摘要：The digital divide related to consumer information technologies (CITs) has diminished, thus increasing the potential to use CITs to overcome barriers of access to health interventions as well as to deliver interventions situated in the context of daily lives. However, the evidence base regarding the use and impact of CIT-enabled interventions in health disparity populations lags behind that for the general population. Literature and case examples are summarized to demonstrate the use of mHealth, telehealth, and social media as behavioral intervention platforms in health disparity populations, identify challenges to achieving their use, describe strategies for overcoming the challenges, and recommend future directions. The evidence base is emerging. However, challenges in design, implementation, and evaluation must be addressed for the promise to be fulfilled. Future directions include (1) improved design methods, (2) enhanced research reporting, (3) advancement of multilevel interventions, (4) rigorous evaluation, (5) efforts to address privacy concerns, and (6) inclusive design and implementation decisions. The digital divide related to consumer information technologies (CITs) has diminished. Cell phone ownership is higher among African Americans and Hispanics than among non-Hispanic Whites, and smartphone ownership is at least 75% for all three groups. 1 Rural residents continue to lag behind those who live in urban and suburban areas in technology ownership, but about two thirds now have desktop computers or laptops and smart phones. 2 This increases the potential to use CITs to overcome barriers of access to health interventions as well as to deliver interventions situated in the context of daily lives and is particularly relevant for interventions aimed at behavior change. However, the evidence base regarding the use and impact of CIT-enabled interventions in health disparity populations lags behind that for the general population. The National Institute on Minority Health and Health Disparities (NIMHD) defines a health disparity as a health difference that adversely affects disadvantaged populations, based on 1 or more health outcomes. The main health outcomes are 1. higher incidence or prevalence of disease, 2. earlier onset or faster progression of disease, 3. poorer daily functioning or quality of life, 4. premature or excessive mortality, and 5. greater global burden of disease. 3 Health disparity populations include “racial/ethnic minorities, low socioeconomic status, rural, sexual and gender minorities, and/or others subject to discrimination who have poorer health outcomes often attributed to being socially disadvantaged, which results in being underserved in the full spectrum of health care.” 3 (pxxx) A substantial number of systematic reviews and meta-analyses have assessed the quality of intervention studies as well as synthesized the evidence across studies, particularly randomized controlled trials, to advance what is known about CIT-enabled interventions in general and for those with specific health conditions, such as heart failure, asthma, tobacco use, obesity, and inadequate physical activity, and reflect a growing evidence base about the efficacy of CIT-enabled behavioral interventions for chronic disease and lifestyle modification. 4–9 In contrast, the reviews about CIT-enabled interventions in health disparity populations are more descriptive in nature. 10,11 For example, a 2012 review of 125 CIT studies focused on health and wellness in historically underserved populations characterized the types of technologies involved, types of users, health topics covered, and evaluation focus, including outcomes measured. 11 Although the authors did not synthesize the findings of the studies reviewed, they made several recommendations about the use of CITs for health and wellness interventions. These included tailoring the CIT-enabled intervention to the intended population, contextually situating the CIT-enabled intervention to increase likelihood of behavior change, and increasing the use of mobile health (mHealth) and social media. They also called for explicit reporting of design processes to promote development of best practices and to standardize evaluation processes to create benchmarks for culturally informed use of CITs for health. Another descriptive review highlighted the promise of CITs for supporting health education and behavior change in underserved populations. 10 Within the overall vision for the science of minority health and health disparities, the vision for CIT-enabled behavioral intervention research is to integrate the mechanisms of behavior change with appropriate CITs and persuasive design principles to rigorously design, implement, and evaluate CIT-enabled behavioral interventions for health disparity populations. The ultimate goal is to reduce health disparities by harnessing CITs to improve access to behavioral interventions, tailor intervention content to user characteristics and contexts, facilitate sustained engagement with the intervention, and support innovative evaluation strategies. Motivated by this vision and goal, we critically analyzed and synthesized research on CIT-enabled behavioral interventions in general along with selected case examples from health disparity populations to (1) briefly summarize what is known about the use of 3 categories of CIT (mHealth, telehealth, and social media) as approaches for single and multilevel interventions aimed at improving health behaviors and outcomes of health disparity populations, (2) identify challenges to achieving their use and impact, (3) describe strategies for overcoming the challenges, and (4) recommend future directions (see the box on this page). Recommendations for Harnessing Consumer Information Technology–Enabled Behavioral Interventions as Tools to Advance Health Equity 1. mHealth, telehealth, and social media–enabled behavioral intervention design should a. Integrate methods that facilitate the alignment of intervention focus, CIT platform, and user characteristics such as cultural beliefs, preferences, and functional, digital, and health literacy as well as ecological context of use; and b. Incorporate mechanisms of action for behavior change and persuasive design principles to sustain user engagement with the CIT-enabled intervention. 2. Encourage rigorous reporting standards for individual studies and promote adherence to the 20 equity-based extensions to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline. 3. Advance multilevel interventions by linking mHealth and social media–enabled interventions with the health care delivery system through EHR-based approaches such as clinical decision support, tethered patient portals, and clinical dashboards. 4. Evaluate mHealth, telehealth, and social media–based interventions rigorously throughout the stages of developing and implementing the CIT-enabled intervention with the evaluation design matched to stage of development (i.e., conceptualization through effectiveness testing). 5. Address user privacy concerns at the individual study level, and through policy advocacy at institutional, state, and national levels. 6. Make design and implementation decisions that foster the inclusion and sustained engagement of health disparity populations in CIT-enabled intervention studies. Open in a separate window Note. CIT = consumer information technology; EHR = electronic health record..
