Advancing African American and Hispanic health literacy with a bilingual,personalized,prevention smartphone application

Abstract

Many online health information sources are generic and difficult to understand, but consumers want information to be personalized and understandable. Smartphone health applications (apps) offer personalized information to support health goals and reduce preventable chronic conditions. This study aimed to determine how the HealthyMe/MiSalud personalized app (1) engaged English-speaking African American and Spanish-speaking Hispanic adults, and (2) motivated them to set goals and follow preventive recommendations. Our study adds to the literature on digital health, health information seeking, and prevention. We used a multi-method approach, including community and participatory design principles, to learn about potential African American and Hispanic adult health app users and evaluate the app in two usability tests and a 12-month field test. Ninety-six African American and Hispanic adults downloaded the HealthyMe/MiSalud app and used it for a minimum of 36 weeks. We found they wanted personalized information on core prevention topics, and their health histories and goals affected how they rated topic relevance. African American females ages 18-34 were more likely to save an article aligned with family health history, and African American females aged 35-49, males age 50-64, and African American males overall were more likely to save an article aligned with their health goals. Our study revealed that a prevention app with personalized recommendations can support health information seeking and health literacy. These findings can help app developers, public health practitioners, and researchers when designing apps for groups of varying identities.

Keywords

mHealth consumer health information digital health

Introduction

Healthy People 2030, the U.S. national health goals and objectives, defines personal health literacy as “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.¹ Smartphone health applications (apps) designed with plain language content and personalization techniques, such as a recommender system (RecSys), may serve as vital tools to ease information seeking and aggregate personalized health information and educational content and recommendations. Identifying how to make online health information activities easier to understand and use is necessary because lower levels of health literacy and digital device access are associated with less online health information seeking and fewer health-promoting behaviors for some health topics.^2,3

A RecSys utilizes data from app users’ personal profiles to recommend highly personalized health information, creating a digital personal health library (PHL).⁴ Digital PHLs assist users with organizing and filtering the health information that is most relevant and important to their health goals.⁵ This approach to highly personalized health apps aligns with the call for attention to eHealth literacy when developing interventions for people with limited literacy and limited digital literacy.⁶ The concept of eHealth literacy recognizes that people need skills for finding, understanding, and using health information services as well as skills to use a range of digital technologies.⁶

The only national study of U.S. adults’ health literacy skills conducted in 2003 found a mere 12% of the English-speaking adult population had proficient skills to understand and use a wide range of print health materials, and the findings showed disparities by race, ethnicity, education, income, and age.⁷ At the time of this study, African American and Hispanic adults reported higher percentages of below basic health literacy than other racial and ethnic groups. Despite scoring lower in health literacy measures, African Americans and Hispanics are reportedly more likely than their White counterparts to use smartphones to access health information, communicate with healthcare providers, and use a health app decision support tool.⁸ In 2021, more than 80% of African American (83%), Hispanic (85%), and White (85%) adults reported having a smartphone.⁹ Additionally, prior studies have reported that Hispanic and African American mobile phone users are more likely to download a health app than White adults.¹⁰

Promotion of prevention activities, such as physical activity and mental health care, are frequent reasons for health app use by Hispanic and African American adults.^11,12 These types of apps provide methods for preventing commonly diagnosed health conditions, such as diabetes and heart disease, in African American and Hispanic communities.^13,14 To our knowledge, these apps do not place an emphasis on promoting health literacy and information seeking activities to support preventive health behaviors.

The World Health Organization has declared that health literacy interventions are necessary for progress in disease prevention, health promotion, and early screening and diagnosis.¹⁵ Yet, people who score lower on health literacy measures often have less health knowledge and seek online health information less often.^3,16,17 Providing consumers with an app based on health literacy principles that allows them to easily find, synthesize, manage, and store personalized health information can support health goals to reduce preventable chronic health conditions that disproportionately impact African American and Hispanic adults.

Many digital health tools are developed without a strong theoretical base, and we combined concepts from the Consumer Information Processing Model (CIP) and adult learning theory (andragogical model) to optimize the app’s design.^18,19 Both the CIP model and adult learning theory consider what motivates and engages adults in information seeking and action. Adult learning theory posits that adults will invest in learning when they perceive a strong “need to know.” Sometimes, they need to be made aware that they need to know, and we propose that the HealthyMe/MiSalud app intervention can serve that purpose. We used the theory’s other key ideas about the importance of adults’ prior experience and their developmental stage to inform app design and content. The CIP model’s core concept is “individual processing capacity,” and the model’s core assumption is that individuals are limited in how much information they can process.¹⁸ Motivation and goals, however, may affect how much effort adults expend to locate and process information for a decision. The app’s content is designed to reflect easy-to-process information chunks, personal health goals for prevention, and action-oriented recommendations.

We developed and tested HealthyMe/MiSalud, a novel English and Spanish language health app that integrates multiple data sources to enhance African American and Hispanic adults’ health information seeking and engagement with preventive services recommendations. This bilingual app provides a digital PHL that integrates publicly available plain language health articles vetted by federal government agencies; personalizes the information with a RecSys; and adds tools for health goal setting, finding healthcare services, reviewing nutrition labels, and planning conversations with healthcare providers.

Our overarching research question was, how can the HealthyMe/MiSalud smartphone app (1) engage English-speaking African American and Spanish-speaking Hispanic adults in building digital personal health libraries (PHLs) and (2) motivate them to set prevention goals and follow preventive services recommendations? We define “engage” as using the app to learn about prevention and complete tasks, and “digital personal health library” as user-saved articles that match their stated health goals. Our primary outcome was saving articles to the PHL. We specifically explored how such engagement may be associated with factors that prior work has shown may influence an individual’s health information-seeking behaviors, such as health history/status, family health history, and goal setting. We also considered users’ frequency of use, article ratings, and satisfaction with the app as additional outcomes of interest, given that engagement often varies by activity and user type.

Methods

Design and setting

We used a multi-method approach, including community participatory design principles, to learn about potential African American and Hispanic adult health app users and evaluate the app in two usability tests and a 12-month field test. The app design sessions and first usability tests took place in 2019 in Maryland; the field test was virtual from mid-2020 to December 2021; and an additional usability test was conducted in Maryland in January 2022. The app was available for Android phones from May 2020 through the end of the study, and in December 2020 we launched a cross-platform version so we could enroll iPhone users. The (University of Maryland) Institutional Review Board conducted an administrative review and approved the team to conduct the usability and field tests. We mailed or emailed consent forms to participants and obtained verbal consent during telephone enrollment sessions.

Design sessions

We conducted a series of three design sessions with the same two small groups of African American and Hispanic adults to solicit their ideas for the app and get feedback on a prototype. Participatory sessions can engage end users in a co-design process to maximize product usefulness.²⁰ Briefly, Design Session 1 involved collage and card sorting activities in which the participants illustrated through words and images what prevention meant to them and what they desired for their health. Design Session two gave participants the app prototype, and we asked for feedback on its interface, functions, and appearance. Design Session three applied a cultural approach in which we asked about participants’ cultural preferences and needs regarding their health.

App design and the RecSys seed data

The app features a collaborative-filtering-based article RecSys trained on a dataset crowdsourced from African American and Hispanic adults using Amazon’s Mechanical Turk (MTurk). MTurk is a crowdsourcing platform for conducting web-based research involving surveys and facilitates access to a large and diverse participant population quickly and at a relatively low cost.²¹ Notably, our RecSys was seeded and trained using data from people like the intended app users. MTurk respondents self-identified as African American/Black or Hispanic, owned a smartphone, and were located in the United States. The delivery of personalized content based on a user’s risk profile represents an under-explored opportunity in public health.²¹ When users query for information about a particular topic, the RecSys returns a set of personalized results containing the articles deemed most relevant for users with similar sociodemographic and clinical characteristics, conditional upon the topic selected and a user’s personal health history, family health history, and health goals. The app is available in a fully English or fully Spanish version. Article content is the same in English and Spanish (i.e., 1:1 mappings exist).

Personalized health information seeking

The app content is based on several federal, public databases that are not copyrighted. The team used healthfinder.gov, a consumer set of health articles in plain language; health topics from Healthy People to create a health goal list; a federal healthcare services finder; USDA’s FoodData Central for nutrition label information; and the Agency for Healthcare Research and Quality’s (AHRQ) Question Builder to generate a list of discussion questions people might want to ask their providers.^22–25 To begin using the app, a person sets up an account and profile with basic demographic information, personal and family health histories, and health goals. App users enter their own personal health history, family health history, and health goals directly into the app and save the information to their personal profile.

Field test

We invited English-speaking African American and Spanish-speaking Hispanic adults 18 years and older to download and use the app on their own smartphones for up to 12 months. We selected 12 months as the study period to allow enough time for participants to set and complete goals for some infrequent preventive services recommendations, such as annual mammograms or annual flu shots. We aimed for an equal balance of self-identified males and females; community or technical college or less; and low to medium information seekers based on four questions from the Health Information National Trends Survey.²⁶ Pregnant females were eligible. We confirmed each participant had a smartphone capable of downloading the app and committed to use the app for 12 months. We offered participants incremental payments of $20 for completing activity milestones and an exit survey with a total of $300 possible in the study period.

Statistical analysis

We generated summary statistics describing participant characteristics of all participants and by completion group, as well as the most frequently accessed and the most frequently viewed and saved articles by all participants and by race/ethnicity. We computed odds ratios of the association between personal health history, family health history, health goals, and saving an article. We then explored the association between personal or family history or health goals and saving articles to a personal health library. Finally, we summarized user-reported satisfaction with the app, overall and by race/ethnicity.

Results

Participant characteristics

We recruited 96 total African American and Hispanic adults to download and use the app for 12 months (45 African American and 51 Hispanic adults). Enrollment characteristics are summarized in Table 1. Among the recruited participants, a majority identified as female (74%), and participants were most likely to be 35-49 years old (42.7%). Most of the recruited participants had a high school diploma (51.0%) and reported searching for health information prior to using the app (81.2%).

Table 1.

Participant characteristics.

	All participants (n = 96)	Completed minimum 36 weeks in study (n = 58)	Completed less than 36 weeks in study (n = 38)
Race/Ethnicity, n (%)
African American	45 (46.9)	24 (41.4)	21 (55.3)
Hispanic	51 (53.1)	34 (58.6)	17 (44.7)
Assigned sex, n (%)
Female	71 (74.0)	44 (75.9)	27 (71.1)
Male	25 (26.0)	14 (24.1)	11 (28.9)
Age Bracket, n (%)
18-34	31 (32.3)	18 (31.0)	13 (34.2)
35-49	41 (42.7)	22 (37.9)	19 (50.0)
50-64	17 (17.7)	12 (20.7)	5 (13.2)
>64	7 (7.3)	6 (10.3)	1 (2.6)
Weeks in study, mean (SD)	38.9 (17.0)	48.5 (5.0)	22.5 (17.7)
Highest level of education completed, n (%)
Some high school	14 (14.6)	8 (13.8)	6 (15.8)
GED	1 (1.0)	1 (1.7)	0 (0.0)
High school	49 (51.0)	29 (50.0)	20 (52.6)
Some community or technical college	11 (11.5)	7 (12.1)	4 (10.5)
2 year community college or technical college	21 (21.9)	13 (22.4)	8 (21.1)
Previously searched for health or medical information from any source, n (%)	78 (81.2)	50 (86.2)	28 (73.7)

App use activities

Participants were asked to use the app for 15 or more minutes each week and engage in several app activities including viewing, saving, and rating health information articles, as well as setting/checking health goals once every eight weeks. Analysis revealed that 58 of the 96 participants (60%) completed two of the three app activity milestones consistently during the 9-month study period. There were no differences in completion rates between African American and Hispanic participants, and there were no demographic differences between participants who completed the 36 weeks and those who did not. Participants who did not complete the 36 weeks still engaged with the app significantly, completing on average 22.5 weeks in the study, and we included the total sample in analyses of app use. On average participants viewed 66 articles (SD = 82) and saved an average of 44 articles (SD = 62).

Participant ratings of health articles

Participants were provided the opportunity to rate the articles they read. Of 1,923 unique (user, article) rating events, 95.7% were positive, suggesting that in most cases, they found article content to be relevant, informative, and/or inoffensive.

Viewing and saving health article topics

Study participants were asked to save articles in the app that were recommended by the HealthyMe/MiSalud RecSys and of interest to them. Participants could choose not to save articles recommended to them which were not of interest. Table 2 presents the most frequently viewed and saved health topics for all participants. Among the articles viewed by all participants, the top five saved health article topics were about healthy eating, managing stress, weight management, flu prevention, and back pain prevention. The most-frequently saved article topic by both African Americans and Hispanics was healthy eating. However, there was a distinct contrast in saving articles about stress management and weight management. Stress management articles were the second most saved article topic by Hispanics and the fifth saved article by African Americans. In comparison, weight management was the second most saved article by African Americans and fourth saved article by Hispanics.

Table 2.

Most frequently viewed and saved health topics (articles).

Viewed				Saved
Overall (n = 96)
Rank	View count	English title	Spanish title	Rank	Save count	English title	Spanish title
1	309	Eat healthy	Come una alimentación saludable	1	136	Eat healthy	Come una alimentación saludable
2	307	Manage stress	Aprende a controlar el estrés	2	113	Manage stress	Aprende a controlar el estrés
3	245	Get active	Mantente activo	3	111	Watch your weight	Mantente en un peso saludable
4	222	Watch your weight	Mantente en un peso saludable	4	102	Protect yourself from seasonal flu	Protégete de la gripe
5	216	Prevent back pain	Cómo prevenir el dolor de espalda	5	96	Prevent back pain	Cómo prevenir el dolor de espalda
African American participants (n = 45)
Rank	View count	Title		Rank	Save count	Title
1	129	Eat healthy		1	69	Eat healthy
2	127	Manage stress		2	57	Watch your weight
3	109	Watch your weight		3	55	Prevent back pain
4	107	Stay active as you get older: Quick tips		4	50	Stay active as you get older: Quick tips
5	94	Protect your health as you grow older		5	49	Manage stress
Hispanic participants (n = 51)
Rank	View count	English title	Spanish title	Rank	Save count	English title	Spanish title
1	180	Eat healthy	Come una alimentación saludable	1	67	Eat healthy	Come una alimentación saludable
2	180	Manage stress	Aprende a controlar el estrés	2	64	Manage stress	Aprende a controlar el estrés
3	166	Get active	Mantente activo	3	61	Protect yourself from seasonal flu	Protégete de la gripe
4	124	Prevent back pain	cómo prevenir el dolor de espalda	4	54	Watch your weight	Mantente en un peso saludable
5	113	Watch your weight	Mantente en un peso saludable	5	49	Get active	Mantente activo

Association between personal health history, family health history, health goals, and saving an article

Odds ratios of the association between saving an article and personal health history, family health history, and health goals were computed using Fisher’s exact test due to small cell sizes and are presented in Table 3. Fisher’s exact test is a two-tailed test, with a null hypothesis that no difference exists in the proportions of saves occurring when a topic is or is not in a participant’s personal health history, family health history, and health goals. African American females ages 18-34 were more likely to save an article when it represented a topic in their family health history, and African American females ages 35-49, males age 50-64, and African American males overall were more likely to save an article when it represented a topic in their health goals. For Hispanic participants, there was no consistent association between personal or family history or goals and saving articles.

Table 3.

Odds ratios of selected factors associated with saving articles to personal health library.

Race/Ethnicity	Sex	Age	Topic in personal health history	Topic in family health history	Topic in goals of health
African American	Female	Overall	0.745*	0.851	0.924
		18-34	0.862	4.792*	0.251***
		35-49	1.057	0.655	1.616**
		50-64	0.758	0.849	0.706**
		>64	0.353***	0.673	1.119
	Male	Overall	1.53	0.465***	1.536***
		18-34
		35-49	0.98	0.591	0.795
		50-64		0.306***	2.458***
		>64	1.22	0.638	1.061
Hispanic	Female	Overall	0.768	0.877	1.166
		18-34	3.011	0.927	0.934
		35-49	1.944	0.83	0.916
		50-64	0.352	2.454	0.927
		>64	0.00	1.514	1.167
	Male	Overall	1.091	0.915	0.877
		18-34	1.39	0.769	0.795
		35-49	0.421	0.575	0.772
		50-64	0.594	1.005	2.32
		>64

Blank cells indicate no observations for this group. p-value from Fisher’s exact test; *p < .1 **p < .05 ***p < .01.

App use satisfaction

Each participant received a survey link when they completed their study period; all 58 participants who completed a minimum of 36 weeks in the study completed the survey. The survey included slightly modified questions from the National Cancer Institute’s Health Information National Trends Survey, the mHealth App Usability Questionnaire (MAUQ), and a mobile health app user satisfaction questionnaire.^26–28 Most African American and Hispanic participants strongly agreed that it was helpful to save articles in their PHL and were satisfied with the recommendations that the app provided (Table 4). African American participants were more likely to think of HealthyMe/MiSalud as their personal digital health library and were more likely to feel they had a personalized source of health information than Hispanic participants.

Table 4.

Participant rating of app as digital personal health library.

Study exit survey statement	Scale	Respondent (sub)group	N	Mean (SD)
It is helpful to save articles in my library	1 (strongly agree) - 7 (strongly disagree)	All respondents	58	1.78 (1.45)
		African-American	24	1.5 (1.29)
		Hispanic	34	1.97 (1.55)
I Think of HealthyMe/MiSalud as my personal digital health library	1 (strongly agree) - 5 (strongly disagree)	All respondents	58	2.91 (1.61)
		African-American	24	1.92 (1.25)
		Hispanic	34	3.62 (1.48)
I am satisfied with the recommendations the app gives me	1 (strongly agree) - 7 (strongly disagree)	All respondents	58	1.95 (1.55)
		African-American	24	1.75 (1.45)
		Hispanic	34	2.09 (1.62)
It made me feel like I have a personalized source of health information	1 (strongly agree) - 5 (strongly disagree)	All respondents	58	2.81 (1.59)
		African-American	24	1.71 (1.12)
		Hispanic	34	3.59 (1.42)

Discussion

When our team began building the HealthyMe/MiSalud app in 2017, health apps, especially culturally and linguistically specific ones, were uncommon as health information delivery devices. As of 2024, both general population and population-specific apps deliver information; track and summarize daily activities, symptoms and conditions; provide behavior change programs; offer disease surveillance and reporting and more. Social media channels have emerged as free, crowdsourced health information sources for millions of people, while the volume and type of health misinformation and disinformation have increased significantly and become topics of global concern. These developments accelerated during the extended COVID-19 pandemic, which, among other effects, heightened awareness of health information disparities and the challenges of establishing information sources as credible and trustworthy. We consider our results in the context of this constantly changing information ecosystem and lessons learned about our app as a health literacy and disease prevention/health promotion tool.

African American and Hispanic smartphone users have been avid online health information seekers, despite reports of scoring lower in health literacy.^7,29 Historically and presently, barriers to education and mistrust in the healthcare systems have prevented these communities from having access to high-quality health information.³⁰ Although not the solution to decades of health inequities, we believe our HealthyMe/MiSalud app is an example of how effective organizational health literacy approaches can intervene at the personal health literacy level and contribute to addressing systemic health inequity issues. Our data show the majority of the users in our study reported that HealthyMe/MiSalud was helpful with saving health information articles to their PHL, and they were satisfied with the recommended health information articles. An app that integrates health literacy-based content and a RecSys in conjunction with a PHL can streamline the process of filtering information and increase the likelihood of a user receiving relevant and accurate health information.

The number one saved health information article topic by HealthyMe/MiSalud our participants was about healthy eating. Diet and nutrition are crucial factors in preventing health conditions such as obesity, heart disease, diabetes, and high blood pressure.³¹ These preventable conditions are within the top leading causes of death for African Americans and Hispanic adults in the US.^32,33 Understanding that healthy eating may be a top health information priority within these communities can inform current and future design of health apps focused on nutrition activities (e.g., calorie tracking) and nutrition information (e.g., recipes, nutrition fact sheets).

Interestingly, our Hispanic and African American participants were different in saving articles about stress management and weight management. Although both Hispanic and African American adults report high levels of stress in comparison to other racial and ethnic groups, this topic was the second most saved article topic in the PHL by Hispanics, whereas African Americans’ second most saved article was weight management. Although article rank differed for stress management and weight management, both topics are associated with healthy eating, which was the number one saved article by both groups.³⁴ These findings suggest a holistic approach that supports mental and physical health might be of value to both communities, and both areas should be considered in app designs to address the relationship between mental and physical health behaviors. Additionally, these findings support the importance of providing a personalized health app and not relying on a “one size fits all” platform because people have different health priorities.

Specific differences in sex, race, and ethnicity were revealed in some of the app activities. Across both Hispanic and African American participants, identifying as a female and being 35-49 years of age was associated with saving health information to a digital personal health library. This supports prior studies that reported women/females and adults younger than 50 years of age are traditionally more likely to seek health information depending on channel/source in comparison to men/males and older adults.³⁵ However, our findings did reveal that African American men/males ages 50-64 were more likely to save health information when this information aligned with their goals. Research reports that African American men/males are likely to seek online health information for a specific health condition if they had some college education and attended a program to prevent a health condition.³⁶ However, this excludes those who are not college educated, and education is associated with health literacy.³⁷ Research should continue to explore motivating factors to engage African American men/males of varying socio demographic and health status in app use for health information seeking.

Motivation for saving health information also revealed demographic differences. African Americans were likely to save health information when it aligned with the health goals they set in their PHL. This suggests that PHLs should not only serve as a source for storing information but also a source to support goal setting. Further research should extend this work and explore app users’ goals setting and completion in relation to the information saved and determine how to seamlessly integrate these data points in a user-controlled, single digital personal health library. Research has noted that consumers are justifiably frustrated with having to navigate multiple platforms for their clinical (biomarkers) and non-clinical data (health information sources).³⁸ Digital health developers, practitioners, and researchers need to explore how to integrate multiple platforms, such as smartphone apps and patient portals, so consumers can have improved “digital health coordination” for their health needs.

An important goal of our app was to provide health information based on language preferences, specifically in Spanish and English. Many smartphone apps are only available in English.³⁹ Research has revealed that those specific for health-related purposes are limited in catering to the language preferences or needs of Hispanics.⁴⁰ This is problematic, considering the Hispanic population is increasing, and this group is also disproportionately experiencing preventable health conditions. Although Hispanic Spanish-speaking/bilingual participants did not specifically comment on the language functions in the app, they did report the app being helpful in receiving and storing relevant health information. Future studies should explore how integration of language functions in health apps can better support health information seeking, processing, and use of the information to support health goals and health behaviors. Additionally, our study did not reveal differences by age or sex in article saving based on personal health history, family health history, or health goals within the Hispanic group. Further research is needed to determine what other factors aside from sex drive PHL use.

In addition to these insights for future research, we suggest that additional research on the functions in the app that were less used is warranted. The app included a function for participants to build lists of questions for their providers that participants did not use. The goal setting function that allowed participants to build and modify lists of goals that they could mark “complete” or delete was also under-used and could have provided more data on actions participants took. The nutrition facts for food products look-up function had technical issues and database gaps that frustrated participants. New formative research with African American and Hispanic adults could provide insights into how to make these functions work better as well as provide ideas for new functions, such as peer-to-peer information sharing and biometric data management within the app. Formative research could provide insights about how to motivate participants to complete more milestone activities.

We consider the COVID-19 pandemic both a strength and a limitation for this research, especially related to our sample and recruitment. Even though African American and Hispanic adults were among the groups most negatively affected by the pandemic, we did successfully recruit enough participants who stayed in the study. More than one participant contacted us or responded to our retention phone calls to let us know they had been sick with COVID or caring for people with COVID but wanted to complete the study. We believe our participants’ commitment to the study, despite adverse circumstances, indicates that a market for a culturally relevant prevention focused app exists. Our participants’ commitment also meant we retained enough people to do statistical analysis of the personal health library related data, which describes our core construct.

The pandemic was also a limitation because we could not use the local community recruitment strategy and screening criteria we had originally planned. Pandemic lockdowns prohibited this approach. Most of our participants came from paid recruitment, and many did have technology struggles that we could only address virtually. Being busy, distracted, or stressed by the pandemic and additional responsibilities may partially explain that 40% of our sample did not complete two or more of the milestone activities, despite incentive payments. Additionally, we recognize that consumer adherence and retention with smartphone health apps continues to be a challenge for researchers, practitioners, and developers. The contributing factors in this study were not the only reasons for dropout. Not including app features such as gamification, notifications, or app usefulness enhancements can also affect continuous engagement.⁴¹ For example, regarding app usefulness, when a user has achieved the goal that the app was intended to achieve, such as weight loss, this can cause a change in adherence and affect retention.⁴¹ More robust goal-setting features could be beneficial to maintain adherence once a user’s goal has been met.

The app itself has limits in the types of data it collects, which also limits insights into participants’ in-app behaviors. The HealthyMe/MiSalud’s RecSys utilizes data from healthfinder.gov to deliver personalized health information utilizing health literacy principles.²⁴ The health information provided by healthfinder.gov aligns with topics in the United States Preventive Services Task Force (USPSTF) recommendations and uses factors such as sex to inform the recommendations. Our app provides health information based on the user’s sex and not gender identity. The USPSTF reported in 2021 “research plans will now consider whether the preventive service is expected to be applied according to biological or physiological sex characteristics, gender identity, or potentially both. In addition, when assessing the evidence, the Task Force will consider how applicable it is to transgender, gender nonbinary, gender diverse, and intersex people”.⁴² Future versions of the app could reflect these changes.

Regarding our questionnaires, the exit survey included questions from validated questionnaires that we modified and combined into a new questionnaire. We did not conduct a pilot study of the new questionnaire, which is a study limitation, but our use of previously validated questions provides a starting point for future validation studies.

Conclusion

Despite the pandemic and other constraints, our study provides new insights about bilingual digital technologies, health information seeking, and engagement with prevention content. Our study revealed that a digital health personal library driven by a RecSys can support health information seeking, or the “finding information” component of the health literacy concept. The activity of saving articles revealed both what our participants looked for and highly valued and what they engaged with enough to want to save and return to. Although the study was not an intentional comparison between African American and Hispanic adults, we did observe key similarities and differences. These findings can inform the work of app developers, public health practitioners, and researchers when designing for groups of varying backgrounds in race, ethnicity, language, health literacy skills, sex, and age, as well as the intersectionality of these identities.

Supplemental Material

Supplemental Material - Advancing African American and hispanic health literacy with a bilingual, personalized, prevention smartphone application

Supplemental Material for Advancing African American and hispanic health literacy with a bilingual, personalized, prevention smartphone application by Neil Jay Sehgal, Devlon Nicole Jackson, Christine Herlihy, John Dickerson and Cynthia Baur in Health Informatics Journal.

Footnotes

Acknowledgements

The authors acknowledge the contributions of Dr Robert Gold, Dr Madeline Diep, and Dr Patricia Garcia; current and former students including Maria Amador, MPH; Shuo Huang, MPH, PhD; Leyla Merlo; and Neil Johnson; and Research Assistant Monica Rodriguez, MS.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this paper was supported by the National Library of Medicine (NLM) of the National Institutes of Health under award number R01LM013039. NLM provided 100% of the $1,344,152 total project costs. The content is solely the responsibility of the HealthyMe/MiSalud team and does not necessarily represent the official views of the National Institutes of Health.

Ethical statement

ORCID iDs

Neil Jay Sehgal

Cynthia Baur

Supplemental Material

Supplemental material for this article is available online.

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