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A variety of eHealth services are available and commonly used by the general public. eHealth has the potential to engage and empower people with managing their health. The prerequisite is, however, that eHealth services are adapted to the sociocultural heterogeneity of the user base and are available in a language and with contents that fit the users’ preference, skills, and abilities. Pakistani immigrants in the Oslo area, Norway, have a much higher risk of Type-2 diabetes (T2D) than their Norwegian counterparts do. In spite of having access to information and communication technology (ICT) and the Internet, ICT skills in this population are reported to be relatively low. Further, there is insufficient information about their use of and attitudes toward eHealth services, necessitating investigation of this group in particular.
This study targets first-generation immigrants from Pakistan living in the Oslo area and examines their use of and attitudes toward eHealth services, specifically: information searches, communication using ICT, and use of ICT for self-management or decision making, all concerning T2D.
Due to a high prevalence of low literacy among the target population, we employed questionnaire-based individual interviews. The questionnaire was developed by implementing potentially relevant theoretical constructs (technology acceptance model (TAM) and health belief model (HBM)) as measures. To explore issues around language, culture, and general ICT skills, we also implemented questions that we assume were particularly relevant in the context studied but do not appear in any theoretical frameworks. The questionnaire was revised to reflect results of a pilot study involving 10 participants. We employed culturally sensitive sampling methods to reach informants who could otherwise fail to be included in the survey.
This paper presents a survey protocol. The data collection is ongoing. The aim is to collect 200 responses in total by March 2016.
For eHealth to become an influential social innovation, equal access to eHealth services regardless of users’ language, culture, and ICT skills is a prerequisite. Results from this study will be of importance for understanding how people who may not maximally benefit from eHealth services today could be targeted in the future.
In light of the rapidly increasing number of people having access to Internet and mobile-broadband subscriptions [
Included in eHealth is technology supporting self-care, or “what people do for themselves to establish and maintain health, prevent and deal with illness” [
One of the advantages of eHealth is that each user can actively choose the eHealth services that best fit their individual needs. eHealth services in the user’s primary language, adapted to cultural preferences, thus appear to be helpful tools. This advantage applies in particular to ethnic minority populations, such as immigrants, to supplement other health services where language and cultural barriers can be of note. In Norway, the number of immigrants has been steadily increasing over the last 40 years. At the beginning of 2015 [
A study among four immigrant groups in the Oslo area [
To date, there is no sufficient information available about the extent to which immigrants with Pakistani background in the Oslo area are using or benefiting from eHealth resources for self-care of T2D, and what their preferences are. Knowledge is scarce regarding their access to and usage of ICT devices and the Internet in general as well. A survey of digital skills and access to ICT among five immigrant groups (Pakistani, Polish, Iraqi, Somali, and Vietnamese) in 2010 [
These results suggest that many individuals among immigrants with a Pakistani background may not have been able to benefit from using eHealth services, despite having ICT devices and access to the Internet. Because of a high proportion of the Pakistani population with low educational level [
The existing knowledge so far [
Today there is a digital divide that goes beyond access to ICT resources among Pakistani immigrants in Norway. This gap needs to be addressed to realize the potential in eHealth to mitigate social disparity.
This study aims to provide new insights into the use of and attitudes toward relevant eHealth services to self-care of T2D in this group. Types of eHealth use studied are information searches, communication using ICT, and use of ICT for self-care or decision making. Information searches include using search engines by entering search terms, visiting specific websites to read relevant information, and use of look-up applications. Communication using ICT includes closed communication such as voice or video conversation as well as text messaging, use of social network services, and online consultation to peers or health care professionals. ICT for self-care or decision making includes applications and similar to either record and track data of oneself, such as diet, physical activity, or blood glucose level, or assess user’s health condition or risk based on input data.
The following research questions will be addressed:
What are the traits of informants concerning the use of and attitudes toward eHealth for their self-care of T2D?
How do informants describe barriers and facilitators of using eHealth services for their self-care of T2D in general?
What are their experiences of eHealth services for their self-care of T2D concerning their language and culture?
The survey will help us to break down the problem areas and provide a necessary overview of the status quo in eHealth use for self-care of T2D and attitudes among the target population. Once complete, the study will contribute to defining target users, their requirements and experiences with eHealth services for self-care of T2D.
It is important to use theoretical frameworks when designing studies on predicting factors of technology use [
Tested antecedent factors on the user side are mainly categorized into personal factors, organizational factors, and social factors. Personal factors include factors related to being a patient (or ones relevant to the purpose of using eHealth), to being an ICT user, and factors potentially related to both issues such as sociodemographic variables. Organizational factors include users’ relationship with health care personnel or institute, users’ satisfaction with them and available support in using technology. Social factors mostly refer to extrinsic motivation by others.
Given that use of eHealth has the potential to enhance or trigger positive health behaviors, if not improve health condition or prevent diseases by itself, it is reasonable to assess eHealth use as a component of relevant health behavior theories (HBTs). A well-known model of individual health behavior is the Health Belief Model (HBM) [
In this study, we do not intend to suggest a new model of eHealth acceptance or to test the applicability of existing models to our settings. Instead, we use relevant established theories as a framework to investigate eHealth use and to identify users’ background traits depending on eHealth use and attitudes to it. Therefore, we implemented questions that supplement measures in the theoretical frameworks to explore areas that those frameworks do not cover. Such questions are especially concentrated on cultural and language oriented traits of the target population.
We are particularly interested in how language barriers and cultural background of the target population are associated with their eHealth use for self-care of T2D. Due to this focus, we employ purposive sampling and use culturally adopted recruiting methods to assure inclusion of otherwise “hard-to-reach” informants. The following inclusion criteria were set: (1) immigrated from Pakistan after the age of 18 and living in the Oslo area, (2) speak Urdu (the official language of Pakistan) as the primary language in their private life, (3) are aged between 25 and 59, (4) have access to or interest in ICT-tools (PC, tablet, or smartphone), connected to the Internet in daily life, and (5) are motivated for and capable of activities for self-management or prevention of T2D.
Before finalizing the inclusion criteria and the questionnaire to use, we carried out a pilot testing with 10 informants who satisfied all the inclusion criteria above but “after the age of 18” in the first criterion. The pilot testing included two informants who immigrated to Norway at an early age. Although they claimed that their primary language was Urdu, they had received primary educations in Norway and did not have any difficulties in using ICT and eHealth in the Norwegian language. Given the fact that many Pakistani people immigrate by marriage to Pakistani-Norwegians [
The upper age limit and the last two inclusion criteria are set to highlight issues of language barriers and cultural differences beyond the access to ICT by eliminating common issues between the target population and the ethnic Norwegian population. Figures from 2010 show a significant drop in the percentage of the Norwegian population over the age of 55 that use the Internet to seek health-related information [
Regarding the last criterion, activities in concern include having a healthy diet and being physically active. We employ a question asking about informant’s intention to change lifestyle for self-care of T2D used in a relevant study [
For recruitment, we follow multirecruitment strategies recommended from the experience of difficulties in recruiting South-Asian people [
We aim to recruit 200 informants in total for the survey. We consider this sample size is reasonable given the project budget and the following reasons. Sample sizes varied a lot in relevant studies that quantitatively assessed acceptance of an eHealth service using theoretical frameworks: 101 [
We collect data in the form of questionnaire-based structured individual interviews. One research assistant asks questions orally, and the other assistant fills out the orally given answers on an answer sheet. Answers to open questions are written down in English by one assistant, and the other assistant assures the expression in English is reasonable.
The primary reason for using individual interview was that low-literacy and -education level is prevalent among the target population. This method has the potential to increase response rate as well as provides possibilities to explain questions and alternative answers for closed questions to assure the quality of data. To keep the condition of data collection consistent, we decided to use only the form of individual interview for all the informants regardless of their literacy levels.
Questions were first formulated in English by the research members. Our approach to developing the questions in the Urdu language was concept driven [
In the pilot testing, we tested the questions expressed in the Urdu language and the agreed procedure of the survey. We iteratively improved the questions and the question structure. By the sixth informant in the pilot testing, the questions and the question structure were finalized.
Structure of the questions to use in the survey.
Questions under this category are divided into three sections corresponding to three subcategories: demographics and language proficiency (section 1), health (section 2), and ICT experiences (section 3).
The “demographics and language proficiency” subcategory includes an educational level in both Pakistan and Norway, the period of being in Norway and their confidence in writing and reading in Urdu script, Roman Urdu, and Norwegian. Roman Urdu is the Urdu language written in Roman letters. We included Roman Urdu because the pilot study revealed that Roman Urdu is often used among the target population, especially for text communication using ICT devices.
The “health” subcategory includes measurement items for theoretical constructs within relevant HBTs. We considered various validated measures used in relevant studies [
The “ICT experiences” subcategory is further divided into two parts. The first part, subsection 3-1, consists of questions asking about access to ICT in general including indirect access. Here, indirect access means that another person operates ICT devices on behalf of an informant. The second part, subsection 3-2, consists of questions asking informant’s experience in using ICT for different types of purpose that correspond to the types of eHealth services in this study. Therefore, these questions serve as a filter to ask further questions about the use of eHealth service.
This category is divided into three sections corresponding to the three types of eHealth services the study is addressing (information searches (section 4), communication using ICT (section 5), and use of ICT for self-management or decision making (section 6)). All the questions asking about experiences of using ICT include subquestions asking which languages informants use for each purpose. The informants in the pilot testing used a variety of methods for both text typing/input and reading. Therefore, we implemented subquestions asking about methods to use for each purpose of ICT use of our interest. To those who have experiences of using the specific types of eHealth services, we prepared an open question to ask about the experiences in detail. For each open question, we prepared a series of keywords and phrases as hints to make it easier for informants to remember the experiences. The key words and phrases include among others content fitness to informants’ culture, lifestyle, language, gender, and age, concern about information security and privacy, and trustworthiness of services. We employed this way to explore any relevant issues to their eHealth use originating from their personal background rather than increasing the number of questions to ask informants about potentially irrelevant issues. During the pilot study, we identified several cases that theoretical constructs within TAM and its derivatives were not applicable to explain not using eHealth services. Thus, we also included questions asking reasons for not using each type of eHealth services as well as their attitudes toward using the eHealth services.
For section 4, the subcategory of information searches, we added a group of questions (subsection 4-2) that ask about informants’ strategy for learning about T2D regardless of using ICT. These questions will be asked regardless of the experience of ICT use for any information searches in general.
Section 7 includes measurement items for theoretical constructs within TAM and its derivatives. These measure are BI, PEOU (adopted from [
The data analysis process will start by examining the validity of measurement models and measurements by using confirmatory factor analysis. Due to a potential for high heterogeneity of given answers and the inclusion of originally formulated questions, we will primarily employ a qualitative approach in data analysis and corroborate with results of quantitative data analysis. We will use descriptive statistics first to find out central tendencies. We will carefully examine the distribution of data for applicability of parametric analysis. If a parametric analysis is not suitable, we will use a nonparametric analysis. Because it is very likely that informants’ backgrounds vary a lot, we expect that answers given to open questions will provide hints of unforeseen factors that may partly explain theoretical constructs. Thus, we will follow the framework of thematic analysis proposed by Braun and Clarke [
This study collects sensitive data such as diagnosis of T2D and educational levels in Pakistan and Norway. Even though the study does not collect any directly identifiable personal data, a relatively small sample size in a limited area of Norway and the inclusion criteria may compromise their anonymity. Ranges rather than exact values were used to record information regarding the informants’ age and the period of being in Norway.
At the recruitment, the research assistants explain informants the purpose of this study, what types of questions are included in the survey, that the data is handled anonymously and kept in secured storage, who will attend the interview, and who will have access to the anonymized data. Informants will receive this information in a written format as well at the beginning of an interview. Informed consent is given verbally, which is allowed by the institutional review board, the Norwegian Social Science Data Services (NSD) [
This paper is a protocol paper and data collection from the main survey is still in progress at the time of submission. The main survey started in September 2015. By the end of November, we collected responses from 103 informants. The expected time to complete data collection is the end of February 2016.
This paper presents the protocol of a survey on eHealth use concerning T2D among first-generation immigrants from Pakistan in the Oslo area. Our focus is on their eHealth experience in relevance with language barriers and cultural differences. Although eHealth has a great potential for immigrant populations for easy access to culturally sensitive health information, knowledge on status-quo of eHealth use in immigrant populations is scarce [
First of all, the methods for recruiting and data collection are time-consuming and resource-demanding. Due to the language, the methods rely on the Urdu-speaking research assistants who recruit informants and collect data. One interview takes 1 to 1.5 hours, so the number of interviews per day is limited.
Secondly, informants’ background variables, such as gender and age range, potentially have a skewed distribution. This challenge is not only related to chosen methods, but to general challenges in the group and other. From very early phases of the study design, we were aware of a potential challenge for recruiting male participants. Our research assistants have relevant experiences from an intervention study to prevent T2D among women with Pakistani background in the Oslo area (InnvaDiab study) [
Lastly, we need to note a potential risk of selection bias, where informants’ personal factors may differ from the represented population. Because we do not have our sample ready yet, we refer to a reliability of the sample in the InnvaDiab study [
For eHealth to be truly a social innovation, it should be readily accessible and useful regardless of users’ ethnicity, country of residence, or primary language. This is in line with a claim by World Health Organization [
The study will also be of importance to research and policy makers that aim to mitigate the social disparity in health among immigrants. In these regards, the study design described in detail in this article will be valuable in providing a basis for designing a survey of eHealth use by immigrants in other contexts.
Survey questionnaire.
behavioral intention
health belief model
health behavior theories
information and communication technology
Norwegian Social Science Data Services
technology acceptance model
type-2 diabetes
personal computer
perceived ease of use
perceived usefulness
short message service
The Department of Computer Science, the Faculty of Technology, Design and Art, Oslo and Akershus University College of Applied Sciences funded this research in December 2014. The authors are grateful for the support given in the phase of writing an internal funding application by professor Else-Lydia Toverud, School of Pharmacy, the Faculty of Mathematics and Natural Sciences, University of Oslo. We also thank Monica Morris and Anica Munir for serving as research assistants, and Tulpesh Patel at the Department of Computer Science, the Faculty of Technology, Design and Art, Oslo and Akershus University College of Applied Sciences for critical comments and proofreading. Last but not least, the authors thank the reviewers for their critical comments.
NT conceived this study. NT drafted the study design and the first version of the manuscript. All the other three authors contributed to further development of the study design and to finalizing the manuscript by giving comments to all versions of the manuscript draft. All authors read and approved the final manuscript.
None declared.