BLACK MEN AND HEALTHCARE: EXPLORING THE POTENTIAL OF VIRTUAL AGENT TECHNOLOGY TO INCREASE ENGAGEMENT BY REDUCING STIGMA, BUILDING TRUST, AND PROVIDING EXPANDED ACCESS

Abstract

ABSTRACT When examining disparities in healthcare, notably those facing black men (Danaei et al. 2010; Thorpe Jr et al 2013), trust formation (Smith 2010; Levine 2013), internalization of stigma (Goffman 1963; Becker 2008), and identity construction (Hill Collins 2009, Crenshaw 2010) are three potentially important social processes worthy of consideration. Research has often sought to explore racialized differences in healthcare utilization and health outcomes by operationalizing trust (Adegbembo, Tomar, and Logan 2006; Carpenter et al. 2009), stigma (Wailoo 2006; Stuber, Meyer, and Link 2008), and identity (Mimiaga et al. 2009), but there is little research that speaks to the dynamic relationship between all three processes as they pertain to healthcare (Eaton et al. 2015). Furthermore, previous research on the three processes has not focused on new healthcare interventions and new medical technologies. This dissertation expands the conversation on trust, stigma, and identity by exploring how technological advances—namely, the use of virtual agents—can be employed to potentially increase engagement in healthcare for black men. This dissertation discusses the reciprocal nature of identity construction and internalization of stigma and the impact that both processes have on the health maintenance behaviors of black men, especially insofar as there exists an avenue for technology to mitigate current disparities. With stigma inherently being affixed to characteristics associated with identity, such as race or sexual orientation, and with stigmatized populations sometimes internalizing the negative labels society casts upon them (Becker 2008), understanding the manner in which these two social processes may serve to reinforce each other is key. Next, adopting a position consistent with Eaton et al. (2015), who argued that medical distrust mediates the effect of stigma on engagement in care, I highlight the process of trust and explore the roles of identity construction and internalization of stigma with respect to its formation. This dissertation explores the proactive use of distrust (Levine 2013), as well as what black men I spoke with are reporting that healthcare can do to (re)earn and maintain their trust. Finally, I detail the impact that (dis)trust has on healthcare utilization and the potential ability of embodied conversational agent (ECA) technology (virtual agents) to reduce the social and structural barriers that impact black men’s access to healthcare. In analyzing the relationship between trust and healthcare utilization, which is captured via patients’ healthcare experiences and their activation behaviors (Hibbard and Greene 2013), the impact of both processes on health outcomes are also examined. This dissertation utilizes a mixed methods research frame (Creswell and Creswell 2017), employing both qualitative and quantitative strategies. Focus groups (N=11; participants N=67), key informant interviews (N=12), and interviews (N=5) with participants who pilot test an online health promotion system (Gabe) are integral in providing this research with valuable insight into the ways in which trust, stigma, and identity impact the health behaviors of black men. Quantitative data from a pilot test (N=30) of the Gabe system, an ECA operated health promotion program designed for black men, are also analyzed. Data from risk assessments, demographic surveys, and participant use of the Gabe system serve to buttress the qualitative analysis. By employing an interdisciplinary approach, and exploring the dynamic relationships that exist across identity, stigma, and trust as they pertain to healthcare utilization, this dissertation presents a unique discussion surrounding the capacity of ECA technology to improve access to healthcare for marginalized populations.