Overcoming Online Health Education Disparity

Overcoming Online Health Education Disparity

Howard, Marion

OBJECTIVES: To learn more about teen internet access, to enable teens to use computers in clinics to obtain health information, to assess the impact of such usage. METHODS: Teens were asked to view a computer-based internet intervention aimed at preventing STDs through increased condom use. Changes in the teens’ knowledge, attitudes, and intended behaviors were studied. RESULTS: Multiple changes occurred. Teen understanding of the Internet as a way to find needed information was greatly impacted. CONCLUSIONS: The “Children’s Internet Protection Act” may further health disparities by preventing low-income youth from accessing reproductive health information. Providing such access in health care settings sewing such youth thus may not only be appropriate but necessary. However, more needs to be learned about how best to use Internet resources to improve health outcomes and whether or not health-focused computer-based learning can be a cost-effective component of publicly funded health service delivery.

KEY WORDS: Adolescence; Internet; Health Education; Health Disparity; Family Planning; Sexually Transmitted Diseases .

The digital divide, in actuality, consists of a series of cracks and fissures. One fissure that potentially affects health disparity in the United States is the limited access that those in poverty have to health information on the Internet. Without some understanding of how much the closing of this fissure could benefit low-income populations or their health care providers, it is difficult to hold policy discussions or create and promote appropriate activities.

The recent passage of the Children’s Internet Protection Act has the potential to further widen this fissure. The purpose of the Children’s Internet Protection Act is to prevent children from viewing pornographic websites. It mandates that schools and public libraries use blocking software. In actuality, such software also blocks positive reproductive health information that people can use to help make decisions about their behaviors and protect themselves from harm. This blocking software may particularly impact low-income teens who are less likely to have computers with Internet connections at home, and are more likely to be dependent upon public computers for such access and information.

Young people increasingly use the Internet to get health information. According to a survey by the Kaiser Family Foundation, three out of four online users age 15-24 have used the Internet for that purpose. Moreover, 14% of these young people visited a doctor and 39% said they changed their behavior based on what they learned online. Of the online users 15-17 years of age, 53% talked with a parent or other adult about the online health information they viewed. In particular, young people are likely to gather information in sensitive areas online-44% have accessed information about HIV/AIDS and other sexually transmitted diseases, birth control, teen pregnancy, and other aspects of reproductive health.

Thus any reduction in access to Internet health information, particularly reproductive health information, is problematic. At their most restrictive, the filters block 25% of all health information and 50% of reproductive health information. At the medium setting, filters still block one in five health sites, and at the least restrictive setting, one in ten health sites.


To learn more about how facilitating Internet usage might affect health disparity, the Morehouse School of Medicine Prevention Research Center in cooperation with the Emory University Jane Fonda Center undertook a project with a three-fold purpose: 1) to learn more about home access to Internet health information among low-income African American teens using a publicly funded health care clinic, 2) to test the feasibility of creating Internet access for such a population within a health care setting, 3) to begin to assess the impact of providing computer-based health information on the teens’ knowledge, attitudes, and behaviors.

Pre-intervention surveys of 90 African American teens 18 years of age and younger attending a publicly-funded teen health care site in Atlanta, GA indicated that 93% of these teens thought having computers at the clinic would be a good idea-close to 40% said they thought they would use the Internet to get health information. A follow-up survey of over 1,800 teens attending the same clinic indicated that, overall, only 24% had computers with Internet access at home in contrast to the state’s average of 47%.

To test the feasibility of reducing disparity with respect to gaining health care information from the Internet, a health-focused computer technology center was created in two health care sites serving low-income populations. One location had two mobile computer units that could be wheeled adjacent to clinic areas to serve children, teens, and their parents. In the other location, the waiting room of a teen clinic was turned into a computer technology center. Eight computers with high-speed Internet access were made available to teens who came for service at the clinic. Onsite printers were installed to enable teens to capture information and take it with them. The response to both sites was immediate and enthusiastic. Following the introduction of the computers, 98% of surveyed teens responded that the computers were a good way to give health information to teens (3/4 strongly agreed with the statement). Indeed, 95% of the teens felt all clinics should have such computers.

Website Reviews

A major purpose of establishing the computer technology center was to encourage teens to obtain health information. A site manager for each location was hired to help teens learn how to use the computers and Internet, and also to point teens toward information most likely to meet their needs. To assure that the websites visited by the teens had accurate information and were appropriate for teen use, the project undertook a survey of Internet health sites. A nurse and two other health educators pulled up over 1,300 sites using search engines, links, reference books, and word of mouth. Each made a subjective judgment as to whether or not the site should be evaluated further for possible use in the health-focused computer technology center. Ultimately the three professionals selected 251 sites for an in-depth examination. Chosen websites were rated on attractiveness, content, reading level, accessibility, and acceptability. To complete the website reviews, both professionals and teens filled out review sheets that contained up to 19 descriptive sub-categories and used a rating scale of 1 to 4 (1=poor, 2=fair, 3=good, and 4=excellent).

Review of the selected websites was a three-step process. The first step involved the professional reviewers. If a site chosen for review was scored by the first professional at or above the 50th percentile, it was passed on for a second review. The second step involved an independent review by a second professional. Then the scores of the two health professionals were averaged to provide a combined score. Only those websites scoring at the 75th percentile or above were considered for the third step: review by teens. In selecting 60 sites for review by teens, an attempt was made to assure that there was at least one website in each of 10 health categories (general health/exercise, dental health, reproductive health, mental health/stress, asthma/allergy, substance abuse, violence, cancer, diet/nutrition, vision/hearing). Beyond that, the highest scoring websites were used (most scored above the 90tn percentile). In case of a numerical tie, a subjective judgment was made as to which website might be more interesting to teens.

The third review step involved 180 teens (161 girls and 19 boys) who were recruited during their clinic visit to review websites that were highly recommended by the professional reviewers. Each of the 60 websites was looked at by three teens during 15 clinics over a four-week period. Overall, teens rated the importance of their peers looking at the site they reviewed as good to excellent. (They rated only five sites as fair in importance). On average, the teens rated their personal interest in revisiting the site they reviewed as good. When asked how they would describe the site they reviewed to a friend, teens again responded with good. In general, the teens found the reviewed sites to be easy to use, felt they had the right information, were easy to read, and were acceptable. However, teens gave over half the sites a low rating for the manner in which the information was presented.

The two areas rated highest by teens were “easy to read” and “easy to use.” The sites reading levels received ratings of good to excellent for using words that teens knew and giving information in a way that teens can understand. The teens found that 88% of the time they needed minimal clicks to reach the information and 90% of the time they found it easy to go back and forth in the sites. Professional reviewers gave slightly lower scores in the “easy to read” category, somewhat underestimating the reading levels of the teens. However, the professionals gave slightly higher ratings in all other categories than were given by the teens.

When evaluating content, teens gave the sites an overall rating of good. The teens felt the information gave answers to questions they would ask and covered information accurately and clearly. They also indicated that the information generally appeared to be unbiased, that the sites gave information that teens like to have, and that the information was right for teens. Only two sites overall were found to be unacceptable by teens. The teens felt one of those sites was not aimed at teens; the other was aimed at teens but judged not useful for either male or female teens. On average, teens felt that 89% of the time, the reviewed sites would be good for female teens, however, only 79% of the time would those same sites be good for male teens.

The area that teens rated the websites less well was their likeability. Forty-six percent (46%) of the time they gave the sites a rating that was less than good. The teens disliked some of the website colors, the teens also found that many of the sites were not very fun. The strongest finding was that, overall, despite the fact that they had rated most sites as being ones they would look at again, the teens didn’t find the sites as interesting as they would have liked them to be. In fact, on average, they gave the sites only a fair to good rating in this area. One out of every six sites was rated as poor.

Following the teen review, teen scores were averaged and then combined with the averaged professional review scores to come up with a list of the 50 best websites for teens. Top sites were then posted next to the computers in the clinic and also used in the next phase of the project.

Does Internet Information Make a Difference?

The project wanted to learn more about the effect of low-income minority populations accessing the World Wide Web in the clinic. In particular, it wanted to determine if the addition of health information from the Internet could contribute to reducing health disparity. African American women represent the fastest growing group of newly infected persons with HIV in the United States. Although the annual incidence among women began to decline in 1996, the incidence among African-American women continued to increase, currently representing 63% of all such cases. An important strategy for preventing the spread of AIDS is to reduce risky behaviors such as unprotected sexual practices. However, sample pretest data from the computer technology center clinics indicated that half of the time the sexually-involved girls there had intercourse without a condom being used. (Only 50% always used, 13% used “a lot”, 27% used “sometimes”, 10% never used.)

To begin to assess the impact of providing computer-based health information on the teens’ knowledge, attitudes, and behaviors, an intervention using the Internet was developed. The goal of the intervention was to use computer technology to enhance teen girls’ knowledge, attitudes, and skills. A two-minute PowerPoint presentation: It Takes Two…to be safe all the time, was created using teen language to help teens focus in on the importance of using a condom in addition to whatever other method of protection they are using. It Takes Two counteracted possible arguments against condom use. At the end of the 18 slide presentation, there were links to three websites that were highly rated by the website review process. These websites offered information about safer sex, STD prevention, and teen pregnancy prevention. Teens were given 15 minutes to complete the intervention: two minutes for the PowerPoint and 10-12 minutes to view the websites.

Thirty-seven girls (37) attending one family planning clinic were asked to participate in the pilot study. Pre and posttests were used to assess any changes in knowledge, attitudes and skills. Analysis of data showed there were positive changes in all areas. Nine out of ten girls found the It Takes Two presentation and Internet sites to be helpful. Moreover, nearly the same proportion said they gained new information about the importance of using two methods of protection.

Following the intervention, girls were more likely to agree that their boyfriends should use condoms each time they have sex (76% pre vs. 89% post) and that using two methods of protection can make a relationship better (27% pre vs. 71% post). (See Table A) Although many girls said they already had the skills to talk to their boyfriends about using condoms, more girls felt they could do so after the intervention. Intended behavior also was affected in that following the Intervention 89% of the girls indicated that they would be more likely to use two methods of protection the next time they had sex. (See Table B) One immediate benefit of the study is that the proportion of girls believing the Internet is a great way to get information about safer sex increased 2-1/2 times, thus opening up a new pathway to information for some teens.

The next phase of our research will be to implement an intervention similar to It Takes Two with a larger group of young people, using controls, to learn if the intentions to use two methods of protection actually are carried out over a period of time (actual behavior change).


The recently enacted “Children’s Internet Protection Act” has the potential to further health disparities by preventing low-income youth, who are likely to be dependent upon computer resources in schools and libraries, from accessing reproductive health information on the Internet. Providing computer/Internet access in health care settings serving such youth thus may not only be appropriate but necessary to eliminate health education disparities. Indeed, professionals and teens in this study found much useful health information on the Internet. Moreover, a pilot study indicated such information has the potential for changing knowledge, attitudes, and behaviors. However, more needs to be learned about how best to use Internet resources to improve health outcomes and whether or not health-focused computer-based learning can be a cost-effective component of publicly funded health service delivery.


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ACKNOWLEDGMENT: This article is based on a paper, Online Prevention – Only A Click Away presented a DHHS CDC-sponsored Conference on “STD/HIV Prevention and the Internet”, August 25-27, 2003, Washington DC. We thank Grady Health System Teen Services Program for their assistance with this project. Funding/Support: This research was supported by a grant from the U. S. Office of Education; Morehouse School of Medicine Prevention Research Center. Jane Fonda Center at Emory University

Marion Howard, PhD, Professor: Department of Gynecology and Obstetrics, Emory University School of Medicine, Jane Fonda Center, Adjunct Professor: Morehouse School of Medicine Prevention Research Center, David Levine MD, FAAP, Associate Clinical Professor/ Clerkship Director: Morehouse, School of Medicine Department of Pediatrics, Jackie Davis MPH, Research Project Coordinator: Emory University Jane Fonda Center, Maya Peek BSEd, Research Assistant: Emory University Jane Fonda Center, Atlanta, Georgia.

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