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Health disparities are a persistent problem worldwide. A major obstacle to reducing health disparities is reliance on “consumable interventions,” that is, interventions that, once used, cannot be used again. To reduce health disparities, interventions are required that can be used again and again without losing their therapeutic power, that can reach people even if local health care systems do not provide them with needed health care, and that can be shared globally without taking resources away from the populations where the interventions were developed.
This paper presents the argument that automated self-help evidence-based Internet interventions meet the above criteria and can contribute to the reduction of health disparities worldwide. Proof-of-concept studies show that evidence-based Internet interventions can reach hundreds of thousands of people worldwide and could be used in public sector settings to augment existing offerings and provide services not currently available (such as prevention interventions). This paper presents a framework for systematically filling in a matrix composed of columns representing common health problems and rows representing languages.
To bring the benefits of evidence-based Internet interventions to the underserved, public sector clinics should establish eHealth resource centers, through which patients could be screened online for common disorders and provided with evidence-based Internet intervention services not currently available at the clinics. These resources should be available in the patients’ languages, in formats that do not require literacy, and that can be accessed with mobile devices. Such evidence-based Internet interventions should then be shared with public sector clinics as well as individuals anywhere in the world.
Finally, this paper addresses sustainability and describes a continuum of evidence-based Internet interventions to share nationally and across the world. This approach to expanding health service delivery will significantly contribute to a reduction of health disparities worldwide, adding to the often-quoted slogan, “Think globally, act locally,” a third line: “Share globally.”
The author’s commitment to using the Internet to help reduce disparities worldwide stems in part from his personal background. He grew up in a small community named Chosica, 40 kilometers east of Lima, Peru. When he was ten, his mother (Clara Luz Valdivia de Muñoz) informed him that the family was going to immigrate to the United States of America. His father (Luis Alberto Muñoz Camino) had a primary school education, his mother had completed high school, and they now wanted their children to attend university. Not being able to afford such in Peru, they were seeking the educational and economic opportunities available in the United States. The plan, his mother said, was for them to return to Peru after obtaining a university education and share their knowledge with the people in Peru. As is often the case with immigrants, they did not return to live in their country of origin. But the mission she instilled in the author of sharing knowledge with as many people as possible remains an essential part of his motivation as a professional.
There are thousands of communities like Chosica throughout the world. The Internet provides an efficient conduit to convey to such communities the most effective preventive and treatment behavioral interventions in the form of evidence-based Internet interventions [
Described below are 5 types of Internet interventions. The least costly to sustain are automated self-help Internet interventions (without additional guidance by online, phone, or in-person providers). The author’s experience conducting randomized controlled trials of such interventions with individuals from anywhere in the world has provided proof of concept regarding the effectiveness of such interventions for smoking cessation. This paper builds upon this experience and asks the reader to imagine how the use of evidence-based Internet interventions for this and other health problems could contribute to the reduction of one aspect of health disparities, namely, having inadequate or no access to evidence-based interventions.
There are over 1.1 billion smokers [
To reduce health disparities, we need interventions that can be used again and again without losing their therapeutic power, that can reach people even if local health care systems cannot or will not provide them with needed health care, and that can be shared widely without taking resources away from the populations where the interventions were developed.
Evidence-based Internet interventions meet all these qualifications. Evidence-based Internet interventions are empirically tested online methods to change individual behavior to prevent or ameliorate health problems. Medications are the active ingredient in many medical interventions; information in the form of “behavioral prescriptions” is the active ingredient in Internet interventions. Both can be standardized, evaluated using randomized controlled trials, and disseminated globally as long as users have funds to buy the medication or access the Web. Both can be used cross-culturally, as long as they are provided in a linguistically and culturally acceptable manner.
A major advantage of fully automated self-help Internet interventions is cost. Bringing a medication to market costs hundreds of millions of dollars [
There are health interventions that can transcend space. Traditional telemedicine consultation, for example, can connect a specialist with a primary care provider and a patient anywhere in the world. However, the time spent with a patient in another locale is time that is not being used to serve patients locally. Internet interventions transcend both space and time: they can be used simultaneously anywhere in the world, and they can be used again and again, at a time of the person’s choosing, even if the specialists who developed and tested the site are no longer active professionally or even no longer alive. In this sense, Internet interventions transcend both space and time.
Internet interventions could help extend health services to patients who are experiencing disparities in terms of care. Imagine that a Spanish-speaking patient who does not speak English arrives at San Francisco General Hospital. She is provided with a mobile device or directed to an eHealth resource room to be screened in her own language for the most common health problems (ideally using audio and video, should she not be able to read). The results would be printed in her own language and her providers’ language (in this case, Spanish and English). If she meets criteria for major depressive episode, her physician might prescribe antidepressants and recommend cognitive-behavioral therapy for depression. If there are no cognitive-behavioral therapists who speak Spanish available, the patient could receive a cognitive-behavioral Internet intervention for depression in Spanish either at the eHealth resource room or, preferably, via a mobile device she could take home. Once such an intervention has been developed and tested at San Francisco General Hospital, it could be shared via the Web with any clinic anywhere in the world. A similar vignette could be described with a Quechua-speaking person going to a public sector clinic in Lima, Peru, or a Laotian-speaking patient at an Amsterdam clinic.
Live health care providers should not be replaced by Internet interventions, even evidence-based Internet interventions. Doing so would be a travesty. Each person who needs health care anywhere in the world should ideally be provided with a physician, nurse, psychologist, and so on, who are well trained to provide evidence-based interventions. Until this has been achieved, we should provide people with some intervention that is effective rather than not providing anything. Evidence-based Internet interventions are, at minimum, a temporary stopgap measure to provide needed interventions where none are available now. However, it will likely take many lifetimes, if ever, before adequate health care becomes accessible to all. Thus, efforts aimed at developing, testing, and disseminating nontraditional interventions to expand health services delivery are a good use of professional time and are sure to benefit large numbers of people [
Internet interventions can be used:
When no other interventions for specific health problems are available
While patients are on waiting lists, for example, during the weeks between being referred for treatment and the time a slot is open for a smoking cessation group or a depression group
During routine treatment, as an adjunct, for example, offering an Internet cognitive-behavioral intervention as an adjunct to pharmacotherapy for depression offered in a primary care clinic
After treatment, to prevent relapse or recurrence
For patients who cannot travel to clinics due to distance, physical limitations, time limitations, or economic limitations
For patients who fear stigma if they come to a mental health clinic
For patients whose providers do not speak their language
To extend health care beyond treatment into prevention
The Institute of Medicine (IOM) of the United States of America has published two reports on the prevention of mental, emotional, and behavioral disorders; one, in 1994 [
The 1994 IOM report argued that it is important to define prevention as interventions that occur prior to the onset of the targeted disorder (see
The mental health intervention spectrum [
Let’s look at a specific disorder. There are now many studies showing that prevention interventions can significantly reduce the number of new cases of major depression [
The argument presented thus far assumes that Internet interventions can be effective. Is there evidence for such a claim? Isaac Marks and colleagues have reviewed an impressive collection of studies that support the contention that computer-assisted therapeutic interventions can, in fact, be effective [
The Latino Mental Health Research Program of the University of California, San Francisco, at San Francisco General Hospital, began work in this area in 1998. Until then, we had been developing and testing face-to-face individual and group interventions for the prevention and treatment of depression and for smoking cessation in English and Spanish, while some had been developed in Chinese as well. Our manuals, designed to train and help providers administer prevention and treatment interventions with fidelity to the intervention protocol as designed, are available at the UCSF/SFGH Latino Mental Health Research Program website [
Concerns that many communities have no access to trained professionals to administer our manuals prompted our group to begin experimenting with creating automated self-help Internet interventions and testing them in randomized control trials conducted on the Web. Thus, the intervention is tested exactly as it will be provided after the trial ends. This eliminates the problem of “drift.” In addition, the intervention is designed to be used directly by the individual and does not require the availability of a health care provider. Nor does this approach require the difficult negotiations involved in trying to convince regional, national, or international health care systems to institute empirically supported services.
We began our research on evidence-based Internet interventions with smoking cessation interventions to determine whether we could “match the patch,” that is, obtain abstinence rates comparable to those found for the nicotine patch. Randomized trials comparing placebo patches with nicotine patches have found 6-month quit rates of 5% to 8% for placebo patches and 14% to 22% for nicotine patches [
Our smoking cessation trials are proof of concept for how evidence-based Internet interventions can provide health interventions worldwide. The Latino Mental Health Research Program established the University of California, San Francisco/San Francisco General Hospital Internet World Health Research Center in 2004. Our goal is to systematically develop and test evidence-based Internet interventions to fill in a matrix of evidence-based Internet interventions for health problems by languages (see
Matrix for systematic development of evidence-based Web interventions: health problems by languages (our goal is to fill this matrix)
Smoking | Depression | Pain | Diabetes | Obesity | Additional Health Problems | |
English | ||||||
Spanish | ||||||
Chinese | ||||||
Arabic | ||||||
Portuguese | ||||||
Additional languages |
This grid is infinitely expandable and will require the contributions of many health experts for the foreseeable future. A third dimension to the grid could represent specific subpopulations (men and women, young and old, diverse ethnic groups, preliterate and well-educated, rich and poor, and so on).
Once evidence-based Internet interventions become more numerous, we will need a system to help users choose among the many interventions that will populate the Web. The author proposes that a credible international body, such as the World Health Organization, create a Website to function as a central exchange or clearinghouse for empirical information on evidence-based Internet intervention sites. A site already exists, called “Beacon” [
Users could search for Internet interventions for depression, for example, and find the box score site for their demographic profile (See
Simplified illustration of how a central website for evidence-based Internet interventions might present data for a specific demographic profile
Website Intervention to Manage Depression | No Longer Depressed | Noticeably Improved, but Not Back to Normal Mood | Cost |
A | 52% | 30% | $49 |
B | 36% | 54% | Public access |
C | 22% | 20% | $250 |
To reduce health disparities, evidence-based Internet interventions should be available worldwide at no charge. This would encourage public health clinics to maintain eHealth resource rooms for low- or no-income patients. It would also provide users who are unable to pay and who have no access to clinics with access to the evidence-based Internet interventions. The bulk of the cost of self-help automated Internet interventions is in their development and the research costs of testing them. Once found effective, keeping these Internet interventions active online requires a relatively modest expenditure. Nevertheless, the cost of maintaining these sites is not zero. Staff is needed to monitor emails from users who request help in using the site or send complaints or thank-you messages and to host and troubleshoot the site. Unless a major donor or global health organization provides ongoing funding for such sites, developers will need to create a revenue stream to maintain them.
One possibility would be to use evidence-based Internet interventions themselves to generate revenue and then funnel the revenue into the creation and maintenance of additional sites for other health problems and languages. For example, an evidence-based Internet intervention found to be effective for smoking cessation could be licensed to a health maintenance organization or a multinational corporation so the members or employees of these organizations could have special access to the site. The funds from the license could be used to maintain both the private site and a public version of the site.
Successful commercial sites are likely to have bigger budgets, faster development times, and a profit motivation to reach more people. Disadvantages of commercial sites include perceived conflict of interest in terms of providing honest reports of participants’ outcomes, similar to the concerns over pharmaceutical companies providing accurate and complete reports of the benefits and risks involved in using their products. There is also the danger that commercial sites may copyright or patent interventions that were formerly freely accessible, thus making them “proprietary.” Advantages of public access sites could include becoming known for their high quality in the same way that public television programming in the United States has achieved an excellent reputation [
Most health care providers aspire to a world in which everyone has access to needed health care. This would include access to well-trained providers who can administer evidence-based interventions, including preventive, treatment, and maintenance interventions. This ideal is unlikely to be achieved in the foreseeable future. But it is possible to begin to approach this ideal by systematically creating a continuum of health interventions that utilize evidence-based Internet interventions.
These evidence-based Internet interventions are the most likely to contribute to the reduction of health disparities worldwide because they have the lowest ongoing cost. They consist of health behavior change interventions that are totally programmed. They can be individualized to as great an extent as programming allows, including sending individually timed educational messages (ITEMs, see [
These evidence-based Internet interventions add live support (staff-generated emails, text messages, or phone calls; advice on which elements of the site to use; encouragement, and so on). Such interventions tend to have larger effect sizes [
These evidence-based Internet interventions expand available interventions in existing health care settings, helping provide services to patients on long waiting lists, supporting active treatment regimens (for example, helping patients to adhere to treatment between medical appointments), and helping reduce relapse and recurrence after acute treatment ends by reminding patients to monitor their status and continue self-care.
An example of expanding health care beyond current offerings is a health care system that would use Internet interventions to move beyond treatment into both prevention and health promotion or to provide services to patients receiving inadequate care because they do not speak the languages available from local providers.
Most current health care systems wait for people to seek help before providing it. The fifth level of intervention involves proactive identification of individuals in the community who are not already coming for services but who need interventions to prevent or manage health conditions. Internet interventions at this level would provide behavioral methods for individuals to use in the community, and, if these methods did not work, the individuals would be encouraged to seek health care at existing facilities. This level provides active case finding and preventive or treatment services in people’s homes. Such services would be considered prohibitively expensive by most health care systems, which is why they are not generally available. An experimental example using face-to-face approaches is the Outcomes of Depression International Network (ODIN) project in Europe [
To envision how Internet interventions could contribute to the reduction of disparities in access to health care worldwide, imagine the systematic development and testing of Level 1 (automated self-help) Internet interventions for the health problems that produce the largest burden of disease in the world [
The often-quoted dictum to “think globally” (that is, consider issues that affect humanity) and “act locally” (begin addressing these issues where you live) can be extended by using the Internet to “share globally.” For example, smoking is the number one cause of preventable death worldwide, with over five million people dying each year from tobacco-related diseases [
To reduce health disparities worldwide, the international community should develop a system to provide evidence-based Internet interventions at no cost to the users. To launch this process, funding agencies and globally minded foundations or corporations would provide ongoing support to host and maintain automated self-help Internet interventions. The number of people who could benefit from such evidence-based Internet interventions would be massive. The return on investment on Internet interventions that can be used again and again is much higher than from provision of consumable interventions whose therapeutic power is spent after one use. The geographical reach of evidence-based Internet interventions is literally worldwide. This initiative is a worthy and feasible challenge for the 21st century.
The proof-of-concept worldwide Internet stop smoking intervention research program described in this paper was supported by grants from the Tobacco-Related Disease Research Program (Muñoz, PI) to the University of California, San Francisco (UCSF)/San Francisco General Hospital (SFGH) Latino Mental Health Research Program (LMHRP: http://www.medschool.ucsf.edu/latino/). Based on this line of research, the LMHRP established the UCSF/SFGH Internet World Health Research Center (www.health.ucsf.edu) in 2004 with support from the Research Evaluation and Allocation Committee of the UCSF School of Medicine's Dean's Office and with support from an infrastructure grant that began in 1993 from the Committee on Latino Research of the University of California Office of the President. The Center for Health and Community (Nancy Adler, Director) has provided office space for our Internet projects since 1998 and additional resources to target Latino smokers. Special thanks go to Google, Inc for awarding our group an AdWords grant since 2003, which has made it possible to recruit smokers worldwide using Google sponsored links, and to the Brin Wojcicki Foundation for their generous support of our Internet intervention research program. Finally, we thank the administration of the Department of Psychiatry at San Francisco General Hospital for its consistent support since 1977 for our work on reducing health disparities.
This article is based on a presentation made at the October, 2009 eMental Health Summit in Amsterdam, hosted by the International Society for Research on Internet Interventions (ISRII). The presentation was chosen for the best presentation award. A narrated version of the PowerPoint presentation can be accessed at
None declared
Original PowerPoint presentation from Amsterdam conference on which the manuscript is based
individually timed educational messages
Institute of Medicine
Latino Mental Health Research Program
Outcomes of Depression International Network
San Francisco General Hospital
University of California, San Francisco