eSalud: Designing and Implementing Culturally Competent eHealth Research With Latino Patient Populations

Abstract

eHealth is characterized by technology-enabled processes, systems, and applications that expedite accurate, real-time health information, feedback, and skill development to advance patient-centered care. When designed and applied in a culturally competent manner, eHealth tools can be particularly beneficial for traditionally marginalized ethnic minority groups, such as Latinos, a group that has been identified as being at the forefront of emerging technology use in the United States.

In this analytic overview, we describe current eHealth research that has been conducted with Latino patient populations. In addition, we highlight cultural and linguistic factors that should be considered during the design and implementation of eHealth interventions with this population.

With increasing disparities in preventive care information, behaviors, and services, as well as health care access in general, culturally competent eHealth tools hold great promise to help narrow this gap and empower communities.

eHealth is defined by the application of electronic processes, systems, and technologies to deliver health information and resources to patients, caregivers, and health care providers.¹ This can include information delivered through the Internet (or private intranet servers) on desktop computers, mobile and tablet devices,² and stand-alone kiosks.^3,4 Specific examples may include online health forums,⁵ short message service texts with medication adherence prompts or health appointment reminders,⁶ smartphone apps to monitor one’s heart rate⁷ or daily activities,⁸ or nutrition education kiosks for promoting healthy eating habits.⁹ A primary goal of eHealth applications is to facilitate rapid, accurate, real-time health information, feedback, and skills training to improve patient care and allocate health care resources to patients in a more efficient, accessible, and cost-effective manner. eHealth can be viewed as a modern update of tailored health communication^10–12 characterized by health resources that are personalized and contextually relevant to its targeted population. eHealth provides a novel way to use new technologies to enable access to health care resources in a similar way. This form of communication, if used correctly, can be a vital system by which to deliver tailored health care information, education, and psychosocial, behavioral, and symptom management support to commonly disenfranchised groups, such as Latinos and other ethnic minority groups, who do not traditionally have immediate access to formal health care networks.

To this end, we provide an analytic overview of previous eHealth research studies and survey data that represent Latino populations and offer suggestions for ensuring culturally tailored intervention design and implementation with this population. Using common online search databases (e.g., PubMed, Web of Science, ProQuest, EBSCO), we entered multiple combinations of the following key terms to identify relevant publications on this topic: Hispanic, Latino/a, eHealth, mHealth, Internet, online, digital, kiosk, mobile, telephone, television, radio, technology, religion, gender, acculturation, language, health disparities, and culture. We began by reviewing abstracts of all peer-reviewed publications and organized and extracted information in a structured manner. Because this published literature made additional references to important non–peer-reviewed sources, we also included information from sources such as the Centers for Disease Control and Prevention, Pew Hispanic Center, and Nielsen Media Research.

LATINO HEALTH INFORMATION SEEKING

Latino health information–seeking behavior and receptivity to health information is complex. Factors of influence that often act as barriers can include lack of health care access, need for English-language proficiency, nationality and acculturation status, and attitudes and beliefs about illness and medical professionals (Figure 1).¹³

FIGURE 1—

eHealth modes of application and factors of influence for interventions with Latinos.

Of all people in the United States, Latinos are the least likely to have health insurance and the most likely to encounter barriers to health care access.^14,15 When Latino patients do receive health care, they are less likely to receive empathy, establish rapport, and participate in the decision-making process—issues magnified in patients with limited English proficiency.^16,17 When forced to rely on limited English skills to make crucial health decisions, their quality of care is compromised, and disparities persist. For these very reasons, alternative health interventions, such as those involving eHealth, are vital components of eliminating health disparities between Latinos and the rest of the population.

A lack of English-language proficiency is closely associated with lower levels of income and lower educational attainment among Latinos.¹⁸ In addition to having lower rates of health insurance and less exposure to health information channels, Latinos who are less comfortable speaking English report lower levels of trust in health information received from television, newspapers, and the Internet.¹⁹ These factors compound to make Latinos who are less comfortable speaking English a highly vulnerable demographic because they represent a population that is (1) more disease prone because of lower income and education, (2) less likely to receive health care owing to lower rates of insurance, (3) less exposed to health information via media channels, and (4) less trusting of health information when it is received. The magnitude of these disparities is made glaringly apparent when one realizes that 44% of Latino immigrants who have been in the United States for longer than 10 years consider themselves less comfortable speaking English.¹⁹ Many Latinos lacking English proficiency are new to the United States and have disproportionately low incomes; thus, a lack of familiarity with and access to traditional health care systems compounds with a diminished capacity to navigate and understand health information, resulting in a substantially diminished internal health locus of control.²⁰ Thus, the most effective and efficacious eHealth intervention is one that is administered through a cost-efficient and widely accessible route in a manner that provides a sense of trustworthiness.

In an observational study of more than 1000 Latinos aged 25 to 64 years, Gordon and Iribarren²¹ confirmed these findings and contributed new evidence that Spanish-dominant Latinos are significantly less likely to rate their physical and mental health favorably, less likely to meet recommended exercise guidelines, and less likely to believe that factors such as diet, exercise, and weight have a large impact on health. They also reported that 86% of Hispanics less comfortable speaking English have no Internet access on a typical day.²¹ Similarly, in a study of 737 low-income Latinos residing in Los Angeles, 49% reported being uninsured and three fourths experienced difficulties in accessing health care.²² Moreover, one fourth of these individuals did not have a regular place for health care, and 40% identified television as a health information resource. For comparison, 27% identified communication with family and friends as a health information source, and only 20% identified health professionals and providers as a source. Fewer than 10% reported using the Internet as a source for obtaining health information, and only 15% said they used books, newspapers, magazines, or pamphlets for this.²²

Oetzel et al.²³ examined the relationship between within-Latina group differences and their preferred breast health information sources. Study participants who self-identified as interdependent (e.g., placed greater value on relational connectedness over independence) reported using significant others and family members as primary sources for breast health information. Furthermore, women who reported placing greater emphasis on their individual actions with regard to health preferred receiving encouraging messages, whereas women who placed greater value on environmental factors with regard to health most preferred fear appeals in their messaging. Those who reported that health outcomes were dependent on some outside force and had little identification with an ethnic group were most likely to prefer no health information.²³

LATINO TECHNOLOGY USE AND eHEALTH APPLICATIONS

Looking ahead, with the ever-increasing population growth among the Latino community, this group is poised to become a major trendsetter with new forms of technology and early adoption of media use. Nielsen Media Research²⁴ has observed that Latinos access media from every available platform, with as many as 60% of Latino households using a minimum of 1 video- and Internet-enabled mobile telephone (compared with 43% of general population). This holds true for time spent watching Internet (68%) or mobile phone (20%) video when compared with non-Hispanic Whites.

Although Latinos may use the same technologies as non-Hispanic Whites, they tend to use them differently, with greater importance placed on cultural and linguistic factors.²⁴ Common use patterns among this group involve content that is available in Spanish; focuses on relevant, culturally important information (vs pure entertainment); and is suitable for coviewing by parents and children. With only 46% of foreign-born Hispanics completing a high school education,²¹ it is imperative that targeted health interventions account for the linguistic proficiency of this demographic. Individuals with limited English proficiency often find themselves overwhelmed and confused by physicians’ use of jargon, which magnifies health disparities.²⁵ López and Grant²⁶ posited that eHealth technologies are not only more cost effective but are also and will become a more effective means of reaching Latinos for health matters. They argued that the digital divide is beginning to narrow because Latinos’ use of the Internet rose 54% to 64% between 2006 and 2008, suggesting that over time, more Latinos will have access to the Internet and other technologies, allowing more to partake in eHealth interventions.

Television and Radio Use

Latinos watch more television than the general population and are more likely to take action as a result of information learned from television. A 2007 study by Wilkin et al.²⁷ demonstrated the feasibility of the telenovela as a medium for increasing behavioral intentions as well as health knowledge. An episode of a popular telenovela targeted to Latino viewers contained a public service announcement encouraging viewers to call a cancer hotline, as well as 3 informational messages regarding breast cancer. On days on which the episode aired, the number of calls to the hotline doubled, and a follow-up survey of viewers indicated that the episode resulted in a significant increase in correct knowledge regarding the emphasized messages. Furthermore, male viewers’ behavioral intention to encourage women in their lives to undergo a mammogram increased significantly.²⁷

Spanish-language radio programming has also been shown to be an acceptable means of conveying health information. La Clınica del Pueblo is a health education program targeted to Latinos that consists of a weekly radio show and corresponding articles in a local Spanish-language newspaper. Analysis of the program has demonstrated significant increases in knowledge regarding health topics addressed by the program.²⁸

Internet Use

When taking into account all possible sources for technology availability (e.g., work, school, public places, and extended family), 90% of Latinos have Internet access, yet more than 75% do not have Internet access at home.²⁴ Selsky et al.²⁹ surveyed 1273 Latino immigrants on Internet accessibility and usage. About 44% of participants had regular Internet access and showed self-efficacy and general trust of information found online. More than half (58%) said they would search the Internet for cancer-related information if or when they needed it. Internet access, however, appeared to be associated with socioeconomic factors, including fluency and comfort with the English language, younger age, and higher health literacy. As education level increased, so too did the likelihood of Internet use for seeking cancer-related information. Furthermore, more women than men used the Internet as a health resource.²⁹ When Roncancio et al.²⁰ examined Internet use among Latinas (n = 932) aged 16 to 24 years, they found that high levels of acculturation, signified by fluency with the English language, and internal health locus of control increased the likelihood of Internet use for health-related information seeking. Highly acculturated Latinas tended to be younger and had higher incomes,²⁰ findings consistent with those of Finney Rutton et al.,³⁰ who found that, beyond age and education level, the Internet is a widely used source and a potentially useful medium through which to dispense information to adult Puerto Ricans.³⁰

Graham et al.³¹ evaluated the effectiveness of 4 Spanish-language online banner advertisements in recruiting Spanish-speaking smokers to a free Spanish-language smoking cessation Web site. Findings showed that 204 surveyed Spanish-speaking Latinos preferred ads using themes relating to the family versus fatalism. In addition, researchers found that surface targeting (based on sociodemographic characteristics) versus deep targeting (based on attitudes, values), loss-framed messages versus gain-framed messages, and gender versus social media Web sites determined how successful the ads were in spreading awareness and recruiting 500 registrants to the Web site. Similarly, Justice-Gardiner et al.³² found that visits to a Spanish-language cancer support Web site nearly doubled when social media (e.g., Facebook, Twitter) campaigns are used.

Roberto et al.³³ compared the effects of individually tailored, culturally targeted, and generic Web-based messages on Latinos’ perceived susceptibility and intention to consult a doctor about kidney disease. Although all 3 message types significantly increased perceived susceptibility compared with the no-message control, the tailored group demonstrated significantly greater perceived susceptibility than the other groups, which did not differ significantly from one another with regard to perceived susceptibility. All 3 experimental groups resulted in a significant increase in intention to consult a doctor, but no significant between-group differences were found. Another study comparing the use of the Cancer Information Service telephone hotline and online messaging service discovered that almost 98% of information seekers elected to use the telephone hotline over the online messaging service. Use of the messaging service was associated with higher educational attainment and being younger than 40 years.³⁴

Owing to the importance of family members in the long-term care of Latinos with Alzheimer’s disease, Weitzman et al.³⁵ developed a culturally attuned, plain-language Web site accessible in English and Spanish to serve as a resource for caretakers of individuals with Alzheimer’s. At posttest, the Web site led to significant increases in Alzheimer’s knowledge among a general sampling of Latino adults. More than 80% of the sample of individuals caring for a family member with Alzheimer’s reported that the Web site was comprehensible and easy to navigate.

The Moreno et al.³⁶ study was the first of its kind to use video conferencing to treat depression in Latino adults. The intervention group (n = 80) met monthly with a psychiatrist via webcam and the control group (n = 87) received psychiatric care as usual. Both groups were assessed at baseline, 3 months, and 6 months. Both groups showed significant reductions in depressive symptoms over time compared with baseline, notable increases in quality of life, and an overall decrease in disability ratings, suggesting that webcam psychiatric treatment may be just as effective as in-person psychiatric treatment.

Kiosk Use

Health interventions that use easily comprehensible text and diagrams are vital to eliminating the communication barrier between Latinos and health information. Makoul et al.³⁷ developed a colorectal cancer information kiosk that relied on diagrams to illustrate key anatomy and plain-language text to discuss basic colorectal cancer information and screening options for Latinos. The intervention increased participants’ ability to identify relevant anatomy by 50% and significantly increased participants’ willingness to undergo 3 different colorectal cancer screenings. In another study by Leeman-Castillo et al.,³⁸ a kiosk that made available targeted health information in English and Spanish was shown to promote physical activity and healthy diet among Latinos. Participants were matched on health status with a computerized role model of the same gender and similar age and given feedback and provided comparisons with the Surgeon General’s recommendations. At a 2-month follow-up, the number of participants eating the recommended 5 or more servings of fruits and vegetables per day doubled, and the number of participants meeting the daily recommendation for exercise increased by 20%.

Andersen et al.³⁹ evaluated a kiosk prototype to deliver bilingual smoking awareness presentations to low health-literate and functionally illiterate Latinos at local clinics. Researchers carried out a street survey (n = 288) on Latino use of self-checkout kiosks, revealing that Latinos use them frequently, find them easy to use, and use computer-mediated technologies as often as Whites. This was followed up with focus-group research to discuss the use of kiosks. Members agreed that short and concise text, images showing real people, and a lack of religious icons would enhance presentations for Latinos.

Mobile Telephone Use

Latinos are 3 times as likely to access the Internet from a mobile device and more than 25% more likely to own a smartphone than non-Hispanic Whites.²⁴ Moreover, 2 studies^26,40 reported on several 2012 Pew Research surveys that demonstrated that Latinos are just as technologically connected as other groups. Findings showed that 86% of Latinos (compared with 84% of Whites and 90% of Blacks) reported cell phone ownership, with 49% reporting smartphone ownership (compared with 46% of Whites and 50% of Blacks). They were also 16% more likely than Whites to access the Internet using a mobile device and 2% more likely to use social networking sites.

Given the prevalence of smartphone and mobile device use among Latinos, López and Grant²⁶ suggested that cell phone–mediated interventions may prove most effective in targeting hard-to-reach populations. Vyas et al.⁴¹ evaluated the potential effectiveness of a mobile phone–mediated intervention among Latino adolescents (n = 428). They used texts and social media to communicate health information that focused on decreasing sexual risk behaviors. The majority (91%) owned, shared, or borrowed a cell phone on a regular basis, and 94% frequently used text messages. Of those using texts, a little fewer than half (41%) sent or received more than 100 text messages a day. Most participants (n = 384) had an account on a social media Web site, and many of those who did (76%) noted daily use. Price et al.⁴² demonstrated that mobile phone health interventions are feasible even among marginalized Latino subgroups. For example, of 80 migrant farm workers surveyed at a South Carolina worksite, 65 (81%) owned short message service text-enabled phones, and all these individuals reported receptive attitudes toward using mobile health technology. Using information from the 2003 Health Information National Trends Survey, Waters et al.³⁴ evaluated the usage rates of the National Cancer Institute’s toll-free cancer hotline among Latinos. Findings demonstrated the viability of the hotline medium and concluded that compared with non-Hispanic users, English-dominant Latinos significantly preferred the hotline over an instant messaging service also offered by the National Cancer Institute. Although almost 50% of Latinos who sought cancer information did so in Spanish, no additional information was available on participants who spoke only Spanish regarding the instant messaging service because the service was only available in English.

CULTURALLY COMPETENT eHEALTH DESIGN AND IMPLEMENTATION

When designing and implementing eHealth interventions with the Latino community, the challenge is not only to provide accurate and comprehensive information but also to tailor the messages so the information is most relevant and accessible to the user. Tailored messages and interventions attempt to embody and incorporate unique cultural norms, values, and structures into the message or intervention itself.^43,44

Spanish-Language Availability

English-language proficiency is both a symptom of and a barrier to Latinos’ health information–seeking behaviors and their access to information. A 2005 Health Information National Trends Survey revealed that more than 80% of predominantly Spanish-speaking Latinos had never looked for cancer information.¹⁸ Compared with English-speaking respondents, Spanish-only speakers who sought cancer information indicated their search took a lot of effort (67%), was hard to understand (54%), and was frustrating (42%).¹⁸ Moreover, Spanish-only speakers noted a lack of confidence in obtaining cancer information. Education, language, and income levels explained much of the within-group differences.¹⁸ These findings mean alternative channels and messages that support language preferences and literacy levels are necessary to provide health information.

Modifications of messages to meet different language needs can take on a variety of forms. For example, the Centers for Disease Control and Prevention has recommended integrating both English and Spanish languages when designing health messages.¹³ This style of message is particularly important with younger populations because it mirrors their blended language pattern. In a focus group study, Kinney et al.⁴⁵ found that Latinos who spoke limited English appreciated health messages that included visual aids, images of Latino-appearing people, and simple language more so than those with more refined English, who wanted more information.

Level of Acculturation and Nationality

When developing tailored eHealth resources for Latino populations, it is important to appreciate the diversity of Latino communities because different communities have varying levels of acculturation. Acculturation is defined as a developmental adaptation that occurs through sustained contact with a culture distinct from one’s culture of origin in which a person integrates native and traditional immigrant cultural values with dominant cultural ones.⁴⁶ Given the developmental nature of the acculturation process, it can be difficult to ascertain at what point someone is. For example, when recruiting children and families of Mexican descent to a school-based program, Dillman Carpentier et al.⁴⁷ found that families whose children were more acculturated were less likely to positively respond to the culturally tailored invitations than families who were predominantly Spanish speaking and less acculturated. This suggests that Spanish-language and culturally tailored health services are most effective for families who are predominantly Spanish speaking and less acculturated, whereas culturally tailored health initiatives may not be as appropriate for families who are already highly acculturated.

In addition to the degree of acculturation, health professionals must also consider the variances in access to health care that exist among different Latino nationalities. Subgroups differ in their lifestyles, health beliefs, and health practices. For example, Berdahl and Torres Stone⁴⁸ found variation among Whites, Mexicans, Puerto Ricans, and Cubans when it came to use of mental health services. Acculturation explained much of the difference in use between Whites and Cubans and some of the difference between Whites and Mexicans, but it explained none of the difference for Puerto Ricans. In general, Mexicans and Cubans may have difficulty accessing health care services because of their legal status, whereas individuals born in Puerto Rico automatically acquire US citizenship. Puerto Ricans not only seek mental health services more often than other Latino subgroups, but their utilization rates are also comparable to those of Whites. Mexicans, as a whole, are disadvantaged in accessing and using any health care service.⁴⁸

Similarly, Latino subgroups exhibit differences in Internet use. Although overall rates are expected to rise, the Pew Hispanic Center found that Latinos of South American origin use the Internet more frequently than other subgroups, followed closely by Puerto Ricans and those of Cuban descent. Individuals of Dominican Republic origin access the Internet close to the average rate of all Latinos, whereas those of Mexican and Central American descent show the lowest rates of Internet use.⁴⁹ These variances suggest that health professionals cannot simply design health communications to target Latinos using generalized ethnic and cultural concepts. Rather, they should incorporate subcultural differences, beliefs, and values into their design of health communications and interventions, especially when working with individuals predominately from one subgroup or another.⁵⁰

Illness Beliefs and Attitudes

Cultural attitudes and beliefs about illness and medical care can impede information-seeking behavior by minimizing communication with family members and health care providers about health risk.⁴⁵ Some Latinos may also believe health is a result of luck and a reward for good behavior, and poor health the opposite.⁵¹ So messages directed toward Latinos should include language intended to alleviate some of the negative perceptions associated with illness.

Latinos might also hold negative attitudes toward medical professionals.⁵² Betancourt et al.⁵⁰ found that Latina women were significantly more likely than White women to report that their professional was not honest and that he or she did not return phone calls, and the intensity of mistreatment for similar events was more frequently cited among Latinas. Such mistrust can eventually lead to less self-efficacy and less positive coping when dealing with health problems.⁵³ These findings indicate the need to uncover the source of these psychological factors while also attending to cultural factors.

Intervention Delivery Preferences and Styles

In addition to culturally tailored design considerations, one must also consider optimal forms of delivery or implementation of eHealth interventions.

Physician as the messenger.

In general, Latinos prefer to receive health information from their physician,⁵⁴ but there can be a mismatch between the preferred and actual amount of involvement in patient–physician health decision making.⁵⁵ Factors contributing to the mismatch include degree of acculturation, language barriers, and poor patient–physician communication practices.⁵⁵ Attention to the barriers described earlier, as well as key cultural considerations, can perhaps reduce this disconnection in delivering eHealth interventions.

Importance of gender roles.

Another consideration in how health messages and interventions are delivered is the role of gender. Traditionally, Latino men are more reluctant to consult with physicians; however, they are often the ones who determine when a family member needs medical care and who give permission for treatment.⁵⁶ This practice often reflects Latinos who subscribe to the values of machismo (strong cultural sense of traditional masculine pride) and marianismo (cultural veneration for traditional feminine virtues). Although men often determine permission, the wife and mother also often serves as a primary target of health promotion interventions given traditional norms and roles. In many cases, the woman serves as the primary force of behavior change within the family.⁵⁷ With this understanding, effective methods of eHealth delivery should be sensitive to who is making health care decisions in a given family.

Role of religion and family networks.

Effective delivery of eHealth messages with Latino populations includes consideration for the role of religion and family. Health messages that attend to faith in God may play an important role when helping families to understand and cope with their illnesses, although this may not hold true for all Latinos.^58,59 Also, recognition of familismo, or the cultural value of loyalty toward one’s family over individual or community needs, should also be considered when delivering eHealth interventions,⁶⁰ which for this reason may attempt to engage the broader family network rather than focusing on 1 level.²⁷ For this reason, social media can be an effective way to reach Latino populations who use social media to guide decisions and opinions.^32,41 Social networking Web sites facilitate collective sharing of information and communication, and although not all Latinos have access to social media, trends in access and use are changing.

CONCLUSIONS

Technology access and use among US Latinos is on the rise, and parallel to this trend is the development and application of eHealth interventions for this population. By designing and delivering eHealth tools that are culturally competent, medical health professionals can help to increase education, support, and access to care, thereby reducing health disparities among Latinos. Health communications that are tailored or targeted to the characteristics and needs of a selected population are more likely to be attended to than those that are not⁶¹; therefore, attending to linguistic and cultural values, norms, and structures is vital to effective eHealth development and delivery with the Latino population.