Emily Z. Kontos

Predictors of eHealth Usage: Insights on The Digital Divide From the Health Information National Trends Survey 2012

Background Recent eHealth developments have elevated the importance of assessing the extent to which technology has empowered patients and improved health, particularly among the most vulnerable populations. With noted disparities across racial and social groups in chronic health outcomes, such as cancer, obesity, and diabetes, it is essential that researchers examine any differences in the implementation, uptake, and impact of eHealth strategies across groups that bear a disproportionate burden of disease. Objective The goal was to examine eHealth use by sociodemographic factors, such as race/ethnicity, socioeconomic status (SES), age, and sex. Methods We drew data from National Cancer Institute’s 2012 Health Information National Trends Survey (HINTS) (N=3959) which is publicly available online. We estimated multivariable logistic regression models to assess sociodemographic predictors of eHealth use among adult Internet users (N=2358) across 3 health communication domains (health care, health information–seeking, and user-generated content/sharing). Results Among online adults, we saw no evidence of a digital use divide by race/ethnicity. However, there were significant differences in use by SES, particularly for health care and health information–seeking items. Patients with lower levels of education had significantly lower odds of going online to look for a health care provider (high school or less: OR 0.50, 95% CI 0.33-0.76) using email or the Internet to communicate with a doctor (high school or less: OR 0.46, 95% CI 0.29-0.72), tracking their personal health information online (high school or less: OR 0.53, 95% CI 0.32-0.84), using a website to help track diet, weight, and physical activity (high school or less: OR 0.64, 95% CI 0.42-0.98; some college: OR 0.67, 95% CI 0.49-0.93), or downloading health information to a mobile device (some college: OR 0.54, 95% CI 0.33-0.89). Being female was a consistent predictor of eHealth use across health care and user-generated content/sharing domains, whereas age was primarily influential for health information–seeking. Conclusions This study illustrates that lower SES, older, and male online US adults were less likely to engage in a number of eHealth activities compared to their counterparts. Future studies should assess issues of health literacy and eHealth literacy and their influence on eHealth engagement across social groups. Clinical care and public health communication efforts attempting to leverage Web 2.0 and 3.0 platforms should acknowledge differential eHealth usage to better address communication inequalities and persistent disparities in health.

Communication Inequalities and Public Health Implications of Adult Social Networking Site Use in the United States

Social media, and specifically social networking sites (SNSs), are emerging as an important platform for communication and health information exchange. Yet, despite the increase in popularity and use, only a limited number of empirical studies document which segments of the adult population are and are not using social networking sites and with what, if any, affect on health. The purpose of this study is to identify potential communication inequalities in social networking site use among a representative sample of U.S. adults and to examine the association between SNS use and psychological well-being. We analyzed data from the National Cancer Institutes 2007 Health Information National Trends Survey (HINTS). Thirty-five percent of online adults reported SNS use within the past 12 months, and there were no significant differences in SNS use by race/ethnicity or socioeconomic position. Younger age (p = .00) was the most significant predictor of SNS use, while being married (p = .02) and having a history of cancer (p = .02) were associated with a decreased odds of SNS use. SNS use was significantly associated with a 0.80 (p = .00) increment in psychological distress score after controlling for other factors. The absence of inequalities in adult SNS use across race/ethnicity and class offers some support for the continued use of social media to promote public health efforts; however, issues such as the persisting digital divide and potential deleterious effects of SNS use on psychological well-being need to be addressed.

Integrating Multiple Social Statuses in Health Disparities Research: The Case of Lung Cancer

OBJECTIVE To illustrate the complex patterns that emerge when race/ethnicity, socioeconomic status (SES), and gender are considered simultaneously in health care disparities research and to outline the needed research to understand them by using disparities in lung cancer risks, treatment, and outcomes as an example. PRINCIPAL FINDINGS SES, gender, and race/ethnicity are social categories that are robust predictors of variations in health and health services utilization. These are usually considered separately, but intersectionality theory indicates that the impact of each depends on the others. Each reflects historically and culturally contingent variations in social, economic, and political status. Distinct patterns of risk and resilience emerge at the intersections of multiple social categories and shape the experience of health, health care access, utilization, quality, and outcomes where these categories intersect. Intersectional approaches call for greater attention to understand social processes at multiple levels of society and require the collection of relevant data and utilization of appropriate analytic approaches to understand how multiple risk factors and resources combine to affect the distribution of disease and its management. CONCLUSIONS Understanding how race/ethnicity, gender, and SES are interactive, interdependent, and social identities can provide new knowledge to enhance our efforts to effectively address health disparities.

Cancer-related direct-to-consumer advertising: a critical review

The direct-to-consumer advertising (DTCA) phenomenon has received attention because of its attempt to reach out to consumers by bypassing important gatekeepers such as physicians. The emergence of new information platforms and the introduction of genetic tests directly to the consumer have heightened the concern with DTCA and its potential consequences. These effects of DTCA are particularly important given the communication inequalities among social groups, with class, race and ethnicity influencing how people access, seek, process and act on information. This Science and Society article reviews the major issues regarding general and cancer-related DTCA and also offers data from a national survey in the United States as an example of the communication inequalities in genetic testing awareness.

Contribution of Communication Inequalities to Disparities in Human Papillomavirus Vaccine Awareness and Knowledge

OBJECTIVES We examined the association of Internet-related communication inequalities on human papillomavirus (HPV) vaccine awareness and infection knowledge. METHODS We drew data from National Cancer Institutes 2007 Health Information National Trends Survey (n = 7674). We estimated multivariable logistic regression models to assess Internet use and Internet health information seeking on HPV vaccine awareness and infection knowledge. RESULTS Non-Internet users, compared with general Internet users, had significantly lower odds of being aware of the HPV vaccine (odds ratio [OR] = 0.42; 95% confidence interval [CI] = 0.34, 0.51) and knowing that HPV causes cervical cancer (OR = 0.70; 95% CI = 0.52, 0.95). Among general health information seekers, non-Internet seekers compared with Internet information seekers exhibit significantly lower odds of HPV vaccine awareness (OR = 0.59; 95% CI = 0.46, 0.75), and of knowing about the link between HPV infection and cervical cancer (OR = 0.79; 95% CI = 0.63, 0.99) and the sexual transmission of HPV (OR = 0.71; 95% CI = 0.57, 0.89). Among cancer information seekers, there were no differences in outcomes between Internet seekers and non-Internet seekers. CONCLUSIONS Use of a communication channel, such as the Internet, whose use is already socially and racially patterned, may widen observed disparities in vaccine completion rates.

Use of Practice-Based Research Network Data to Measure Neighborhood Smoking Prevalence

Introduction Practice-Based Research Networks (PBRNs) and health systems may provide timely, reliable data to guide the development and distribution of public health resources to promote healthy behaviors, such as quitting smoking. The objective of this study was to determine if PBRN data could be used to make neighborhood-level estimates of smoking prevalence. Methods We estimated the smoking prevalence in 32 greater Boston neighborhoods (population = 877,943 adults) by using the electronic health record data of adults who in 2009 visited one of 26 Partners Primary Care PBRN practices (n = 77,529). We compared PBRN-derived estimates to population-based estimates derived from 1999–2009 Behavioral Risk Factor Surveillance System (BRFSS) data (n = 20,475). Results The PBRN estimates of neighborhood smoking status ranged from 5% to 22% and averaged 11%. The 2009 neighborhood-level smoking prevalence estimates derived from the BRFSS ranged from 5% to 26% and averaged 13%. The difference in smoking prevalence between the PBRN and the BRFSS averaged −2 percentage points (standard deviation, 3 percentage points). Conclusion Health behavior data collected during routine clinical care by PBRNs and health systems could supplement or be an alternative to using traditional sources of public health data.

Associations among neighborhood, race, and sleep apnea severity in children: A six-city analysis

Rationale: Prior researchers found that individual‐level environmental and social indicators did not explain the racial disparity in obstructive sleep apnea syndrome. Neighborhood socioeconomic variables, as well as risk factors for a range of adverse behavioral and health outcomes, may better explain this racial disparity and help identify modifiable intervention targets. Objectives: To evaluate the associations of neighborhood socioeconomic variables with obstructive sleep apnea severity and to assess whether the neighborhood variables explain the association between race and obstructive sleep apnea severity. Methods: We performed a cross‐sectional analysis of data of 774 children in six cities who participated in the Childhood Adenotonsillectomy Trial. The outcome variable was the apnea‐hypopnea index (AHI). Neighborhood socioeconomic variables were obtained on the basis of the childrens residential addresses and information in the American Community Survey. Regression models were used to assess the associations among neighborhood conditions, race, and AHI. Measurements and Main Results: Higher poverty rate and percentage of single‐female‐headed households were associated with higher AHI (P = 0.008 and 0.002, respectively). African American race was associated with a 1.33 (1.08‐1.64 95% confidence interval)‐fold increase in AHI, adjusting for age and sex. After controlling for poverty rate or percentage of single‐female‐headed households with children, the association between race and AHI levels was no longer significant (P = 0.15 and 0.26, respectively), and the magnitude of race association decreased 34 or 55%, suggesting that the association between race and AHI levels was largely explained by poverty rate or percentage of single‐female‐headed households with children. Conclusions: Neighborhood socioeconomic variables in comparison with individual‐level socioeconomic indicators provides better explanations for the racial disparity in pediatric obstructive sleep apnea syndrome. Further research aimed at identifying factors that aggregate in disadvantaged neighborhoods and increase sleep apnea risk may suggest modifiable intervention targets. Clinical trial registered with clinicaltrials.gov (NCT00560859).

A Qualitative Assessment of the Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents

ABSTRACT Background: Daily behaviors such as sleep can be targeted by smartphone app-based interventions, with potential utility among young people of minority ethnic backgrounds who commonly access smartphone devices and are short sleepers. There is a need to understand the acceptability and youth’s readiness to use apps to improve sleep, and to identify desired app components that would motivate engagement. Participants and Methods: We conducted three focus group discussions (N = 27 total, age 14–18 years) within low- and middle-income ethnically diverse Boston neighborhoods. We also interviewed 10 participants who provided specific feedback on two commercially available sleep-promoting apps, one of which they had used on their smartphone preceding the interviews. All focus group discussions and interviews were audio-recorded, transcribed, and thematically analyzed. Results: We identified several barriers to adoption of sleep hygiene interventions, namely reluctance to follow scheduled sleep routines on weekends and concern about “parting” with electronics at bedtime. Participants were intrigued by the idea of adopting an app-based sleep intervention, but were skeptical that they could successfully adopt sleep hygiene practices, and were more interested in making changes on school days than on weekends. Nonetheless, the overall feedback on two commercial sleep apps, neither targeted at youth, was positive, with a good adherence and engagement rate, and perceived health benefits. Conclusions: Our findings highlight the need to adapt sleep hygiene recommendations to targeted populations, considering preferences and social and cultural contextual factors. Our research also underscores the importance of the platform, setting, and messenger when delivering health information to adolescents.

Enhancing yoga participation: A qualitative investigation of barriers and facilitators to yoga among predominantly racial/ethnic minority, low-income adults

Yoga is underutilized among racial/ethnic minorities and low-income populations. To enhance participation among these demographic groups and to inform a future clinical trial, we conducted a qualitative formative investigation, informed by the Social Contextual Model of health behavior change, to identify barriers and facilitators to yoga that could impact study participation. We recruited twenty-four racially/ethnically diverse adults, with and without prior yoga experience, from a low-income, urban housing community to participate in either an individual interview or focus group. A thematic data analysis approach was employed. Barriers to yoga engagement included the perception that yoga lacks physicality and weight loss benefits, fear of injury, lack of ability/self-efficacy to perform the practices, preference for other physical activities, and scheduling difficulties. Facilitators of yoga engagement included a quality yoga instructor who provides individualized instruction, beginner level classes, and promotional messaging that highlights the potential benefits of yoga, such as stress reduction.

Abstract ED05-03: Social media use, communication inequalities, and public health: Where we are and where we need to go

Social media are emerging as an important platform for communication and health information exchange. Yet, despite the increase in popularity and use, only a limited number of empirical studies document which segments of the adult population are and are not using social media and with what, if any, affect on health. Preliminary studies highlight that while there are still significant inequalities by race and socioeconomic status in Internet access, once access is gained, use of social media such as social networking sites is equally prolific across socio-demographic groups. This ubiquity of use presents both significant opportunities and challenges for cancer communication efforts. With the new communication channel emerges a real need for refined measurement that adequately reflects the innate dynamism of the platform and a nuanced understanding of the links between computer/technology-mediated communication and health across populations to ensure that existing digital divides and health disparities are not exacerbated but rather narrowed. Citation Information: Cancer Prev Res 2011;4(10 Suppl):ED05-03.