Health and Wellness Technology Use by Historically Underserved Health Consumers: Systematic Review

Background 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. Objective 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. Methods 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). Results 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. Conclusions 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.

Health and nutrient content claims in food advertisements on Hispanic and mainstream prime-time television Abbatangelo-Gray et al., 2008 [32] To characterize frequency and type of nutrient and health claims on prime-time weeknight Spanish and English television advertisements Spanish-language television aired more health and nutrition information than English-language television which may A mass mediated intervention on Hispanic live kidney donation. Alvaro et al., 2010 [33] To determine the impact of a Spanish language mass media campaign on attitudes and behaviors referring to living organ donors.
The use of television and radio campaigns to improve Hispanics feelings and behaviors towards living organ donors.
Assessing the Cultural Relevance of an Education Program for Urban African Americans with Diabetes Anderson et al., 2000 [34] To determine the cultural relevance of an education program about diabetes for African Americans The videotape vignettes were culturally relevant and effective.
Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Arora et al., 2007 [35] To determine the benefit of project ECHO which is a telemedicine and distance-learning program designated to improve access to quality health care for New Mexicans with Hepatitis C.
Project ECHO's teleconferencing, videoconferencing, internet-based assessment tools, online presentation, and telephone, fax, and email communications that connected specialists with primary-care providers in prisons and rural areas helped promote the use of best practices. The Use of Quality Improvement and Health Information Technology Approaches to Improve Diabetes Outcomes in African American and Hispanic Patients Baig et al., 2010 [36] To review the effectiveness of health IT in health care interventions to improve diabetes process of care and outcomes in African American and Hispanics No studies were found using health IT applications to enhance patient communication with providers, facilitate shared decision-making, or ones that emphasized culturally competent interactions with patients.
A pilot study of diabetes education via telemedicine in a rural underserved community-opportunities and challenges: a continuous quality improvement Balamurugan et al., 2009 [37] To look at the effects of a pilot study that implemented telemedicine technology for diabetes self-management education (DSME) for people in underserved rural communities.
The DMSE-T offers opportunities for DSME in rural areas. process.
Is There a Digital Divide among Physicians? A Geographic Analysis of Information Technology in Southern California Physician Offices Bell et al., 2003 [38] To determine whether physician offices in low income neighborhoods have different access levels to information technology than those offices in higher-income areas.
Primary care offices in poor and minority communities had high levels of access to and interest in web-based systems.
A study of the receptivity to telecare technology in a community-based elderly minority population Bertera et al., 2007 [39] To determine the willingness of elderly minority to use a variety of technology for telecare Black and Teti, 1997 [40] To determine the effectiveness of a 15-minute culturally sensitive videotape about mealtimes for African-American mothers of infants.
The video was effective in creating mothers that are more involved with their infant.
Where's Maria? A video to increase awareness about breast cancer and mammography screening among low-literacy Latinas. Borrayo, 2004 [41] To discuss the need for a culturally competent intervention for Latina women surrounding Breast Cancer and the way in which an 8 minute Entertainment-Education soap opera formatted video was created for this intervention Psychological barriers of Latina women that cause them to have low screening rates for breast cancer can be decreased by targeting certain attitudinal and behavioral issues in the community.

A PDA Intervention to Sustain Smoking Cessation in Clients With Socioeconomic Vulnerability
Buchanan and Khazanchi, 2010 [42] To describe the acceptance, portability, technical difficulty, satisfaction and use time of PDAs as a tool to quit smoking The PDA is useful to the task of quitting smoking but was not easy to use A randomized control trial evaluating the educational effectiveness of a rapid HIV posttest counseling video. Calderon et al., 2009 [43] To determine if a 15-minute educational video (in either Spanish or English) is as effective as a 20 minute session with an HIV counselor The video was found to be at least as effective as the session with an HIV counselor. To discuss the effectiveness of a telepharmacy program that dispenses low -cost medications through use of remote dispensing and counseling.
The program was effective and a majority of the patients were satisfied with the time required to obtain the medications and counseling via the videoconferencing Telehealth for elders and their caregivers in rural communities. Coen et al., 2002 [4] To discuss the pros and cons of using telehealth for rural elderly. To determine the differences in how Hispanics and Anglos use and evaluate advertising and mediated sources of prescription drug information.
Hispanics use doctors, internet sources, and direct to consumer advertising (DTCA) for sources of information while Anglos use health websites and health care professionals. Further, Anglos are more likely to use health websites like WebMD while Hispanics rely on television and DCT TV advertisements and like having Spanish language media and healthcare professionals.
The effect of prevention messages and self-efficacy skill building with inner-city women at risk for HIV infection. DeMarco et al., 2009 [53] To examine if gendersensitive and culturally relevant HIV prevention films combined with self-efficacy and skill building exercises can positively influence safe sex for inner city women.
The intervention led to self-reported safer sex behaviors.
Culturally relevant HIV interventions: transcending ethnicity. Norris, 2004 [54] To discuss the pretesting of a culturally relevant film for African American and Latina teen girls about HIV.

DeMarco and
The people that were pretested found the messages of the video to be strong, especially those who shared gender identity and socioeconomic status. The Digital Divide at an Urban Community Health Center: Implications for Quality Improvement and Health Care Access Denizard-Thompson et al., 2011 [55] To determine the number of clinic patients that use the internet and cell phones and to determine their interest in using these technologies for health purposes (managing clinical appointments and patient education) African Americans were more likely than whites and females more likely than males to use text messages. Also the patient's interest in using the technologies was high. To examine the number of homeless people who do not use the shelter system but own mobile phones and to examine how they to effectively use their mobile phones Half (44%) of the sample owned mobile phone. Of those who owned a phone 100% of them made or received a call in the last 30 days, 61% of them sent or received a text, and 20% of them accessed the internet. Comparison of assisted reproductive technology utilization and outcomes between Caucasian and African American patients in an equalaccess-to-care setting Feinberg et al., 2006 [60] To determine the reasons for the disparity existing for minorities using assisted reproductive technology (ART) African American women utilized ART services more when access to care was improved.
Exploring feasibility of home telemanagement in African Americans with congestive heart failure.

Finkelstein et al., 2010 [61]
To determine the feasibility of using a Home Automated Telemanagement for African Americans with congestive heart failure who don't have prior computer experience.
There was a high level of acceptance of the Home Automated Telemanagement system.
Health information technology and quality improvement for community health centers Fiscella and Geiger, 2006 [13] To show why HITs should be federally supported at community health centers in order to improve quality control. To examine if policy initiatives set in place in the 1990s eliminated the information "digital divide".
Between 2000 and 2002, the divide between computer usage Hispanics and Whites and between African-Americans and Whites lessened while the gaps in internet usage stayed the same. Further, there was a disparity in health information seeking between these populations. Social equity and access to the world wide web and e-mail: Implications for design and implementation of medical applications Mandl et al., 1998 [90] To measure the predictors, rates, and types of access to web based medical services.
Income directly correlates to internet access and internet access is unevenly distributed across races.
Designing e-health interventions for low-health-literate culturally diverse parents: addressing the obesity epidemic. Mackert et al., 2009 [91] To determine the ability of e-health to educate low-health-literate audiences on the topic of obesity E-health can be used as an effective education tool for low-health-literate audiences but the interventions must be very usable in order to meet the different levels of health literacy. Marketing nutrition among urban Latinos: the SALUD! campaign. Perez-Escamilla et al., 2000 [100] To determine the ability of Salud!, a radio and print media campaign that targets Latino children and their caretakers , to improve understanding of nutrition.
The campaign was successful. Further, multiple media channels should be used as one single channel did not strongly dominate the coverage of the campaign. An intervention to decrease cancer fatalism among rural elders. Powe and Weinrich, 1999 [101] To determine the effectiveness of a video intervention for rural elders (mostly African American) on the topic of colorectal cancer. To determine if a tailored self-management system (SMS) that works in multiple languages (English, Spanish, and Cantonese) paired with weekly automated telephone disease management (ATDM) or monthly group visits would reach patients in a safety net system. ATDM resulted in higher engagement with those with limited English language proficiency and literacy having the highest engagement.
Caring for Hispanic patients interactively: simulations and practices for allied health professionals Schitai, 2004 [110] To determine the effectiveness of a new tool for training professionals about Hispanic Patients in a culturally competent way The computer-based training (CHISPA) that includes a CD and website that focus on patient simulations, Spanish language and internet practices, and an activities module was effective in increasing cultural understanding, integrating real-world experiences with theory, and providing useful information. Perceptions of factors influencing use of an electronic Schnall et al., 2011 [111] To determine the current perceptions of Case Managers (CMs) who The CMs were worried about predisposing (system functionality and record for case management of persons living with HIV facilitate continuity of care for people living with HIV on using HIT confidentiality), training, efficiency and quality of the systems. While HITs may still be used for continuity of care, these fears must be addressed Disparity in assisted reproductive technologies outcomes in black women compared with white women Seifer et al., 2008 [112] To compare success rates of African-American and Caucasian women undergoing In Vitro Fertilization African-Americans are less likely to seek IVF; Black race is an independent risk factor that is not explained by the characteristics looked at in the study Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for Assisted Reproductive Technology 1999and 2000vs. 2004-2006. Seifer et al., 2010 To continue the previous study (2008) but this time examine In Vitro Fertilization for years [2004][2005][2006] While numbers improved slightly from 2000, African-Americans are still less likely to seek IVF and more likely to have fewer live births.
Information technology as a tool to improve the quality of American Indian health care. Sequist et al., 2005 [114] To describe the disparities for American Indians and the work being done by the Indian Health Service (IHS) to improve these disparities. Further, the article discusses how the IHS is using information systems to increase standardization and improve American Indian health.
The Indian Health Service (IHS) consists of three units: (1) federally operated direct care system (2) tribally operated care (3) urban care services. However, health disparities do exist. EHRs are being installed and should help address quality improvements Implementation and use of an electronic health record within the Indian Health Service. Sequist et al., 2007 [115] To evaluate the implementation of Electronic Health Records in the Indian Health Service (IHS) Overall clinicians were found to support the EHR technology but felt that the limited use of key functions of the technology led them to not be able to use the technology to its full potential. Media influence on awareness and utilization of assisted reproduction technology in Hispanic populations. Quintero, 2011 [116] The letter to the editor was written to discuss a recent article about the utilization and outcomes of assisted reproduction technology in minority women (especially Hispanic women).

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The authors noted that when cost is set aside, Hispanics are less likely to seek infertility treatments because of issues like language/cultural barriers, lack of provider communication, scheduling problems, and decreased availability of services.
The Informatics for Diabetes and Education Telemedicine (IDEATel) project. Shea, 2007 [117] To determine the effectiveness of telemedicine (specifically IDEATel) for mostly Hispanic and African Americans in New York city and upstate New York Telemedicine helped improve glycemic control, blood pressure levels, and cholesterol levels and was found to be effective for managing diabetes in undeserved populations Columbia University's Informatics for Diabetes Education and Telemedicine (IDEATel) Project: rationale and design. Shea et al., 2002 [118] To describe the IDEATel project's rationale and design.
The project consists of a video camera for voice conferencing with nurse managers, home glucose meter and blood pressure cuff that can take readings and upload the results to a computer database, an access point for patients to view their clinical data through graphical displays, secure messaging including email and a webpage that is in both English and Spanish. Adoption of health information technology in community health centers: Results of a national survey Shields et al., 2007 [119] To determine the number of community health centers (CHCs) with health IT and EHRs Nine-tenths of the CHCs stated lack of capital to invest in EHRs as a barrier to adoption, four-fifths stated inability to integrate EHR with the current system, and three-fourths stated concerns about the loss of productivity or income during transactions Older Patients' Enthusiasm to Use Electronic Mail to Communicate With Their Physicians: Cross-Sectional Survey Singh et al., 2009 [120] To determine the enthusiasm levels of older adults in using email as a communication method with their physicians African Americans and Hispanics were more enthusiastic than their Caucasian counterparts about using email to communicate with their physician. Client satisfaction with rapid HIV testing: Comparison between an urban sexually transmitted disease clinic and a community-based testing center. Smith et al., 2006 [121] To determine if rapid HIV testing which allows same-day results is a positive improvement in HIV testing or if it makes people uncomfortable.
Latinos were more likely to state that the results were returned too quickly and that they would rather wait a week. Overall, the clients found the rapid results to be more stressful.
Asthma 1-2-3: a low literacy multimedia tool to educate African American adults about asthma Sobel et al., 2009 [122] To determine the effectiveness of using a video script combined with storyboard imagery to educate African-American adults on asthma The tool developed is useful for future education Latina breast cancer survivors informational needs: information partners Sorensen et al., 2009 [123] To access and understand how Latinas with breast cancer use informatics tools to manage their health.
Latinas find having a select support network of people a necessity and therefore e-health and informatics should focus on networks rather than individuals. Racial disparity and technology diffusion: The case of cardioverter defibrillator implants, 1996-2001Stanley et al., 2007 To determine the racial disparities of elderly people using implantable cardioverter defibrillators.
Elderly black patients were less likely to use implantable cardioverter defibrillators (ICDs) than their white counterparts. However, the disparity declined by 40% over the 3 years of the study. A program of interventions designed to increase mammography rates in women ages 50 years and older for an underserved racial minority Stelger et al., 2003 [125] To determine if the intervention strategies used for African-American women who were being encouraged to get a mammography in Philadelphia worked The intervention that consisted of a video, educational mailings, posters, prepaid postcards, and public service messages most likely worked. However, due to limited responses, the researchers cannot make hard conclusions. Recent epidemiology of pediatric cochlear implantation in the United States: Disparity among children of different ethnicity and socioeconomic status Stern et al., 2005 [126] To determine if SEC and race/ethnicity play a part in the number of children provided with cochlear implantation.
White and Asian children were more likely to be implanted than Hispanic and African-American children.
African American women's online evaluation of the breast cancer awareness and prevention portal of the www.divahealth.org website: using personal-level data and website ratings to tailor and improve the portal Sultan-Khan, 2010 [127] To conduct a survey to evaluate a new Breast Cancer Awareness and Prevention Portal for African American Women as an additional resource to the www.divhealth.org website Income and valuing the website features were found to be significantly correlated with website rating. Overall, the website is a viable method to provide preventative health information to this population.
Educating African American men about the prostate cancer screening dilemma: a randomized intervention. Taylor et al., 2006 [128] To determine the effect of educational interventions on knowledge, decisional conflict over whether or not to get screened, satisfaction with decision to do a screening, and self-reported screening; intervention was provided through a video or a Being given either the video or booklet (as opposed to nothing like the control group) increased screening rate and knowledge and decreased the decisional conflict over whether or not to get screened, but no difference was found between the two printed booklet types of media Development of a theory-based internet program promoting maintenance of diet and physical activity change to 8-year-old African American girls. Thompson et al., 2007 [129] To determine the effectiveness of a theory-based internet and multimedia program that promotes healthy eating and physical activity for 8 year old African American girls The multimedia tool that utilizes the internet and integrates theories is a viable method for changing diets and physical activity of 8 year old African American girls.
Audio computerized self-report interview use in prenatal clinics Thornberry et al., 2002 [130] To determine if computer interviewing women about their alcohol consumption at a prenatal clinic is a viable way to reach undeserved women Even though many of them women were disadvantaged (24% did not complete high school, 43% unemployed, 30% received public assistance, 59% used computers occasionally or never), 96% of the women stated that the computer was not difficult to use and 90% liked answering the questions via the computer Acceptance, Communication Mode and Use of Audio Computer-Assisted Self Interview Using Touchscreen to Identify Risk Factors among Pregnant Minority Women Thornberry et al., 2010 [131] To determine the acceptability, communication mode, and use of Audio Computer Assisted Self Interview (A-CASI) to change risk behaviors in pregnant women.
A-CASI was accepted amongst the women with African American's enjoying the experience the most.
Role of mobile health in the care of culturally and linguistically diverse US populations.

Tirado, 2011 [132]
To review public policy on four areas: mobile health service access and duty of care of physicians, affordability of mobile health, protocols for health data collection and distribution on mobile phones, and cultural and linguistic appropriateness of mobile health Policy recommendations are listed. However, the question posed is whether policy makers should plan ahead for these challenges or wait until the technology exist before taking action.
Racial differences of frail elders in assistive technology. Tomita et al., 1997 [133] To compare the differences in Black and White elderly patients living at home.
African Americans had fewer home modifications (most likely because they often rent their residencies) Specifically the study looked at assistive devices and home modifications. and had fewer assistive devices that their white counterparts.
Benefits & barriers to adoption of health IT in an elderly low-income, minority community-based environment Tran et al., 2009 [134] To discuss the attitudes, benefits, and barriers to implementation of health IT Despite challenges to the adoption of technology, senior residents will adopt the technology if they understand the benefits of the technology which includes keeping their independence Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project. Trief et al., 2009 [135] To determine whether self efficacy in older diabetic patients can relate to better health outcomes such as gycaemic control.
Diabetes self efficacy was linked to improving glycaemic control.
Impact of a multimedia breast cancer education intervention on use of mammography by low-income Latinas. Valdez et al., 2001 [136] To determine the effectiveness of a multimedia (video, animation, still photos, music, and sound on a kiosk) made up of ten modules on educating women on breast cancer The kiosks were effective as 40% of the women who had or scheduled a mammography after the intervention stated that the intervention was the reason they made the appointment To design and evaluate an interactive computer questionnaire regarding asthma symptoms of children whose parents have either low health literacy and/or limited English proficiency.
The reliability of the computer based questionnaire was higher than that of a pen and pencil questionnaire.
Using focus groups to develop a culturally competent diabetes self-management program for Mexican Americans. Vincent et al., 2006 [138] To describe factors that help or hinder diabetes self-management and to use these factors to create a culturally component diabetes self-management program.
The culturally competent diabetes self management program should contain a family aspect and include techniques for self management and diet modification. Further, information should be delivered in a few different methods. Telephone intervention to promote diabetic retinopathy screening among the urban poor Walker et al., 2008 [139] To determine if a bilingual tailored telephone intervention for an urban minority diabetes population would result in higher screening rates for The intervention was successful, especially among subjects who had poor diabetes control. To determine if the IDEATel project would help lower LDL-C cholesterol for older, ethnically diverse older adults.
The IDEATel project increased statin use and lowered LDL-C levels.
Glycemic control and health disparities in older ethnically diverse underserved adults with diabetes: five-year results from the Informatics for Diabetes Education and Telemedicine (IDEATel) study. Weinstock et al., 2011 [142] To discuss the possible benefits of telemedicine intervention Telemedicine intervention can reduce racial and ethnic disparities in glycemic control for older and underserved adults; Hispanics had the greatest improvement Goal setting using telemedicine in rural underserved older adults with diabetes: experiences from the informatics for diabetes education and telemedicine project. West et al., 2010 [143] To describe using IDEATel to set goals for behavioral change.
Out of all the rural patients, the elderly participants had the most difficulty using the computer. Overall, televisits were found to be a successful way to help improve diabetes self management Does entertainmenteducation work with Latinos in the United States? Identification and the effects of a Wilkin et al., 2007 [144] Examines the possible benefits of providing health information on a Telenova Education through use of a telenovela works telenovela breast cancer storyline.
The effect of an educational intervention on promoting breast self-examination in older African American and Caucasian women. Wood et al., 2002 [145] To determine the effectiveness of an age and race sensitive, self-monitored, video breast health kit for increasing knowledge about breast cancer.
The age and race sensitive video intervention was successful at increasing knowledge about both breast cancer risk and breast cancer screening.
Tribal connections health information outreach: results, evaluation, and challenges. Wood et al., 2003 [146] To discuss the implementation of the Pacific Northwest Regional Medical Library (PNRLM) which was created to improve tribal access to health information on the internet.
The project showed how important the involvement and empowerment of the community is for a successful outreach.
The health impact of resolving racial disparities: An analysis of US mortality data Woolf et al., 2004 [147] To determine if the focus on improving and including technology of care (aka drugs and devices) is hindering the process of reducing mortality disparities.
Achieving equity between African Americans and Whites would reduce mortality more than technological advances Text messaging for HIV prevention with young Black men: formative research and campaign development Wright et al., 2011 [148] To test the feasibility of using text messages as an HIV prevention method for young African-American Men The focus groups found that the men were open to text messages and suggested that humor be used and that the messages not be directed only at African-Americans as they felt like the senders were engaging in stereotypes Bilingual health literacy assessment using the Talking Touchscreen/la Pantalla Parlanchina: Development and pilot testing. Yost et al., 2009 [149] To determine the effectiveness of commercials about fruits and vegetables can have an impact on children's preferences for certain fruits and vegetables The talking touchscreen is expected to help improve health literacy and will be evaluated after it is tested on 1200 primary care patients