This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
The implementation of health technology is a national priority in the United States and widely discussed in the literature. However, literature about the use of this technology by historically underserved populations is limited. Information on culturally informed health and wellness technology and the use of these technologies to reduce health disparities facing historically underserved populations in the United States is sparse in the literature.
To examine ways in which technology is being used by historically underserved populations to decrease health disparities through facilitating or improving health care access and health and wellness outcomes.
We conducted a systematic review in four library databases (PubMed, PsycINFO, Web of Science, and Engineering Village) to investigate the use of technology by historically underserved populations. Search strings consisted of three topics (eg, technology, historically underserved populations, and health).
A total of 424 search phrases applied in the four databases returned 16,108 papers. After review, 125 papers met the selection criteria. Within the selected papers, 30 types of technology, 19 historically underserved groups, and 23 health issues were discussed. Further, almost half of the papers (62 papers) examined the use of technology to create effective and culturally informed interventions or educational tools. Finally, 12 evaluation techniques were used to assess the technology.
While the reviewed studies show how technology can be used to positively affect the health of historically underserved populations, the technology must be tailored toward the intended population, as personally relevant and contextually situated health technology is more likely than broader technology to create behavior changes. Social media, cell phones, and videotapes are types of technology that should be used more often in the future. Further, culturally informed health information technology should be used more for chronic diseases and disease management, as it is an innovative way to provide holistic care and reminders to otherwise underserved populations. Additionally, design processes should be stated regularly so that best practices can be created. Finally, the evaluation process should be standardized to create a benchmark for culturally informed health information technology.
While the visibility of health disparities has recently come to the forefront of the US health care agenda, the topic of health care disparities is not new. In 1984 the health of the nation was addressed in the “Health, United States, 1983” report conducted by the US Department of Health and Human Services. This report stated that African Americans and other racial and ethnic minorities were experiencing a higher burden of death and illness than the rest of the nation [
In the United States, historically underserved populations are growing in size, and hence health disparities are affecting a growing proportion of Americans. For instance, while 2000 census findings showed that 82% of the population was white, by 2015 this number is predicted to decrease to 79%. At that time, it is expected that these will be 5% Asian, 13% African American, and 15% Latino [
With historically underserved populations growing in the United States, it is important to study the potential and existing health disparities facing them. While there is no consensus regarding the specific definition of what constitutes a health disparity, the National Institutes of Health defined a health disparity as “differences in the incidence, prevalence, mortality, and burden of diseases and other adverse health conditions that exist among specific population groups in the United States” [
As technology is being used to further the success of the health care system, there is interest in understanding how the increased use of technology affects the already unequal ability of minorities to access health care [
Technology can be used in a variety of ways to positively affect historically underserved health care consumers. For example, telemedicine has been suggested as a possible way to address health care disparities among historically underserved urban populations. Research shows that urban communities are often unable to access health care in a timely manner due to low physician-to-population ratios, limited specialty care, and overcrowded, inadequate, and inefficient organizational structures [
To promote widespread adoption of health IT, the US Department of Health and Human Services established the Office of the National Coordinator for Health Information Technology [
The purpose of this review was to examine ways in which technology is being used by historically underserved populations in order to decrease the health disparity through facilitating or improving health care access and health and wellness outcomes. While several studies have investigated how historically underserved populations use technology when addressing their health, these studies focused on a single historically underserved group or a single health issue. We used a methods-description approach method to synthesize published research from reference databases to draw a larger conclusion from the current literature [
The term minority has been used often in health research. However, the term is problematic, as it can create a sense of inferiority for the population in question [
Larson stated that simplistic definitions of health should be avoided, as they lead to simplistic measures of health, health outcomes, and quality of care [
The
eHealth refers to the use of electronic communication and information technology within the health sector. Tools often referred to in connection with eHealth include personal digital assistants, compact discs and DVDs, and interactive games [
Electronic health records (EHRs) are an electronic form of the traditional patient health record (patient’s health profile, and environmental and behavioral information). EHRs include a time dimension and allow multiple providers to contribute information to the record [
For this review, we used a broad definition of technology that includes technology designed for both health and wellness. In this review, health-specific technology designed specifically for the clinical setting includes health IT, EHRs, and telemedicine. We also included wellness informatics, defined as “a human-centered computing science focused on the design, deployment, and evaluation of human-facing technological solutions to promote and manage wellness acts such as the prevention of disease and the management of health” [
From July to October 2011, we searched the online reference databases PubMed, Web of Knowledge, PsycINFO, and Engineering Village. For each database, we chose keywords to match the specific database’s thesaurus and used them to create search phrases. Each search phrase consisted of three key components: a word or phrase considering historically underserved populations, a word or phrase considering technology, and a phrase considering health, health access, or wellness (
Search terms by topic.
Historically underserved populations | Technology | Health and health access |
Cultural diversitya | Telemedicinea,b,c | Health educationa |
Ethnic groupsa,d | Technolog*a,b,c | Patient acceptance of healthcare/ethnologya |
Medically underserved areasa | Medical technolog*a,d | Acceptance of healthcarea |
Minority groupa | Educational technologya | Attitudes to healtha |
Cross-sectional studiesa | Electronic healthcared | Access to informationa |
Cultural competenc*a,d | E-healthd | Health knowledge, attitudes, practicea |
Health status disparitiesa | Health technololog*d | Evaluationd |
Disparit*d | Healthcare technolog*d | Health accessd |
Social factorsd | Medical information systemsb | Technolog* acceptanced |
Ethnocentricd | Medical computingb | Healthcare professionalsd |
Reference group cultured | Information technologyb,c,d | Health systemd |
Cultur* biasd | Healthd | |
Minorit*d | Healthcareb | |
Cultural aspectsb | Patient careb | |
Culture bound syndromesc | Health disparitiesc | |
Ethnologyc | Health attitudesc | |
Cross cultural differencesc | Health knowledgec | |
Racial and ethnic attitudesc | Health impairmentsc | |
Racial and ethnic differencesc | Health complaintsc | |
Racial and ethnic groupsc | ||
Race and ethnic discriminationc |
a PubMed.
b Engineering Village.
c PsycINFO.
d Web of Science.
The scope of the review was focused by establishing inclusion and exclusion criteria. The selection criteria were that the paper (1) focused on a specific priority population(s), (2) discussed how the populations’ identity affected their experience within the health care system, and (3) discussed how technology use affected the experience.
We excluded studies if they (1) were published over 15 years ago (prior to 1996), (2) were not in English, (3) were conducted outside of the United States, (4) did not deal with health or wellness, (5) discussed mental health, end-of-life care, or dental care, or examined cost as the main variable, and (6) discussed the historically underserved population as a current or future employee of the health system instead of as a patient.
We used a methods-description approach to analyze papers that met the inclusion criteria. This method documented the objective characteristics (as they were described by the primary author) of each study’s methods [
The 424 search phrases returned 16,108 papers. We excluded 15,422 papers as duplications or via the exclusion criteria through reading the titles. After reviewing the abstracts and full papers, we eliminated another 561papers as not meeting the inclusion criteria. A total of 125 papers met the inclusion criteria and were included in this review (
All selected papers discussed the health disparity facing the historically underserved group in question and the importance of closing the gap or reducing the disparity. One-quarter of the papers (32) focused only on the health disparity without analyzing a potential solution. The remaining 93 papers briefly mentioned the disparity but focused on accessing a possible solution to lessen the disparity. For instance, 1 report discussed the health disparities facing the Hispanic community in the background of the paper. However, the main purpose of the paper was to determine the effectiveness of
Flow diagram of the study selection process.
We identified 30 types of technology in the selected papers (
Paper breakdown by technology.
Technology | Number of papers |
Video | 34 |
Internet (email, social networking sites) | 23 |
Telemedicine | 10 |
Computer (computers in clinics) | 9 |
Television (advertisements and shows) | 8 |
General health information technology | 6 |
Electronic health record | 6 |
Radio | 5 |
Telephone | 5 |
Mobile phone (text messaging) | 5 |
Assisted reproductive technology | 5 |
Multimedia tool | 4 |
Assistive technology | 4 |
Telehealth | 3 |
Compact disc | 2 |
Kiosk | 2 |
Telemanagement | 2 |
eHealth | 2 |
Medical technology | 1 |
Electronic medical record | 1 |
Personal health record | 1 |
Personal digital assistant | 1 |
Mobile computer | 1 |
High-technology hospitals | 1 |
MP3 | 1 |
Rapid HIVa testing | 1 |
Implantable cardioverter defibrillator | 1 |
Cochlear implants | 1 |
Instant messaging (on a computer) | 1 |
Fax machine | 1 |
a Human immunodeficiency virus.
The reviewed papers discussed 23 health issues (
Nearly half of the papers (62) examined the use of technology to create effective and culturally informed interventions (16 papers) or educational tools (46 papers). The reviewed papers pointed to many interventions and educational tools that were successfully designed for a historically underserved group. A study found that having famous athletes, musicians, and other celebrities from the African American community record commercials for adolescents’ MP3 players resulted in better health knowledge about asthma [
Paper breakdown by health issue.
Health issue | Number of papers |
General health | 33 |
Cancer | 17 |
Diabetes | 14 |
HIV/AIDSa | 14 |
Nutrition, physical activity | 8 |
Sexually transmitted infections | 7 |
Reproduction | 5 |
Obesity | 4 |
Cardiovascular disease, heart problems | 4 |
Breast-feeding | 3 |
Smoking | 3 |
Asthma | 3 |
Persons with disabilities | 3 |
Pregnancy issues | 2 |
Pharmacy | 2 |
Sensorineural hearing loss | 1 |
Organ donation | 1 |
Hepatitis C | 1 |
Health literacy | 1 |
High blood pressure | 1 |
Poison control | 1 |
Hypertension | 1 |
Child development | 1 |
a Human immunodeficiency virus/acquired immunodeficiency syndrome.
The papers identified 19 different historically underserved populations (
Paper breakdown by historically underserved group.
Historically underserved group | Number of papers |
African American | 64 |
Hispanic | 51 |
Women (mothers) | 26 |
Low socioeconomic status | 11 |
Elderly | 11 |
Adolescents, teens, and children | 8 |
Racial and ethnic minorities | 8 |
English as a second language | 5 |
Native American and Alaskan | 4 |
Men | 4 |
Rural | 4 |
Underresourced setting, underserved community | 3 |
Community health center: underserved, low socioeconomic status, racial and ethnic groups | 2 |
People getting tested for HIVa | 2 |
Asian American | 1 |
Immigrant | 1 |
Homeless | 1 |
People with AIDSb | 1 |
People living with HIV | 1 |
a Human immunodeficiency virus.
b Acquired immunodeficiency syndrome.
Other than the 3 review papers, the papers all used formative technology evaluation. They used two forms of evaluation: (1) evaluation of health changes related to use of the technology and (2) evaluation of the technology itself; few papers (23) used both types of evaluation. A total of 76 of the papers evaluated health changes due to use of the technology (eg, changes in health knowledge, health behavior changes, biometric changes, or changes in health-related quality of life). Of the 107 papers that evaluated technology, 57 evaluated acceptance of the technology (satisfaction or acceptance, usefulness, and willingness to use), 14 evaluated usability (ease of use), 35 evaluated the user’s ability to access the technology (access or usage rates and number of websites or television advertisements with the desired information), and 1 measured improvements in technology literacy. In addition, 64 papers relied on the participants’ self-report to evaluate the technology, 14 measured ease of use, 22 measured usefulness of the technology, and 28 evaluated satisfaction with the technology. When an intervention or educational tool was evaluated, some of the authors (25 papers) measured improvement in participant health knowledge, while others measured behavior change (22 self-reported behavior changes and 18 observed behavior changes). Furthermore, 10 papers measured biometric changes in the observed health condition, 31 examined access and usage rates of the technology, and 7 recorded whether patients were interested in using the technology in the future. Finally, 4 papers measured the number of websites or television advertisements viewed by the population being studied.
Evaluation metrics.
Evaluation metric | Number of papers | |
|
||
Health knowledge | 25 | |
Behavior change (self-reported) | 22 | |
Behavior change (observed) | 18 | |
Biometric change | 10 | |
Health-related quality of life | 1 | |
|
||
Access and usage rates | 31 | |
Self-reported satisfaction and acceptance | 28 | |
Usefulness (self-reported) | 22 | |
Ease of use (self-reported) | 14 | |
Willingness to use | 7 | |
Number of websites or television advertisements with desired information | 4 | |
Technology literacy improvement | 1 |
The purpose of this study was to examine ways in which technology is being designed for historically underserved populations to facilitate or improve health care access and health outcomes. The reviewed studies focused on either (1) a defined historically underserved population, such as African Americans or people with a lower socioeconomic status, or (2) a historically underserved population, such as racial and ethnic minorities, as a group.
The results are organized into the four main questions. (1) Which types of technologies are used to address negative health outcomes for historically underserved populations? (2) At which disease, health problem, or potential problem is the technology aimed? (3) Which historically underserved groups are technology-based interventions designed for in the literature? (4) How are the health benefits and technologies evaluated?
The papers discussed 30 different types of technology; half (15) are typically used within a clinical setting, while the remaining 15 types are often used outside of a medical setting. Technologies that are often used outside of a clinical setting were mentioned in the majority of papers (102 papers) and included technologies such as videotapes, Internet, computer, and radio. While not originally created for the health care system, these types of technology were readily adapted to aid health consumers. If a historically underserved population is already familiar with and has access to this type of technology, the technology might be an appropriate platform choice. For instance, 34 papers used videos to relay health messages. Videos are readily understood and easily accessed by the majority of the US population and therefore likely a good choice for health education or interventions aimed at historically underserved populations.
A total of 45 papers used technology typically used within a health care setting (eg, telemedicine, EHRs, or assisted reproductive technology). However, seven of these technologies (medical technology, electronic medical records, personal health records, high-technology hospitals, rapid HIV testing, implantable cardioverter defibrillator, and cochlear implants) were mentioned in only 1 paper [
Additionally, 16 papers discussed more than one type of technology, and the majority of these papers (14) mentioned two types of technology typically used outside of the medical office. The remaining 2 papers mentioned one type of each: one type of technology typically used at a clinic, and one type typically used outside of a clinic (telemedicine and videotapes [
Among the reviewed papers, videotapes were widely discussed as a method for interventions and educational tools (24 papers). Using videotapes instead of written materials to educate patients increased comprehension among breast cancer patients with low literacy skills [
The Internet is highly used by health care professionals for interventions and education. One study showed the increased benefit of the Internet to individuals with lower incomes and education levels despite their lower use of the Internet to access health information [
Using mobile phones as a means to send information via text messaging is mentioned in the literature as a viable option for racial groups. Similar to their usage of mobile phones, African Americans use text messaging more than their white counterparts do [
To access the desired and undesired effects of technology and to search for relevant literature about a technology, a clear definition and delineation of technology is necessary [
Questions 1 and 2 point to the need to effectively design technology that can overcome cultural differences that are exaggerated by the digital divide, health literacy, and language differences between historically underserved groups and the larger population. Every user needs to be able to operate and understand the technology to effectively access and use it to improve his or her health [
Types of technology
Application of technology | Number of papers |
Intervention or education tool | 62 |
Health management tool | 19 |
Tool for communication with provider | 6 |
Health record | 5 |
Reproduction | 5 |
Assistive technology | 4 |
Information-gathering tool | 3 |
Interpretation tool | 2 |
Information and communication technology | 1 |
Health information tool | 1 |
Cardioverter defibrillation—medical technology | 1 |
Cochlear implant—medical technology | 1 |
Pharmacy tool | 1 |
Drug advertisements | 1 |
Knowledge acquisition | 1 |
Health literacy assessment | 1 |
Although 23 health issues were discussed in the reviewed papers, general health was discussed in one-quarter of the papers (33). The next five most mentioned health issues (cancer, diabetes, HIV/AIDS, nutrition and physical activity, and sexually transmitted infections) were mentioned in a disproportionate number of papers (60), while the remaining 17 health issues were mentioned in only 37 papers. Furthermore, eight of the health issues (sensorineural hearing loss, organ donation, hepatitis C, health literacy, high blood pressure, poison control, hypertension, and child development) were mentioned a only single paper each.
The reviewed papers discussed 19 historically underserved groups. African American and Hispanic populations were mentioned at least twice as often (64 and 51 papers, respectively) as the second-largest target group (ie, women were mentioned in 26 papers). While African American and Hispanic populations were mentioned often, other racial and ethnic groups were rarely mentioned. Native Americans and Alaskan natives were mentioned in 4 papers and Asian Americans were mentioned in only 1 paper. The studies involving Native Americans and Alaskan natives provided an overview of the Indian Health Service [
While the majority of the papers did not mention gender, when gender was mentioned, women were discussed in 26 papers, while men were specifically discussed in only 4 papers. Of the 26 papers focused on women, 16 described health issues specific to women (7 papers on reproduction, 7 on breast cancer, and 2 on breast-feeding). The remaining 10 papers discussed health conditions that are not gender specific and that could affect males (3 papers on HIV, 2 on obesity, and 1 on the remaining health issues: general health, cardiovascular disease, sexually transmitted infections, nutrition, and cancer). Of the 4 papers dedicated to men, 1 discussed prostate cancer, which is specific only to men; however, the remaining 3 papers discussed HIV and sexually transmitted infections, which can also affect women. While it is understandable that papers discussing gender-specific health issues such as breast cancer or prostate cancer would focus on a single gender, 10 papers targeted only women and 3 papers targeted only men while addressing a non-gender-specific health issue.
It is important to note that attitudes toward technological interventions vary between historically underserved populations, not just between majority populations and historically underserved populations. A single intervention will not necessarily work for two separate racial or ethnic groups; interventions should be tailored to each population to be most effective. For instance, 1 study found that African American and Hispanic populations have different concerns regarding telemedicine [
The review papers used 12 types of evaluation. While we expected that most of the papers would use quantitative evaluation techniques, only half of the papers used these techniques. Objective evaluations were used in 90 papers (31 papers measured access or usage rates, 25 measured changes in health knowledge, 18 measured behavior changes, 10 measured biometric changes, 4 counted the number of websites or television advertisements with the desired information, 1 measured improvements in technology literacy, and 1 measured health-related quality of life). Self-reported measures were used in 93 papers (28 papers measured self-reported satisfaction or acceptance, 22 measured self-reported behavior changes, 22 measured self-reported usefulness, 14 measured self-reported ease of use, and 7 measure willingness to use the technology). Though 10 of the papers measured biometric changes, most of the papers did not evaluate the effects of the technology on health outcomes. Instead, the papers evaluated intermediate measures such as behavior changes or access rates of the technology.
Of the 67 papers that tested a culturally informed technology, 66 found the technology successful in at least one of the evaluated metrics; this points to the fact that health technology is an effective method to improve the health of historically underserved populations. The one study that did not have success aimed to improve HIV risk and sexual behaviors through a culturally appropriate educational video for 15- to 19-year-old black males [
This review illustrates how technology is being used by historically underserved populations to facilitate or improve their health care access and health and wellness outcomes. Synthesis of the literature points to the benefit of accounting for the end user’s culture when designing health technology. A person’s culture shapes how health information is received, what a health consumer considers a health problem, how symptoms are expressed, who should provide treatment, and what treatment should be provided [
The reviewed papers discussed 30 different types of technology, both those typically used inside a medical setting and those typically used outside of a medical setting. Health IT can lessen barriers facing historically underserved populations [
Choosing an appropriate type of technology is not enough; the technology should be tailored toward the intended population, as personally relevant health technology is more likely than more broad technology to change behavior [
The reviewed papers discussed 23 health issues, with 33 of the papers discussing general health concerns. Since the US federal government requires recipients of federal funds to provide language assistance services, including bilingual staff and interpreters, at no cost to the patient [
Nearly half of the papers discussed how the technology was used to create culturally informed interventions or educational tools. Obtaining access to culturally appropriate and accessible health education is a necessary piece of receiving high-quality, patient-centered care [
The papers included in this review highlight a relatively limited number of historically underserved groups (19). However, the review papers did discuss seven priority populations defined by the AHRQ. The AHRQ focused on seven priority populations as specified by Congress in the Healthcare Research and Quality Act of 1999: racial and ethnic minorities, low-income groups, women, children, older adults, residents of rural areas, and individuals with special health care needs, such as individuals with disabilities and individuals who need chronic care or end-of-life care [
Of the 19 historically underserved groups discussed in the reviewed papers, 11 of these groups were discussed in fewer than 5 papers. Further, five groups (Asian Americans, immigrants, the homeless, people with AIDS, and people living with HIV) were discussed in a single paper. The discrepancy in the number of papers reviewed per historically underserved population is potentially problematic, as it can result in gaps in information regarding the less-studied populations [
The reviewed papers tended to examine one identity that an individual might hold. In addition to studying historically underserved groups separately, researchers should examine populations from an intersectional theoretical perspective. Intersectionality refers to particular forms of intersecting oppressions [
We identified 2 main forms of evaluation in the reviewed papers: evaluation of health changes related to use of the technology and evaluation of the technology itself. A fraction of the papers (23) used both types of evaluation. A wide range of evaluation metrics were used; about half of the papers (64) used self-reported measures as part of their evaluation, while 10 papers measured biometric changes. Even though previous research found self-reports to not be an accurate predictor of health information competencies [
The reviewed papers did not include a validated method to evaluate the specific cultural aspect of the health technology. Design processes should be reported in the research so that best practices can be created for culturally relevant design methods. Only 13 of the reviewed papers provided detail on the design process of the interventions and educational tools. Future research should evaluate metrics for culturally informed health technology. These metrics will need to be adapted and changed for different cultural groups, as diverse cultural groups expect different criteria from their health technology.
We followed systematic review methodology; however, this method has several limitations. Systematic reviews can only assess published work and report on the findings in those articles. Other potential limitations include the use of a single reviewer and the exclusion of studies regarding mental health, end-of-life care, and dental care.
More research about culturally informed technology for health is needed. In conjunction with this research, it is imperative for researchers to continue collecting data on cultural populations [
Theoretical models and perspectives are needed to design culturally informed technologies.
Methodologically, more research should be conducted to create a culturally informed approach to the design of health technology geared toward historically underserved populations. While methods should vary based on the technology, cultural population, and health issue, a broad methodology should be recommended for the future design of culturally informed health technology. This methodology might include formative research, which can aid researchers in overcoming their own implicit biases by using participatory methods to help them understand the population, create programs specific to the population’s needs, and ensure the programs are acceptable to the population through pilot testing [
Financial incentives should be provided to organizations that adopt technology for historically underserved populations. The financial burden of purchasing, implementing, and maintaining health IT serves as a barrier to the adoption among underresourced providers who frequently serve lower socioeconomic patients [
Recommendations related to the type of technology chosen are as follows:
When designing or implementing health technology for historically underserved populations, the type of technology should be carefully considered. Barriers to access and use of health IT differ between populations; different types of technology can be used to overcome distinct barriers. Therefore, the choice of technology type is important. Future research should create a comprehensive list of which types of technology would be most beneficial for each group. For instance, telemedicine is a useful tool to reach rural populations, and mobile telephones are a useful tool to reach African American populations.
Trust and lack of cultural relevance have been found to be a barrier, as lack of trust in the technology, technical problems, or confusing instructions have a negative impact on adoption and usage rates among historically underserved populations [
Future studies should examine how to best diffuse technology into a population [
As new technology is invented and as the cost of current technology decreases, culturally informed health technology should be adapted. For instance, social media, which have rapidly grown in the 21st century [
Recommendations related to the disease, health problem, or potential problem are the following:
Future studies should use culturally informed health IT for chronic disease management. The emphasis on self-management support programs has shifted from pedagogical education with education content defined by health care professionals to an individualized approach that addresses the specific needs of a patient’s situation [
The recommendation related to the evaluation of the technology is the following:
The evaluation process should be standardized to create a benchmark for culturally informed health IT. Participatory approaches should be used when possible to evaluate technologies, but metrics related to culturally informed design are needed. While research should dictate these metrics, possible metrics might include issues surrounding access, usability, perceived usefulness, and cultural appropriateness.
Overview of reviewed papers.
Agency for Healthcare Research and Quality
acquired immunodeficiency syndrome
electronic health record
human immunodeficiency virus
information technology
This publication is supported by grant 1UL1RR025011 from National Institutes of Health and the University of Wisconsin-Madison Systems Engineering Initiative for Patient Safety (http://cqpi.engr.wisc.edu). The Agency for Healthcare Research and Quality’s training grant provided support for this project (http://www.ahrq.gov/fund/training/rsrchtng.htm).
None declared.