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Speaking of Health: Assessing Health Communication Strategies for Diverse Populations (2002)

Chapter: 6 New Communication Applications and Technologies and Diverse Populations

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Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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6
New Communication Applications and Technologies and Diverse Populations

THE CHANGING HEALTH COMMUNICATION LANDSCAPE1

Communication applications and technologies changed dramatically over the 20th century. The telephone did not become a routine means of communication in the United States until World War I (Mandl, Kohane, and Brandt, 1998). In the early years of its use, there was concern that the telephone might harm doctor-patient relationships. Now we accept the telephone as part of everyday life and as an essential part of health care. The committee recognizes that telephone coverage averages about 95 percent for the United States, but noncoverage varies from 1.8 percent in Delaware to 13.3 percent in New Mexico. Telephone coverage also is lower for some population groups, e.g., Blacks in the South, persons with low incomes, and people in rural areas (Cen-

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We are grateful to David Gustafson and Bernard Glassman for their contributions to this chapter. We also thank Lee Rainie, Director, Pew Internet & American Life Project, for generously sharing information.

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

ters for Disease Control and Prevention Comparability of Data, http://www.cdc.gov; Behavioral Risk Factor Surveillance System, 2000). The evolution of social activities and social relations brought about by the telephone pales in comparison to the communication revolution being propelled by the Internet. Health communication is at the forefront of that revolution.

The last decade of the 20th century was distinguished by massive changes in the way people get information, including health information. By the beginning of the 21st century, there were more communication channels than ever before—not only face-to-face, print, telephone, radio, TV, fax, VCR, DVD, and CD-ROM, but also the many options possible through personal and networked computers, including the Internet, with both wired and wireless options. New phrases such as “instant messaging” became part of the global vocabulary nearly overnight. The early 20th century discussions about the impact of the telephone were replaced by commentaries about the impact of e-mail on doctor-patient relationships. Perhaps no other innovation has transformed communication as quickly and with as much reach as the Internet (Lucky, 2000). As Bandura (2001:6) observed, “new ideas, values, behavior patterns and social practices now are being rapidly diffused by symbolic modeling worldwide in ways that foster a globally distributed consciousness.”

The growth of new technologies parallels changes over the past half century in the patient role and the patient-physician relationship. Increasingly, patients want to play an active role in making decisions about health (see, e.g., Chen and Siu, 2001; Edwards and Elwyn, 1999). Across a number of health topics, patients say they want to receive as much information as possible (Chen and Siu, 2001; Fallowfield, 2001; Cassileth, 2001; Bluman et al., 1999). Furthermore, whether they want to play an active role or not, the evolution of the health system may force them to play that role to an ever-increasing extent. Physicians and other health professionals may have less time available to follow up aggressively with patients. Patients and their families may assume increasing responsibilities for negotiating their way through the system, obtain-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

ing prevention information, finding appropriate care, and gaining follow-up advice.

This chapter will explore the use of new health communication technologies and new uses of current technologies, with a focus on diverse audiences. We will describe the nature and potential benefits and limitations of these communications, summarize the evidence especially with regard to diverse populations, and recommend several actions to reduce the barriers to their use and to speed access to a range of new communication applications and technologies, including Internet-based applications among all population groups. Our recommendations also include potential research. A caveat is in order: Little research has been published on the experience of diverse populations with these new technologies. The research that is reported generally includes few controlled trials, and many of the samples are still small. In most cases, if there are data on diverse populations, they are in the context of studies that include both diverse and nondiverse populations. Like other good interventions, computer-based applications should be developed and measured with theory as a foundation, as described elsewhere in this volume (Chapter 2). Moreover, they should specify the linkages among cognitive/affective domains, behavioral objectives, and program content (Rhodes, Fishbein, and Reis, 1997).

INNOVATIVE USES OF CURRENT TECHNOLOGIES

New uses of current and widely accessible communication media, such as print and telephone, have been possible because of computer applications that have permitted content to be tailored to individuals, allowing people to use older tools in new ways. Tailored print communications (TPCs) and telephone-delivered interventions (TDIs) are among the most widely used innovations. The potential of these media for reaching those with and without Internet access, and people with highly diverse linguistic and cultural requirements, should not be underestimated, nor should the challenge of harnessing the new media to reach diverse audiences.

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Tailored Print Communication

TPCs are printed materials created especially for an individual based on relevant information about that person, usually from the person (e.g., by telephone interview or self-administered questionnaire) with or without other data (such as medical records) (Skinner et al., 1999; de Vries and Brug, 1999; Kreuter and Skinner, 2000; Kreuter et al., 2000b). At least theoretically, computer-tailored print materials permit the reach of mass media, with content that is relevant and appropriate to recipients. This is why tailored approaches have been referred to as mass customization. Where generic materials might include a substantial amount of irrelevant content for any individual, tailored materials can provide information needed to modify specific antecedents of behavior change and enhance skills for a particular individual. For example, tailored materials can suggest dietary changes based on the recipients’ eating patterns and preferences. Tailored information is different from personalized information, which may be as simple as putting a name on a brochure, and has no demonstrable impact on behavior change (Kreuter et al., 1999; Kreuter and Skinner, 2000b). Tailored information also is distinct from targeted communication, which is based on the social marketing principle of market segmentation, using group variables such as ethnicity to design special communication to meet group needs. Segmentation is discussed further in Chapters 2 and 3.

Tailored interventions range from those that are very simple and tailor only a few variables, perhaps in a letter, to more elaborate tailored booklets based on algorithms that have potentially billions of combinations of pieces of health-related information. Tailoring can range from the most precise algorithm that adjusts individual words and phrases within a sentence to methods that choose whether to include a whole topic (Bental, Cawsey, and Jones, 1999). Some systems allow specific questions to be answered (Buchanan et al., 1995). Many formats are possible, including tailored letters, booklets, calendars, newsletters, games, and church bulletins. The possibilities are nearly limitless, but

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

should be appropriate to particular audiences. Like any good intervention, tailored interventions should reflect participation of potential users at every stage. As with other print interventions, some are designed better than others.

Bental, Cawsey, and Jones (1999), Dijkstra and de Vries (1999), Kreuter et al. (1999), Rimer and Glassman (1999), and Kreuter et al. (2000b) provide more detail about how tailored communication is created. Briefly, tailored materials require: (1) identification of relevant individual-level characteristics; (2) a message library; and (3) an algorithm that specifies the decision rules for assigning particular messages to individuals (Dijkstra and de Vries, 1999). A fundamental part of developing TPCs is the creation of a message library that contains all possible messages that could be given to an individual under different conditions (Rimer and Glassman, 1999; Kreuter et al., 1999; Kreuter et al., 2000b). For example, a woman who is thinking about getting a mammogram would get a very different message from a woman who has never considered having one.

More than 40 studies of TPCs have been reported, and several summary articles have been published (see, e.g., Strecher, 1999; Rimer and Glassman, 1999; Dijkstra and de Vries, 1999; Skinner et al., 1999). As Table 6-1 shows, reports of TPCs have covered a wide range of health-related behaviors, including diet, exercise, smoking cessation, weight reduction, mammography, prostate cancer screening, hormone replacement therapy, health risk appraisal, and multiple risk behaviors. More recent studies, as well as some that are ongoing, have extended tailoring to new formats and variables, including the use of cultural tailoring (Kreuter et al., in press; Lukwago et al., in press; Lukwago et al., 2001).

TPCs that were tested in these studies used many kinds of tailoring based on theories such as the Elaboration Likelihood Method (Petty and Cacioppo, 1979b; Kreuter et al., 2000; Kreuter and Holt, 2001), Stages of Change Model, Social Cognitive Theory, and the Health Belief Model, and using variables such as self-efficacy, perceived susceptibility and risk, as well as barriers and facilitators to behavior change (Glanz, Rimer, and Lewis, in

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

TABLE 6-1 Evidence for the Effectiveness of Tailored Print Communications

 

Significant Outcome by Authora

Impact

Yes

No

More likely to be read, recalled, rated more highly, discussed with other people, and perceived as interesting and relevant

Brinberg and Axelson, 1990

Campbell et al., 1994,b 1999,b 2002b

Skinner et al., 1994

Dijkstra et al., 1998a

Strecher, 1999

Brug et al., 1996, 1998

Lipkus et al., 1999,b 2000

Kreuter et al., 1999, 2000b

Rimer et al., 1999,b 2002

DeBourdeaudhuij and Brug, 2000

Etter and Perneger, 2001

Nansel et al., 2002b

Blalock et al., 2002

McBride et al., 2002b

Curry et al., 1995

Bull et al., 1999a

Significant main effect or subgroup effect on smoking cessation

Dijkstra et al., 1999

Strecher, 1999

Lipkus et al., 1999,b 2000

Velicer et al., 1999

Orleans et al., 2000

Prochaska et al., 2001

Becona and Vazquez, 2001b

Etter and Perneger, 2001

Lennox et al., 2001

McBride et al., 2002b

Curry et al., 1995

Dijkstra et al., 1998b

Campbell et al., 2002b

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

 

Significant Outcome by Authora

Impact

Yes

No

Significant decrease in dietary fat intake

Brinberg and Axelson, 1990

Bowen et al., 1992

Campbell et al., 1994,b 1999,b 2002b

Kreuter and Strecher, 1996

Brug et al., 1996, 1998

DeBourdeaudhuij and Brug, 2000

Siero et al., 2000b

Significant increase in fruit and vegetable intake

Brug et al., 1998

Campbell et al., 1999,b 2002b

Kristal et al., 2000

Delichatsios et al., 2001

Campbell et al., 1994b

Brug et al., 1996

Lutz et al., 1999

Significant effect on weight reduction

Burnett et al., 1985

 

Significant effect on exercise behavior or main effect on those not exercising at baseline

Kreuter and Strecher, 1996

Bull et al., 1999a

Marcus et al., 2000b

Bock et al., 2001

Campbell et al., 2002b

Bull et al., 1999b

Blalock et al., 2002

Increased adoption of home and car safety behaviors among parents of young children

Nansel et al., 2002b

 

Increase use of calcium supplements to prevent osteoporosis among persons thinking about but not appropriately performing the behaviors

Blalock et al., 2002

 

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

 

Significant Outcome by Authora

Impact

Yes

No

Improve decision making about HRT

McBride et al., in pressb

 

Significant main effect or subgroup effect on use of mammography

Skinner et al., 1994

Rakowski et al., 1998

Rimer et al., 2001, 2002

Valanis et al., 2002 1999b

Meldrum et al., 1994b

Drossaert et al., 1996

Rimer et al.,

More accurate assessment of breast cancer risk

Lipkus, Rimer, Strigo, 1996

Rimer et al., 2002

McBride et al., in pressb

Skinner et al., in press

 

Improved completion of multiple tests needed by women

Harpole et al., 2000b

 

Increased adherence to early detection for prostate cancer

Myers et al., 1999b

 

Increased adherence to cervical cancer screening

Campbell et al., 2002

 

Improved knowledge about genetic testing and related issues and increase accurate assessment of risk of being a mutation carrier

Skinner et al., in press

 

aNote: Only first or first and second author(s) listed here in order to conserve space, co-authors can be found in reference list.

bFocuses on or analyzes impact on diverse populations.

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

press). In some cases, pictorial material was tailored, as were variables such as personal risk, self-confidence, smoking characteristics, and specific behavioral recommendations. Very different approaches to tailoring have been used. For example, some studies have created materials that are stage matched and tailored, while others have been tailored entirely for individual items or variables. No reported study has compared the effects of different tailoring systems.

Although the data are not unequivocal, most studies have shown main effects or important interactions. In some cases (e.g., Lutz et al., 1999; Lennox et al., 2001), tailored materials outperformed the control group, but were no better than nontailored materials. More research is needed to understand the mechanisms underlying both effective and ineffective TPCs and whether some tailoring algorithms and approaches are better than others. Substantial evidence shows that TPCs are more likely to be read and kept, that they are rated more highly than generic materials, and that they produce changes in knowledge, beliefs, and behaviors. Where they are effective, their success seems to be partly because of the greater level of attention paid to tailored communication (de Vries and Brug, 1999; Kreuter et al., 1999; Becona and Vazquez, 2001). Consistent with the Elaboration Likelihood Method, there is increasing evidence that tailoring causes recipients to pay more attention and to process more deeply, leading to improved comprehension and behavior change (Kreuter et al., 1999; 2000). When combined with a physician message that “primes” patients to pay attention to subsequent messages, TPCs may be especially powerful (Kreuter, Chheda, and Bull, 2000).

More work is needed in this area. Specifically, none of the reported studies was designed to answer the following question: Did a particular intervention perform differentially with a diverse population? However, several of the published studies focused on or included analyses of effects on diverse populations (e.g., Campbell et al., 1994, 1999, 2002; Skinner, Strecher, and Hospers, 1994; Rimer et al., 1999; Becona and Vazquez, 2001) (see Table 6-1). The results are encouraging. Skinner and colleagues showed

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

that tailored letters about mammography had a significant subgroup effect on African-American women. Lipkus and colleagues (Lipkus, Lyna, and Rimer, 1999) found that tailored birthday letters and newsletters had a highly significant effect on smoking quit rates among low-income African-Americans, especially men. Campbell et al. (1994) showed that a combination of tailored church bulletins and other culturally appropriate interventions resulted in significant increases in fruit and vegetable consumption in a low-income African-American population. In a study of blue-collar women, Campbell et al. (2002) found increases in several behaviors, including fruit and vegetable consumption, flexibility exercise, and short-term change in fat intake, but no changes in smoking or cervical cancer screening in a worksite program that also included natural helpers. Kreuter, Vehige, and McGuire (1996) reported that a tailored calendar improved the rate at which parents adhered to their children’s immunization schedules. Myers and colleagues (1999) demonstrated that an enhanced intervention composed of telephone and print materials tailored to African-American men with no previous history of prostate cancer resulted in increased adherence to early detection for prostate cancer. Becona and Vazquez (2001) showed that the combination of a standard self-help smoking cessation intervention and tailored letters resulted in a significant improvement over self-help alone for Hispanic smokers, with impressive abstinence rates.

Nansel et al. (2002) tested the efficacy of tailored print materials produced for parents to reduce child injury-promoting behaviors in the home and car in a primarily minority sample. McBride et al. (2002) extended previous work on genetic susceptibility and tobacco control by examining the use of feedback about a genetic biomarker of cancer susceptibility to increase smoking cessation in a low-income African-American population. At 6 months (but not at 12 months), there was a significant difference between those who received TPCs with biomarker feedback (19-percent quit rate) versus enhanced usual care (10-percent quit rate). These studies are encouraging. They show that for a wide range of topics, TPCs are efficacious for both white and ethnic minority populations. In

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

one of the few studies that showed an ethnic group disadvantage, McBride et al. (in press) found that tailored materials about hormone replacement therapy were less effective for African-American women than for white women.

In many cases, TPCs are more effective when combined with other interventions. Among the most promising are telephone counseling and natural helpers (e.g., Lipkus, Rimer, and Strigo, 1996; Rimer et al., 2002; Blalock et al., 2002; Campbell et al., 2002; Earp et al., 2002). The addition of such components may be especially important in reaching women with lower levels of income and education and in explaining topics that are complex and require informed decision making. More research is needed that examines combinations of tailored interventions with other appropriate interventions. It is important to think about systems of interventions.

Telephone-Delivered Interventions

TDIs include a range of human-delivered counseling and reminder interventions delivered using the telephone and computer-generated voice response systems. These are often complex interventions that include components designed to motivate people, provide information, and overcome barriers to action. Substantial evidence-based literature documents the efficacy of TDIs across health behaviors, settings, and populations. McBride and Rimer (1999) reviewed the published literature to late 1997, with a special focus on diverse populations. TDIs have a number of variable components that, in combination, yield a broad continuum of applications (Soet and Basch, 1997). From the perspective of the intervener, calls can be initiated reactively—through calls to services or helplines, often with toll-free numbers—or proactively, via outbound calls initiated by trained interventionists. TDIs also vary by service provider (e.g., health professionals or lay staff) and whether they are paid staff or volunteers. They differ in the extent to which the call is scripted, the degree to which the script varies algorithmically with the characteristics and responses of the re-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

spondent, and the extent to which each subsequent call takes into account what was learned in previous calls or other encounters with an individual. The number, length, and timing of calls range from single contacts to multiple calls over a 12-month period. Most rely on brief calls, 10 minutes or less, although some services provide longer contacts. Increasingly, calls are based on motivational interviewing, a nondirective, behavioral process developed by Miller and Rollnick (1991).

TDIs also have served as the main intervention or as one adjunctive component of multicomponent interventions or services. This wide array of variable components increases the potential flexibility and cost-effectiveness of providing individualized services.

Examination of participation rates and demographic characteristics of study participants indicates that TDIs, particularly reactive helplines, do not have the broad-based reach that initially was expected. In one study, only 4 percent of eligible smokers in a five-county area took advantage of a telephone hotline for smokers (Ossip-Klein et al., 1991). There is no question that reactive services are underused by diverse populations. Nevertheless, the data show that TDIs are effective across different health behaviors and populations. Dini, Linkins, and Sigafoos (2000) conducted one of the few studies with substantial numbers of minorities; they reported effectiveness of brief tailored calls and/or printed reminders for childhood immunizations, with a comparison of ethnic groups versus the white population. Children assigned to the intervention groups had higher screening rates, regardless of race. One recent study (Fishman et al., 2000) compared brief reminder calls versus motivational calls as a means to increase mammography use. The study found that the reminder calls were the most cost-effective intervention. Thus, if other studies support this conclusion, we might conclude that the additional time and effort to conduct motivational calls may be unnecessary for most people. Although few studies have had sufficient sample size to compare subgroups with adequate power, the evidence suggests that diverse populations seem to benefit as much as or more than other groups (e.g., King et al., 1994).

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

Interactive voice response (IVR) systems are a newer variant of TDIs that allow users to call a computer to report their status and to receive information; in addition, they can be used to initiate proactive calls (Piette, 2000). The cost and complexity of creating IVR systems are now nearly as low as those for creating a Web page, with the introduction of the Voice Markup Language standard. Although still few in number, tests among diverse populations have shown positive results (Ramelson, Friedman, and Ockene, 1999; Schneider, Schwartz, and Fast, 1995; Greist et al., 1999; Piette, 1997, 1999, 2000; Piette et al., 1999). Particularly relevant to closing the digital divide, Alemi and colleagues (1996) found that low-income, chemically dependent, inner-city mothers using an IVR system of data collection, reminders, and appointment scheduling were more likely than the control group to enroll in drug treatment programs and to reduce use of health services while maintaining their health status.

Piette et al. (1999) showed that an ethnically diverse, low-income veterans population was responsive to use of automated calls for disease management. Automated calls were acceptable to both English- and Spanish-speaking patients with diabetes, including low-income patients (Piette, 1999; Piette et al., 1999). Moreover, the information people provided during the calls was reliable and clinically significant. Such calls may be useful for symptom reporting and prevention/disease monitoring in low-income and other populations. IVR and similar techniques may contribute to improved patient care without using scarce provider resources for routine monitoring (Piette, 1997).

Combinations of Tailored Print Communications and Telephone Delivery Interventions

Several studies have assessed the impact of combined interventions, such as TPCs and TDIs (e.g., Rimer et al., 1999; Lipkus et al., 2000; Blalock et al., 2002; Wakefield et al., 2002). For some topics, such as decision making about mammography, the combination appears to be more effective than TPCs alone. In a few

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

surprising cases, TPCs performed worse than usual care, while the combination of TPC and TDI was highly effective (e.g., Rimer et al., 2001). Not enough is known about how tailored interventions work to explain these unintended effects. In at least a few studies, the use of TDIs appeared to increase the likelihood that TPCs would be attended to, read, and retained (e.g., Lipkus et al., 2000; Rimer et al., 2001). However, some studies (e.g., Wakefield et al., 2002) showed no effects—in this case, on home smoking bans, parents’ smoking, or children’s cotinine levels. More research is needed to determine whether there are topics that are inappropriate for tailoring as well as other macro-level conditions that should be considered. In addition, more understanding is needed of the mediators of outcome and the active ingredients in interventions. For example, Blalock et al. combined tailored print and telephone with or without community intervention. In addition, some tailored interventions seem to perform better for people in some behavioral stages. Generally, people who are not thinking about making changes are least influenced by tailored interventions (e.g., Blalock et al., 2002). All of these issues must be pursued for diverse populations.

A recent review (Revere and Dunbar, 2001) concluded that tailored intervention studies improved outcomes, as did targeting; however, little research compared tailored with targeted strategies. An important distinction must be made among these technologies. Some of them do not require users to actively seek information. TPC and TDI systems can incorporate user interaction, but do not need to do so. They can be used to reach largely passive audiences. In contrast, the IVR system assumes an active audience seeking information. Whenever a system requires active seeking of information, new questions loom. One question is the extent to which these interventions, once made available, are used by the population in the way they are intended. There is always a risk that a new technology will appeal only to the minority motivated to seek information about their health, but prove too demanding for the majority of consumers. Similarly, there is a concern that an early engagement with a technology will not be sustained. Once the first

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

blush of technological appeal passes, there may be some tendency to reduce use. These concerns are particularly relevant in the context of diverse audiences that may vary sharply in their habits of actively seeking health information.

The next section deals with new communication technologies. In many cases, their use assumes active seeking of information by users. It will not be enough for research to show that these technologies are productive for those who use them, although that is an essential first step. The research also should address whether active audience-dependent technologies reach target and diverse audiences, and whether they can sustain active engagement among those audiences. What are the contexts in which large-scale active engagement occurs, and/or what specific incentives engender large-scale active use?

NEW HEALTH COMMUNICATION TECHNOLOGIES

The Rise of the Internet

The Internet has been adopted faster than any other known innovation in history (Institute for the Future, 1999). It took 20 years from its inception as ARPANET for the Internet to reach critical mass, where enough people were using it for it to be self-sustaining (Chamberlain, 1996). But in only 11 more years, the Internet was adopted by nearly half of the U.S. population (Rogers, 2000). In 2000, 44 percent of Americans (117 million people) reported using the Internet (U.S. Department of Commerce, 2000). Every day during the first quarter of 2000, 55,000 people became first-time users of the Internet, and 3.2 million pages of content were added.

By 2001, 54 percent of Americans—143 million people—were online (Lebo, 2001). A recent U.S. Department of Commerce (2002) report suggests that the digital divide is narrowing. Between September 1998 and September 2001, Internet use by the nation’s poorest citizens—those earning less than $15,000 a year— increased at an annual rate of 25 percent. The most important

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

reason people said they went online was to get information quickly (U.S. Department of Commerce, 2002). Over the past 2 years, there has been a trend toward more e-mail sharing of worries and seeking of advice (Pew Internet & American Life Project, 2002).

By 2001, 40 percent of African-Americans, 32 percent of Hispanics, 60 percent of whites, and 60 percent of Asian Americans/ Pacific Islanders had Internet access (U.S. Department of Commerce, 2002). All of these data are changing rapidly, and thus become outdated quickly. Moreover, the statistics vary from one report to another. Little data are available on Internet usage by some important populations, including Native Americans. In spite of large increases in the proportion of Americans with Internet access, large numbers of people still lack home access (especially important for health information) or any access at all. Numerous reports have documented the characteristics of this ever-changing population. As of 2001, although some ethnic differences in access still existed, the most profound determinants of those without access were low income and a high school education or less (U.S. Department of Commerce, 2002). Important disparities in Internet use that are relevant for health communication are as follows:

  • Older Americans are less likely than younger Americans to use the Internet. Even though the number of older adults using the Internet is increasing, 85 percent of those age 65 and older, and 59 percent between the ages of 50 and 64 do not go online (Lenhart, 2000).

  • Approximately 80 percent of people in households earning more than $75,000 have Internet access. In contrast, one-fourth of those living in households earning less than $15,000 annually have access (U.S. Department of Commerce, 2002).

  • Adults without Internet access tend to have less education than those with access. Only 32 percent of Internet users have a high school education or less, compared with 71 percent of nonusers (Lenhart, 2000).

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×
  • Internet access from home for racial/ethnic groups is as follows: Asian Americans/ Pacific Islanders, 56 percent; whites, 44 percent; African-Americans, 24 percent; and Hispanics, 24 percent (U.S. Department of Commerce, 2001). Cost is the greatest deterrent to at-home access by African-Americans and Hispanics (Cultural Access Group, 2001).

  • People with mental or physical disabilities (such as blindness, deafness, or difficulty walking, typing, or leaving home) are less likely than those without disabilities to use computers or the Internet (U.S. Department of Commerce, 2002). New government regulations that require all government Web sites to be configured to enhance access could make a significant difference.

  • At least 50 million Americans (20 percent) are estimated to face one or more content-related barriers to the benefits offered by the Internet. These barriers include lack of local information, literacy barriers, language barriers, and lack of cultural suitability (The Children’s Partnership, 2000).

A recent report by the Cultural Access Group (2001) highlighted some important ethnic differences in attitudes toward Internet use. For example, more than 60 percent of Hispanics and African-Americans said the Internet helped them stay connected to their cultures. Overall, more than 66 percent of African-Americans and Hispanics said they visited ethnic Web sites. However, more than half the African-American respondents said people of color have unique online needs, compared to only 16 percent of Hispanics and the general market. Furthermore, 66 percent of Hispanics said online content is adequate for them, compared to only 33 percent of African-Americans. A recent report by the Institute for the Future (Cain, Sarasohn-Kahn, and Wayne, 2000) concluded that significant opportunities exist to customize information to different segments of the population, based on factors such as age, socioeconomic status, ethnicity, health status, and medical condition.

The Internet is potentially one of the most powerful tools available for communicating with diverse audiences. It is critical that

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
×

we understand the potential of the Internet and other computer applications for health communication with and among diverse populations.

Use of the Internet for Health Communication

The phenomenal increase in use of the Internet for health information can be attributed to many factors, several of which have particular implications for health communication for diverse audiences. Among the most important is the short time available for the health encounter (now averaging 15 minutes or less) and the increased attention to informed decision making. In the United States and most Western countries, concerns about health care costs have led to increased emphasis on the health of populations and on prevention (Eysenbach and Kohler, 2001). Many people seek health advice via the Internet to supplement their physicians’ advice (Pew Internet & American Life Project, 2000b; Science Panel on Interactive Communication and Health, 1999), but there is little evidence that the Internet is replacing physician advice. In a diverse sample of Californians, including African-Americans, Hispanics, and Asian Americans/Pacific Islanders, physicians were the most common source of health information among both Internet users and nonusers. The Internet was the fifth most common source of health information, behind family/friends and various print media (Pennbridge, Moya, and Rodriguez, 1999).

By 2001, about 64 percent of U.S. Internet users said they had used the Internet for health information (Pew Internet & American Life Project, 2002). Over time, all population groups have shown a steady increase in the use of computers for health information, and this trend is likely to increase. A recent Pew Report (Pew Internet & American Life Project, 2000b) found that those seeking health information on the Internet were more likely to be members of minority groups and to have low incomes than those who use the Internet for other reasons. More than 40 percent said the information they found during their most recent search affected their health-related decisions. Half the people who sought health infor-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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mation on the Web said it helped them improve the way they take care of themselves (Pew Internet & American Life Project, 2000b). Forty-five percent of African-American users said the Internet helps them find health care information, compared with 35 percent of whites (Pew Internet & American Life Project, 2000a).

On one hand, these numbers are remarkable; all of them would have been near zero only a few years ago. On the other hand, they provide only the beginnings of evidence that the Internet, as it is now used, has a substantial role in health. We do not know whether those reporting Internet influence on decisions are making many new decisions about major aspects of their health or are only reporting on quite rare and/or trivial decisions, such as which brand of daily vitamins costs the least. Moreover, we do not know the extent to which self-reporting about these activities is accurate and reliable.

Networking for Health (Institute of Medicine, 1999b) identified four classes of Internet health applications: (1) real-time video transmission, (2) static file transfer, (3) remote control information search and retrieval, and (4) real-time collaboration. Each of these applications has potential uses for diverse populations that should be more fully developed.

One of the characteristics of the Internet that consumers and patients value most is access to vast amounts of information coupled with the opportunity to customize information to individual needs and characteristics. Furthermore, consumers are making use of information that until recently was available only to health professionals. For example, National Library of Medicine searches increased from 7 million in 1996 to 120 million in 1997, when free public access was inaugurated (Eysenbach and Jadad, 2001). The Internet has many other important attributes as well. Users can access information at their own pace, when and how they want, theoretically at least, 24 hours a day, 7 days a week. Communication can be real time or asynchronous, one-to-one or in a group. Multiple presentation modes can be used, such as video, audio, text, and/or animation. Moreover, interactive health communication systems can be entertaining (Lieberman, 2000).

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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For some health topics, such as HIV/AIDS, the anonymity afforded by the Internet may be perceived as a strong asset (DeGuzman and Ross, 1999). An excellent recent report by MacDonald, Case, and Metzger (2001) provides an overview of the range of possible uses for e-health.

Another advantage of the Internet is that it provides the latest information on given health topics. Users can obtain the level and kind of information they want—from simple explanations provided by support group participants to journal articles. Increasingly, users can select language to suit their needs, and people with visual or literacy deficits can use speech functions to receive information. Geographic boundaries per se are not a limitation, although they may reflect differences in access to certain technologies (e.g., broadband). Similarly, people with hearing limitations can use print, significantly expanding their communication opportunities. Furthermore, people with disabilities do not have to leave their homes to get information.

For sensitive topics, the privacy afforded on the Internet may be a paramount advantage, even when people have other worries about privacy. The very act of creating Web sites for the Internet can be used to facilitate the involvement of particular groups, such as teens, using action research methods (Skinner et al., 1997). In addition, e-health encounters can be self-documenting and relationship enhancing (MacDonald, Case, and Metzger, 2001). The possibilities for use of the Internet range from e-mail, support, and searches for information, to much more organized approaches, including e-health encounters (two-way exchanges of information) and e-disease management, which involves coordinated and proactive approaches to managing patients with chronic illnesses (LeGrow and Metzger, 2001). Online tools for health management can include health risk assessments, surveys, retail stores that sell health products, and home monitoring. Case managers can provide a strong link between the patient and his or her medical team.

At present, disease management appears to be attracting greater interest than e-health for prevention. This does not mean

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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that prevention will not work online, but rather that it poses unique challenges, particularly in creating awareness and demand where none is inherently present. For example, a person’s disease condition (or that of a friend or relative) may drive a search for online tools to address the problem. But because much prevention requires action in the absence of symptoms or in acute problems, the user demand for such programs will be less.

From a theoretical perspective, Internet and computer-based applications have other advantages as well. Didactic and experiential learning can be combined. Notably, these features can permit people to simulate experiences, provide believable models, and generate feedback to cue and reinforce people embarked on behavior change. People also find support through online communities. Hundreds of electronic support groups operate every day on the Internet (Winzelberg et al., 1998). The potential of these groups for health communication may be substantial. People experiencing social isolation, such as adolescent mothers with young children, can obtain a level of social support through Internet-based programs that otherwise might not be attainable (Dunham et al., 1998). A program developed for new adolescent mothers showed that the mothers used online services an average of two times a day. Low-income, socially isolated young mothers were most likely to participate. Moreover, mothers who participated most consistently had lower levels of parenting stress. The appeal of the social support components of Internet programs also was shown in a program for people with diabetes (McKay et al., 1998).

As Bandura (2002b) observed, electronic media can go beyond transmission of information. The media can be used to build virtual social networks for creating shared knowledge through collaborative learning and problem solving. One spinoff of the social support function of the Internet is especially striking. As a recent Wired magazine article described, some parents of desperately ill children have become Net-connected activists who not only search for and share information relevant to their children’s health, but also fund medical research and contribute to research. Solovitch (2001:9) concluded, “Look online and you’ll also find something

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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more: a spirit of community, a level of candor rarely broached in polite conversation, and a warehouse of information, often routinely monitored by medical specialists.” While acknowledging the questionable information on the Internet, she argued persuasively for the power and the permanence of these new Net-inspired citizen scientists who are changing not only the search for health information, but the practice of medicine and research (Solovitch, 2001).

Selnow (2000:59) provided an excellent description of the key features of the Internet:

Here is where I think the Internet stakes its claim. The most obvious features of the Net parallel the traditional media: like print, the Internet provides public information. Like the telephone, it permits interpersonal exchange. Like books and manuals, it offers tutorials, and like movies and TV, it provides entertainment. The Internet is a remarkable Swiss Army knife of information and communication and unlike the other media, it does the job simultaneously in print, audio and video. Unlike the traditional one-way flow of information where audiences remain passive receptacles, the Internet gives users an active role as it enables them to fulfill personal requests.

For these reasons, Cassell, Jackson, and Cheuvront (1998) referred to health communication on the Internet as a hybrid channel. It is both transactional and response dependent and combines attributes of both mass and interpersonal communications.

A growing focus on informed decision making (IDM) assumes that consumers can be educated about health care choices (see Frosch and Kaplan, 1999; Volk, Cass, and Spann, 1999; Flood et al., 1996). The Internet may be especially promising in supporting individual autonomy and choice in decision making (Skinner et al., 1997).

Consumers value online interaction with their doctors, and they want more of it. Four million U.S. adults have e-mailed a doctor’s office, and 34 million more would like to do so (Cyber Dialogue, 2000a), while only 10 to 21 percent of physicians e-mail

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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their patients (Journal of the Mississippi State Medical Association, 2000; Cyber Dialogue, 2000b). Eighty percent of people surveyed in a recent poll online (Harris Interactive, 2001) said they would like to receive e-mail health reminders from their physicians. Physicians’ associations such as the American Society of Clinical Oncologists and the American Gastroenterological Association have begun helping their members to create Web sites for which the associations provide content (e.g., news) and services (e.g., search functions).

A survey of patients conducted through medical oncology practices in Canada, with parallel surveys of the oncologists, confirmed the important role of physicians as sources of health information, but also shed light on why the Internet has become so valuable to patients. A majority of patients (86 percent) said they wanted as much information as possible about their illnesses (Chen and Siu, 2001). More than half the patients (54 percent) said the information from their physicians was insufficient. Most patients (71 percent) searched for information about their illness, with the Internet as the most popular choice (Chen and Siu, 2001). The overwhelming majority of patients (88 percent) said their physicians were willing to discuss this information with them and believed (70 percent) it did not adversely affect their relationships with their physicians. The corresponding view from oncologists was cautiously supportive. Most physicians (70 percent) said they searched the Internet, and one reason was to find information that might interest their patients. Like patients, the oncologists did not believe the Internet had adversely affected their relationships with patients. The patient population for this study was primarily white and with a high school education or less. More information is needed about how nonwhite patients and those with low income and education use the Internet for health information and how this affects their relationships with their physicians.

Kassirer (2000) predicted that consumers will expect more and more from the Internet in terms of health care. Not only will they demand better services tailored to their needs, but patients will want to use e-mail with their physicians and discuss with them the

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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information they find on the Internet. Unfortunately, physicians have been slow to adopt e-mail for communication with patients. Thus, patients’ preferences and physicians’ behavior are likely to become more disconnected (Kassirer, 2000). Eysenbach and Jadad (2001) cautioned that although there is a strong international trend toward shared decision making, many consumers still visit health providers who favor authoritarian models for the patient-provider encounter. Patients who come to their visits with information obtained on the Internet sometimes may be rebuffed by their health providers, although specific data are needed to document both positive and negative outcomes of patients’ Internet use.

Ultimately, changes will be needed in the health care system to accommodate the growing consumer demand for online support. For example, it is unlikely that physicians are going to be able to answer potentially hundreds of e-mails a day. Some practices are using technology to organize e-mail so it can be processed more efficiently, but such tools do not appear to be widely used. In addition, new kinds of human interfaces may be needed to expedite the process. Payment may be needed as an important incentive.

As a number of observers have noted, to be without Internet access today is much like being without a telephone was earlier in the century. More and more, lacking access to the Internet may limit one’s potential economic growth as well as access to health information. As the Internet has grown, it has attracted more women, more ethnic minorities, and more people from different age groups (Cain, Sarasohn-Kahn, and Wayne, 2000). The Internet is not the only—or even the most important—health communication strategy for diverse audiences, but it is a vital force and it must be considered. The challenge is to harness its potential as part of the menu of communication options for diverse audiences.

To do that, a recent survey by the Children’s Partnership (2000) shows that the Internet will have to provide more of the health information that diverse groups want and need. Serious barriers also will have to be surmounted. These barriers have been articulated by a number of authors and include variable quality of

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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information, difficulty finding high-quality information because of the vagaries of commercial search engines, lack of access, and concerns about privacy (Eng et al., 1998). One of the most important deficiencies is the lack of content, the Children’s Partnership notes. Moreover, most of the text on the Web is written at a reading level too advanced to be understood by many users (Graber et al., 1999; Oermann and Wilson, 2000). According to the survey, persons with low incomes want more information in their native languages, more sites written for beginning-level English speakers, and more information about health services. For those with low health literacy—a third or more of the U.S. population—this may represent a major information barrier (Eysenbach and Jadad, 2001). In addition, recent data show that consumers use search engines that may restrict their access to high-quality health information (Taylor and Leitman, 2001; Harris Interactive, 2001).

Many people in the United States and other societies, especially those about whom this volume is most concerned, lack any access to the Internet, limiting the effectiveness of Internet-based health communication. This may be a special problem for rural populations. Limitations also include the lack of verbal, aural, and visual clues (DeGuzman and Ross, 1999); the mass of information of unknown or poor quality; and the difficulty of navigation (Cline and Haynes, 2001). The startup costs of computer-based applications can be high, although efficiencies can be achieved in the long run. As discussed elsewhere in this volume, many people remain concerned about lack of privacy on the Internet.

The potential of the Internet is extraordinary, but this is not the same as the realization of the potential. Successful use of the Internet can require a fundamental shift among the population in how users make sense of the world. They need to be motivated to seek information; they need the skills to know how to frame a question, how to seek good information, and how to interpret information they receive. People commonly express their desire to move from a passive role to an active role, and the Internet offers that promise. However, what proportion of the need for informa-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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tion will be met in this way in practice is the hard question. It is likely to vary sharply by domain and by audience characteristics. If only a small proportion of the need for a particular domain for a given audience is actually met through active Internet use, this may create a worrisome tension. Although physicians report few negative experiences with patients’ use of the Internet, they do report some negative sequelae (Potts and Wyatt, 2001). Moreover, we are still at an early point in studying how the Internet affects patients’ health behaviors and their communication with health professionals. It is possible that institutions could reduce their outreach efforts after confusing the extraordinary availability of Internet information with the actual limited use of that information by the audience. They may believe the Internet has solved the problem when it has not.

Interactive Health Communication

Interactive Health Communication is defined as the interaction of an individual—consumer, patient, caregiver, or professional—with or through an electronic device or communication technology to access or transmit health information or to receive guidance and support on a health-related issue (Patrick et al., 1999). Many of the early applications demonstrated increases in users’ knowledge and acceptability of the systems (Kumar et al., 1993). Most applications now are Internet based or will be in the future. IHC includes computer health enhancement systems, interactive computer games, and Web-based applications, including the Internet. IHC services can range from simple applications, such as a single article or a discussion group, to online support groups and programs that offer many services, including information, communication, analysis, and a personalized Web page or a computer-based game intended to promote a certain behavior change (see Bental, Cawsey, and Jones, 1999, for an excellent overview of computer-mediated patient education techniques). Telemedicine and telecomputing offer a host of new communication opportunities, including electronic house calls (Ostbye and Hurlen, 1997).

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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IHC applications operate through telephones, personal digital assistants, Internet appliances, personal computers, and public kiosks. As wireless computers become more available, there will be even more delivery options. The Science Panel on Interactive Communication and Health (SciPICH) (1999) concluded that IHC reduces disease risk, improves quality of life, and influences use of health services.

Much of the potential for IHC in behavior change can be attributed to five things this communication does well: (1) provides social support and guidance, (2) tailors messages, (3) analyzes data, (4) monitors performance, and (5) provides reminders. IHC may improve adherence by providing motivation, social support, and guidance during the early and maintenance periods of personal change. It can increase salience and relevance by tailoring for age, ethnicity, and disease characteristics. Guidance can be adjusted to reflect a person’s efficacy level, unique impediments in their lives, and progress they are making (Bandura, 1997a, 2000). Information can be adjusted to reflect a person’s past behavior. In addition, graphic information, such as portion sizes for dietary recommendations, can be person specific (Oenema, Brug, and Lechner, 2001). Because distance is not an issue, people who share problems can be brought together from all over the world. This is especially useful for rare conditions. In addition, the anonymity of the Internet may make it easier for people with stigmatizing conditions to disclose and discuss them (White and Dorman, 2001). Feedback can be provided in many ways.

The absence of individualized guidance places limits on the power of mass communication. The advances in interactive technology provide the means to increase the scope and productivity of health promotion and other health communication programs (Bandura, 2000). One can distinguish between the enhancement of health impacts through electronic technologies on the input side and on the behavioral adoption side. On the input side, health communication can be tailored personally to factors that are causally related to health behavior. Individualized interactivity, on the behavioral adoption side, further enhances the impact of health

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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promotion programs. Social support and guidance during early periods of personal change and maintenance increase long-term success. Group-oriented systems often do not fare well because of arbitrary timing, bothersome accessibility, and inconvenience. Informal social systems do not necessarily provide good guidance.

Interactive computer-assisted feedback can provide a convenient means for informing, motivating, and guiding people in their efforts to make lifestyle changes. Tailored guidance can be adjusted to participants’ efficacy levels, the unique impediments in their lives, and the progress they are making. The feedback may take a variety of forms, including TPC, telephone counseling, and linkage to supportive social networks. For example, the self-management model for health promotion developed by DeBusk and colleagues (1994) centers heavily on interactive guidance on the behavioral adoption side. Moreover, online support groups can be available to people 24 hours a day, 7 days a week (White and Dorman, 2001).

We provide brief descriptions and summaries of how some of these computer-based technologies have been used, especially with diverse populations, and a selective review of the evidence.

The Comprehensive Health Enhancement Support System (CHESS) developed at the University of Wisconsin is one of the best examples of the potential of IHC to improve health among diverse populations (see http://chess.chsra.wisc.edu/Chess/). CHESS was developed in 1989, has been tested in several research studies, and is now Internet based. Patients obtain access to CHESS through their health care providers. Many organizations that offer CHESS can loan computers to participants.

After entering a code name and password, users see a main menu from which they can choose a general topic, pick a particular keyword, or enter a service of interest. Descriptions of the services follow, using prostate cancer as an example:

  • Information Services include several features. Questions and Answers provides brief answers to 400 frequently asked prostate cancer questions. The Instant Library includes more than 200

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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full-length articles drawn from the scientific and/or popular press available on other Web sites. The Consumer Guide provides descriptions of 150 services to help users visualize what it will be like to receive the service, learn to identify a good provider, and become an effective consumer. Web Links includes direct connections to other Web sites or specific pages in those sites. The Resource Directory describes local and/or national services and ways to contact them.

  • Communication Services offer information and emotional support to users. Professionally moderated bulletin board Discussion Groups for patients, partners, prayer groups, and other groups are open to any CHESS user, but are limited to 50 participants. Ask an Expert allows people to receive a confidential response to questions from specialists at the National Cancer Institute’s (NCI’s) regional Cancer Information Service. Responses are made anonymously and available for all users within Open Expert. Live Chats are scheduled real-time discussions facilitated by content experts. Journaling provides a private (content saved only on the user’s floppy disk) forum for users to write their deepest thoughts and feelings about prostate cancer in a controlled and timed environment. Personal Stories are accounts of how people cope with prostate cancer. Video Gallery allows users to see prostate cancer patients and their spouses talk about how they coped with the disease and its treatment.

  • CHESS Analysis Services include: (1) Health Tracking— people enter data on their health status every 2 weeks and receive graphs of how their health status is changing; (2) Decision and Conflicts—patients and families examine important treatment decisions by watching video clips of prostate cancer patients talking about how they made their decision, or by using a structured decision analysis; and (3) Action Plans—a decision theory model helps users plan behavior changes by identifying goals, resources, and ways to overcome obstacles.

In a randomized CHESS trial of younger women with breast cancer, about one-third of the participants were low-income, in-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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ner-city African-American women. They used CHESS as much as affluent white women with breast cancer (Gustafson et al., 2000). However, they used it very differently. In particular, low-income women (older and younger) used the computer-mediated communication services (e.g., electronic discussion groups) less frequently and information services (e.g., frequently asked questions and library) and analysis services (e.g., decision analysis and health tracking) more often. A growing body of research suggests that using IHC for information and analysis is more important to improving quality of life than using them for emotional support (Bass et al., 1998; Shaw et al., 2000; Boberg et al., 1997; Smaglik et al., 1998). This suggestion may be especially relevant for diverse populations. CHESS also has resulted in quality-of-life improvements, shorter ambulatory care visits, and fewer and shorter hospitalizations (Gustafson et al., 1999). These are particularly noteworthy health services outcomes.

Computer games are another important IHC. Packy and Marlon is a Super Nintendo video game designed to teach children with diabetes self-management skills to address specific challenges facing diabetes patients. The characters are two adolescent elephant friends with diabetes who are going to a diabetes summer camp. The players (one or two) play the role of the elephant friends who must save their camp from rodents who have scattered the camp’s food and diabetes supplies. Players must help their elephant character monitor blood glucose, take appropriate amounts of insulin, review a diabetes logbook, and find foods that contain the right amount of food exchanges. Through entertaining experiences, players learn about self-care and typical social situations related to diabetes. To win, players must learn how to engage in behaviors that help their character stay healthy. Packy and Marlon improved diabetes-related communication between parents and children with diabetes, increased parents’ ratings of self-care and self-efficacy, and reduced clinic visits (Brown et al., 1997).

Psychosocial programs for health promotion will be implemented increasingly via interactive Internet-based systems in a variety of formats. For example, young women at risk for eating

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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disorders often refuse preventive or remedial health services, but some may pursue online individualized behavioral guidance. In several studies, participants reduced their dissatisfaction with their weight and body shape, and they positively altered dysfunctional attitudes and disordered eating behavior by this means (Winzelberg et al., 2000).

Most studies have shown that computer-based education programs are accepted by people of different ages, educational levels, economic strata, and ethnicity (Balas et al., 1997; Krishna et al., 1997; Fieler and Borch, 1996; Bental, Cawsey, and Jones, 1999; Alemi et al., 1996; Prochaska et al., 2000; Jones et al., 2000). IHC using structured psychoeducational approaches has the potential to transfer knowledge and help people develop skills to change behaviors (Lewis, 1999). The BARN Research Group found that teenagers using IHC were more likely to remain free of risk-taking behaviors and improve risk-relevant behaviors such as stress reduction, smoking cessation, and contraceptive use (Bosworth, Gustafson, and Hawkins, 1994). Other examples of IHC for adolescents have been well received and have focused on topics such as conflict resolution (Bosworth et al., 1996) and safer sex negotiation (Thomas, Cahill, and Santilli, 1997). Chewning et al. (1999) reported significantly increased knowledge of oral contraceptives as well as increased rates of adopting (though not increased adherence to) oral contraceptives. Some of the benefit from using IHC may result from the greater involvement and deeper processing compared to passive methods.

A number of other outcome studies of IHC have been reported, several with diverse populations and across a range of health areas, including adolescent risk behaviors (Paperny and Hedberg, 1999; Bosworth et al., 1994), AIDS (Gustafson et al., 2000), exercise, diet, smoking cessation, asthma (Yawn et al., 2000; Homer et al., 2000), safe sex (Thomas et al., 1997), conflict resolution, eating disorders (Winzelberg, 2000), immunization, and skin cancer prevention (Hornung et al., 2000; Chewning et al., 1999). The results show improvements in outcomes such as knowledge and beliefs, quality of life, reduced hospitalizations, improved func-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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tional status, reduced pain, confidence in asking questions, body image, decisional confidence, self-efficacy, and knowledge. Krishna et al. (1997:25) concluded that “Computerized educational interventions can lead to improved health status in several major areas of care, and appear not to be a substitute for, but a valuable supplement to, face-to-face time with physicians.” However, more studies are needed that report outcomes on diverse populations.

IHC has the capacity to provide real-time feedback to patients recovering from acute illnesses and patients with chronic diseases. For example, Brennan et al. (2001) reported on the development of HeartCare, an Internet-based information and support system for patients recovering at home after coronary artery bypass graft surgery. HeartCare provides information tailored to patients’ recovery needs. Such tools may be especially useful as patients spend fewer days in the hospital. Nursing assessments and patient-specific data are used to tailor information to individual needs. Patients use “smart cards” and Web TVs to access HeartCare, thus reducing potential access problems. Although data are not yet available, systems like HeartCare are likely to become more common in the future. Moreover, by providing easy tools for access, they are more likely to meet the needs of diverse populations.

Balas et al. (1997) conducted a synthesis of published articles that reported on electronic communication with patients. Of 80 eligible clinical trials, 61 (76 percent) analyzed provider-initiated communication with patients and 50 (63 percent) reported positive outcome, improved performance, or significant benefits, including studies of computerized communication (7 of 7), telephone followup and counseling (20 of 37), telephone reminders (14 of 23), interactive telephone systems (5 of 6), telephone access (3 of 4), and telephone screening (1 of 3). Significantly improved outcomes were found in studies of preventive care, management of osteoarthritis, cardiac rehabilitation, and diabetes care. There were no reported outcomes for diverse populations.

Patients want more interactions with their physicians than physicians are willing to provide. Physicians consistently give sev-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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eral reasons for not participating in e-mail exchanges and what have been referred to as e-encounters. The reasons include not being reimbursed, concern about professional liability, and concern about volume (MacDonald, Case, and Metzger, 2001). These reasons will have to be addressed before major advances can be made in the use of the Internet for patient-physician (or other health professional) encounters. In addition, medical curricula should include interactive health communication (Cline and Haynes, 2001).

A recent conference on consumer health informatics concluded that “consumers want personalized relationships with their clinicians . . . so they get information that addresses their individual concerns and conditions” (Kaplan and Brennan, 2001:310). They also want interactive tools to manage their health and diseases. Today’s children will grow up with interactive technologies. Thus, it is certain that acceptance will increase over time.

CONCLUSIONS

As Rainie (2002) envisioned, the Internet permits Net-savvy patients to individualize a virtual Net world to meet their individual needs. Such a world provides information and educational tools, and gives self-helpers supportive techniques and even opportunities for conversations with one’s physician or other health experts. We view this world as potentially even larger, with messages and cues from the mass media part of the environment.

The Internet is likely to be used more for distance learning (e.g., Steckler et al., 2001) and as a way to collect information efficiently from potentially large numbers of people, such as stake-holders on a particular issue (Atkinson and Gold, 2001). This may be an important democratizing force in health care.

Interactive technologies offer great potential to strengthen diverse communities and improve their health. However, this is now more a promise than a reality (Bernhardt, 2000). In fact, even the very issue of interactivity is not a given: Stout, Villegas, and Kim (2001) recently examined health Web sites across different domains

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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and found that few of them employed interactive tools. Ideally, the new communication technologies will expand choices for how people get health information, not constrain them. The new technologies, like the old, should represent a choice, not a requirement, for diverse populations.

Achieving the potential of new technologies for diverse populations requires attention to access, as well as to the acceptability, availability, appropriateness, and applicability of content. As Eysenbach and Jadad (2001) warned, without deliberate action, new computer technologies may exacerbate inequities in health and health care. Merely providing computers rarely will be sufficient. Rather, ongoing training and support will be required. As in other areas of health care, participation of community members in program planning will heighten the potential for success.

Although poor-quality information cannot be removed from the Internet, consumers can be taught how to search for information and separate the good from the bad (Eysenbach et al., 2000; Cooke, 1999). There is some evidence that consumers’ search strategies are suboptimal, but training could help (Eysenbach and Kohler, 2002). Moreover, consumers should be taught to use search engines that direct them to high-quality health Web sites. Within the European Union, progress has been made in developing interoperative standards for rating health Web sites (Eysenbach et al., 2000). More attention is focusing on issues of access and usability (see, e.g., Eveland and Dunwoody, 2000), but more effort is needed (Cline and Haynes, 2001). This will benefit all Internet users.

We should not become so focused on the medium that we ignore the message. The content of health information is vitally important. As Cline and Haynes (2001) stressed, the Internet should be viewed as a communication process that activates social influence. This requires shifting focus from information alone to messages and meanings. At this point in time, a focus on all these areas, including content and quality, is needed.

More research is needed to fully understand the impact of IHC on diverse populations. This means that the mechanisms by which

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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they operate should be examined. Today, most research on behavioral interventions using new communication technologies relies on “kitchen sink” approaches that do not permit an assessment of the individual and combined contributions of intervention components. Currently available reports in the literature focus disproportionately on nonbehavioral outcomes, such as knowledge. In addition, most studies follow participants for only short periods. Multifactorial designs should be used more, with measures of both mediators of behavior and behavioral and health outcomes. Research designs should incorporate the means to study the Internet as a communication process rather than merely a high-tech conveyer of information (Cline and Haynes, 2001). Of the computer-based studies, Winzelberg et al. (1998, 2000) were the only ones to assess mediators of outcomes.

More attention also should be paid to the relationship between behavioral determinants and individual characteristics that are identified as important for tailored and Internet-based interventions. As Kukafka and colleagues (2001:1477) noted, Web technology permits us to “deliver a tailored mix of educational content, directed simultaneously at motivations, beliefs, and skills.” However, they stressed the importance of the selection of determinants and constructs: “Sophisticated tailoring to weak or irrelevant determinants and individual characteristics will yield poor results” (Kukafka et al., 2001:1477).

A recent review concluded that tailored communication can affect health outcomes more than generic, targeted, or personalized interventions. However, the review also highlighted a number of problems we have noted earlier. These include the lack of explicit theoretic basis, few studies that compare tailored approaches, and an inability to explain what design features affected the outcomes (Revere and Dunbar, 2001). In addition, few studies have assessed the impact of mobile devices for patients, except for data input and monitoring (Revere and Dunbar, 2001). Only 23 studies (62 percent) stated use of a theory to guide the health behavior intervention: 19 were print communication, and 4 were telephone (Revere and Dunbar, 2001). Moreover, more research is needed

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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on wireless devices. Mobile systems have particular appeal because of their portability, privacy, and other features. In addition, they can provide discrete, immediate, and frequent feedback (Revere and Dunbar, 2001; Dirkin, 1994). Of course, cost and availability barriers first must be transcended.

In the future, large-scale health campaigns may look vastly different from those with which we are familiar. The mass media may be used to direct people to Internet sites from which they can receive tailored health communication programs, combining the reach of the mass media with the effectiveness of individualized counseling. Such approaches would use segmentation to capture the attention of diverse populations and tailoring techniques to reach individuals. By providing access points in communities, the digital divide could be transformed into digital access. Many new technology commentators have predicted devices that combine several elements and perform multiple functions. An even more important type of convergence may be the convergence of different media, such as mass and micro media, to achieve health communication goals.

As new communication technologies proliferate, there is a great risk that an additional divide will develop between the public health sector and other health settings. Urgent attention must be paid to how to increase the availability and use of new communication technologies within the public health sector, where they can meet specific needs of diverse populations. The private and public sectors both have roles in meeting the health information needs of diverse populations and in facilitating the dissemination of new technologies.

Although the new media world has many real and potential benefits, potential dangers also exist. The availability of large amounts of data on individual users of the Internet presents a major threat to individuals’ privacy. It is not yet clear how new U.S. Department of Health and Human Services (HHS) regulations governing access to medical data will affect health communication applications on the Internet. Multiple surveys indicate the public is very concerned about privacy online, and health communication

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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researchers and practitioners should pay attention to this issue. The Internet is a bit like the Wild West: It has vast amounts of unregulated territory and no one in charge. Many people believe the Internet is inherently self-regulating, but more regulation may be needed where health information is concerned.

Issues of privacy, quality, access, and appropriateness of content for diverse populations must be addressed if the potential of the new technologies to benefit all people is to be achieved. Finally, we want to emphasize our strong belief that although the Internet should be part of the menu of choices available to people who want health information, consumers should not be forced to use new technologies and they should not be denied information because they are nonusers. It would be unfortunate if the Internet became the voice mail of the future. Such a scenario would represent yet another way to meet demand without meeting need in an effort to cut costs.

COMMUNICATION: THE NEXT FRONTIER

The astronomical increase in wireless technologies providing Internet access through handheld devices brings new meaning to the term personal computer. Many new delivery devices are now available, including kiosks, interactive pagers such as the Black-berry, Web TV, and Internet appliances such as I-Opener and Audrey (designed for placement in the kitchen). Some of these, such as Audrey, already are being displaced by the next generation of technology. Internet-ready cellular phones have made instant messaging a worldwide phenomenon. The handheld devices offer new opportunities to put health messages literally in the palm of one’s hand. New devices are proliferating, and more people are using them. Greater bandwidth and videoconferencing may provide new ways for patients and their health providers to interact (Jadad, 1999).

These devices often start as gadgets for the affluent, but then become tools for the masses. In a shorter and shorter amount of time, price goes down and access increases, making the devices

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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more accessible and appealing to diverse populations. Promising examples include devices such as Web Pads, which are now being used in some hospitals to provide Internet access to patients and their families (Bennett, 2001). It may be years before these devices become household products, but now is the time to prepare for the future.

In the not-too-distant future, use of Internet radio will be even more important than it is today. Some churches and community groups already have their own radio stations. This trend is likely to increase. Partnerships between health- and faith-based organizations may provide new outlets for health messages. Parallel trends in the syndication of Internet content offer opportunities to customize health content to diverse populations as well as to individuals within those populations.

Complementary tools from science and biology will be delivered increasingly via the Internet. An example is the NCI’s Breast Cancer Risk Assessment Tool, which allows women to calculate their probability of developing breast cancer and to receive feedback about potential preventive strategies. The Harvard Cancer Risk Index (http://www.yourcancerrisk.harvard.edu/index.htm) is another Internet-based tool that provides comprehensive cancer prevention assessment and feedback (Colditz et al., 2000). In the future, users of these and other individualized risk assessments will be able to receive private, individualized health advice; make plans; and track their progress. Such tools are likely to be accompanied by biological sensors carried by individuals to monitor bodily processes and provide feedback. In the future, patients may be able to access their own medical records online and to monitor their own test results. This kind of activity now occurs only in limited settings.

Instant translation services on the Internet are breaking down language barriers between people. Text-to-speech capabilities are improving and will offer further options to maximize access for diverse populations. The Simputer can read Web pages aloud in Native American languages and is one of a new generation of handheld devices that could make a tremendous difference in ac-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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cess to information by poor, illiterate people (Ward, 2001). Today’s children and adolescents are growing up with fast-paced, high-tech computer games and television shows and movies that look like the games and vice versa. They will have a facility with computers that few of today’s health professionals have developed. Moreover, their expectation for high production quality will raise the standards for health information. To compete, health communication professionals will have to partner with experts in areas such as marketing, computer design, and computer games.

To imagine health communications of the future, one can rely on both a theoretical basis and growing evidence. Undoubtedly, there will be more tailored health communication of every type, using a variety of media and formats. This communication will be increasingly interactive and based on theory-relevant variables as well as other variables, such as cultural factors appropriate to specific behavior. Ideally, this new health communication will complement other communication strategies, such as mass media, social network interventions, policies, and provider counseling. The convergence of mass media and new techniques could permit social-level attention to health issues, with the potential to individualize programs through tailored interventions. The combination of mass and micro media could produce synergistic effects leading to greater behavioral impact.

However, we must express appropriate caution. Funding of most health communication research relies on processes that are too slow to accommodate the speed of technology development. Some attempts have been made to correct this problem in other fields, and new approaches should be developed for health communication as well. In addition, public health efforts must compete with much more remunerative private health efforts. Programming and design talent are critical to creating programs that will compete in a sophisticated and information-rich environment, yet such personnel often demand salaries that exceed existing university structures. These concerns could be assuaged by greater collaboration with the private sector and by some creative restructuring of funding mechanisms that support such research.

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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The evolving information technologies increasingly will serve as a vehicle for building social networks. Online transactions transcend the barriers of time and space (Hiltz and Turoff, 1978; Wellman, 1997). Interactive electronic networking can link people in widely dispersed locales, and permit them to exchange information, share new ideas, and transact business. Virtual networking provides a flexible means for creating diffusion structures to serve given purposes, expanding their membership, extending them geographically, and disbanding them when they have outlived their usefulness.

Tailored technologies present challenges for delivery and evaluation—especially in public health settings that tend to be computer poor. Demand for health communication interventions using new technologies is likely to outstrip availability. Measurement challenges also exist—such as how to analyze data from trials in which every individual receives a different intervention. Today’s tools will require substantial transformation to be adapted to the methods, messages, and media of tomorrow.

The rapidly changing world of the Internet also is changing the look and feel of other media. Magazines and television commercials look more and more like Web sites. In the near future, we may no longer think of mass media, new media, and old media, but many media with different and complementary uses, ultimately able to reach through and touch individuals while creating and enhancing real and virtual communities.

The result may be enhanced personal and collective efficacy and, ultimately, improved health. The borders between individuals and countries already have been reduced as health information travels throughout the world in mere seconds. The media boundaries may become indistinct as well. The messages will be far more than the media. But, in a new way, the media will be the message.

Another area offering significant, although yet unrealized, potential is disease management through remote monitoring and feedback (Patel, 2001). This may be especially true for asthma and other diseases for which meaningful information exchange and proactive partnerships are essential. Clearly, there are many pri-

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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vacy issues that must be confronted, among other challenges. Nevertheless, some early data suggest that diverse populations can participate in their own self-management through Internet-based assessment and capture of spirometric data (Patel, 2001).

Although the committee is optimistic about the future opportunities afforded by new technologies, we recognize that storm clouds are on the horizon. The potential of new technologies still is far greater than today’s reality. As noted earlier in this chapter, the clouds include availability, accessibility, and affordability of the new technologies. Content relevant to and appropriate for diverse populations is a high-priority need. Technology is a means to an end, not an end in itself. We should not place excessive hope in the technology itself (Bandura, 2002b:4).

The growing social and economic divide between rich and poor nations presents more daunting challenges to make globalization more inclusive and equitable (Bandura, 2002b:6). Electronic technologies not only may be unaffordable in many parts of the United States and in poor nations, but such places also may lack the educational, communication, organizational, and service infrastructure to manage the use of new technologies.

On an individual level, the clouds involve not only threats to privacy, but the ways, still not well understood, in which the medium of new technologies may encourage or at least provide permission for socially unacceptable behaviors. Bandura (2002b) cautioned that concealment and depersonalization can bring out the worst in people.

Another problem, whose scope is still unknown, is the amount of incomplete or inaccurate information that is acquired on the Internet. Bichakjian et al. (2002) assessed the accuracy and completeness of information about melanoma on the Internet. Identified Web sites were evaluated by independent reviewers with high reliability. The authors concluded that the majority of Web sites that mentioned melanoma failed to provide complete information on risk factors, diagnosis, treatment, prevention, and prognosis. Fourteen percent of the Web sites included factual inaccuracies. None of the sites used innovative graphic techniques, including

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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videos, to enhance understanding. What the authors failed to point out was that many of the Web pages in their sample were the personal anecdotes of melanoma survivors, and did not purport to be either comprehensive or medically rigorous. As a recent British Medical Journal editorial cautioned, there probably cannot be a single standard of quality on the Internet, just as there could not be for other media (Purcell, 2002). We should be cautious about adding new regulations.

Moreover, the Internet has an unexpected dark side. Although it is still a small proportion of overall sales, there is evidence that adolescent minors buy cigarettes on the Internet (Unger, Rohrbach, and Ribisl, 2001). In 2001, Ribisl, Kim, and Williams estimated that more than 88 vendors sold cigarettes online, and the number is growing. Connolly (2001:299) cautioned, “if the tobacco industry embraces this new unregulated medium, many of the major public interventions that we have developed to curb real world lung cancer could go up in a puff of cyber smoke. Taxes, ad bans, and youth access laws are easily eroded online.”

In spite of the storm clouds and frank concerns about the new communication technologies, these technologies are diffusing widely throughout the world, with rapid and consistent growth among diverse populations. Our recommendations about the new technologies are made in light of both the vast potential and the possible pitfalls.

RECOMMENDATIONS

Previously, the Science Panel on Interactive Communication and Health made a series of excellent recommendations about priorities for IHCs (Science Panel on Interactive Communication and Health, 1999). Recommendations focused on several broad areas, including the development and application of models for quality and evaluation; improvement of basic knowledge and understanding of the uses and applications of IHCs; enhancement of capacity, particularly in the public health sector; and increased access to new technologies, especially for diverse populations. We support

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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these recommendations. Most important, we support the goal of universal access as articulated by SciPICH (see Eng et al., 1998:1374):

Technology, if used appropriately, can help people increase their knowledge of health, enhance their ability to negotiate the health care system, understand and modify their health risk behaviors, and acquire coping skills and social support. Furthermore, by reducing the information divide now, the next century may bring us closer to health equity.

The following recommendations are additional high-priority topics that must be addressed if the advances in health communication are to reach their potential for diverse audiences. The priorities are in the areas of research, practice, training, and policy:

  • Support continued experimental research to understand new communication technologies, including how they are used, how they work, and how they may be used effectively with other communication strategies, such as the mass media, natural helpers, and interpersonal counseling, to increase population reach and maximize health outcomes, especially for diverse populations. This includes assessment of psychosocial, cultural, and other potential determinants of health behavior from the perspective of the public, patients, and health providers, and assessment of how their interactions are changed by new technologies. A goal should be to identify the “active ingredients” that provide informative guides for constructing effective health promotion programs (Abrams, 1999). Are some tailoring algorithms more effective than others? How can one enhance dissemination? Research should be sponsored by the National Institutes of Health (NIH), National Science Foundation, and other organizations, including foundations and the corporate sector. NCI is currently the only NIH Institute that has allocated research support to research designed to increase digital access. More Institutes should invest in this area. Moreover,

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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partnerships, such as that developed by the NCI and the Markle Foundation to fund digital divide projects, can be productive.

  • Increase access of diverse populations to health care information through new technologies. The roles of the public and private sectors should be examined and clarified. New public-private partnerships (some might include faith-based organizations) are needed to develop new technologies, increase access, and develop health information content appropriate for diverse populations. It is unlikely that a technological fix will be sufficient. Both access and content are important. Also important is an understanding of the sociostructural conditions that shape the use of new communication technologies.

  • Support interdisciplinary training in the new technologies at multiple levels, including the next generation of health communication researchers and practitioners, as well as those currently in the field. Training also is needed to equip potential users with the skills to maximize the new technologies to meet their own needs.

  • Encourage HHS to form a cross-departmental working group to make recommendations about how to interface with the commercial sector and should specifically address the issue of search engines. Commercial search engines increasingly are giving priority to paying commercial sites and bypassing public sector and nonprofit sites. This trend may pose a special threat for diverse audiences. User-friendly health portals will be especially important for diverse populations. This priority is consistent with the leadership that HHS has taken with SciPICH, its scientific panel on IHC.

  • Encourage open source development of interventions using new health communication technologies, including those developed for research, to ensure that new tools have wide availability (see Schrage, 2000; Raymond, 1999). This will increase the likelihood that diverse populations benefit from advances in health communication and from the large tax-supported research investment.

  • Develop and test new methods for studying and reporting the nature, uses, users, and impact of the new media. Recognizing

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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that the new technologies create new environments, new kinds of use, and new communities, research methods must be adapted. Provide some fast-track funding to enable researchers to use new technology as developed and to obtain answers quickly.

  • Create a high-level public-private partnership to focus on the multiple issues related to quality and ethics on the Internet, including the consideration of a rating system to brand Web sites that are rated as trustworthy and accurate. However, any quality system must go beyond Web site ratings and deal with content as well. Internet users should be trained to assess the accuracy of health information on the Internet. Important ethical issues are involved in health communication using the new technologies, particularly because of the potential for collecting, storing, and using personal data on Internet users (see Spielberg, 1998; Institute of Medicine, 1999b; Eysenbach, 2000; Eysenbach et al., 2000). Although the issues transcend particular populations, special attention should be paid to the concerns by and for diverse populations. We commend the Internet Healthcare Coalition for its e-Health Ethics Initiative (2000) and encourage wide participation in this effort.

Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Suggested Citation:"6 New Communication Applications and Technologies and Diverse Populations." Institute of Medicine. 2002. Speaking of Health: Assessing Health Communication Strategies for Diverse Populations. Washington, DC: The National Academies Press. doi: 10.17226/10018.
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Next: 7 Toward a New Definition of Diversity »
Speaking of Health: Assessing Health Communication Strategies for Diverse Populations Get This Book
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We are what we eat. That old expression seems particularly poignant every time we have our blood drawn for a routine physical to check our cholesterol levels. And, it's not just what we eat that affects our health. Whole ranges of behaviors ultimately make a difference in how we feel and how we maintain our health. Lifestyle choices have enormous impact on our health and well being. But, how do we communicate the language of good health so that it is uniformly received-and accepted-by people from different cultures and backgrounds?

Take, for example, the case of a 66 year old Latina. She has been told by her doctor that she should have a mammogram. But her sense of fatalism tells her that it is better not to know if anything is wrong. To know that something is wrong will cause her distress and this may well lead to even more health problems. Before she leaves her doctor's office she has decided not to have a mammogram-that is until her doctor points out that having a mammogram is a way to take care of herself so that she can continue to take care of her family. In this way, the decision to have a mammogram feels like a positive step.

Public health communicators and health professionals face dilemmas like this every day. Speaking of Health looks at the challenges of delivering important messages to different audiences. Using case studies in the areas of diabetes, mammography, and mass communication campaigns, it examines the ways in which messages must be adapted to the unique informational needs of their audiences if they are to have any real impact.

Speaking of Health looks at basic theories of communication and behavior change and focuses on where they apply and where they don't. By suggesting creative strategies and guidelines for speaking to diverse audiences now and in the future, the Institute of Medicine seeks to take health communication into the 21st century. In an age where we are inundated by multiple messages every day, this book will be a critical tool for all who are interested in communicating with diverse communities about health issues.

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