Abstract
There is a rapid evolution of care delivery taking place across the globe in response to an explosion of novel health technologies. Growing in parallel to this expansion is the anticipation of mHealth technologies to drive patient-centered care into the future. Despite this hope, continuing reports of health inequities and lived experiences of substandard care fill national, state, and community health reports. The impact of these inequities is particularly pernicious on Black men and their long-term health status. As decades of robust evidence substantiates needed interventions, current progress is not seeing expected gains. In this commentary, we argue that at the heart of these inequities are issues of access, health literacy, institutional racism, and growing social distance between clinicians and Black men. To address these inequities, we suggest that digital interventions, designed to support decision-making, information exchange, and shared accountability have the best hope to overcome current inequities by promoting authentic relationships that ultimately drive better communication between Black men and their clinicians.
Current health care delivery strategies and care use practices are in transition. The traditional health care landscape is evolving in response to novel technologies and digital health initiatives offering better, more targeted solutions for both patients and clinicians. Yet, continuing reports of inequities and lived experiences of substandard care fill national, state, and community health reports. Issues of access, health literacy, institutional racism, and growing social distance characterize a broken system between those who deliver care and those who receive. This issue is too important to ignore and George Benjamin,
1
the Executive Director of the American Public Health Association, argues that the way forward requires self-awareness and humility: Seeing health through a health equity lens means listening to those we serve and acknowledging their experiences. It means looking deep inside ourselves and our institutions, no matter how uncomfortable the journey.
Among Black men, interactions with the American health care system have been defined by struggle. Despite modest gains in mortality rates over the last 30 years, 2 too many Black men still experience neglect, displacement, isolation, and invisibility. Documented evidence links some of these experiences to racial discordance between Black men and their clinicians.3,4 Recent data argue that Black men do much better with Black clinicians than with White clinicians. 5 Given the history of abuse, ignorance, and willful disempowerment experienced by many Black men, there is little doubt that clinicians from a similar racial or ethnic background may be more sympathetic. At the same time, given the overwhelming practical limitations of matching Black men with Black clinicians (that is for a different commentary), does it not make sense to partner with Black men to build better more thoughtful strategies within the current system?
We believe that mHealth technologies offer incredible opportunities that positively disrupt traditional models of care (read: prescriptive, disconnected, paternalistic) by mediating the interaction between patients and clinicians. Van Heerden et al 6 define mHealth as medical and public health practice that is supported by mobile devices. Evidence from electronic medical records, 7 patient-facing smartphone applications, 8 patient use of digital recordings, 9 and the rise of shared medical notes 10 all suggest advantages of using technologies to improve clinical communication between patients and clinicians. Nevertheless, advances in mHealth and eHealth have been moderate and findings mixed. 11 Eysenbach, the editor of the Journal of Medical Internet Research (JMIR), defines eHealth as the intersection of medical informatics, public health, and business, where health services are enhanced by the Internet and related technologies. 12 Meanwhile, the acknowledged health benefits of eHealth or mHealth initiatives have seen limited application among populations of color, particularly communities of Black men. 13
The implications of routine racial bias and feelings of invisibility have been linked to mistrust of dominant culture systems (read: White) and institutions.2,14–16 Many young Black men are at higher risk for experiencing chronic illness as adults due to acknowledged neighborhood effects and contextual stressors associated with growing up in highly volatile environments characterized by under-resourced schools and poorly maintained neighborhood infrastructure.2,17 Despite the mountain of evidence linking systematic determinants to the health of Black men, many argue that resilience and social supportive effects serve to bolster men who experience discrimination. 18 Recent review data strongly suggest that health technologies like cell phones and social media can be leveraged among traditionally underserved populations, like Black men, to inform better quality of care, improve access, and support chronic disease management. 19
In a recent commentary, we suggested that tailoring digital technologies in partnership with Black men may bring hope to delivering health and self-management skills to Black men. 13 Whereas our commentary offered evidence-based and practical strategies to improve self-management strategies with Black men, we are aware of a more incisive and potentially disruptive discussion of how digital technologies have the opportunity to improve relationships between clinicians and communities of Black men. It is our position that digital technologies including mHealth and eHealth initiatives, currently underexplored among Black men, offer an untapped resource for health education, health promotion, social support, and self-management in the promotion of health and mitigation of illness.
Preceding Experiences of Racism, Distrust, and Mistrust
Black men have a history riddled by oppression, false assumptions, stereotypes, and abuse, which have contributed to distrust and an increase in social distance. Racism and distrust have by far been the most often cited faults in the delivery of health care and barriers of health-seeking among Black men. Racism is a pervasive issue, the effects of which are evident in many societal institutions, including the medical system. 20 The impact of racism, whether actual or perceived, is tangible to many Black men when considering risks and benefits of seeking health care. 21 Consequently, many Black men avoid primary health care and therefore do not benefit from the preventive care services offered. For various reasons, Black men opt instead to use emergency departments, delay treatment until their condition worsens, or to avoid care completely. 21 Under these conditions, Black men unwittingly relinquish the benefits associated with continuity of care, access to tailored risk reduction and illness management strategies, and the potential of having a meaningful relationship with a care provider.
These behaviors, together with other factors, have contributed to disparities in life expectancy, escalated disease morbidity, and increased mortality for Black men. Given that the average life expectancy of Black men in the United States is 72 years of age, on average, this is 4 years less than White men, 6 years less than Black women, and 9 years less than White women. 22 Such disparities are made worse by being both preventable and well-defined. If we believe the argument that mistrust is the consequence of poor understanding and unchallenged stereotypes, perhaps technologies that serve to bridge the social distance between Black men and clinicians is a solution.
Bridging (Technology) the Divide Between Black Men and Clinicians
Several studies have concluded that the use of cell phones is popular for Black men (compared with other technology devices such as an iPad or the Internet) and find that they have public health and clinical implications for identifying the most effective ways to develop and deliver health information.23–25 Using cell phones to communicate health information and implement health promotion interventions can be useful. 23 Practitioners or researchers could develop pre-recorded messages or send text messages that communicate health information to men that will inform them or remind them of certain activities that are important for their health promotion or maintenance.
In the other direction, men could send updates to clinicians in the form of texts, notes, data, or health status changes. Further updates could be curated by the preferences of Black men to be shared with clinicians prior to clinic visits. Using well-designed mobile apps on cell phones could enhance the delivery of health information 26 to clinicians and staff that frees time at the point of care for more personal, meaningful conversations.
Ultimately, the use of health technology to meaningfully connect Black men with their clinicians extends to both promotion and advocacy. We are not talking about text messages or cell phone alerts, but actual curated information linking daily experiences with clinical expertise. For example, giving men an “opt-in” feature, where accepting updates, alerts, or notices from their clinician respects individual/patient choice. Taken a step further, when an “opt-in” choice comes in the form of an offer by a clinician or a clinically supported health application, it acts to transfer autonomy from clinician to the user—in this case—Black men. The very act of sharing in the decision-making process also serves as a proxy for enhancing what matters most to both parties. For Black men, this might mean requesting advice on drug interactions, and for clinicians it might be clarifying dosage or symptom management.
Using mHealth or eHealth technology to guide shared approaches to treatment also promotes responsibility and accountability. Used as either a supplement or an alternative to traditional face-to-face interactions, a virtual interaction between patient and clinician can reduce social distance over time through the slow and methodical process of exchanging meaningful health information. Use of these tools by design promotes consistent, short, and helpful interactions. In time, as research has shown, this “new model” of care is in high demand and allows for “richer engagement and deeper doctor-patient relationships.” 27 Whereas more work is needed, enhanced relationships in a virtual space may indeed lessen the impact of historical legacies associated with face-to-face interactions. Therefore, if mHealth or eHealth can assist in the process of reducing social distance and improve patient perceptions of care, then a more authentic and honest relationship is certainly possible—one where Black men and their clinicians are supported to exchange what matters most. Some have argued that mHealth functions in this way like a social good, 28 where the technology bridges a divide between Black men and their clinicians.
Upholding Authentic Communication and Shared Accountability
Technology may offer opportunities to Black men and the clinicians who care for them to build better relationships through mutual understanding and shared accountability. At the margins of care, emergency rooms, and other rare events, there is very little time to build rapport and establish trust in patient-provider relationships. In more common occurrences where Black men struggle to manage their chronic illness needs or concerns, there is indeed time and place for relationship building, a key factor in providing patient-centered care. Although missed opportunities occur at the margins, and perhaps contribute to the rough edges of conversations between Black men and clinicians, technology may offer spaces to guide more authentic relationships—built on shared trust and accountability.
One of the benefits of using digital technologies is being able to overcome barriers of communication through transparency—using patient-reported data to ensure that records and clinical notes are easily accessible and shared. 29 Being able to share and update data about behaviors and outcomes instantly through smartphones or computers permits the seamless presentation and sharing of personal data. From both the patient and clinician perspectives, the unfiltered sharing of data and behaviors removes typical bureaucratic and systematic barriers that limit authentic interaction. Examples of this type of technology, apps that link patients and families, or patients and families with providers, have incredible potential to overcome the communication challenges inherent to systems like health care.
There is also the potential opportunity for shared accountability through the use of digital technology. Like students and homework, teachers who are able to assign work to students and then follow up with students often get more in return. For clinicians who assign medications or treatment protocols to patients, but never follow up, the likelihood of completion or compliance is low. The same holds for clinicians, who, if asked a question from a patient and never follow up, are seen as untrustworthy or incompetent. This form of mutual accountability, where both patient and clinician hold each other to a standard of care and practice, has immense potential for relationship growth and trust.
A Tool for Preparing for Meaningful Communication
Information asymmetry, the contextual and content gaps between clinician and patient, contributes to the formation of assumptions, which exacerbate biases in decision-making. Depending on location, for most Black men in the United States who visit a physician, that physician is more likely to be White than Black. Consequently, there are needed interventions and skill building opportunities for these clinicians who are not persons of color to better prepare for meaningful conversations. There are many examples of communication tools that help clinicians and patients have more productive conversations at the point of care.30,31 The health services research literature is rich with descriptions of decision aids, tools that provide evidence-based information in a way that both clinicians and patients can discuss together.
In many ways, smartphones and apps have been adopted to function like decision aids, permitting patients to read, annotate, and share information that is most meaningful to them. 32 There are newer tools being developed that also support patient activation for more informed conversations, ultimately reducing the need to overstate or restate information the patient already has. What these tools provide is space to move away from pure information exchange to a more robust collaboration, where engagement can be attained and more authentic conversation achieved.
Conclusions
The data outlining health disparities impacting Black men’s health are irrefutable. In this commentary, we propose one strategy to guide meaningful interactions between clinicians and Black men. Enhancing the quality of health among Black men will require awareness, ambition, and effort on their part; conscientiousness and creativity among physicians, nurse practitioners and other clinicians; and system-wide changes within the medical establishment.
Recognizing the important words of Georges Benjamin, who called for introspection and courage, the path to promoting meaningful interactions between Black men and clinicians may be long and arduous. The data are clear, current systems are not working, and health disparities persist. Researchers must not become discouraged by the seemingly daunting task we have laid out, nor should they fear mHealth or eHealth interventions. As we show, there is tremendous promise. Instead, researchers should pledge to explore these novel technologies and their innovative communication features to improve the health of Black men with Black men. 21
Footnotes
Declaration of Conflicting Interests:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding:
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Author Contributions
Both authors contributed equally to the conception, writing, and editing of this manuscript.
