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<div id="article">
<h2 id="article_title">
Decreasing Health Disparities through Technology:
Building a Community Health Website
</h2>
<div id="article_author">
Olga Idriss Davis, Kristen Bean, Dominica McBride
</div>
<h3 class="article_subhead">
Introduction
</h3>
<p>
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 <sup>1</sup> and/or the health care
system <sup>2</sup> . Health disparities are defined as
the inequitable differences in the quality of health care
treatment and overall health status <sup>3</sup>. Myriad
variables exist in the path that leads to these health
differences, including differences in availability,
accessibility, and/or quality of health care <sup>4</sup>
, disparities in health literacy and/or health education
<sup>5-6</sup> , and lack of cultural competence in
health systems <sup>7-8</sup> . Knowledge on health and
behaviors that impact health have been shown to change
people's ideas and behaviors <sup>9-10</sup> , thus
enhancing their health status.
</p>
<p>
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 <sup>11</sup> . 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 <sup>12-13</sup> or
a significant proportion of the target population does
not have access to the Internet <sup>14-15</sup> . 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.
</p>
<h3 class="article_subhead">
Educating Community on Health Disparities
</h3><em>Health Disparities</em>
<p>
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
<sup>16</sup> . In contrast, Caucasians constitute
approximately 74% of the US population, but only 30% of
HIV/AIDS cases <sup>17</sup> . While making up 14% of the
total population in the US, Hispanics represent 18% of
HIV/AIDS cases nationwide <sup>18</sup> . In 2005, the
prevalence rate of Hispanics was three times that of
Whites <sup>19</sup> . 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 <sup>20</sup> .
</p>
<p>
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 <sup>21-22</sup> . However, discrimination in
the quality of treatment persists in research where
factors of income and education are controlled for
<sup>23</sup> . The Agency for Healthcare and Research
Quality <sup>24</sup> 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.
</p>
<p>
The relationship between healthcare professionals and
each ethnic minority group falters in adequacy
<sup>24</sup> . 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 <sup>25</sup> .
</p><em>Access and the Internet</em>
<p>
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
<sup>26</sup> . For instance, Bach, Pham, Schrag, Tate,
& Hargraves <sup>27</sup> 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 <sup>28</sup> 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.
</p>
<p>
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
<sup>29-30</sup> . Gaining health information has been
shown to help people change health-related behaviors
<sup>31</sup> and has sparked informed questions and
dialogue between health providers and patients
<sup>32</sup> . 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 <sup>33-34</sup> . A broader and
equal distribution of health information will help in the
elimination of today's stark health disparities.
</p>
<p>
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
<sup>35</sup> . Health information on the Internet offers
health seekers myriad opportunities, including changing
health-related behaviors <sup>36</sup> , caring for
themselves, caring for their families, and strengthening
the doctor-patient relationship <sup>37</sup> . Health
information received through media has served as an
ancillary tool in helping the public to make better,
informed health-related decisions <sup>38-39</sup> . The
Internet has the potential to play a pivotal role in
decreasing health disparities <sup>40</sup> , if done in
a way that is culturally responsive, respectful, and
competent <sup>41</sup> . Cotton and Gupta <sup>42</sup>
reinforce this sentiment:
</p>
<blockquote>
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).
</blockquote>
<p>
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 <sup>43</sup> , is visually overwhelming
(e.g. too many active graphics <sup>44</sup> ), and/or
they do not adequately reflect cultural
competence/sensitivity <sup>45</sup> or present the
pressing issues facing specific ethnic groups
<sup>46</sup> . 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 <sup>46</sup> , another
reported that Spanish-speaking participants were more
likely to prefer talking with a person than using a
computer <sup>47</sup> .
</p>
<p>
Access to and use of the Internet in searching for health
information is yet another example of unjust disparities.
Cotton and Gupta <sup>48</sup> 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 <sup>49</sup> 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 <sup>50</sup> . Gilmore
<sup>51</sup> 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.
</p>
<h3 class="article_subhead">
Culture-Centered Approach to Building a Community Health
Website
</h3>
<p>
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:
</p>
<ul>
<li>1. To educate the local ethnic minority communities
(including Hispanics, African Americans, Native
Americans, and Asian Americans/Pacific Islanders), both
community members and health professionals, on
health-related facts about HIV/AIDS, mental health, and
substance usage and related health disparities.
</li>
<li>2. To disseminate information on local and national
resources for each specified area (i.e. HIV/AIDS, mental
health, and substance usage).
</li>
<li>3. To highlight cultural strengths to be used in
overcoming health disparities.
</li>
<li>4. To provide a way for community members to ask
questions and provide comments in regards to each topic
area and connected resources.
</li>
</ul>
<p>
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.
</p><em>Readability</em>
<p>
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 <sup>52</sup> advises those constructing health
websites to write content at an 8 <sup>th</sup> grade
reading level. Zarcadoolas, Blanco, and Boyer
<sup>53</sup> conducted a study with low literacy adults
and their navigation of the Internet. They found that the
average website is written at a 10 <sup>th</sup> grade
level whereas the average reading level for their sample
was between 5 <sup>th</sup> and 7 <sup>th</sup> grades.
Due to our target population, which consisted of
marginalized and underserved groups, our target reading
level was between the 3 <sup>rd</sup> and 4 <sup>th</sup>
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.
</p><em>Visual Simplicity</em>
<p>
The complexity and over-activity of graphics and visual
stimuli can serve as a distracting and aversive agent
<sup>54</sup> . 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 <sup>55</sup> . 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.
</p><em>Cultural Competence and Representation</em>
<p>
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
<sup>56</sup> . 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 <em>they</em> needed.
</p>
<p>
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.
</p><em>Language</em>
<p>
Language is a major obstacle in disseminating health
information via the Internet to non-English speaking
groups in the United States <sup>57-58</sup> .
Non-English speaking individuals are one of the groups
most affected by the digital divide <sup>59</sup> . 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.
</p>
<p>
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.
</p><em>Internet Accessibility</em>
<p>
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
<sup>60</sup> . 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.
</p>
<p>
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.
</p>
<h3 class="article_subhead">
Discussion
</h3>
<p>
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 <sup>61, 62</sup> . Airhihenbuwa <sup>63</sup>
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:
</p>
<blockquote>
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
praxis<sup>64</sup>. (Airhihenbuwa)
</blockquote>
<p>
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 <sup>65</sup> . 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.
</p>
<h3 class="article_subhead">
References
</h3>
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King, R. & Betancourt, J. R. (2011). Bridging the
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information technology in addressing racial and ethnic
disparities. <cite>Joint Commission Journal of Quality
and Patient Safety, 37</cite> (10), 437-445.
</div>
<div class="reference">
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Characteristics of online and offline health information
seekers and factors that discriminate between them.
<cite>Social Science & Medicine, 59,</cite>
1795-1806.
</div>
<div class="reference">
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(2006). <cite>National Health Disparities Report</cite>
Retrieved July 28, 2008 from <a href=
"http://www.ahrq.gov/qual/nhdr06/report/">http://www.ahrq.gov/qual/nhdr06/report/</a>
</div>
<div class="reference">
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(2006). <cite>National Health Disparities Report</cite>
Retrieved July 28, 2008 from <a href=
"http://www.ahrq.gov/qual/nhdr06/report/">http://www.ahrq.gov/qual/nhdr06/report/</a>
</div>
<div class="reference">
<sup>25</sup> Agency for Health care and Research Quality
(2006). <cite>National Health Disparities Report</cite>
Retrieved July 28, 2008 from <a href=
"http://www.ahrq.gov/qual/nhdr06/report/">http://www.ahrq.gov/qual/nhdr06/report/</a>
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