Abstract
Black men have the highest age-adjusted death rate of any major race-gender group in America. Understanding their perceived barriers to accessing health care may benefit future interventions working to increase Black men’s health care engagement. Data collected from focus groups of Black men(N = 67), key informant interviews(N = 12), and interviews(N = 5) with participants who pilot tested an online health education system (called “Gabe”) were analyzed to explore their health care experiences and how computer-based health programs might better assist Black men. Concerns pertaining to health care systems’ failure to recognize the diversity among Black men, and physicians’ lack of sociocultural awareness about the challenges they regularly face, were most salient. Building trust with providers was cited as being central to engagement, with Gabe users perceiving the system to be both trustworthy and accessible. Participants reported an openness to technology assisting with health management and provided suggestions of how online systems can meet the needs of Black men.
Introduction
Black men have the highest age-adjusted death rate of any major race-gender group in the United States (Xu et al., 2016), with data indicating Black men live on average 5.4 years less than White men (Harper et al., 2014). Black men have higher death and shorter survival rates for many cancers, as well increased rates of asthma, high blood pressure, diabetes, and stroke (Cunningham et al., 2017). The reasons for these disparities are complex and likely include numerous factors, including institutional and systemic racism, lower socioeconomic status, lack of access to high quality health care, and mass incarceration (Martin et al., 2015).
Despite passage of the Obama Administration’s 2010 Affordable Care Act, resulting in increased rates of insured for all racial groups from 2013 to 2017, the ratio between uninsured Whites and Blacks remained constant, with Black non-elderly individuals still over 50% more likely than non-elderly Whites to be uninsured (Artiga et al., 2019). Black individuals are more likely to live in medically underserved areas, which are characterized by an insufficient number of primary care providers, elevated poverty, and poor population health (Molina et al., 2017).
Distrust of the medical community is well documented in the Black community and especially among Black men (Adegbembo et al., 2006; Boulware et al., 2016; Brandon et al., 2005; Carpenter et al., 2009; Musa et al., 2009), resulting from a long history of abuse and deception (King, 2003; Nelson, 2002), and ultimately contributing to racial differences in health care utilization (Washington, 2006). As detailed in Unequal Treatment (Nelson, 2002), published by the Institute of Medicine (now the National Academy of Medicine), “bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care” and that “differences in health care occur in the context of broader historic and contemporary social and economic inequality.”
This article explores Black men’s health care experiences by utilizing definitions of racism articulated in Racism Without Racists (Bonilla-Silva, 2010), with the frames of “cultural racism” and “abstract liberalism” (a form of color-blind racism) providing constructs through which participants’ accounts of differential treatment can be understood. Cultural racism is more overt and linked directly to stereotyping and assuming [negative] value ascriptions for racial/ethnic groups, whereas abstract liberalism is often hidden within meritocracy via “one size fits all” approaches and can result from a failure to understand hardships that may differentially impact various populations (Bonilla-Silva, 2010). Abstract liberalism asserts that present racialized inequalities are preserved when past and current social, economic, and educational discrimination is ignored and the idea of equal opportunity for everyone, without considering the inequalities between Whites and Blacks, is supported (Bonilla-Silva, 2010).
Addressing the diminished rates of health care engagement for Black men, including both structural barriers impacting access (Artiga et al., 2019) and social forces dissuading participation (Stuber et al., 2008), is important to closing the health disparity gap, as participation in health care is correlated with health outcomes (Alegría et al., 2009; Hibbard et al., 2008; Hibbard & Greene, 2013). Health promotion initiatives could play an important role, as research finds that smoking, physical inactivity, and unhealthy weight are all linked to elevated mortality for Black men (Thorpe et al., 2013).
Technology may offer an opportunity to address health disparities. The “Gabe System” (hereafter called “Gabe”) is an embodied conversational agent (ECA) that simulates face-to-face conversation with a health counselor (Figure 1). ECAs are computer-animated characters that use speech and synchronous conversational nonverbal behavior—such as hand gesture, eye gaze, head nods, and facial displays—to convey meaning and regulate the flow of conversation simulating what people do in face-to-face interactions (Cassell et al., 2000). Prior research demonstrates that ECA health counselors can lead to successful health behavior change, especially for underserved populations with low health or computer literacy (Bickmore et al., 2010, 2013). The model for Gabe is an ECA system known as “Gabby,” developed to address preconception health risks for young Black and African American women. Participants that used Gabby in a between-subjects experiment had significant health risk reduction compared to a non-intervention control (Gardiner et al., 2013; Jack et al., 2015, 2020), with the system adopted for wide-scale use by Cook County Health (IL) in 2020 (Cook County Health, 2020).
Gabe discussing reproductive care.
Gabe is an ECA software application delivering health promotion interventions accessible through the web. It offers evidence-based information and creates achievable objectives with its users, emphasizing increasing Black men’s daily participation in health behaviors, such as healthy eating or safe sexual practices, and navigating social determinants of health, such as unemployment or housing instability (Cunningham et al., 2017; Thorpe et al., 2013; Warner & Hayward, 2006). The evidence guiding Gabe’s development included literature on positive patient–provider interactions within Black communities (Earl et al., 2011), successful strategies for engaging Black men in help-seeking behavior (Powell et al., 2016), factors associated with Black men’s resilience (Teti et al., 2012), and innovative technological interventions (Bickmore et al., 2010) as a way to engage young Black men in health care. The primary charge of Gabe is to deliver health care interventions to Black men employing an anti-racist framework (Crear-Perry et al., 2020; Maiter, 2009), with the development of system content (Table 1) being a joint process between Boston University School of Medicine (BUSM) and Northeastern University researchers and the advisory board, comprised of six Black men serving in community leadership capacities across the Northeast and Midwest U.S. Gabe’s prioritization of an anti-racist framework is paramount to its overall mission, as Crear-Perry et al. (2020) explain that “an anti-racist, structural justice approach is the crucial narrative frame that health-care practitioners need so that they can dismantle, reimagine, and redesign health care in a changing society” (p. 453).
Gabe Content Domains.
We conducted a multimodal qualitative study, utilizing interviews and focus groups to examine young Black men’s experiences with, and suggestions for, health care systems, while also exploring the acceptability of ECA technology to address some of these concerns. Little is known about how ECAs, such as Gabe, could be designed to increase the engagement of young Black men in health care, or how this technology may address some of their perceived barriers; however, this article will present initial findings that future research can seek to build off of.
Methods
All data analyzed in this study were collected by the BUSM research team, with two qualitatively trained members having conducted focus groups (N = 11; participants N = 67), key informant interviews (N = 12), and individual interviews with participants from the 30-man pilot test of Gabe (N = 5). These approaches to data collection were used to obtain multiple perspectives about the Gabe system, culturally informed health care, and strategies to promote sustained participant engagement in health care. All study protocols were approved by the BUSM Institutional Review Board and informed consent was obtained from all adult participants, with parental consent and participant assent having been obtained for those under the age of 18 years.
Data analysis was performed by two members of the research team utilizing inductive coding strategies (Saldaña, 2015), with the emergent themes for each of the three data points (e.g., focus groups, interviews) having been presented to the wider research team for discussion. Findings were collectively reviewed during team meetings, with three overarching themes having been identified as important to both the barriers impacting Black men’s engagement in health care, as well as the development of virtual agent-led health education systems. Since each methodology sought to qualitatively understand different processes related to the health care experiences of Black men, while the various perspectives are complimentary and often provide triangulation for findings, not every theme is explicitly supported by each of the three data points. That said, when the findings are viewed in conjunction with one another, a more comprehensive discussion as to the potential of online systems to assist Black men with health care can be presented.
Focus Groups (FG)
Participants were recruited from community institutions in Boston (MA), New Haven (CT), Providence (RI), and Philadelphia (PA) with programs serving young Black and African American men. The study’s advisory board connected the research team to leaders at each community site, and site leaders invited their program participants and other community members to participate in this study.
Focus group participants were all between the ages of 15 and 27 years and self-identified as Black males (Table 2). All focus groups were co-facilitated following a semi-structured interview guide, audio recorded, and transcribed (Drever, 1995). At least one co-facilitator for each focus group self-identified as Black and self-identified as male. The topics discussed during each focus group included (but were not limited to): participants’ general definitions and perceptions of health, health care utilization and alternative methods of health management, motivations and barriers impacting health behavior change, individual accounts of positive and negative past experiences with health care, and perceptions of the acceptability of Gabe. Sections of Gabe were regularly presented during focus groups to obtain feedback about system content, interface design, and gauge the appropriateness of the ECA-to-user dialogue. All transcripts were reviewed for transcription accuracy and to remove any identifying information. Two research team members trained in qualitative research methods individually coded a few initial transcripts using constant comparative analysis and developed an initial coding dictionary (Boeije, 2002). Each coded transcript and coding dictionary were collaboratively reviewed to reconcile discrepancies, and the reconciled coding dictionary was iteratively refined and used by both research team members to independently code the remaining transcripts. Coded transcripts were continuously reviewed and coding decisions were confirmed by referring to the coding definitions and criteria outlined in the reconciled coding dictionary. Similar codes were merged into categories, and descriptive and in vivo coding methods were used to identify the connections between categories and combine related categories into larger themes (Saldaña, 2015). NVivo was used to manage all transcript data during analysis (QSR International, 2019).
Focus Group Participant Demographics.
Employment data were not collected for 10 individuals in the Providence adult FGs. Percentages are N = 9.
The percentages are for N = 57, as data are missing for 10 Providence adult participants.
Key Informant Interviews (KII)
Key informants (N = 12) were recruited from community sites across the Northeast, with each informant working for a different organization and serving a distinct community role, including supervising fatherhood groups, leading non-violence interventions, supporting families involved in the criminal justice system, and managing community health sites. Four interviewees were members of the study’s advisory board, and the other key informants were recruited through snowball sampling. Interview questions focused on each informants’ professional experience, including their successes engaging the community, barriers impacting community programming serving Black men and their families, and their perceptions as to the needs of Black men. In addition, informants were explicitly asked to share their perspectives about online health education systems’ ability to meet the needs of Black men; however, these discussions were largely framed in a general sense, as only the interviewees who were also advisory board members (N = 4) had previously engaged with Gabe. All interviews were analyzed by two research team members using the coding and reconciliation process described above (Boeije, 2002; QSR International, 2019; Saldaña, 2015).
Post Pilot Test Interviews (PPI)
Post pilot test interviewees (N = 5) were recruited from the sample of 30 men who used Gabe for 2 weeks during the system’s feasibility test. Pilot test participants were all between the ages of 18 and 27 years, with the five post pilot test interviewees having a mean age of 19.4 years. Invitations to interview were extended to all 13 users who completed [at minimum] the introduction portion of the Gabe system, with these men averaging over four system log-ins and roughly 2 hours of unstructured Gabe engagement during the 2-week pilot. Ultimately, five men accepted and interviews were completed at community sites in Providence, RI and New Haven, CT. Interviews were facilitated by two members of the research team using a semi-structured interview guide (Drever, 1995). The interview questions examined men’s perceptions of Gabe, perceived trust of system content, and any challenges associated with using the system. Interview transcripts were analyzed by two research team members using the qualitative methods detailed in the above sections (Boeije, 2002; QSR International, 2019; Saldaña, 2015).
Results
Three major themes emerged from the data, with young Black men noting (a) a desire for a more inclusive account of their racial and ethnic identity in health care, (b) perceived differences between providers’ cultural ignorance (color-blind racism) and explicit racial bias (cultural racism) during clinical encounters, and (c) strategies to build Black men’s trust of health care. In addition, participants felt that Gabe could be effective in engaging young Black men in health care, understanding the barriers preventing and dissuading health care utilization, and providing a desirable option for those who might not otherwise seek to utilize health care services. Each of these themes is described in the following.
Inclusive Racial and Ethnic Identity
Of the 67 focus group participants, 10 men (15%) self-identified as Black/Other (ethnicity), as opposed to Black/African American, with many feeling disconnected to the term “African.” These men reported that health care providers needed to be cognizant of the differing ethnic, multi-racial, and nationalities that Black men belong to. As one participant in New Haven (FG) noted, My family is from the Caribbean. No one in my family is from Africa . . . so they’re not African American, they’re Caribbean.
Concerns were also expressed with respect to the term “Black,” with one Boston (FG) man stating “please call me Haitian and Native American—don't just call me some Black boy.” Among the focus group participants, 9 men (13%) identified as Hispanic, with 5 of these men (7%) reporting that they primarily speak Spanish at home. These percentages climb to 30% and 15%, respectively, when looking just at the Providence, RI groups.
When discussing how programs aiming to address the health disparities facing Black men should reference potential participants, terms such as “urban” and “men of color” drew mixed feedback, with men offering dissenting views (Table 3). Men cited positives with respect to the inclusivity of these descriptors, stating that “men of color can mean Asian, Spanish too” (Providence FG), or “something with urban [. . .] that way it won’t just be looking at one race” (Providence FG); however, too broad of terms may lose the desired specificity for tailored interventions such as Gabe. Furthermore, the term “urban” was met with push back from other participants, as it was perceived to be stigmatizing toward Black men. As a man in Boston (FG) and another from New Haven (PPI) explained,
Participant Accounts of Identity.
Note. FG = Focus Groups.
Boston: “If you talk about ‘we doing something for the urban community,’ then the first thing you do is put up a Black guy [Gabe ECA] like ‘hi. . .’ It don’t matter, it could be an Asian person, bro. This is weird, like ‘we working with the urban community so the first thing we wanna do is throw a Black guy. . .’” New Haven: “Why we using a super Black man [Gabe ECA]? Like, why’s he gotta be extra dark because we’re doing urban? You see what I'm saying?”
When explicitly discussing the racial preferences of the Gabe ECA, or even the capacity of the system to incorporate multiple virtual characters, many participants expressed a desire for racial diversity, with a man in Providence (FG) explaining that It would be cool to see all genres and races on here. [. . .] It doesn’t matter. I think that would benefit if it’s different. A different culture person telling you about their health.
Other participants argued that the ECA’s race did not matter, with a New Haven (FG) participant noting that “race really doesn’t matter. [. . .] We’re all human, the same shit happens.” Further examples of this discussion can be seen in Table 3.
Providers’ Cultural Ignorance and Color-Blind Racism During the Clinical Encounter
When discussing previous interactions with health care providers, participants across sites raised the need for health systems to have an increased understanding of the environmental challenges faced by Black men outside of the clinical context. Men frequently cited instances in which they experienced or witnessed health care providers acting callously toward Black patients (Table 4), which they often attributed to a lack of cultural and social awareness. The accounts shared by participants often noted a racial mismatch of the providers and patients; however, in many cases, men were more inclined to cite a lack of understanding on the part of the provider, as opposed to explicit racial bias. Boston (FG) participants explained that many of the physicians they encounter, while well intentioned, are not from their neighborhoods, lamenting “you used to be able to see your doctor [outside], now you don’t because he’s probably from New Hampshire. He probably don’t even stay out here.” This leads to situations where participants question whether they, and their communities, receive the same treatment as others during the clinical encounter. As a man from Boston (FG) explains,
Providers’ Understanding of Young Black Men.
Note. FG = Focus Groups.
I still got crazy asbestos in my basement. You know the lady next door, her daughters just had to rush her to the hospital last night because they said the building –have some type of lead in it you know—so it’s like a lot of crazy things going on—so you don’t know if that lady got the same treatment. You don’t know if the doctor’s like ‘that lady can’t even keep her house up.’ You don’t know what’s going.
Participants reported that physicians’ inability to understand their daily life circumstances greatly impacted their care, with providers’ lack of awareness of the unique environmental challenges faced by Black men being a prime example of color-blind racism [specifically “abstract liberalism”] (Bonilla-Silva, 2010).
Participants suggested trainings for physicians to address the lack of cultural competency and environmental awareness and increase physicians’ capacity to understand and be empathetic toward the hardships of young Black men. The need for increased cultural awareness extended beyond the clinical encounter and the value of long-term training was highlighted when discussing the criminal justice system. For example, when discussing their community’s police department Boston (FG) participants reported, Boston 1: “It should be a standard, like people working in these fields, they need to be trained or there has to be a standard on how you deal with, well, people in general, but I mean, I think young Black men. Having a year—like a training year.” Boston 2: “Or have someone that can relate. Boston Police just hired you know people from the cadet program. They just hired people from the community that look like the people they gonna serve, so why can’t hospitals do that?”
The theme of having “someone that can relate” was recommended by focus group participants in Boston, New Haven, and Providence as being a key to engaging Black men in health care, with increasing providers’ ability to understand the experiences of the Black community, and Black men in particular, being a commonly referenced solution. Table 4 provides additional data that highlight these discussions.
Explicit Bias and Cultural Racism
Juxtaposed to the previous accounts of cultural ignorance, or perhaps more aptly color-blind racism, some participants felt that explicit racial bias directly led to poor provider interactions. The most commonly referenced experiences pertained to participants perceiving that they or their family members were not listened to, judged, or negatively spoken to by a health care provider, which can be seen in this exchange between two New Haven (FG) participants, New Haven 1: “If you get in a fight, you break a knuckle or something and you got to go to the hospital, you tell them why you’re there, they start talking shit. Like ‘oh, you dumb for doing that. You’re dumb for fighting.’ I could’ve been dumb by myself. You don’t know the circumstance. They wanna judge you and talk down on you.” New Haven 2: “Racism.”
Similar ideas were expressed when describing individuals in black communities’ non-engagement in health care. For example, a Boston (FG) participant stated, A lot of my friends or family, they generally do not want to go to the doctor. [ . . .] ‘Oh, I don't need the doctor. The doctor doesn't even care.’ And maybe someone in the black community, they don't really want to go to the doctor just because they feel like maybe they don't get treated the same.
This account describes “cultural racism” (Bonilla-Silva, 2010), as it details how expectations of differential treatment by providers may preemptively deter Black men from engaging health care.
Building Black Men’s Trust of Healthcare
Participants reiterated known challenges of trust between Black men and health care institutions and offered specific solutions to develop and maintain the trust of Black communities. Two main themes emerged, with participants in our sample reporting that they want to feel cared about and safe, while also being presented with evidence-based information from educated individuals. Both themes emphasize trust, but the latter focuses on the need for clout when presenting information and facts, whereas the former highlights the importance of relationships.
The importance of feeling cared about on building trusting relationships
Detailing the need for trusting relationships, an interviewee who leads a fatherhood group in Hartford, CT (KII) explained that: It’s got to be personal. I do a lot of stories. I find that there's a need to build a relationship and I want to build a relationship with them at the first session. I also want to demonstrate vulnerability. And vulnerability is like a portal. It's a way into a relationship and if I can be vulnerable, then they'll be vulnerable and they will really get some work done.
The interviewee noted that when being openly vulnerable about personal life struggles, trusting relationships between individuals can be established.
When building trusting relationships with Black men, an interviewee who works for a non-violence program in Providence (KII) talked about the importance of following-up and engaging men outside of normal program operation. They explained that: It’s the follow-up, we believe everything is in the follow-up. It’s not a phone call and say, ‘Hey do you want to come to this program?’ ‘Yeah I’ll come.’ We’re calling again tomorrow. And then once you're in the program, we’re following up with you that night. ‘How was the program?’ I think it’s all in the communication.
Their program prioritized using multiple methods of communication to engage participants, such as phone calls, texts, and unannounced house visits, which they believed were instrumental in maintaining participation. Support of this idea was provided by a Providence (FG) participant, as they explained that “you see him one day or whatever, and he’s like, ‘how you doing? Everything’s all right? You need anything to talk about, or what?’ You can tell if somebody cares.”
After being shown a demonstration of Gabe, participants noted their willingness to engage Gabe and the system’s health promotion interventions, with multiple Gabe users saying that he was easy to talk to, with one New Haven (PPI) participant explaining that: He’s [Gabe ECA] a computer, so it’s kind of a little more open for me to talk to him. [ . . .] It’s not like somebody’s there. They’re lookin’ at me directly. I’m like a little nervous to open a little bit more. With the computer, it’s kind of like talking to myself a little bit, so I can be a little more open and give a little more detail to Gabe.
A similar theme was presented by an individual working with high-school aged youth in Providence (KII), as they noted that “there’s nothing like this [Gabe] in Providence [ . . .] and the kids are extremely embarrassed to go to the clinics because I might see you there and I’ll know why you’re there.” While participants noted benefits of ECAs systems, and a willingness to trust Gabe, they were also clear that developing a relationship with a provider, even a virtual one, takes time. As a different New Haven (PPI) explains, Comfortability takes time. I feel like you can get comfortable with Gabe, but you just have to give it time, because people will have the same pediatrician since they’re like 11, 12, 13, you know what I mean?
The importance of clout in building trust
In regard to how to develop trust, participants discussed wanting to be provided with content that could be sourced and verified, with a Providence (FG) participant explaining that: I think what’s important is if you’re worried about people not believing what’s on the site, what people do is have proof on the site and have sources. How do you know that? Stats would help. You’re dealing with people, intellectuals. You’ve got to tell us why we shouldn’t drink so much alcohol. I’m not gonna believe you just because you say that.
Similarly, most did not express strong feelings as to the race/ethnicity of their provider, assuming they are knowledgeable, which is explained by a New Haven (PPI) interviewee in the following quote: What I see though is that if you’re Indian, Asian—if you know what you’re talking about—I’ll go to a Yale graduate before I go to a Hill High sophomore dropout. I want you to know what you’re talking about. I don’t care how you look. As long as you speak English and you know what you’re talking about I’ll go to you.
While many individuals expressed the desire to hear from celebrities with respect to certain issues (via video clips), participants also noted that success in one arena does not qualify individuals to be trusted on all issues. As a man in New Haven (FG) explains, What credentials do you have for me to believe you? I know you’re in shape because I see you’re in the NBA. You gotta be in shape for that. But what do you know about domestic violence? You went to school to learn? You’re certified for that? Nah, I don’t want to hear about none of that.
Although the conversation initially focused on human providers, participants were optimistic about technology’s ability to provide Black men guidance that was socially and culturally informed. They noted the potential for online health systems to incorporate outside content that was relevant to their unique challenges, such as allowing them to hear from other Black men, famous or otherwise, who have come from similar environments and can speak to the struggles that they faced. One frequently cited example was Magic Johnson with respect to content on HIV.
The Desired Content and Expanded Utility of ECA Systems for Black Men
In discussing their system use, post pilot interviewees noted that a seminal factor impacting their decision to engage with certain content or not was their perception as to how that material may have specific relevance to them. Similar themes were detailed by all interviewees, with two nuanced approaches being cited. First, users explained that content was perceived relevant if it had applicability to the behaviors of peers and/or the environments they often find themselves in. As explained by a New Haven (PPI) Gabe user, I really touched on the drug and alcohol aspect a lot more for some reason. I don’t know why, but it drew me to it. Because I’m in college and it’s around me more often than not, you know? And my friends dabble in it. It’s nothing serious, but I like to research what’s happening around me, and drug and alcohol is the biggest thing.
In this instance, the Gabe user was not necessarily motivated by his own personal behaviors, but rather by the behaviors of those around him. A similar motivation was expressed by a different New Haven (PPI) Gabe user, although he framed his interest in terms of the content’s specific relevance to him, not his peers, stating that: I went through somethin’ that stuck out. I went with it. So, like for example, discrimination, because I had run-in with police officers for my color as well, so it kinda stood out to me. I wanted to know more about it and how to deal with the situation if it ever occurred again.
Interviewees were clear in asserting that their choices for what content to engage was motivated by their perceptions of applicability, whether direct or through peers, of the material being provided.
Across all qualitative efforts, participants shared many potential uses and areas of expansion for Gabe, and ECAs in general, that they feel would better assist Black men in managing their health. Some explicitly noted the benefits of Gabe’s 24/7 availability and the ease of obtaining access, while others detailed limitations pertaining to the system not being readily accessible on their cellphone, with a Providence (FG) participant explaining that: If you can get this on your phone, then you can do like a whole bunch of stuff, like you can add in stuff. Like you can have reminders that—like reminders and stuff like to exercise and stuff like that.
Table 5 details further participant suggestions for the expanded utility of ECA health systems, such as assisting users with scheduling medical appointments or being used in providers’ offices prior to patient (or client) visits.
Potential Expansion and Uses of Gabe and ECA Technology.
Note. ECA = embodied conversational agent; KII = Key Informant Interviews; FG = Focus Groups; PPI = Post Pilot Test Interviews.
Discussion
Our findings suggest that Black men have many concerns about accessing health care, as participants noted struggles in their health care experiences which failed to recognize their diversity or demonstrated actively racist practices. Participants cited specific concerns pertaining to the disconnect between Black men and non-Black providers, such as physicians not understanding the lived experience of Black men. Informants highlighted a similar theme, emphasizing the importance of building trusting relationships when working with Black men, with frequent communication and making men feel cared about being key to this process.
The negative provider experiences that participants shared often fell into two distinct frames of racism, cultural racism and abstract liberalism, with the former being associated with explicit racial bias and stereotyping, while the latter pertains to physicians’ ignorance as to the unique challenges facing Black men (Bonilla-Silva, 2010). Participants noted that increasing racial diversity among hospital employees and offering cultural competency trainings for providers may serve to improve the health care experiences of Black men.
At the same time, participants noted that factors such as having a trusting relationship with their provider and physician competency were more important than racial concordance. This is consistent with prior research, which has shown mixed findings on the effects of racial concordance on patient-provider communication (Cooper et al., 2003; Shen et al., 2018; Sweeney et al., 2016). As Sweeney et al. (2016) explain, while non-White patients might seek out racially matched health care providers, “they are not more satisfied with the patient-provider communication experience than when in race-discordant provider arrangements.” Similarly, displaying a greater sensitivity to the ethnic, nationality, and multi-racial diversity of Black men in America may be an important factor in improving health care experiences (Gilbert et al., 2016; Griffith, 2012; Russell & Jewell, 1992), especially in race-discordant encounters. Although phrases such as “Black” and “African American” are often colloquially used as synonyms, some focus group participants found this problematic as Black men in America are exceedingly diverse. It is paramount that health care providers and community programs address them via terms that they themselves use to self-identify, otherwise interventions risk alienating potential users.
ECA technology may be well equipped to contribute to the health of Black men, as it can incorporate culturally informed programing that eliminates bias, builds trust, and elevates the concerns of its users. Participants, for example, reflected an array of relationship-damaging experiences with health care systems and providers along the entire spectrum of racism. A system like Gabe, developed with an anti-racist framework (Crear-Perry et al., 2020; Maiter, 2009) with health content that is informed through constant input and contribution from the community it aims to serve, may contribute to bridging the gap between provider and patient, and potentially help in improving relationships between Black men and health care systems. Past studies have recommended that researchers developing ECA-led health promotion systems utilize “stakeholder-inclusive design approaches” (Kramer et al., 2020), which may both empower those who are the intended recipients of the intervention, while also ensuring that the content being provided is culturally relevant and appropriately framed. Participatory research is not without challenges though, as subject-researcher power imbalances run the risk of exploitation (Roura, 2021), which highlights the need for adequate representation on the research team and the benefits of utilizing an advisory board for oversight. In addition, the importance of an anti-racist framework cannot be overstated, as research has emphasized the need to be aware of the “consequences of race on racialized populations,” as this can yield a greater understanding of the different hardships they face (Maiter, 2009).
Participants viewed Gabe to be trustworthy, with some users reporting that they were more willing and less nervous to share health concerns with Gabe than an in-person provider. However, participants noted the virtual nature of the system did not preclude the need to build trust and that trust could not simply be assumed because Gabe is a computer. Black men can find themselves in vulnerable situations when addressing health concerns, so obtaining their trust is paramount. Providing evidence-based recommendations and supporting data with ECAs, in a non-stigmatizing and judgment free manner, is important to building this trust. Furthermore, consistent with past research that advocates for an increased cognizance of intersectional identities within public health (Gilbert et al., 2016; Griffith, 2012), and noting the detrimental impact of intersectional stigma on Black men’s health care engagement (Quinn et al., 2018), future interventions should seek to address the unique plights associated with Black men’s engagement with society. This may serve to both increase the perceived applicability of content to would-be Black male participants, which could increase initial participation, as well as meet the expectations of men once they engage with the program, which may increase sustained engagement. Post pilot interviewees were explicit in noting that the perceived relevance of the Gabe content impacted their willingness to engage, so future interventions should work to be clear in explaining why their programs are important, as this may have an impact on Black men’s participation.
Key informants also commented on the importance of periodic check-ins with young men to establish trust, as did focus group participants. Maintaining frequent contact is an area where online health care systems can potentially experience positive results, such as providing text alerts and calendar reminders, which participants commented would be helpful in achieving their health goals. This consistency might prove beneficial in building trust of both the systems, for example, Gabe, and of collaborating community programs that partner with the software, as ECA systems could be used as an adjunct to in-person programs. In addition, while ECA systems require resources to maintain operationality, for example, a network server, they could potentially be cost-effective insofar as they can assist with tasks that previously required in-person attention.
Although not specifically mentioned by our participants, a potential obstacle for using ECAs to reach underserved Black men may be the lack of ready access to technology and internet services. According to U.S. census data, only 61.3% of Black households have home access to the internet, compared to 77.4% of White households, and for those without a high school graduate, only 25.3% have access to home internet (File, 2013; McCloud et al., 2016). However, an estimated 90% of African Americans live in households that own a smartphone (Neilson Company, 2018), so deploying ECA technology on a mobile platform may be worth exploring (Bickmore et al., 2018). Other issues with ECAs include potential misinterpretation of users’ social attitudes leading to ineffective verbal and nonverbal ECA behavior (Novielli et al., 2010), as well as general privacy concerns pertaining to eHealth (Kelly & Unsal, 2002). There are also potential risks for harm with this technology, namely that unintended negative experiences with ECA systems may result in a decreased likelihood of seeking future help from in-person providers (Miner et al., 2017) or potential hacking of the system with the intent of providing harmful recommendations, for which future researchers will need to consider (McGreevey et al., 2020).
Limitations include a limited sample of participants who were recruited from four northeastern sites, which may impact the generalizability of the findings for Black men in other regions of the United States. This is particularly relevant given that participants repeatedly stressed the diversity of the Black population. In addition, this study’s sample population was younger in age and recruited from community sites, so the perspectives of older Black men and those who do not engage the selected community sites would have been excluded.
The health care needs and concerns of the Black male LGBTQIA+ population were not addressed in this study and should be addressed in future studies. The inability to account for the potential influence of masculinity norms on the health care utilization of Black men is also a limitation. Past research has found that masculinity is a barrier to engagement in care (Cheatham et al., 2008), noting that Black men with increased adherence to traditional masculinity norms, particularly those associated with self-reliance, were significantly less likely to engage in routine health care screening (Hammond et al., 2010). Future research should explore the association between help-seeking and masculinity as it pertains to Black men, as this may have utility in explaining patterned intra-racial differences in health care utilization.
In summary, Black men are often deterred in their ability or willingness to access health care services because of social and institutional barriers. Our data suggest these issues could potentially be mitigated by using ECA technology to provide health education and advice, as the men we spoke with expressed optimism that online health education systems can be programmed to be informed on pertinent cultural, social, and environmental issues. Future research should further explore the effectiveness of ECA systems in addressing the unmet health care needs of Black men, while health care systems explore ways to address the social and institutional barriers contributing to current racialized health disparities.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Gabe was developed through a 4-year grant from the W.K. Kellogg Foundation, award number P3032173.
