Abstract
Digital inclusion is a multidimensional concept that refers to the ability of individuals and communities to access information and communication technologies (ICTs), to possess the skills to use them, and to participate meaningfully through these technologies in economic, social, and health-related life. Although it originates from the digital divide literature, digital inclusion focuses not only on inequality of access but also on the layers of skills, support, and meaningful use. This review aims to introduce the concept to the Turkish academic community in detail; to present its definitional dimensions, theoretical foundations, and measurement approaches; and, in particular, to set out its applied axes in the health field (healthy ageing, mental health, clinical populations and telemedicine, health literacy, access to health services, and health policy) within an integrative framework. The review draws on publications retrieved from the Web of Science Core Collection that jointly contain “digital inclusion” and health-related terms and that were judged topically relevant.
1. Introduction
The increasing migration of health services to digital channels, together with the fact that health-related information has often become accessible only in digital form, has placed a new public health problem on the agenda: digital health inequality (Gann, 2019). The most striking paradox of this transformation is that the groups least likely to be online (older adults, people with disabilities, individuals living in poverty) are at the same time the groups bearing the heaviest burden of disease (Gann, 2019; Borg et al., 2019). Consequently, when the digitalization of health systems is not supported by appropriate policies, it risks deepening existing health inequalities rather than reducing them.
Within this framework, the concept of digital inclusion has become a critical unit of analysis for both health policy and health management. The concept asks not merely whether an individual can access the internet, but whether they can use digital services in ways that protect and improve their health. The aim of this review is to systematically introduce the concept of digital inclusion—which rests largely on the international literature—to the Turkish-speaking academic reader, and to address its applied axes in the fields of health sciences and health management from an integrative perspective.
2. From the Digital Divide to Digital Inclusion: The Birth of the Concept
The concept of digital inclusion emerged as a natural extension of the “digital divide” debate that became widespread in the 1990s and 2000s. The first generation of digital divide literature focused primarily on the distinction between the “haves” and “have-nots” with respect to access to technology. However, as access became more widespread, researchers showed that the real inequality was concentrated less in access than in patterns of use, levels of skill, and the benefits obtained—that is, that second- and third-level digital divides had become decisive (Tsai et al., 2015; Yu and Liu, 2022).
This theoretical shift moved the conceptual focus from a deficit-based narrative of “digital exclusion” to a narrative of “digital inclusion” grounded in opportunity and participation. It has been shown that access alone is not transformative; as in the case of rural India, the diffusion of mobile phones can leave some disadvantaged groups comparatively even further behind (Haenssgen, 2018). Likewise, Australian household data reveal that the relationship between digital inclusion and quality of life is neither unidirectional nor automatic, but possesses a simultaneous and reciprocal structure (Ali et al., 2020).
3. Conceptual Framework and Definitional Dimensions
In the contemporary literature, digital inclusion is conceptualized as a multidimensional construct that goes beyond basic access to encompass skills, support, and meaningful participation (Almakrob et al., 2026). This multidimensional understanding considers three core layers together: (i) access to infrastructure and devices, (ii) digital skills and self-efficacy, and (iii) the ability to use technology meaningfully in pursuit of one’s own life goals. Studies conducted on older communities in Korea and Singapore show that digital skills are not a single whole; rather, they consist of distinct dimensions such as operational internet skills, information-navigation skills, social skills, creative skills, and mobile skills, and that these dimensions are associated with health outcomes in different ways (Pan et al., 2024; Htoo Pan et al., 2026).
It is also emphasized that digital inclusion is not merely a question of technical capacity but is at the same time a power relationship. The process by which community health workers in rural India adopted an mHealth application demonstrates that digital inclusion simultaneously contains both empowering and subjugating dimensions (empowerment and subjugation) (Pandey and Zheng, 2023). For this reason, the concept must be read not solely through access indicators but through the user’s experience, autonomy, and relationship with the institutional context.
4. Theoretical Approaches
The digital inclusion literature draws on numerous theoretical traditions. Service- and capability-based approaches treat digital inclusion as an opportunity that expands an individual’s functional capabilities. The life course perspective, in turn, argues that—particularly among rural older adults—the motivation, trajectory, and barriers related to digital inclusion are shaped not only by current circumstances but by the advantages and disadvantages accumulated over the individual’s life (Zhang and He, 2022). By pointing to the distal roots of inequalities, this approach overlaps directly with the health-inequality literature.
Critical and social theories also enrich the concept. Foucault’s analysis of subjectivity and power renders visible the implicit power dynamics within digital inclusion processes (Pandey and Zheng, 2023). Studies in the Brazilian context draw on Habermas’s theory of communicative action and Paulo Freire’s liberating pedagogy to position digital inclusion as a practice of social participation and citizenship (Sales Paixao et al., 2011). From the perspective of health services management, Donabedian’s Structure–Process–Outcome framework provides an analytical scaffold that links digital maturity (structure) and information literacy/inclusion (process) to patient satisfaction (outcome) (Geada and Alturas, 2026).
5. Why Health? Digital Health Inequality
While the digitalization of health communication turns ICTs into a powerful instrument for improving health, it carries the potential to widen inequalities for vulnerable groups unable to benefit from digital opportunities (Borg et al., 2019). The case of Wales demonstrates that digital inclusion must be conceptualized directly as a public health issue (Gann, 2019). The COVID-19 pandemic sharpened this tension; with the restriction of face-to-face services, access to remotely delivered health services became a new barrier for digitally excluded groups (Oliver et al., 2024; Chadwick et al., 2022).
Overcoming this inequality requires more than merely providing technology; interventions that explicitly target digital inclusion are needed. A pilot randomized controlled trial conducted in the context of the United Kingdom’s National Health System revealed that a digital inclusion intervention designed to improve access of digitally excluded adults to a digital health intervention was both feasible and acceptable (Walklin et al., 2026). A study examining the transition from digital inclusion to digital transformation in the prevention of drug-related deaths in Scotland likewise shows that digital inclusion can be a concrete policy lever in harm-reduction services (Daneshvar et al., 2024).
6. Measurement and Evaluation
The maturation of the concept has required the development of valid and reliable measurement instruments. The Digital Inclusion Questionnaire (DIQUEST), developed to assess suitability for telemedicine in clinical populations, is an original example that has been psychometrically tested to measure access and skills in Parkinson’s patients (Canoro et al., 2024). In community-based older samples, the LSE digital skills measurement instrument has been used to quantify the relationship between five skill dimensions and health behaviors (Pan et al., 2024; Htoo Pan et al., 2026).
Measurement approaches are not limited to the individual level. A structural equation model based on the Donabedian framework tested the effect of digital maturity and digital inclusion/literacy on patient satisfaction (Geada and Alturas, 2026); the “Ideias” model developed in Brazil integrated the axes of skills, knowledge, and attitudes to evaluate the digital inclusion and health-focused information literacy of community health workers (Cuevas-Cervero and Garcia-Moreno, 2010). A mixed-methods study analyzing discourse on Twitter through machine learning likewise exemplifies how new data sources can be used to measure the social perception of the concept (Salzmann-Erikson, 2023).
7. Older Adults and Healthy Ageing
The axis on which the literature is most concentrated is the relationship between digital inclusion and healthy ageing among older individuals. With the ageing of the population, digital inclusion is positioned as a healthy-ageing tool aligned with the World Health Organization’s Global Strategy on Ageing and Health and with the Sustainable Development Goals (Xu et al., 2021; Ani and Batisai, 2024). In the case of Nanjing in China, digital inclusion has been shown to predict quality of life (Yang et al., 2022); and among older adults living alone, it has been shown to improve physical and mental health (Yan and Xing, 2025).
Recent studies on the direction of this relationship reveal a reciprocal (bidirectional) bond between digital inclusion and healthy ageing. A four-wave cross-lagged study in China demonstrated that the two phenomena feed one another over time (Yang et al., 2026); a multi-wave cohort study conducted in Japan found that digital inclusion plays a buffering role in the vicious cycle between social isolation and functional disability (Cui et al., 2025). The pathways by which older adults arrive at digital inclusion have also been modeled using a grounded theory approach in hospital outpatient settings (Chen et al., 2025).
Nursing and care perspectives come to the fore along this axis. A qualitative study examining smartphone use and the willingness to acquire digital skills among Chinese older adults argues that nursing can be an effective actor in closing the digital divide (Ma et al., 2022). Older adults’ proactive health behaviors (Lu et al., 2025), subjective well-being (Hu et al., 2025; Yi and Jia, 2025), internet-use profiles (Diniz et al., 2020), and the paradoxical outcomes of digital participation such as identity reconstruction and digital addiction (Chen et al., 2026) have also been studied intensively. A comparison of Germany, Japan, and Thailand reveals the decisive role of socio-cultural and infrastructural context in closing the “gray digital divide” (Chen and Phanumartwiwath, 2025).
8. Mental Health
In the field of mental health, digital inclusion is examined as both a condition of access and a protective factor. The fact that individuals with mental health problems are more prone to digital exclusion makes it more difficult for them to benefit from digital mental health services, and this in turn renders holistic digital inclusion initiatives essential (Petrou et al., 2023; Oliver et al., 2024). In China, digital inclusion has been shown to reduce depression among older adults through a mechanism mediated by noncognitive abilities (Li et al., 2025), while cognitive function plays a critical moderating role in this relationship (Xiao and Nie, 2025). In Vietnam, digital inclusion was found to mediate the effect of living arrangements on late-life depression (Vu and Pothisiri, 2026).
In the context of the pandemic, digital inclusion functioned as a mediating variable in the effect of resilience, social support, and academic self-efficacy on the mental health of Peruvian university students (Cassaretto et al., 2024). The concept’s relationship with mental health was also raised in early conceptual discussions (Francisco, 2009).
9. Clinical Populations and Telemedicine
Digital inclusion is a decisive precondition for the transition of telemedicine into clinical practice. In rural cancer survivorship, limitations in broadband access weaken the potential of telemedicine to improve access to care and turn digital inclusion into a driver of inequity (DeGuzman et al., 2020). In Parkinson’s patients, the level of digital inclusion has been compared with healthy individuals using a case-control design, and socio-demographic factors together with disease characteristics were shown to shape exclusion (Canoro et al., 2025; Canoro et al., 2024). In advanced dementia, the feasibility of a wearable actigraphy application has been evaluated within the context of digital inclusion (Guu et al., 2024).
Hospital-based and system-level examples are also available. In the Scottish national pulmonary hypertension population, levels of digital inclusion have been mapped according to deprivation deciles (Ingram et al., 2025); in North-West London, lessons regarding digital inclusion have been drawn from the implementation of a COVID virtual ward (Fox et al., 2022). In Saudi Arabia, the relationship between telemedicine use and digital inclusion among people with disabilities has been examined together with post-pandemic policy implications (Albasheer et al., 2026). User-centered and inclusive design approaches stand out in the inclusion of older adults in e-health services (Revenas et al., 2025).
10. Cognitive Function and Intervention Studies
Digital inclusion is tested not only as an access target but also as an intervention component. Randomized controlled pilot studies conducted in Brazil show that programs of cognitive stimulation, physical activity, and social interaction delivered together with digital inclusion can improve markers of neuroplasticity and cognitive status in older individuals (Quialheiro et al., 2022; Bonilha et al., 2024). These findings indicate that digital inclusion can be designed as a complementary element of health-promoting interventions.
11. Health Literacy, Access to Information, and Patient-Centered Care
Digital inclusion is closely related to the concepts of health literacy and patient-centered care. Among older adults, digital inclusion has been shown to support health literacy (Polonski et al., 2022); in the context of adolescent health, weaknesses in digital inclusion have been shown to limit access to health information (Cavalcante et al., 2017). In the U.S. context, readiness for patient-centered care has been linked to capacities for access to health information and for coordination/communication—and hence to “health digital inclusion” (Sun et al., 2013). During the Affordable Care Act (ACA) period, the digital inclusion function of public libraries was decisive for citizens’ enrollment in health insurance (Real et al., 2015). The information-management dimension of the concept has also been discussed through the DATASUS example in Brazil, by way of the contribution of health data management to digital inclusion (Prudencio and Ferreira, 2020).
12. Actors, Equity, and Health Policy
The realization of digital inclusion is a multi-actor process. Nurses, as frontline workers, often undertake an invisible labor of digital support; this labor creates gray areas with respect to professional ethics and role boundaries (Moe and Skaarup, 2026; Ma et al., 2022). In the Brazilian examples, health counselors and health councils occupy a central position in reducing social inequalities and strengthening social control through digital inclusion (Sozzi de Moraes et al., 2009; Fernandes et al., 2017; Sales Paixao et al., 2011).
Equity-based and participatory approaches are gaining increasing importance. Data-driven, stakeholder-centered participatory interventions can improve health equity and digital inclusion together while avoiding the pitfalls of top-down technocratic methods (Fotopoulou et al., 2023). In Nigeria, public-private partnerships have been evaluated as a way of promoting digital inclusion among older adults (Ani and Batisai, 2024); in Saudi Arabia, national policy frameworks for neurodiverse and vulnerable communities have been analyzed (Almakrob et al., 2026). The barriers to digital inclusion among older adults with visual impairment (Soderberg et al., 2026), individuals with intellectual disabilities (Murphy et al., 2022; Chadwick et al., 2022), and women in vulnerable regions (Valencia et al., 2024) point to the intersectional vulnerabilities that policy must target.
13. Implications and a Research Agenda for the Turkish Academic Community
The literature reviewed shows that the concept has developed strongly along the axes of old age, healthy ageing, and health inequality, and that it is geographically concentrated in contexts such as China, Brazil, England, and Scotland (Yang et al., 2022; Zhang and He, 2022; Gann, 2019; Daneshvar et al., 2024). Despite the existence of examples such as Lithuania (Tretjakova and Rapoliene, 2025), Colombia (Valencia et al., 2024), and Peru (Galan-Rodas et al., 2025), the marked scarcity of studies specific to the Turkish context creates an important field of opportunity for the Turkish academic community.
The salient items of a research agenda for Türkiye may be listed as follows:
- The development and psychometric testing of a valid, multidimensional (access–skills–meaningful use) digital inclusion measurement instrument specific to Türkiye and linked to health outcomes.
- The evaluation of the equity effects of digital health infrastructures such as e-Nabız, the Central Physician Appointment System (MHRS), and city hospitals, from the standpoint of digital inclusion.
- The design of digital inclusion interventions that account for the intersectional vulnerabilities of older adults, people with disabilities, rural populations, and low-income groups, and their testing with randomized/quasi-experimental designs.
- The documentation, in the Turkish context, of the invisible digital support labor undertaken by nurses and primary care workers, and the examination of its workload and ethical dimensions.
- The testing, through structural models, of the relationships among digital maturity, digital inclusion, and patient satisfaction/health outcomes on the basis of the Donabedian framework.
14. Conclusion
In an era in which health services are becoming digitalized, digital inclusion has become a defining component of health equity. The concept has moved beyond the access-focused digital divide narrative to evolve into a multidimensional framework encompassing skills, support, and meaningful participation (Almakrob et al., 2026); it has produced a rich applied literature in the fields of old age, mental health, clinical populations, health literacy, and health policy. For the Turkish academic community, the concept offers both a strong theoretical foundation and a largely unexplored field of empirical research. From a health management perspective, the design of measurable and implementable interventions that explicitly target digital inclusion is of critical importance for fulfilling the promise that digitalization will reduce health inequalities.
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