Decreasing Health Disparities through Technology: Building a Community Health Website

Olga Idriss Davis, Kristen Bean, Dominica McBride

Introduction

The existence of health disparities is one of the greatest problems facing equality of United States citizens. While the nation is built on the ideal that "all men are created equal", there are inequities in the healthcare treatment of individuals. Unjust differences exist in both the experience and treatment of diverse populations including race, ethnic, and class differentials. One such injustice is the stark difference in health status and outcomes for certain ethnic and/or socioeconomic groups, often resulting from treatment by greater society 1 and/or the health care system 2 . Health disparities are defined as the inequitable differences in the quality of health care treatment and overall health status 3. Myriad variables exist in the path that leads to these health differences, including differences in availability, accessibility, and/or quality of health care 4 , disparities in health literacy and/or health education 5-6 , and lack of cultural competence in health systems 7-8 . Knowledge on health and behaviors that impact health have been shown to change people's ideas and behaviors 9-10 , thus enhancing their health status.

In this new age where technology is used to build communication and relationships, heal the sick, and teach worldwide, the Internet is being utilized as a means of overcoming health inequalities 11 . There are a variety of websites that disseminate health information; however, oftentimes the material is written in a language (be it scholarly or foreign) that many of the intended users do not understand 12-13 or a significant proportion of the target population does not have access to the Internet 14-15 . Thus, those who are in most need of health education are the ones just out of reach of this knowledge. The purpose of this paper is to describe a process of health literacy and education through community engagement and outreach to address health disparities in the areas of HIV/AIDS, substance abuse, and mental health. Building a community health information website as a health intervention is designed to alleviate the limitations of access and understandability.

Educating Community on Health Disparities

Health Disparities

Health disparities are most often discussed in regards to race and ethnicity and covers both physical and mental disorders ranging from diabetes to substance abuse. One of the most striking health disparities in the US is the case of HIV/AIDS. Although African Americans make up 13% of the US population, they make up 49% of HIV/AIDS cases 16 . In contrast, Caucasians constitute approximately 74% of the US population, but only 30% of HIV/AIDS cases 17 . While making up 14% of the total population in the US, Hispanics represent 18% of HIV/AIDS cases nationwide 18 . In 2005, the prevalence rate of Hispanics was three times that of Whites 19 . Similar examples exist among Native Americans and Asian Americans/Pacific Islanders with other disorders including diabetes, cardiovascular disease, various types of cancers, and substance abuse and dependence 20 .

Researchers who study health disparities also find that many of these differences by race are accounted for by income and education as it relates to the prevalence of illnesses 21-22 . However, discrimination in the quality of treatment persists in research where factors of income and education are controlled for 23 . The Agency for Healthcare and Research Quality 24 describes several areas where African Americans, Hispanics, Native Americans, and Asian Americans/Pacific Islanders do not receive the quality of care of their White counterparts. African Americans report more postoperative care complications than Caucasians. Appropriate and timely post-surgery antibiotics were given at a lesser rate to African Americans, Hispanics, and Native Americans when compared to Anglos. Deaths following complications of care were significantly higher among Asians than other ethnic groups. Hospitalized African Americans taking insulin or oral hypoglycemics were significantly more likely to experience negative side effects from the drugs than their White peers. In regards to obtaining the proper care in a desired period of time, African Americans and Hispanics were less likely to be seen by a health care professional in a timely manner compared with Caucasians.

The relationship between healthcare professionals and each ethnic minority group falters in adequacy 24 . The patient-provider relationship is vital in patients' understanding and implementation of the health education they receive. This relationship between African Americans, Hispanics, Asian Americans/Pacific Islanders, and Native Americans and their healthcare professionals was weaker than that of their White counterparts. More often, African Americans, Asian American/Pacific Islanders and Hispanics reported they were not listened to carefully, were given improper explanations, or perceived a lack of disrespect more often than Whites. When compared to their White peers in income and education, disparity endured on all levels for Hispanics, on middle and high income levels for Asians, and on the poor and near poor income levels and all levels of education for African Americans. Underrepresented populations reported sometimes or never having good communication with health care professionals more often than their White counterparts. Effective communication, or the lack thereof, is vital in the relationship between provider and patient and can impact the patient health status and outcomes, often exacerbating health disparities 25 .

Access and the Internet

Unequal access to information, prevention and health care is a significant determinant of health differences. A disproportionate number of African Americans, Hispanics, and Native Americans live at or below the poverty line. Both variables of socioeconomic status and ethnicity have been shown to correlate with access to healthcare 26 . For instance, Bach, Pham, Schrag, Tate, & Hargraves 27 found that, when examining differences in physician characteristics and access to high quality healthcare, there were significant discrepancies. African Americans had less access to high quality healthcare, specialty medical services, and other clinical resources than Whites. Zuckerman, Haley, Roubideaux, & Lillie-Blanton 28 found that the rate of uninsured Native Americans was three times that of Whites, which has a direct impact on their access to healthcare. More Native Americans reported a low level of confidence in healthcare than Whites. They also found that Native Americans were less likely to use healthcare services including prevention.

The propensity for ethnic and racial minorities, especially in lower income levels, to have less access to healthcare in general is also underscored by the notion that they have less access to health information 29-30 . Gaining health information has been shown to help people change health-related behaviors 31 and has sparked informed questions and dialogue between health providers and patients 32 . Without health information, many go on living their lives in a way that is potentially harmful to their bodies (e.g. consuming unhealthy foods, engaging in unprotected sex). Attaining and understanding this knowledge is integral in the process of making informed and healthier decisions 33-34 . A broader and equal distribution of health information will help in the elimination of today's stark health disparities.

With the advent of the Internet, millions who may not have had access to this information now have it at the press of a button. The Internet has been a critical space used to disseminate this education to the masses 35 . Health information on the Internet offers health seekers myriad opportunities, including changing health-related behaviors 36 , caring for themselves, caring for their families, and strengthening the doctor-patient relationship 37 . Health information received through media has served as an ancillary tool in helping the public to make better, informed health-related decisions 38-39 . The Internet has the potential to play a pivotal role in decreasing health disparities 40 , if done in a way that is culturally responsive, respectful, and competent 41 . Cotton and Gupta 42 reinforce this sentiment:

Using the Internet for health information seeking can help to disseminate health information to marginalized groups and to empower health care consumers more generally. Determining ways to increase Internet usage among less educated and lower income groups may be one way to decrease inequalities associated with health care provision and decision-making (p. 10).

Extant in cyber space, the myriad health websites serve to inform the public. Oftentimes, however, these sites are written at a reading level that is above many who need this information, in a different language, in a disorganized way 43 , is visually overwhelming (e.g. too many active graphics 44 ), and/or they do not adequately reflect cultural competence/sensitivity 45 or present the pressing issues facing specific ethnic groups 46 . These aspects, along with low income levels and/or limited access to computers, leave many of those in need of health education outside this information loop. Bilingual health websites that have targeted participants with low-literacy levels have experienced varying effectiveness. While one study reported success in utilizing a website to inform bilingual people about health 46 , another reported that Spanish-speaking participants were more likely to prefer talking with a person than using a computer 47 .

Access to and use of the Internet in searching for health information is yet another example of unjust disparities. Cotton and Gupta 48 contend that "...indeed, larger societal inequalities discriminate between whether or not individuals utilize online or offline venues for health information." They found that lower income African Americans are especially affected by the digital divide, which is the inequality of Internet access. The Pew Internet and American Life Project 49 found that 14% more Whites than Blacks have Internet access due to income inequalities. There are indications that the digital divide between African Americans, Hispanics, and Whites is increasing, which calls for stronger proactive amelioration to this problem 50 . Gilmore 51 suggests improving Internet accessibility and use by all populations by improving the readability and cultural acceptability of health websites and providing free Internet services at strategically placed sites.

Culture-Centered Approach to Building a Community Health Website

In ascertaining the multitude of disparities and barriers in both areas of health and the Internet, we have taken steps in using a combined effort to address health disparities in health sites and Internet access. The Southwest Interdisciplinary Research Center (SIRC) Community Health Website launched from Phoenix, Arizona, is designed to promote health literacy and increase understanding of needs in underserved populations of the Southwest. The vision for a community health website is to be proactive, taking one step towards eliminating inequalities in health for ethnic minority communities. The purpose of our website is fourfold:

In creating the SIRC Community Health Website, we considered major problems conveyed in previous research: a) Readability, b) Visual simplicity, c) Cultural competence and representation, d) Language and e) Internet Accessibility, using various methods to address each problem. The following is a description of the process of developing the Community Health Website.

Readability

The reading level of those who are suffering most from health disparities is quite often below the average reading level due to a lesser degree of education. Gilmore 52 advises those constructing health websites to write content at an 8 th grade reading level. Zarcadoolas, Blanco, and Boyer 53 conducted a study with low literacy adults and their navigation of the Internet. They found that the average website is written at a 10 th grade level whereas the average reading level for their sample was between 5 th and 7 th grades. Due to our target population, which consisted of marginalized and underserved groups, our target reading level was between the 3 rd and 4 th grades. The content was originally written in narrative form, including information on health disparities for each community, both locally and nationally, descriptions of local resources (e.g. HIV testing services, behavioral health counseling, substance abuse treatment) contact information, and definitions, including health disparities, cultural resilience, HIV/AIDS, mental health, and substance abuse. When the initial writing was completed, a reading specialist edited the content to a third-to-fourth grade level, changing long sentences to short statements, changing erudite wording or bombastic language to simple words and phrases, and bulleting key information points.

Visual Simplicity

The complexity and over-activity of graphics and visual stimuli can serve as a distracting and aversive agent 54 . Those who have little contact or familiarity with the Internet can be overwhelmed by an abundance of visuals and active graphics. This can also cause disorganization in websites and lead to unfamiliar users leaving the site or avoiding use of the Internet altogether 55 . We have considered this in our site construction and minimized the amount of active graphics, used still pictures and symbols, including large buttons and pictures (e.g. HIV/AIDS, Latino/as), and included both buttons and pictures that coincide and lead to the same destination for those who may be illiterate. Along with these organizational strategies, we coordinated the colors of the central topic area boxes (i.e. HIV/AIDS, mental health, and substance usage) and the connecting site pages. The aim of these procedures was to create visual simplicity, organization, and uniformity. During testing of the website design, community members and professionals advocated for the simplistic design; however, also requested was the use of pictures to describe facts instead of text. The website was adapted slightly to a larger quantity of pictures to explain information without overcrowding each page with too many visuals.

Cultural Competence and Representation

A lack of cultural competence, sensitivity, and representation can serve as a hindrance in Internet engagement for ethnic minorities. Relatively little attention has been paid to ethnic-specific or minority-relevant health information in the media 56 . Brodie, Flourney, Hoff et al. conducted a study on African Americans', Latino/as' and Whites' perceptions of health and the media. They found that African Americans and Latinos reported that the media failed to give proper coverage of their health-related concerns and they were not receiving the health related information they needed.

To address this problem, we purposefully targeted African Americans, Latino/as, Native Americans, and Asian Americans/Pacific Islanders. Each ethnic group is not only represented in pictorial form but also in information on relevant health disparities, cultural assets, and cultural history. From the very first encounter with this website, the onlookers should be made aware of this focus. On the home page, we present pictures of each group, directly state our specified focus on health disparities as it relates to each group, and display links to internal pages that are specific for each ethnic group. In these group-specific pages, we list external links to sites that delve into cultural history, strengths, resources, and media. Further, we provide the definition of cultural resilience, highlighting our belief in the potential of the incorporation of cultural assets contributing to the decline of health disparities.

Language

Language is a major obstacle in disseminating health information via the Internet to non-English speaking groups in the United States 57-58 . Non-English speaking individuals are one of the groups most affected by the digital divide 59 . In order to address this problem, content was translated into Spanish and will include both Native American and Asian American/Pacific Islander languages later in the site development.

There are various strategies in translation. The ease of translation programs makes them attractive; however, there are many inaccuracies in the translations. Due to this predicament, we decided to have two Spanish-speaking professionals translate the completed content. One translated from English to Spanish and the other performed a back translation to ensure accuracy. Key stakeholders from the community who represented organizations that serve communities affected by health disparities were consulted on the language translation. Small changes were made to the translations to adapt the language for simpler and greater readability of the website for users who have low literacy levels.

Internet Accessibility

The accessibility of the Internet is the greatest barrier in confronting health disparities from a culture-centered approach. Many of those who are negatively affected by the digital divide do not have access to the Internet 60 . Providing access is the first step in overcoming the digital divide. With community partnerships as a potential intervention to alleviate the barrier, we have begun to collaborate with community agencies and local health service centers. Community agencies who service disadvantaged communities (i.e. ethnic and socioeconomic minorities) are hosting electronic kiosks in their lobbies. The space of the community site provides those who would not normally access the Internet, and especially a health website, with an opportunity to interact with this information. Personnel at each community site were trained on the design of the website and its content, and in how to guide clients in their navigation of the site. Further, our community partners who have computers at their agency also host the website as their Internet homepage, providing additional opportunities for access.

By editing the readability level, offering translated material, and providing computer access, we have been able to comprehensively address the problem of information access. However, there are many problems that are still outside of the bounds of these solutions. The usability of the website will continue to be assessed in the community agencies. The community partners will be consulted continually for improvements on the website. Further outreach, health education, marketing, and motivation are needed to truly overcome the digital divide in health disparities.

Discussion

A culture-centered approach to health disparities research frames the theoretical perspective of this project. Shared systems of belief, values, rituals, language, and various other aspects reflect the dynamics of the shifting cultural landscape and create the climate for multicultural health education and communication efforts 61, 62 . Airhihenbuwa 63 posits that health is a cultural construct and health theory and practice must be rooted in cultural codes and meanings, inherently tied to values. Situating culture and context at the core of public health communication practices underscores the intersections of culture, community, and health:

It has become common practice in the field of public health and in the social and behavioral sciences to pay lip service to the importance of culture in the study and understanding of health behaviors, but culture has yet to be inscribed at the root of health promotion and disease prevention programs, at least in the manner that legitimates its centrality in public health praxis64. (Airhihenbuwa)

Building a Community Health Website includes consciousness of health literacy, health communication and language effectiveness. It is not simply message repetition, but includes recognition and respect for culture and cultural difference, community engagement and empowerment of communities, and the development of an environment for community involvement to espouse common values of humankind. The use of community health websites is a potential way to decrease health disparities. The use of social networking and other Web 2.0 technologies among minority populations has created additional technological opportunities to engage minority groups in health-related issues 65 . With effective communication and health education in underserved communities, worldwide health knowledge and access to health care can become a reality in the 21st century, embodying health as a central tenet of human life.

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