residents to verify health-related information with healthcare professionals, which usually involves communication via the internet (Top Ways to Fight Health Misinformation, n.d.).\

This paper emphasizes how improvements in education, social violence issues, and the healthcare system have been shown to emerge from the implementation of broadband internet access. The case study on Ghana further demonstrates the potential benefits that could arise as a result of bringing broadband internet to a community such as Tasso Island. RowdyOrb.it, which is a Baltimore-based digital for-profit company, aims to facilitate this process by laying down the groundwork for an internet system and training Tasso Island residents in basic information technology (IT). This ground-up approach centers around economic empowerment and ensures self-sufficient management of the internet by residents. The addition of broadband internet access in Tasso Island will likely allow the Island to experience economic growth with an increase in wealth that could enhance the quality of life for all residents.

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