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 [19]. Eysenbach suggested that eHealth is a broad topic encompassing 10 main concepts, one of which is equity [20]. He noted that certain patient populations are disadvantaged based on their lack of money, skills, and access to computers. However, the use of the term minority only further perpetrates these inequities. For this reason, we will not use the term minority in this paper. Instead, we will use the term historically underserved to refer to populations that are disadvantaged based on their race, ethnicity, age, gender, socioeconomic status, health status, or geographic location.

Larson stated that simplistic definitions of health should be avoided, as they lead to simplistic measures of health, health outcomes, and quality of care [21]. Therefore, it is important to use a more holistic definition of health that includes wellness; for instance, the World Health Organization defined health as “a state of complete physical, mental and social well-being, not just absence of disease” [21]. Pervasive health care takes this concept a step further and can be defined as “healthcare to anyone, anytime, and anywhere by removing locational, time and other restraints while increasing both the coverage and the quality of healthcare” [22].

The Health Technology Assessment Handbook defined health technology as “a collective term for procedures and methods for examination, treatment, care and rehabilitation of patients, including instruments, drugs, and preventive procedures” [23]. Health IT, which differs slightly from health technology, refers to the implementation of information processing that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge to facilitate both decision making and communication [24]. Health IT used directly by consumers is called consumer health IT. Or and Karsh defined consumer health IT as “computer-based systems that are designed to facilitate information access and exchange, enhance decision making, provide social and emotional support, and help behavior changes that promote health and well-being” [25].

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 [26]. Telemedicine, which is a part of eHealth, allows providers and patients in different geographic locations to communicate through computers, information, and telecommunication [12]. Telehealth, which is often used synonymously with telemedicine, is defined by the World Health Organization as telemedicine used by others beyond the physician [10] such as nurses and pharmacists. For this review, the author of the original paper differentiated between these 2 terms. For instance, if the author of the paper under review used the term telemedicine, we used it for this review; if the author of the reviewed paper used telehealth, we used it for this review as well.

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 [27]. EHRs have been shown to have a positive influence on quality of care, patient safety, and system delivery [17]. Electronic medical records are similar to EHRs except they are created solely for care delivery organizations—that is, hospitals and physician’s offices [28]. EHRs have the ability to increase access to health care, reduce medication errors, and improve administrative efficiency and quality of care [16]. In contrast to the EHR, personal health records are an optional tool that allows people to manage their own health records [29]. The personal health record is a lifelong resource of health information that is managed by the individual in an electronic, universally available form [29].

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” [30], in this review. Wellness informatics encompasses technology that may have little or no interaction with the health care system and is used primarily by the consumer [30]. For this review, wellness informatics tools included media technology created for other domains, such as television, radio, and computers.

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 (Table 1). Keywords about historically underserved populations included cultural diversity, ethnic groups, minority groups, cultural competency, ethnocentric, cross-cultural difference, racial and ethnic attitudes, racial and ethnic differences, and racial and ethnic discrimination. Keywords pertaining to health or health access included health education, patient acceptance of health care, attitudes to health, access to information, electronic health care, health, health system, and patient care. Finally, words considering technology included telemedicine, technology, medical technology, educational technology, medical information systems, eHealth, and health technology. When combined into the longer 3-part phrases, a total of 424 search phrases were used.

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 [18]. In compliance with the methods-description approach and to ensure standardized data extraction of the reviewed papers, we created a data table [18] with the following sections: title, author, purpose, and key findings. After completing the table, we defined recurrent topics through coding. Coding is defined as the “analytical process through which concepts are identified and dimensions are discovered in data” [31]. Through use of coding, the following ideas were explored: the targeted historically underserved group, the health issue examined, how technology was used, evaluation techniques, and barriers to access or adoption (Multimedia Appendix 1 [4,9,12,13,15-17,32-149]).

We identified 30 types of technology in the selected papers (Table 2). The technology included both health informatics tools (personal digital assistant, radio, Internet, telephone, mobile computer, mobile phone, videotape, computer, kiosk, MP3, television, compact disc, multimedia tool, instant messaging, and fax machine) and more traditional health technology (general health IT, medical technology, telemedicine, telehealth, telemanagement, electronic medical records, personal health records, EHR, eHealth, assisted reproductive technology, high technology hospitals, rapid human immunodeficiency virus (HIV) testing, implantable cardioverter defibrillator, cochlear implants, and assistive technology). The technology was used in a variety of ways, including as educational tools, as pieces of interventions, or as collaboration tools between physicians and patients.

The reviewed papers discussed 23 health issues (Table 3). Roughly one-quarter of the papers (33) did not focus on a single health topic, but instead discussed the general health of a population. Other papers examined health issues such as disease management (eg, diabetes, asthma, and obesity); health behaviors (eg, nutrition and smoking); and short-term issues (eg, breast-feeding, issues facing pregnant mothers, and child development).

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 [95]. Another study created a telenovela for Latinas to discuss breast cancer in the dramatic and narrative format of a typical telenovela. Relating to the women on a cultural level, such as through the telenovela, resulted in higher breast cancer knowledge for the participants [144].

The papers identified 19 different historically underserved populations (Table 4). Of the reviewed papers, 18 discussed multiple groups (eg, elderly African Americans or Hispanic women) and therefore appear in 2 categories in the table. In 8 the group in question self-identified as “racial and ethnic minorities.” We copied this term in this review paper only when the original author did not provide sufficient details to determine which racial or ethnic minorities were being examined. In addition to racial and ethnic minorities, the reviewed papers also included historically underserved groups that were characterized by their age, gender, location, and socioeconomic status.

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. Table 5 lists the evaluation methods.

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 [69,77,85,88,121,124,126]. Furthermore, telemedicine was the only type of health-specific technology mentioned in 10 or more papers.

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 [142], assistive technology and Internet [72]). None of the papers mentioned using more than one type of technology that is typically used inside a medical office.

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 [41]. Culturally tailored videotapes that employed characters of the same ethnic background as the patient influenced African American and Hispanic women on both a cognitive and emotional level [41]. Additionally, multiple studies showed increased trust among the patients when the narrator or main character of the educational videotape was the same ethnicity or race as the audience [47,144,150]. In addition, 2 studies demonstrated how storytelling can be used in videotapes to effectively communicate and educate patients about a specific health condition [78,122]. Videotapes were often complemented by other technology such as informational brochures [63], the radio [125], the computer [45,47], self-efficacy and skill-building exercises [53], multimedia tools [102,136], and telemedicine [142].

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 [151]. Women, minorities, and poverty-stricken individuals (who are also part of the population with the fastest-growing rate of HIV/acquired immunodeficiency syndrome [AIDS]) are those most likely to not have access to the Internet [59]. While many historically underserved populations have lower access to the Internet on a computer, they have higher usage rates of mobile Internet access on handheld devices [151]. Almost two-thirds of African American (64%) and Hispanic people (63%) have wireless access to the Internet. In fact, more African American and Hispanic people own cell phones (87%) than their white counterparts (80%) and, further, these historically underserved populations use their phone data functions more than their white counterparts do [9]. Gibbons suggested that, due to the high usage rates, these tools could improve patient engagement and be an effective mode for interventions [9]. Crilly and colleagues suggested wireless handheld devices as a viable alternative for patients who face barriers due to geography [151]. Eyrich-Garg conducted a study on homeless individuals who faced barriers due to geography. Of the participants in his study, nearly half (44%) owned a mobile phone [59]. Of this 44%, one-fifth had accessed the Internet via their mobile phone in the past 30 days. For this reason, Eyrich-Garg suggested that health care providers could disseminate health information to the homeless through use of mobile phones [59].

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 [55]. Samal et al found that text messaging was an acceptable mode of information and communication technology for African American women in an urban sexually transmitted infection clinic [105]. Another study tested the feasibility of text messages as an HIV prevention method for young African American men. The results were positive and suggested that humor be used to initially engage the patient before providing an HIV fact later in the text [148]. While the research is new and applied to only a few select historically underserved populations, text messages are being used as a modality to disseminate health information to these populations.

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 [23]. When the technology is a surgical instrument or a piece of equipment, the definition is seldom a problem; however, other technologies are more complex and unformed, and require more thought to define (eg, wound care, fast-track surgery, or electronic medication). When a definition is created, the technology should be described from its material nature, its purpose, the degree of dissemination, and its maturity [23]. Kristensen and Sigmund suggested that the technology can be defined through a series of questions about how the technology is used for the disease or illness, or the technology [23]. To define the technologies in this review, we asked the following questions [23]. (1) Are there any special professional or technical requirements for operating the technology? (2) Are there factors that affect the application of the technology? (3) What is the purpose and application area of the technology? (4) At which disease, health problem, or potential problem is the technology aimed?

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 [23]. With regard to question 3, 23 identified 16 types of technology applications (Table 6). Question 4 is discussed in detail below.

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 [114] and evaluated the positive implementation of EHRs [115], a telehealth network [56], and library access through the Internet [146]. The studies demonstrated the importance of involving and empowering the community to successfully implement health IT [56,146]. More research is needed on this population to better understand the intricacies of implementing health IT in the Indian Health Service. Only 1 paper mentioned Asian Americans [126]; however, this paper was not singularly about Asian Americans. The paper showed that white and Asian American children were more likely to receive cochlear implants than their Hispanic and African American counterparts [126].

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 [12]. While African American participants were concerned by the physical absence of the health care professional and the ability to monitor their qualifications, Hispanic participants were concerned with whether telemedicine would be available to uninsured or undocumented individuals.

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 [51]. Instead, the researchers suggested that an African American health educator conduct face-to-face interventions in order to have a greater impact.

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 [152]. The review conveys that culturally informed technology affects the health outcomes of the historically underserved populations facing health disparities in the United States.

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 [162]. Gaps in knowledge about the access to and use of health services by historically underserved populations exist in terms of learning practices, methods to navigate services, and help-seeking behaviors [163]. Further research is necessary to understand the limitations of the data and avoid overgeneralizations [162]. Future recommendations include the following:

Recommendations related to the type of technology chosen are as follows:

Recommendations related to the disease, health problem, or potential problem are the following:

The recommendation related to the evaluation of the technology is the following: