Minority Women and eHealth: Social Inclusion in Online HIV/AIDS Information Lynette Kvasny [email protected] School of Information Sciences and Technology The Pennsylvania State University University Park, PA 16802-6823 Jing Chong [email protected] School of Information Sciences and Technology The Pennsylvania State University University Park, PA 16802-6823 Fay Cobb Payton [email protected] College of Management Department of Business Management North Carolina State University Raleigh, NC 27695

ABSTRACT: In this paper, we examine the social inclusiveness of online health resources for African American women in the US. We study African American women for two reasons. First, HIV/AIDS infections are growing most rapidly among African American women. Secondly, African American women are increasingly adopting and using the Internet to acquire health information. Informed by literature on the identity, usability, and the social construction of information, we investigate the classification schemes used on US government’s Healthfinder portal to determine the extent to which content was inclusive of African American women. Our findings suggest that taken for granted notions about nationality, gender and race are generally reproduced in these online health resources. KEYWORDS: eHealth, ethnicity, gender, HIV/AIDS, internet, race, social inclusion

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INTRODUCTION In this paper, we present a formative research study which examines social inclusion in online health information resources from the standpoint of African American women. Social inclusion, in this study, is the process by which efforts are made to ensure that everyone, regardless of their experiences and circumstances, can achieve their potential in life. Our work brings together two domains, health and the internet, which have received significant attention by US government agencies, researchers, and policy makers seeking to redress health disparities and the digital divide experienced by racial and ethnic minorities. Healthy People 2010 is a US government initiative sponsored by policy makers, researchers, medical centers, managed care organizations and advocacy groups across the country. Although there is no consensus regarding what a health disparity is, sponsors agree that “racial and ethnic minorities experience multiple barriers to accessing healthcare, including not having health insurance, not having a usual source of care, location of providers, lack of transportation, lack of child care, and other factors. A growing body of evidence shows that racial and ethnic disparities in health outcomes, healthcare access, and quality of care exist even when insurance, income, and other access-related factors are controlled.” (http://www.healthypeople.gov/) Health disparities are pronounced in HIV/AIDS, an infectious disease which represents a growing and significant health threat to African Americans. At the end of 2002, approximately 385,000 persons in the US were living with AIDS: 42% were African American, 37% white, 20% Hispanic, and <1% American Indian/Alaska Native or Asian/Pacific Islander. Anderson and Smith (2004) report that, HIV infection was the leading cause of death in 2001 for African American women aged 25–34 years and was among the four leading causes of death for African American women aged 20-24 and 35– 44 years. The rate of AIDS diagnoses for African American women (50.2 / 100,000 women) was approximately 25 times the rate for white women (2.0 / 100,000) and 4 times the rate for Hispanic women (12.4 / 100,000) (CDC, 1999). African American and Hispanic women represented about 25% of all US women (US Census Bureau, 2000), yet they account for 83% of AIDS diagnoses reported in 2003 (CDC, 2004). African American women alone account for 72% of new HIV diagnoses in all US women (Centers for Disease Control and Prevention, 2003). The reasons for the disproportionate number of HIV/AIDS infections among African American women are multifaceted, including cultural attitudes towards homosexuality, racism, low economic status, and gender inequality (Gupta, 2000). Health provider bias, stereotyping, prejudice and clinical uncertainty also contribute to health disparities (Balsa et al., 2003). For instance, in a study by Bird et al. (2001), 63% of survey participants indicated that they had experienced discrimination in their interactions with their healthcare provider because of their race or ethnicity. Similarly, African Americans interviewees reported perceived discriminatory experiences such as inferior treatment, negative attitudes, being treated as if they were unintelligent, being ignored, inappropriate allegations, and racist remarks (Hobson, 2001). Ogle and Payton (2004) find that differences in the patient/physician relationship, use and availability of healthcare

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resources are pervasive and profoundly impact attitudes towards receiving care, and willingness to comply with physician recommendations. Patients are however becoming empowered and more educated as health information becomes increasingly over the Internet (Ryer, 1997; Brennan, et al, 1991; Payton, 2003). With the flourishing field of eHealth --- the applications of the Internet and global networking technologies to medicine and public health (Eysenbach, Sa and Diepgen, 1999), the Internet increasingly provides a useful platform for disseminating health information to a large cross-section of Americans. The number of Americans going online for medical advice on a typical day has already exceeded the number of Americans who actually visit health professionals (Fox and Rainie, 2002). Most online health searchers (66% of all US Internet users in 2002) were conducted to find information on specific diseases (Fox, 2005). HIV/AIDS patients are among the healthcare consumers with chronic and stigmatized medical conditions who increasingly use the Internet as a major source of information (Kalichman, Weinhardt, Benotsch & Cherry, 2002). Also 45% of online African-Americans say the Internet helps them get health care information, compared to 35% of whites who say that. And, compared to African-American men, African-American women are much more likely to have sought health information online (Spooner and Rainie, 2000).This suggests that African American women are increasingly able to gain access to online health resources, and that the actual. Socially inclusive eHealth applications may, therefore, play an important role in reducing health disparities. However, while African American women may be going online, the Web content may draw heavily on the traditional media content (Brock, forthcoming) and therefore reproduce and disseminate existing norms, rules, attitudes, ideologies and power relations which exist offline. Miller and Slater (2000) have argued “…Internet media as continuous and embedded in other social spaces…within mundane social structures and relations…they cannot escape into a self-enclosed cyberian apartness” (Let’s Not Start From There section, para. 5). In fact, Lazarus and Lipper (2000) found that there is little Internet content which reflects cultural diversity of low-income and minority users. Given the arguments both for and against the role that the Web may play in providing equitable access to health information, we conducted an exploratory study to investigate the extent to which HIV/AIDS prevention websites produced by the US government were inclusive of African American women. Our work is informed by scholarly literature on the construction and performance of online identity, the usability of products and the social construction of information. We begin by reviewing this literature and then take four web pages as examples for a closer examination. Our analysis focuses on the classification schemes found on the web pages, and the extent to which these categories reflect African American female identity. Lastly, we make some suggestions for future studies.

Online Identity and the Social Construction of Information Identity can be defined as one’s answers to the question “Who am I?” (Stryker and Serpe, 1982). It has a set of associated meanings and expectations for the self (Burke and Reitzes, 1981). Hecht (1993) identifies four frames through which identity is

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communicated. Personal identity involves self-concept, and develops through socially ascribed meanings and behaviors which are learned as one is socialized in a society (eg. Black women stereotyped as mammy-the nurturer; jezebel-the seductress; sapphire–the wisecracking emasculating women; welfare queen–the lazy, economically unstable mother of many bad kids). Enacted identity focuses on how messages express identity (eg. I’m black and I’m proud, girl power). Relational identities are those formed through one's relationships (eg. I’m a mother, sister, wife). Communal identities are those shared by groups of people in some particular community (eg. I belong to my neighborhood, church, school, nation). For us, identities are structured around the experience of consumption. By consumption, we are not concerned with the economic definition (i.e. buying) but rather using and interpreting an informational good. Bourdieu (1984) describes consumption as a set of social and cultural practices which establish differences between groups, moving beyond the idea that consumption merely expresses already existing differences. Baudrillard (1988) further argues that people create a sense of who they are through what they consume; thus consumers actively are involved in constructing identity. Finding a sense of identity can, therefore, be seen as a process in which we make use of consumable items such as health messages. Identity is therefore inextricable from communication (Phillips, 2003). In this paper, we are most interested in identity enacted in health messages. Health messages transmit and exchange values, beliefs, and norms, which may or may not affirm individuals’ or groups’ understandings of their own identities (Jackson, Warren, Pitts, & Wilson, in press). Identities also act as interpretative frames in the communication process (Hecht, 1993). Messages are filtered and made sense of in relation to how individuals perceive themselves. If health messages communicate an identity, which is in conflict with how users perceive themselves, then the information may be viewed as unusable. Cognitive dissonance theory, for instance, suggests that individuals tend to seek and select information that is congruent with their established attitudes and beliefs, but ignore or avoid information that is incompatible (Festinger, 1957; Oliver, 2002). Similarly relevancy theory (Fiske, 1998) argues that individuals select meanings relevant to their social allegiances. “The viewer makes meanings and pleasures from television that is relevant to his or her social allegiances at the moment of viewing; the criteria for relevance proceed the viewing moment” (p 247). As with all communication, health messages that diverge from the identities of minority populations are unlikely to prove effective as prevention interventions. Hence, health information must be situated within the target audiences’ sphere of experiences and understanding, otherwise, they may not be consumed. The situated nature of identity and the consumption of information builds conceptually from the social construction of reality (Berger and Luckmann, 1966). Schutz (1967), for instance, proposed that all information lacks objectivity. Instead, information has different meanings for different individuals depending on their biographies and positions in the social setting. Garfinkel (1967) also emphasized the subjective aspect of meaning, and believed that interpretation is rooted in the situation in which it emerges. Ricoeur

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(1981) argued that meaning is situational not only in spoken discourse, but also in written discourse. Even without any interaction, the meaning of a text is still subjectively constructed by the readers. Therefore, information requires a subjective and social interpretation (Miranda & Saunders, 2003). If information is indeed subjective, then interface and information design for African American female consumers is inherently difficult. For instance, their identities (i.e. gender and race) have traditionally be marginalized, disregarded or portrayed in an unconstructive way by mainstream information channels (Brock, forthcoming). This produces negative consequences such as needs/information disconnects, the nuisance of finding content customized to the needs of African American women and other minority users (Hoffman, Novak and Schlosser, 2000), dissatisfaction with and mistrust of the biased content (Kretchmer and Carveth, 2001; Lazarus and Lipper, 2000) and, finally, the decision to resist the available content (Foster, 2000; Morkes and Nielsen, 2003; Mitra and Watts, 2002). Design is also made more difficult if it is informed by the traditional biomedical model which is concerned with only four concepts: the patient, the disease, the diagnosis, and the treatment (Foss & Rothenberg, 1987). The patient is seen as a de-contextualized body. Therefore, health providers are, in a sense, “trained” to ignore minority status and cultural differences (Bayne-Smith, 1995). If online health information, like many mainstream sources of information and biomedical models, is not socially inclusive then it will fail to accommodate minority identities (Kolko, 2000).

CONCEPTURAL MODEL Nakumara’s (2002) theory of “menu-driven identities” focuses on the ways in which identity is represented and expressed through computerized user interfaces. Menu driven identities theorize the relations between the information provider, the user, and the interface (see figure 1). The user interface serves as a discursive site in which content providers represent identities through the design of the interface and the personalization of content, and users perform their identity as they search and consume information online. In fact, identity is the first thing that you do (create a profile or log in) before you can perform any activity. Identity performance is often a practical necessity created by designers who create the interface. Identities framed by modern notions of race, class and gender are important because health is very much a bodied sphere, not a disembodied experience. The importance of identity is evidenced when content providers organize information and use language and images to resonant with idealized users’ identities. At the same time, web users are required to reveal and perform their identities through the user interface and the embedded navigational choices produced by the content provider. While the physical body may be hidden in the cyberspace, identity is still constantly constructed and performed (Kvasny and Warren, forthcoming). Nakumara (2002) uses the term “architecture of belief” to signify how designers, through their choice of keywords, images, and use of language, create interfaces which represent

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the identities of some idealized user population(s). Thus, the interface reflects the cultural imagination of the designer, and performs familiar versions of race, gender, and class. It is an authored space in which identities are enacted through computer mediating conversations between users and designers. The interface serves as a site for the production, representation, distribution, and reception of texts (health messages) which convey meanings that affects relations of power. The distinctive rhetorical conditions of the speaker, utterance, audience and reception are created as the designer and user cocreate a communicative situation in cyberspace Figure 1 illustrates how the computer interface mediates the interaction between information providers and consumers. The actual effectiveness of HIV/AIDS prevention message that is being communicated is dependent upon the degree of congruence between the identity enacted in the providers’ content, and consumers’ sense of personal, communal and relational identity. A comparatively high level of congruency can increase the social inclusiveness of the information being provided. This may, in turn, lead to lifestyle changes that reduce health disparities among African American women.

COMPUTER INTERFACE Site for designer and user interaction which structures menu-driven identities

health message

Health message

DESIGNER Healthcare Professionals & Web Developers

USER African American Women

Information Repositories & Web tools

• Web sites • Discussion boards • Healthcare facilities & providers database • FAQ • Audio/visual lectures

Figure 1: Conceptual Model

WEBPAGE EXAMPLES In this section, we present how menu-driven identities are constructed in the US Department of Health and Human Services Healthfinder portal www.healthfinder.gov/justforyou/ (see figure 2). Healthfinder is a general health information portal and is one of the top ten most useful sites according to the Medical Library Association (www.mlanet.org/resources/medspeak/topten.html). The navigation scheme reflects the categories imposed by the more privileged actor (the government sponsor) in

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the communicative situation. Users can click through the health library, which provides an alphabetical listing of hundreds of health issues.

Figure 2: Healthfinder start page

The health library page for HIV is displayed below (Figure 3). This website features a list of twenty four categories of information representing “specific kinds of information”, with no reference to cultural diversity other than the five languages. The web page represents how minority women are rendered invisible by not including any category related to gender, race or ethnicity. There are no images to visually signify a connection with diverse users. The red, white and blue colors do however suggest a generic American audience.

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Figure 3: Health Library

On the Just for You page (see figure 4), we see familiar versions of identity which are typified in US government information sources. Users must select an identity which is limited to sex, four age categories, four ethnic / racial categories, and five roles. White and European American ethnicities are omitted from the choices, which we believe suggests that they are taken to be the default category. In the US, whiteness as a racial category is not generally interrogated (McIntosh, 1988). Intersectional identities such as woman and African American cannot be expressed through this interface.

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Figure 4: Just for You

For African American women, predefined categories force the performance of race and gender in ways that marginalize, and in some cases deny, their existence. This occurs when there is limited space for identity expression because the categories reproduce the limited number of choices based on historical labels and ideologies around race, gender, age, and role. Health portals, therefore, become another discursive field in which African American women are rendered invisible because they are assumed to be only African American or female – multiple selections are not allowed because there are no categories which capture both race and gender. In the Figure 5, we provide an example of a more socially inclusive web page http://womenshealth.gov/minority/, which is accessible from the “gender” link on Health Finder. The photograph at the top of the page presents a diverse grouping of women. On the left hand side, there is a list of options for women of various racial and ethnic groups. There are, however, limited choices for health topics. To find information on HIV or AIDS, the user would have to perform a search or select one of the ethnic/racial categories on the left.

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Figure 5: Women's Health.gov

If the user selects African American, Hispanic American or American Indian, she will receive a listing of relevant health topics (termed “health problems”), including HIV/AIDS (see figure 6). However, the web page for Asian American women does not include HIV/AIDS. We infer that this omission occurred because HIV/AIDS infections among Asian American women are relatively low. However, failing to provide easy access to HIV/AIDS prevention information may unwittingly place these women at risk. In all cases, minority women are compared to white women (“Even though minority women have many of the same health problems as White women, they are in poorer health.”). The diversity within each minority category is acknowledge, but the diversity among White women is ignored (“Also, because minority groups are very diverse, even within one group, these women's access to health care, their health behaviors, and their health status can vary widely.”). Again, we see familiar American discourses on power and minority status reproduced online.

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Figure 6: Health Problems for African American Women

DISCUSSION These examples provide some evidence which suggests why category schemes are not simply passive tools through which labeling takes place. Instead, they are the outcomes of practices of meaning making, and are loaded with social and cultural values of their creators (Harrison and Zappen, 2003). Designers of classification schemes constantly have to decide what categories are important, and in doing so, they develop an economy of knowledge that articulates omissions and inclusions, and ensures that only relevant features are classified (Bowker and Star, 1999). These familiar representations of difference are performed by designers as they create systems based upon what they think life is like for the other. Therefore, the ideologies embedded in the information and the interface can possibly become a barrier to the effective use by non-traditional users if they are perceived inimical by the designers (Brock, forthcoming). These taxonomy schemes reflect the unspoken biases of the more privileged actor (the designers) in the communicative situation, which are then reinforced through interfaces based on biased assumptions and priorities. Web portals, thus, serve as platforms for creating discourses around difference and the simplification of the complexity of the unique identities of minority women by limiting choices and the full participation of minority women who exist at the margins based on historical labels and ideologies 11

around nationality, race, gender, age, and role. Since users have to take the paths prescribed by the interface, there is limited space for multicultural expression.

CONCLUSION AND IMPLICATIONS FOR FUTURE STUDIES In this paper, we theorize and provide some empirical examples of identity representation and performance, and the social inclusiveness of web-based health information. If web interfaces do not contain categories that are relevant to the users’ identities, then users will be less able to retrieve information. Relevant information often exists if minority women can perform effective searchers or drill deeper into the hyperlink. However, the classification schemes found on the websites are generally limited to a few taken for granted categories of difference. Additional evaluative research on existing websites should be conducted with both information providers and consumers to better understand the interaction between the avowed identities of minority users and the identities ascribed to them by designers. Content analysis or discourse analysis could be carried out to unpack and evaluate the cultural usability of HIV/AIDS websites in terms of identity sensitiveness. Another line of research could consider how minority women respond to the stereotypical messages that are portrayed in online health resources. The agenda setting, priming and framing theories in the area of media effects suggest that the amount of media coverage and the way news are reported in media are able to shape viewers thoughts (Price and Tewksbury, 1997). If we extend this reasoning to the internet, we would theorize that eHealth consumers may question their original ideologies about their own identities, as they are primed and framed by the agenda setting content that they encounter online. For example, information packaged by an international organization such as UNAIDS may be perceived as too authoritative to cast doubt on, or the information transmitted is too consistent across most of the websites to be resisted as not telling the truth. As a result, future studies should seek to explore the social, political, and personal factors that influence how minority women perceive the constructed identities of minority women on HIV/AIDS websites (i.e. why do they reject or accept constructed identities). These insights would be useful in the design of counter hegemonic HIV/AIDS websites. A third line of research could focus on design principles for and evaluation of socially inclusive web sites. The cultural usability literature provides conceptual grounding for a humanist approach to the design of information systems and technologies. Cultural usability is a design approach that depends largely on the “social models of usage” which can be individual or collective and are built as a function of experience acquired in society (DeSouza & Dejean, 2000). Cultural usability considers the production and exchange of meanings between the members of a society or group, as well as issues of representation, identity and power (Sun, 2002). It is a critical design sensibility where technology is situated within its cultural and social contexts (Tarkka & Tikka, 2001). By combining culture and technology, interpretation and implementation, web designers and health care providers may do better in reaching historically underserved groups.

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REFERENCES Anderson, R.N & Smith, B.L. (2003). Deaths: leading causes for 2001. National Vital Statistics Reports, 52(9),32–33,53–54. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_09.pdf, last accessed October 2005. Ayonrinde, O. (2003). Importance of cultural sensitivity in therapeutic transactions: Considerations for healthcare providers. Disease Management & Health Outcomes, (11)4, 233-248. Balsa A.I., & McGuire T.G. (2003). Prejudice, clinical uncertainty and stereotyping as sources of health disparities. Journal of Health Economics. 22, 89-116. Baudrillard, J. (1988). The Consumer Society: Myths and Structures. London: Sage. Bayne-Smith, M. (1995) Health and women of color: A contextual overview. In M. Bayne-Smith (Eds.) Race, Gender, and Health (Sage Series on Race and Ethnic Relations: v.15), 1-42, Thousand Oaks, CA: SAGE Publications, Inc. Berger, P.L.& Luckmann, T. (1966). The social construction of reality. Garden City, NY: Doubleday. Bird S.T., & Bogart L.M. (2001). Perceived race-based and socioeconomic status (SES)– based discrimination in interactions with health care providers. Ethnicity and Disease, 11:554-563. Bourdieu, P. (1984 ) Distinctions: The Judgement of Taste, Boston: Harvard University Press. Bowker, G.C. & Star, S.L. (1999) Sorting Things Out: Classification and Its Consequences. Cambridge, MA: MIT Press. Brock, A. (forthcoming). “A belief in humanity is a belief in colored men’: Using culture to span the digital divide. Journal of Computer Mediated Communication. Burke, P. J. & Reitzes, D. C. (1981). The link between identity and role performance. Social Psychology Quarterly, 44, 83-92. Centers for Disease Control and Prevention (1999). CDC guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. Morbidity and Mortality Weekly Report, 48, RR-13. Centers for Disease Control and Prevention (2004). HIV/AIDS Surveillance Report (Vol. 15). Atlanta: US Department of Health and Human Services, Centers for Disease

13

Control and Prevention. Available at http://www.cdc.gov/hiv/stats/hasrlink.htm, last accessed October 2005. Charlesworth, D. (2003). Transmitters, caregivers, and flowerpots: Rhetorical constructions of women's early identities in the AIDS pandemic. Women's Studies in Communication, 26 (1), 60-87. DeSouza, M. & Dejean, P. (2000). Cultural influence on usability. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 6, 162-165. Eysenbach, G., Sa, E. R.& Diepgen, T. L. (1999). Shopping around the internet today and tomorrow: towards the millennium of cybermedicine. BMJ, 319, 1294. Festinger, L. (1957). A Theory of Cognitive Dissonance. Evanston, IL: Row, Peterson. Fiske, J. (1988). Meaningful moments. Critical Studies in Mass Communication, 5, 246250. Foss, L. and Rothenberg, K. (1987). The Second Medical Revolution: From Biomedicine to Infomedicine. Boston, MA: New Science Library-Shambhala. Foster, S. (2000). The digital divide: some reflections. The International Information & Library Review, 32(3/4), 437-451. Fox, S. (2005). Health Information Online. Pew Internet and American Life, Washington, DC. Available at http://www.pewinternet.org/pdfs/PIP_Healthtopics_May05.pdf, last accessed October 2005. Fox, S. &Rainie, L. (2002). Vital decisions: How internet users decide what information to trust when they or their loved ones are sick. Pew Internet and American Life. Washington, DC. Available at http://www.pewinternet.org/pdfs/PIP_Vital_Decisions_May2002.pdf, last accessed October2005. Garfinkel, H. (1967). Studies in Ethnomethodology. Englewood Cliffs, NJ: Prentice-Hall Guidry, J.J., Fagan P. & Walker, V. (1998).Cultural Sensitivity and Readability of Breast and Prostate Printed Cancer Education Materials Targeting African Americans. Journal of National Medical Association, 90(3), 165-169. Gupta, G.R. (2000). Gender, Sexuality, and HIV/AIDS: The What, the Why, and the How’, Plenary Address, XIIIth International AIDS Conference, Durban, South Africa, July 12, 2000, International Center for Research on Women, Washington, D.C.

14

Harrison, T. & Zappen, J. (2003). Methodological and theoretical frameworks for the design of community information systems. Journal of Computer-Mediated Communication, 8(3). Available at http://jcmc.indiana.edu/vol8/issue3/harrison.html, last accessed March 2005. Hecht, M. L. (1993). 2002-A research odyssey: Toward the development of a communication theory of identity. Communication Monographs, 60, 76-82. Hobson, W.D. (2001). Racial discrimination in a health care interview project. Special Report. Public Health Seattle and King County. Seattle, Washington. Hoffman, D.L., Novak, T.P. and Schlosser, A. (2000). The evolution of the digital divide: How gaps in internet access may impact electronic commerce. Journal of Computer-Mediated Communication, 5(3). Available at http://www.ascusc.org/jcmc/vol5/issue3/, last accessed May 2005. Jackson, R. L., Warren, J. R., Pitts, M. J., & Wilson, K. B. (in press). "It is Not My Responsibility to Teach Culture!": White Graduate Teaching Assistants Negotiating Identity and Pedagogy. In L. Cooks (Ed.), Whiteness, Pedagogy, and Performance. New York: Routledge. Kalichman, S.C., Weinhardt, L., Benotsch, E & Cherry, C. (2002). Closing the Digital Divide in HIV/AIDS Care: Development of a Theory-Based Intervention to Increase Internet Access. AIDS Care, 14(4), 523–537 Kolko, B., Nakamura, L. & Rodman, G. (2000) Race in cyberspace, Routledge, New. Kretchmer, S. & Carveth, R. (2001). The color of the net: African-Americans, race, and cyberspace. Computers and Society, 31(3), 9-14. Kvasny, L. & Warren, J. (forthcoming). The Representation and Performance of MenuDriven Identities in Online Health Portals, In E. Trauth (Ed.), Encyclopedia of Information Technology and Gender, Hershey: Idea Group Publishing. Lazarus, W. & Lipper, L. (2000). Online content for low-income and underserved americans: The digital divide’s new frontier. Available at http://www.childrenspartnership.org/pub/low_income/index.html, last accessed October 2005. McIntosh, P. (1988). White Privilege and Male Privilege: A Persoanl Account of Coming to See Correspondences through Work in Women’s Studies, Working Paper 189, Wellesley College Center for Research on Women, Wellesley, MA. Available at http://www.cwru.edu/president/aaction/UnpackingTheKnapsack.pdf, last accessed October 2005. Miller, D. & Slater, D. (2000). The Internet: An ethnographic approach. Oxford: Berg.

15

Miranda, S.M. & Saunders, C.S. (2003). The social construction of meaning: An alternative perspective on information Sharing. Information Systems Research, 14(1), 87-106. Mitra, A. & Watts, E. (2002). Theorizing cyberspace: the idea of voice applied to the internet discourse. New Media & Society, 4(4). 479-498. Morkes, J. & Nielsen, J. (2003). Concise, SCANNABLE, and Objective: How to Write webwriting/writing.html for the Web. Available from http://www.useit.com/papers, last accessed March 2005. Myrick, R. (1999). Making Women Visible Through Health Communication: Representations of Gender in AIDS PSAs. Women’s Studies in Communication, 22, 45-65. Nakamura, L. (2002). Cybertypes: Race, ethnicity, and identity on the internet, Routledge, New York. Ogle, M. & Payton, F.C. (2004). Combating AIDS/HIV Among Rural Residents in North Carolina – Why Rapid Testing Counts? CDC Grant Proposal. Oliver, M. B. (2002). Individual Differences in Media Effects. In Bryant, J., & Zillmann, D(Eds) Media effects: Advances in theory and research (2nd ed.). Mahwah, N.J.: Lawrence Erlbaum. Payton, F. C. (2003). e-Health Leading to B2E Commerce in the Human Resource Function, Journal of Organizational Computing and Electronic Commerce, 13:(2), 147-161. Phillips, C. (2003). How do consumers express their identity through the choice of products that they buy. Working Paper Series. Piaget, J. (1954). The Construction of Reality in the World (M. Cook. Trans). New York: Basic Books. Price, V. & Tewksbury , D. (1997). News values and public opinion: A theoretical account of media priming and framing. In H. Sawhney and G.A. Barnett (Eds.) Progress in the Communication Sciences, 173-212, Norwood, NJ: Ablex Publishing Raheim, S. (1996). The Reconstruction of AIDS as a Women’s Health Issue. In R.L. Parrott & C.M. Condit (Eds.), Evaluating Women’s Health Messages: A Resource Book (pp. 402-413). Thousand Oaks, CA: Sage Publications. Ricoeur, P. (1981). From Text to Action. Evanston, IL: Northwestern University Press.

16

Ryer, J.C. (1997). Health Net: Your Essential Resource for the Most Up-to-Date Medical Information Online, John Wiley and Sons, Inc., New York, NY. Schutz, A. (1967). Phenomenology of the Social World. Evanston, IL: Northwestern University Press. Spooner, T. & Rainie, L. (2000). African Americans and the Internet, Pew Internet and American Life. Available at http://www.pewinternet.org/pdfs/PIP_African_Americans_Report.pdf, last accessed October 2005. Stryker, S., & Serpe, (1982). Commitment, Identity Salience and Role Behavior: Theory and Research Example. In W. Ickes & E. S. Knowles (Eds.) Personality, Roles, and Social Behavior. New York: Springer-Verlag. Sun, H. (2002). Exploring Cultural Usability. IEEE, 319-330 Tarkka, M., & Tikka, H. (2001). Cultural Usability: Towards a Design Sensibility. Available at http://mlab.uiah.fi/culturalusability/introduction.html, last accessed April 2005. Tate, D.M. (2003). Cultural Awareness: Bridging the Gap Between Caregivers and Hispanic Patients. Journal of Continuing Education in Nursing, 34(5), 213-217. US Census Bureau. Census Brief: Women in the United States: a profile. Available at http://www.census.gov/prod/ 2000pubs/cenbr001.pdf, last accessed March 2000. U.S. Department of Commerce (2002) A Nation Online: How Americans are Expanding Their Use of the Internet, Report prepared by The National Telecommunications and Information Administration. Available at http://www.ntia.doc.gov/ntiahome/dn, last accessed September 2004. Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.

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