Report on Evaluation Set-Aside Project
for Tailoring Web Sites for Special Populations
Office of Disease Prevention and Health Promotion
U.S. Department of Health and Human Services
May 2003
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This report could not have been compiled without the support of John Quoc Duong and Betty Lam of the White House Initiative on Asian Americans and Pacific Islanders; Betty Lee Hawks of the Office of Minority Health, U.S. Department of Health and Human Services; and Dr. Butch de Castro of the American Public Health Association's Asian Pacific Islander Caucus.
The Office of Disease Prevention and Health Promotion
(ODPHP) would like to thank all the individuals who submitted comments
and were interviewed for this report (appendix
A). We are grateful for all their suggestions. We hope that
what we learned can be shared with other organizations that are
working to deliver better health information to Asian American,
Native Hawaiian, and other Pacific Islander populations.
Data collection for this report was supported by Nancy Fa'asiu Glass, Rachel Langston, Mona Shah, and Sarah Baron of IQ Solutions under ODPHP's National Health Information Center contract.
For more information or to make comments or suggestions, please
contact Leslie Hsu at lhsu@osophs.dhhs.gov
or 202-401-0732.
David Baker
Senior Publishing Advisor (Internet)
Christy Choi
System Administrator
Mary Jo Deering, Ph.D.
Deputy Director for e-Health and Management
Leslie D. Hsu, M.P.H.
Consumer Health Informatics Advisor
Lead, Evaluation Projects for Tailoring Web Sites for Special Populations, and writer, "Understanding our Users" reports
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Table of Contents
Executive Summary
Section 1: Introduction
Section 2: Goals
Section 3: Background Research
Section 4: Study Overview
Section 5: Research Results
Section 6: Recommendations
Section 7: Conclusion
Footnotes
Appendix A: Intermediaries Who Provided Comments
Appendix B: Audience Profiles
Appendix C: User Task Matrix
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Executive Summary
Designers of Web sites have started to pay attention to the fact
that their designs should be tailored to the cultural communities
that make up their target audiences. Users have a cultural model
of methodology to be employed in a given task and that this model
should be taken into consideration when designing technological
tools for supporting the task.
Albert N. Badre1
The Office of Disease Prevention and Health Promotion (ODPHP) conducted
qualitative studies on healthfinder®'s American Indian and Alaska
Native section and Asian American, Native Hawaiian, and other Pacific
Islander section to build user-focused sites for their cultural
communities.
Section 1 presents findings from user
research, including "cultural usability" tests conducted between
January 2003 and April 2003 to better understand online seekers
of Asian American, Native Hawaiian, and other Pacific Islander health
information.
Section 2 describes the specific goals
of the study and the report:
- Goal 1: To assess the
range of health information-seeking behaviors of intermediaries
and individuals of Asian American, Native Hawaiian, and other
Pacific Islander communities.
- Goal 2: To identify tasks
that intermediaries of Asian American, Native Hawaiian, and other
Pacific Islander communities want to accomplish on a health information
Web site.
- Goal 3: To understand
how Federal agencies can best serve Asian American, Native Hawaiian,
and other Pacific Islander communities in the area of health education
materials.
- Goal 4: To investigate
the overall usability of healthfinder®.
- Goal 5:
To understand how healthfinder® can best serve intermediaries
of Asian American, Native Hawaiian, and other Pacific Islander
communities.
Section 3 provides background research
to better understand the diversity of Asian American, Native Hawaiian,
and other Pacific Islander communities. Section
4 outlines the methods of the study, and Section
5 summarizes the results for each goal of the study. Section
6 presents recommendations based on the research results.
Appendix A provides names of intermediaries
who participated in the study. Appendices
B and C are tools that can be used
as key building blocks for a health information Web site, especially
for Asian American, Native Hawaiian, and other Pacific Islander
populations.
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Section 1 - Introduction
The Office of Disease Prevention and Health Promotion (ODPHP) seeks
to provide health information for a variety of audiences through
healthfinder® (www.healthfinder.gov).
Launched in 1997, healthfinder®
is a portal site, linking the general public to reliable health
information resources. Known for being user-friendly,
healthfinder®
is regularly evaluated by its users through interviews, usability
tests, online comments, and expert reviews.
From August 2002 to November 2002, ODPHP conducted interviews and
usability tests2 with American Indian
and Alaska Native leaders, patients, and students in Anchorage,
the Navajo Nation, and Denver to identify their needs and preferences
for online health information. ODPHP identified user personas and
tasks that American Indian and Alaska Native populations wanted
to accomplish on a health Web site. Due to the success of this model
in involving the community, and developing user personas and the
user task matrix in the enhancement of healthfinder®,
ODPHP adapted a similar process for expanding resources for Asian
American, Native Hawaiian, and other Pacific Islander populations
in 2003.
Because of the diverse and multilingual needs of these populations,
ODPHP decided to test the concept of delivering a searchable database
of multilingual patient education materials, each paired with its
English equivalent to support its use by intermediaries. Our first
goal was to identify a collection of translated materials for the
top nine Asian American, Native Hawaiian, and other Pacific Islander
languages spoken at home, based on Census 2000 data, which are Chinese,
Hmong, Khmer, Korean, Laotian, Samoan, Thai, Tongan, and Vietnamese.3
Our second goal was to develop, with the community, a user-friendly
Web portal for delivering this collection of materials.
From January 2003 to April 2003, ODPHP conducted a series of interviews and usability
tests with Asian American, Native Hawaiian, and other Pacific Islander
intermediaries. We received e-mail comments and suggestions and collected
qualitative data on how people in these communities access health
information on the Internet and how Federal agencies can best serve
their communities. ODPHP collected quantitative data on what the intermediaries
want to accomplish on a health Web site. Because of its limited scope,
this study is not representative of all Asian American, Native Hawaiian,
and other Pacific Islander peoples.
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Section 2 - Goals
Goal 1: To assess the range of health information-seeking
behaviors of intermediaries and individuals of Asian American, Native
Hawaiian, and other Pacific Islander communities.
- Identify who their sources of authoritative information
are.
- Discover when they would use health information
and why.
- Find out when they would use the Internet, and why they would choose
this option.
Goal 2: To identify tasks that intermediaries
of Asian American, Native Hawaiian, and other Pacific Islander communities
want to accomplish on a health information Web site.
Goal 3: To understand how Federal agencies
can best serve Asian American, Native Hawaiian, and other Pacific
Islander communities in the area of health education materials.
- Identify preferences for existing online translated materials.
- Identify preferences for creating translated materials.
- Identify preferences for visual displays of information.
Goal 4: To investigate the overall usability
of healthfinder®
- Identify differences between users' expressed preferences for
seeking health information and their actual performance.
- Explore users' patterns for searching for and filtering information.
Goal 5: To understand how healthfinder®
can best serve intermediaries of Asian American, Native Hawaiian,
and other Pacific Islander communities.
- Validate approach of an English searchable database of multilingual patient education materials for Asian American, Native Hawaiian, and other Pacific Islander intermediaries.
This report summarizes the data we collected and provides recommendations related to improving resources for Asian Americans, Native Hawaiians, and other Pacific Islanders on a health information Web site. Specific recommendations for healthfinder® are not included in this report.
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Section 3 - Background Research
More than 60 nationalities from South Asia, Central Asia, Southeast
Asia, and the islands in the Pacific Ocean have been defined by
the U.S. Census Bureau as "Asian Pacific Islanders," "Asian
Americans and Pacific Islanders," and most recently, in light
of the Revisions to the Standards for the Classification of Federal
Data on Race and Ethnicity, Statistical Directive 15,4
issued by the Office of Management and Budget (OMB), "Asians"
and "Native Hawaiians and other Pacific Islanders."
Asian Americans, Native Hawaiians, and other Pacific Islanders
have lived in the United States since the 1800s. Together, they
represent the fastest growing minority population in America. In
2000, Asian Americans, Native Hawaiians, and other Pacific Islanders
combined numbered nearly 4 percent of the total U.S. population;
by 2020, this number is expected to reach 6 percent.5
It is important to understand the different Asian American, Native
Hawaiian, and other Pacific Islander communities in this country
because they are not a homogeneous population. What we present here
is very brief; a better understanding of the culture and history
of each of these populations can be gained from reading The New
Face of Asian Pacific America: Numbers, Diversity, & Change
in the 21st Century by Eric Lai and Dennis Arguelles.5
Nearly 12 million people identified themselves as
Asian6 in 2000, compared to 6.9 million
in 1990. Compared to the total U.S. population, which experienced
a growth of 13 percent in this time period, the Asian American population
grew by 72 percent. Some 1.3 million Asian Americans live below
the poverty line. Sixty-nine percent of Asian Americans are born
outside of the United States.5 The leading
causes of death for Asian Americans are cancer, heart disease, and
stroke7 (see table
1).
Table 1: Ten leading
causes of death in the United States in 2000 for Asian Americans |
Cancer |
Heart disease |
Stroke |
Unintentional injuries |
Chronic lower respiratory disease |
Influenza and pneumonia |
Diabetes |
Suicide |
Nephritis, nephrotic syndrome, and nephrosis |
Birth defects |
The six largest groups of Asian Americans include Chinese, Filipinos,
Asian Indians, Vietnamese, Koreans, and Japanese, and these groups
comprise numerous subgroups such as South Asians, Southeast Asians,
and Hapas.
South Asian Americans encompass nearly 2 million people whose origins
are from Afghanistan, Bangladesh, Bhutan, India, Maldives, Myanmar
(formerly Burma), Nepal, Pakistan, Sri Lanka, and Tibet.8
Among South Asian Americans, 21 percent have no health insurance,
25 percent are limited in English proficiency, and 25 percent live
in households with incomes below $25,000. South Asian languages
most commonly spoken in the United States include Bengali, Gujarati,
Hindi, Punjabi, and Urdu.
Southeast Asian Americans include people whose origins are from
Cambodia, Laos, Thai, and Vietnam.5
The main ethnic groups include Khmer, Hmong (from the northern mountains
of Laos), Laotian, Thai, and Vietnamese. They are the largest group
of refugees to come to the United States in the past 30 years and
number approximately 1.5 million. Because of their refugee status,
many Southeast Asian Americans face economic hardship, lack of higher
learning opportunities, and lack of parental supervision due to
long work hours. Many of them do not become U.S. citizens because
of language barriers. Poverty rates are high with Khmer (and Hmong
populations (47 percent and 67 percent, respectively).
Hapas are Asian Americans, Native Hawaiians, and other Pacific
Islanders of mixed heritage. Numbering 2.1 million people in the
United States, Hapas are the second-largest subgroup after Chinese.
The term "Hapa" originated in Hawaii to describe those of mixed
White and Hawaiian descent.5
Nearly 874,000 people reported being Native Hawaiian or Pacific
Islander. Of this demographic group, 141,000 people identified themselves
as Native Hawaiian only; they are the largest Pacific Islander group.
In Hawaii, Native Hawaiians earn lower incomes, hold lower status
jobs, and have the highest rate of unemployment of all ethnic groups
living on the Hawaiian islands.5
Of the 874,000 people who reported being Native Hawaiian or other
Pacific Islander, 398,000 people reported being Pacific Islanders
only. After Native Hawaiians, the largest Pacific Islander groups
are Samoan and Guamanian/Chamorro.
The majority of Pacific Islanders live in six island jurisdictions:
American Samoa, the Commonwealth of the Northern Mariana Islands,
the Federated States of Micronesia, Guam, the Republic of the Marshall
Islands, and the Republic of Palau. These populations are diverse
in language and culture.
Native Hawaiians and other Pacific Islanders tend
to lag behind other races in income, median earnings, and educational
attainment, especially those age 25 and older. Native Hawaiians
and other Pacific Islanders also have higher rates of unemployment
(10.4 percent for men and 10.9 percent for women) than the general
U.S. population (5.7 percent). Sixty-five thousand Native Hawaiians
and other Pacific Islanders live below the poverty line. The leading
causes of death for Native Hawaiians and other Pacific Islanders
are cancer, heart disease, and stroke9
(see table 2).
Table 2: Ten leading
causes of death in the United States in 2000 for Native Hawaiians
and other Pacific Islanders |
Cancer |
Heart disease |
Stroke |
Unintentional injuries |
Chronic lower respiratory disease |
Influenza and pneumonia |
Diabetes |
Suicide |
Nephritis, nephrotic syndrome, and nephrosis |
Birth defects |
Asian American, Native Hawaiian, and other Pacific Islander peoples
are often considered a "model community"stereotyped as passive,
compliant, overachieving, and without problems or needs.10
Supporting this myth is the fact that these populations combined
continue to have the highest median household income and education
compared to all other races in the United States. However, 1.4 million
Asian Americans and Pacific Islanders, or 13 percent of this population,
were living at or below the Federal poverty level in 1998. Two million
Asian Americans and Pacific Islanders do not have health insurance;
Korean Americans have the highest rate (40 percent) of noninsurance.11
Some 17.7 percent of Native Hawaiians and other Pacific Islanders
(22.7 percent for Pacific Islander children) lived in poverty compared
to a national rate of 12.4 percent. Twenty-nine percent of Asian-language
households were linguistically isolatedthat is, all the adults
in these households (high school age and older) had limitations
in communicating in English.
Underemployment . . . lack of community health care resources
and external pressure in the form of neighborhood gentrification
. . . linguistic isolation . . . lack of affordable housing .
. . While some contemporary APA [Asian and Pacific American] communities
have prospered, others face significant economic development challenges
as APAs are amongst the richest and poorest, the best educated
and least educated of all Americans.
Paul Ong and Doug Miller12
Asian American, Native Hawaiian, and other Pacific Islander communities
are more vulnerable to depression and other mental health disorders
due to stress related to immigration and acculturation, as well
as cultural values regarding health care, disease, and family honor.13
The Pew Internet and American Life Project14
found that 75 percent of English-speaking Asian American adults
have gone online, compared to 58 percent of White adults, 50 percent
of English-speaking Hispanic American adults, and 43 percent of
African American adults.
With more than 5 million Asian Americans online, they are the Web's
most experienced ethnic group. Seventy percent of Asian American
Internet users are online on a typical day, compared to 58 percent
of White Internet users. Eighty percent of Asian Americans have
been using the Web for more than 2 years. In addition, Asian American
users stay online longer than anyone else. Forty percent of Asian
American Internet users stay online for 2 or more hours. About 15
percent spend 4 or more hours online at a time.
Lack of Internet access is a major issue for Native Hawaiians and
Pacific Islanders. Efforts are underway to connect all Hawaiians
who live on homestead lands.
Significant health disparities exist among Asian American, Native
Hawaiian, and other Pacific Islander populations, especially in
cardiovascular disease, cancer (liver, lung, nasopharyngeal, cervical,
breast, stomach, and colorectal), diabetes, family violence, hepatitis
B and C, HIV/AIDS, tuberculosis, mental health, and substance abuse.15
- Although Asian Americans represent 4 percent of the population,
they account for more than half of the 1.3 million chronic hepatitis
B cases in the United States.5
- Fifty-five percent of Tongan women, 74 percent of Samoan women, and 77 percent of men and women
living in Nauru are obese.16
- Native Hawaiians have the highest mortality rates and the lowest life expectancy among the five
major ethnic populations in Hawaii.17
- Asian American women over age 65 have the highest female suicide rate across all racial/ethnic
groups.18
- Chinese, Filipino, Japanese, and Korean immigrants consistently
report higher numbers of depressive symptoms than do Whites.19
- Analysis of data collected in Hawaii from 1996 to 2000 showed
that Native Hawaiians were 2.5 times more likely than non-Hispanic
White residents of similar age to have diabetes.20
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Section 4 - Study Overview
This section identifies the research audiences and summarizes the
research process.
ODPHP interviewed 30 Asian American, Native Hawaiian, and other
Pacific Islander intermediaries and received online comments from
108 additional intermediaries (appendix
A) representing these target populations. Intermediaries were
asked about their own use of the Internet as well as use by the
communities they serve.
To synthesize the research findings into a useful tool for Web
development, we extracted similarities to build audience profiles
or user personas. Appendix B provides
brief personas of typical Asian American, Native Hawaiian, and other
Pacific Islander intermediaries, organized into the following eight
categories that reflect the context in which they might use the
Internet to find health information.
- Executive directors
- Health educators and social workers
- Legislative analysts
- Librarians
- Physicians and nurses
- Program administrators
- Researchers
- Traditional healing practitioners.
Interviewed intermediaries were selected based on word-of-mouth recommendations from the White House Initiative on Asian Americans and Pacific Islanders and the Office of Minority Health, U.S. Department of Health and Human Services.
Other intermediaries who participated self-selected to provide comments via e-mail or an online form. The White House Initiative on Asian Americans and Pacific Islanders and the American Public Health Association's Asian Pacific Islander Caucus sent out e-mails to their listservs requesting participation.
ODPHP solicited feedback from intermediaries in three ways, as
described below.
Letter. The White House Initiative on
Asian Americans and Pacific Islanders e-mailed a letter via e-mail
to their listservs to inform intermediaries about this project and
request their participation. The main goal was to identify tasks
that they might want to accomplish on a health information Web site.
Between January 27 and February 19, 2003, 42 intermediaries submitted
comments via e-mail to ODPHP.
Interviews: From March 17 to April
10, 2003, ODPHP conducted 30 one-hour interviews and usability tests
on a prototype version of healthfinder®'s Asian American, Native
Hawaiian, and other Pacific Islander section (see
figure 1) with intermediary audiences. These interviews were
conducted at intermediaries' workplace environment, where they normally
access the Internet. For nonlocal intermediaries, ODPHP interviewed
the person over the telephone.
Online form: To validate and rank the tasks that 42 intermediaries suggested as things they might want to accomplish on a health information Web site, the American Public Health Association's Asian Pacific Islander Caucus sent a request to its listserv asking members to complete an online form. Between March 17 and April 20, 2003, 66 intermediaries (including most of the 30 intermediaries interviewed directly) submitted comments online to ODPHP. They also had the option of providing additional feedback about topics that were most important to the communities they served and identifying quality translated materials.
Figure 1: Prototype version
tested in March 2003
Due to limited resources,
ODPHP interviewed only 30 intermediaries for this project. We did
not get the opportunity to speak in person to the other respondents
who contributed comments via e-mail or the online form. The following
limitations were identified:
- Tasks identified by intermediaries were mixed between what they want to perform on behalf of their clients and what they want to do for themselves.
- Tape recorder documentation was incomplete for two participants.
- Views represented in this report reflect the experiences of only the 30 intermediaries interviewed.
- Interviews and usability tests were performed over the phone for
nonlocal interviewees.
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Section 5 - Research Results
This section summarizes the results for each goal.
Goal 1: To assess the range of
health information-seeking behaviors of intermediaries and individuals
of Asian American, Native Hawaiian, and other Pacific Islander communities.
- Identify who their sources of authoritative information
are.
- Discover when they would use health information
and why.
- Find out when they would use the Internet, and
why they would choose this option.
Most Asian American, Native Hawaiian, and other Pacific
Islander interviewees used the Internet to find health information
for themselves and others. All interviewees had completed a college
degree, 73 percent had advanced degrees. Sixty percent used the
Internet more than 2 hours per day. Those who used the Internet
fewer than 2 hours a day usually requested staff to access the Internet
on their behalf. Eighty percent accessed the Internet both at home
and at the office. Fifty percent of those who accessed the Internet
at home had broadband service. The intermediaries considered Government
Web sites to be authoritative sources of information. Many used
a search engine such as Google as a starting point.
Asian American, Native Hawaiian, and other Pacific
Islander communities are extremely diverse. According to the intermediaries,
access to the Internet directly correlated with a person's socioeconomic
status. Their clients usually did not have access to the Internet
because most were immigrants with low socioeconomic status. Intermediaries
described how children usually accessed the Internet at school,
looking up information for their parents when needed.
Intermediaries reported ongoing activities such as
providing technology centers where they train people how to use
the computer and the Internet.21 They also donate refurbished computers
to people who finished the course so they could continue to practice
at home. In Hawaii, there is an ongoing effort to link all Hawaiian
homesteads by providing a computer for every Hawaiian family.22 Also,
some community clinics such as the Wa'anae Coast Comprehensive Health
Center have Internet cafés for their patients.
Most of the time, intermediaries received phone calls
from community members asking them to locate health information
or services on their behalf. Although the Internet might be the
first source of information for intermediaries, most of the time
they were disappointed by the lack of quality translated materials.
Some intermediary organizations, especially those
that provide health care, developed their own health education materials,
translating Government or hospital materials into multiple Asian
American, Native Hawaiian, and other Pacific Islander languages.
When they received requests for health information materials in
these languages, they usually looked in-house and then to their
partner organizations before researching the Internet or library.
In partnership with Asian American, Native Hawaiian,
and other Pacific Islander organizations, libraries have experimented
with kiosks for print materials set up in grocery stores, temples,
and apartment complexes that are heavily populated by Asian communities.
One interviewee describes the problems they've experienced.
We had one placed at a Vietnamese Buddhist temple,
and when we went to do a site visit last year, the monks had placed
the kiosk outside on the porch in the weather. We are supposed
to have someone on staff there [where the kiosks are located]
who will alert us if the paper kiosks are running low of materials.
That's never happened. One person did mention that perhaps the
Asian community is scared to take the brochures thinking they
are going to be charged to pay for them.
Adela Calbillo, Texas Medical
Center Library
This library subsequently experienced greater success
with electronic kiosks in which an evaluation system recorded what
people were looking at, what language they were looking at, and
what they printed. Users were also given the opportunity to rate
the materials they find. To date, the results have been positive.
Despite these attempts to help the community access
the Internet, the intermediaries reported that the immigrant population
received health information primarily through word-of-mouth.23
Family members or friends read about a health issue in language
newspapers they receive either from overseas or from their local
community. They then talk about it over meals or during a haircut.
One intermediary discovered that language newspaper
reporters helped to perpetuate myths in their health news stories.
Reporters appeared to have interviewed community health center staff
members who were fluent in their native language and therefore usually
trained overseas. Unknowingly, these foreign-trained staff persons
tell reporters false health facts, which were then printed in the
very newspapers on which the community relied for health information.
The National Heart, Lung, and Blood Institute, in partnership with
the Asian Pacific Islander American Health Forum, conducted focus
groups and key informant interviews with Cambodians, Filipinos,
Native Hawaiians, and Vietnamese Americans.24 The Vietnamese community
believes that good health means living without pain and being emotionally
stable. Health is a blessing from God, and people often meditate,
practice yoga, or pray to maintain a healthy mind and body. The
Filipino community believes that good health is achieved through
balance among mental, emotional, and physical states of mind.25
They don't talk about health issues because these
issues are personal and private. They believe if you have good
karma then you have good health. If you are afflicted with cervical
cancer, then that means you must have been a bad woman, not in
this life but in previous lives.
Dr. Thang Nguyen, Boat People
SOS
I'll give one example in the treatment of high blood
pressure. A health care provider must be aware that health is
often perceived of as an absence of pain in the Asian culture.
Therefore, from the perspective of an Asian patient who has high
blood pressure, the patient may think that they were completely
healthy, until they saw the doctor who made them sick by starting
them on medicines and giving them a diagnosis.
Dr. Ming-Hui Chen, Former Medical
Director,
South Cove Community Health Center
Most immigrants believe in myths they learned in their
home country. For example, people from China believe that children
inherit hepatitis B from their mothers and that the disease is transmitted
through food and water. Neither of these myths is true: children
have a 95 percent chance of developing immunity to hepatitis B through
vaccination at birth and the disease is transmitted through blood
and sexual fluids only. Focus groups and surveys conducted in several
hepatitis B outreach programs around the Nation have demonstrated
that these myths are widely believed in the Asian American, Native
Hawaiian, and other Pacific Islander community.26
Native Hawaiians base their concepts of health and
wellness on relationships with natural elements, natural environments,
specific places, other living things, and people. These relationships
form the Hawaiian concept of ola, built upon a strong spiritual
foundation. Traditional Hawaiian healing practices are a central
part of Native Hawaiian life. They include both physical and mental
health interventions.27
Goal 2: To identify tasks that
intermediaries of Asian American, Native Hawaiian, and other Pacific
Islander communities want to accomplish on a health information
Web site.
To achieve this goal, ODPHP collected 32 tasks identified
by 42 intermediaries who responded to the letter from the White
House Initiative on Asian Americans and Pacific Islanders. Through
an online comment form, 66 intermediaries subsequently ranked these
32 tasks on a scale of 0 to 3, with 0 being that they would never
try to accomplish this task on a health information Web site and
3 being that they always will try to accomplish this task on a health
information Web site.
The top three tasks identified by 14 executive
directors were:
1. |
Search for statistics. |
2. |
Find grant information. |
3. |
Find information on health specific to communities. |
The top three tasks identified by 11 health educators
and social workers were:
1. |
Provide information to individuals or groups
(tie). |
1. |
Find information on health specific to communities
(tie). |
2. |
Find information on disease or condition. |
The top three tasks identified by 6 legislative
analysts were:
1. |
Gather information for a meeting. |
2. |
Find updates on health news (tie). |
2. |
Search for topic related to health care
organization (tie). |
The top three tasks identified by 2 librarians
were:
1. |
Search for translated materials (tie). |
1. |
Find journal articles (tie). |
2. |
Search for statistics (tie). |
2. |
Find organizations that work on a specific
issue (tie). |
2. |
See how many Asian sites are available (tie). |
2. |
Find information on health specific to communities
(tie). |
2. |
Find information on treatment and management
(tie). |
2. |
Provide information to individuals or groups
(tie). |
2. |
Find information on disease or condition
(tie). |
The top three tasks identified by 9 physicans and
nurses were:
1. |
Find information on disease or condition.
|
2. |
Search for statistics. |
3. |
Print handouts for patients (tie). |
3. |
Find information on treatment and management
(tie). |
3. |
Provide information to individuals or groups
(tie). |
The top three tasks identified by 13 program administrators
were:
1. |
Provide to individuals or groups (tie). |
1. |
Gather information for a meeting (tie). |
2. |
Search for statistics. |
The top three tasks identified by 8 researchers
were:
1. |
Find journal articles. |
2. |
Find information on disease or condition. |
3. |
Search for statistics. |
The top three tasks identified by 3 traditional
healing practitioners were:
1. |
Find information on traditional healing
(tie). |
1. |
Find information on alternative nutrition
(tie). |
2. |
Find information on disease or condition. |
Among the most significant tasks, from the perspectives
of all Asian American, Native Hawaiian, and other Pacific Islander
intermediaries, were the following:
- Find information on disease or condition.
- Search for statistics.
- Find information on health specific to communities.
- Find journal articles.
- Provide information to individuals or groups.
- Find grant information.
- Gather information for a meeting.
- Find updates on health news.
- Find organizations who work on specific issue.
- Search for topic related to health care organizations.
Appendix C provides specific
information on users and their tasks.
Goal 3: To understand how Federal
agencies can best serve Asian American, Native Hawaiian, and other
Pacific Islander communities in the area of health education materials.
- Identify preferences for existing online translated
materials.
- Identify preferences for creating translated materials.
- Identify preferences for visual displays of information.
Most intermediaries spoke with great passion
about the difficulties they encountered with language materials.
First, quality online translated materials are scarce. Second, even
quality online translated materials may not be accessible to many
potential users.
There is a quality issue and effectiveness issue.
Federal agencies usually hire contractors who translate materials
at a Ph.D. level and who are not familiar with the audience for
consumer education materials. It would be more effective and might
also cost less to hire a community based organization that has
knowledge about effective messages, cultural beliefs and commonly
used terminology. I have seen federal agencies spend resources
to print and disseminate materials where the accents are printed
alongside instead of above the characters. This is frustrating
for both the federal agency who is attempting to do the right
thing and it perpetuates the notion that federal agencies and
programs are not culturally and linguistically competent. Many
member community based organizations can't access PDF materials.
We have to fax things to them.
Lisa Hasegawa, National Coalition
for Asian Pacific
American Community Development
Intermediaries suggested providing several options
such as PDF files, graphics, or entire translated Web sites that
require browsers with the language plug-in. They also preferred
bilingual materials because the English version of the material
can become separated from the translated materials. Community health
centers especially experienced this problem as newly hired staff
may continue to distribute translated materials provided by their
predecessor, without knowing where the materials originally came
from or what they say.
One of the things we do at AAPCHO is create health
education materials that are bilingualboth in English and
the client's language. One reason we do this is because let's
say someone e-mailed me a link to this Vietnamese hepatitis B
materialor even worse, someone printed it out and handed
it to me or our patients. I can't read Vietnamese so I wouldn't
know what the material says, how reliable it is, or where it came
from. If the resource is bilingual, then we don't have to worry
about the English and in-language text being separated.
Jeff Caballero, Association
of Asian Pacific Community Health Organizations
To address the lack of quality translated materials, many intermediaries
create their own translated materials. Usually, they try to locate
quality English content to translate into Asian American, Native
Hawaiian, and other Pacific Islander languages. The process is slow
because a number of problems surface during the translation process.
There is no standard lexicon for health words. It
is extremely difficult to translate, since everyone translates
differently. A term like "AIDS" has no standard or comparable
or competent translation in Vietnamese. They have no concept for
"hepatitis B." Sometimes it is translated as "swollen liver."
Dr. Thang Nguyen, Boat People
SOS
In addition, standards and processes are lacking.
Organizations have developed their own guidelines or process for
translating materials. The strategies vary from beginning with an
original English-language document to beginning with an original
Asian American-, Native Hawaiian-, or other Pacific Islander-language
document or from conducting focus groups with community members
to establishing expert review teams with intermediaries.
One question asked in the White House Initiative letter was "What
symbols or phrases suggest health and well-being to you?" Out of
42 respondents, the top suggestions were nature, nutrition, exercise,
happiness, and balance.
During our one-on-one interviews, ODPHP tested two
brochure concepts developed based on the 42 comments we received
from the White House Initiative letter. One brochure contained nature
scenes, and the other featured photographs of Asian American, Native
Hawaiian, and other Pacific Islander faces. We showed these brochures
to the interviewees interviewed locally only. Most interviewees
preferred images of faces combined with images of scenes where interviewees
are working with community members, such as teaching them how to
use the computer or passing out fliers at health fairs. Interviewees
noted that too few stock photos of Asian Americans, Native Hawaiians,
and other Pacific Islanders are available on the market; therefore,
unfortunately, the respondents see the same stock photos all the
time. They also talked about how stock photos sometimes depict these
communities as "too perfect" or looking like "movie stars."
In addition to the print materials, ODPHP tested the
use of graphics on the Web site. On our prototype, the graphic on
the Asian American, Native Hawaiian, and other Pacific Islander
main page was an animated sequence of Asian artwork symbolizing
health and longevity, donated by the Smithsonian Institution (see
figure 2). Most interviewees who were born outside of the United
States enjoyed the artwork, saying it was a nice touch and culturally
appropriate. The Hawaiians preferred seeing Native Hawaiian crafts.
Figure 2: Images donated from
Freer and Sackler Art Gallery, Smithsonian Institution
However, the images produced negative reactions from
many who could not relate to the artwork:
I don't see the relevance. Are we feeding into stereotypes?
Is this the way the American society views Asian Americans and
Pacific Islanders?
Dr. Butch de Castro, American
Public Health Association's
Asian Pacific Islander Caucus
Interviewees also took the opportunity to discuss
the importance of using photographs of everyday Asian American,
Native Hawaiian, and other Pacific Islander life in American society,
instead of photographs of community members in their native dress
or native countries.
Goal 4: To investigate the overall
usability of healthfinder®.
During our interviews, ODPHP asked participants to
accomplish specific tasks. We noted the decisions and choices interviewees
made as they tried to perform efficiently. We were specifically
interested in ascertaining the following information:
- Identify differences between users' expressed preferences
for seeking health information and their actual performance.
- Explore users' patterns for searching for and filtering
information.
ODPHP asked users to begin on the "Just For You" main
page as this is the main entry point we are promoting to special
populations (see figure 3). When users were
asked to perform a task on the "Just For You" page of healthfinder®,
52 percent used the search bar, whereas 41 percent of users selected
the Asian American, Native Hawaiian, and other Pacific Islander
link. The remainder selected another link on the page.
Figure 3: Screen capture
of http://www.healthfinder.gov/justforyou
A majority of interviewees were pleased to see a link
for "Asian Americans, Native Hawaiians, and Pacific Islanders" as
opposed to "Asian Americans and Pacific Islanders." However, Hawaiian
and other Pacific Islander interviewees suggested that it would
still be best to disaggregate Native Hawaiians from Pacific Islanders,
as well as from Asian Americans.
It would be no different if we were lumped with
Native Americans or any other ethnic group. The problem would
be that we still would have the difficulty as far as interpreting
what in fact are the data that relate to our communities.
Robert Uhrle, Advocate Initiatives
for Grassroots Access
If people are really honed in to their ethnicity,
then you need to be able to pop up their ethnic related stuff
quickly. They shouldn't have to jump through hoops to get to it.
For instance, if I want to know what material you have about Native
Hawaiians, show me all health-related materials you have about
Native Hawaiians. I don't want to know about Pacific Islanders.
I don't want to know about Asian Americans. I don't want to jump
through groups to get to Native Hawaiians.
Gerald Ohta, Hawaii Department
of Health
Despite the concern expressed around aggregating information
for the populations, none of the intermediaries had a problem completing
the task of locating translated materials on hepatitis B. The average
time to complete the task was less than a minute. Those who had
some difficulty locating the translated materials pointed out that
the "Also available in" link was not visible to their eye because
they were focused on scanning through the abstract information.
They usually saw the "Also available in: Spanish" link because the
link appeared much shorter and noticeable when only one language
was listed. They noted that "Spanish" should not be displayed in
the Asian American, Native Hawaiian, and other Pacific Islander
section. Others did not see the "TraditionalChinese" or "SimplifiedChinese"
link because they were scanning for the letter "C" for "Chinese"
(see figure 4).
Figure 4: Screen capture of how translated
materials display
The majority of interviewees did not notice the "see
categories and related topics" link (see figure
4). Some suggested that the italics made the link less noticeable.
However, all the interviewees were very pleased with the choices
on the "see categories and related topics" page (see
figure 5).
Figure 5: Screen capture
of "categories and related topics" page
Interviewees were most interested in the list of languages,
the "organizations" link, and the "statistics" link. They would
prefer seeing these choices up front on the Asian Americans, Native
Hawaiians, and other Pacific Islanders main page. The "general"
link caused some confusion as users were unsure what to expect if
they selected it. They also expressed a preference for the list
of choices to be in alphabetical order.
The title of "show resources" and the list of languages
created some confusion. Users expected the whole site to be in the
language they selected. Upon selecting a language, most users said,
"Oh, I got the same result as before"?meaning that they automatically
assumed they were seeing the page with all hepatitis B results for
Asian Americans, Native Hawaiians, and other Pacific Islanders (figure
4) instead of just hepatitis B results that had translated materials
for the selected language.
I do like the ability to click on a language. However,
if someone speaks or reads only Chinese, they would not necessarily
be able to read the English word "Chinese." [User selects Chinese
link.] But I see now that what it does is actually provide you
documents that are in the language you choose. I wish it came
earlier because I would never have thought to click on "see categories
and related topics." If I clicked on "Asian American, Native Hawaiian,
and other Pacific Islanders," I think it would have been useful
to immediately have the top documents filtered by language.
Angelo Locsin, National Asian
Pacific Center on Aging
Another page that users had trouble with was the "directory
of healthfinder® organizations" (see figure
6). Before seeing this page, users expressed preferences for
viewing Asian American, Native Hawaiian, and other Pacific Islander
organizations.
Figure 6: Screen capture
of www.healthfinder.gov/organization
After using the page, users were confused by the interface.
They expected the A-Z list to be the first letter of the names of
organizationsfor example, "A" for "Asian Pacific Islander
American Health Forum." Interviewees were all surprised to find
that the A-Z list was actually a list of health topics. Some thought
they had arrived at the same list they saw earlier in other parts
of the site. They expressed a desire to see all organizations and
be able to browse through them alphabetically or find organizations
grouped by the communities they serve.
None of the 30 interviewees independently used the advanced search.
When they were asked to view the advanced search page, some users
were confused by the two search boxes appearing on the page. Others
had trouble with the meaning of the titles and the drop-down menu
choices (see figure 7). The choices available
for "search within" were especially confusing. Users wanted to know
why you could select "documents" and "organizations" together"Documents
& Organizations"but not all three"news, documents, and
organizations." Also, some were confused about the difference between
documents and organizations.
Search within documents, within organizations .
. . what organization here, I'm not very clear about this. What
organization are you talking about? Is it U.S. Department of Health
and Human Services? Sort results by title. Okay, but is it title
of documents or title of organization? Minor category: dictionaries
are very good I think, especially to have medical dictionary for
Chinese to English or English to Chinese. What is Metasite? What's
the difference between Research and Clinical Trials? What's the
difference between self-help and quick tips? What's a test?
Dr. Weidong Lu, Dana-Farber
Cancer Institute
Figure 7: Screen capture
of advanced search options
All interviewees were extremely interested in being
able to search for a specific language. For "population group,"
some Native Hawaiians and Pacific Islanders expressed a preference
for being able to select "Native Hawaiians" or "Pacific Islanders"
only.
Following suggestions from our previous American Indian
and Alaska Native evaluation, we added a search within the Asian
American, Native Hawaiian, and other Pacific Islander section. None
of the interviewees used the search text box that was specifically
for searching within this section (see figure
1). Some complained that they did not see it because it was
below the fold. Others thought that the search text box at the top
and the one for the Asian American, Native Hawaiian, and other Pacific
Islander section were identical. Part of the problem was that the
instructions for using the A-Z list were underneath the search text
box, so people were associating the instructions to the search text
box. However, once they knew about this feature, they were all glad
it was available.
Goal 5: To
understand how healthfinder® can best serve intermediaries of
Asian American, Native Hawaiian, and other Pacific Islander communities.
- Validate approach of an English searchable database
of multilingual patient education materials for Asian American,
Native Hawaiian, and other Pacific Islander intermediaries.
Intermediaries were asked the question, "How can healthfinder®
best serve Asian American, Native Hawaiian, and other Pacific Islander
populations?" Most respondents were very pleased that ODPHP was
conducting these interviews and consulting with community groups.
They were especially pleased to learn of a central location where
they can go for translated materials.
This is fantastic. This is good. I've been wanting
something like this since 1987. This is really nice.
Emilie Dearing, National Asian
Pacific American Families Against Substance Abuse
I think what you have is really good and would really
help, but unless they [Asian American, Native Hawaiian, and other
Pacific Islander populations] have the mechanism to access the
information, then it's hard to serve them. We have an Internet
café with three or four computers at our health center. So if
we can get information out on where to access the information
that you have, it would be really helpful because it [healthfinder®]
does have really good information.
Kauila Clark, Wai'anae Coast
Comprehensive Health Center
Just try to get some more resources, some more sites.
I know it's hard because there aren't that many. But at least
you're supplying the information here. You're making it simpler,
too. They can just go right to a certain site for specific information
and that's good. I like this site. In fact, I've already bookmarked
it.
Marion Hannemann, Samoan National
Nurses Association
Our approach of creating an English-language searchable
database of translated materials was similar to successful models
developed by other international organizations. MultiLingual-Health-Education.net
(MLHEN), developed in Canada, identified the need for a coordinated
effort to address translation needs in 1995. The project gathered
all the health-related translated materials used by the 22 health
care agencies involved in the partnership. MLHEN's translated materials
are designed for the general public to use with the help of health
care professionals, particularly in multicultural settings where
translations of quick and reliable health-related information are
needed. (See http://www.multilingual-health-education.net.)
The Multicultural Health Communication Service, developed
in Australia, provides information and services to help health professionals
communicate with non-English-speaking communities throughout New
South Wales. This organization has more than 450 publications available
in a wide variety of languages. (See http://mhcs.health.nsw.gov.au/health-public-affairs/mhcs/index.html.)
The main concern expressed by intermediaries is the
disaggregation of Native Hawaiians and other Pacific Islanders from
Asian Americans. However, most agreed that we had to start somewhere.
It was better to include Native Hawaiians and other Pacific Islanders
than not have any resources for them.
You have to start somewhere, right? If I'm an intermediary
and thinking what I need most is to find out where do I go for
help or if I have a client that I'm trying to find information
for, then I can come here.
Hardy Spoehr, Papa Ola Lakahi
In terms of content, the top health topics requested
were traditional healing, diabetes, mental health, HIV/AIDS, cardiovascular
disease, cancer, access to care, hepatitis B and C, nutrition, and
tuberculosis. For Native Hawaiians and Pacific Islanders, obesity
and hypertension were additional topics of importance. One intermediary
described how important it was in his work to find or provide information
on traditional healing.
If you have a cold or a very low fever, especially
with a cold and coughing, they rub your skin with a coin. They
call it "coining" in English because they sometimes use a quarter
and some special oil and they pretty much rub your skin. They
leave big bruises on your skin and they believe it heals . . .
and it does heal the cold. We have hundreds of calls from schools
because children go back to school after having a cold with very
large bruises on their neck or their back. It looks like they
have been beaten up by their parents. I think for the past 10
years, we have been slowly educating ourselves and the schools
that this is a form of traditional healing among the Southeast
Asian families.
Vaka Faletau, County of Los
Angeles, Asian Pacific Project
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Section 6 - Recommendations
This section provides general recommendations based on
the research results. Recommendations specific to healthfinder®
are not included.
Intermediaries recommended that Federal agencies develop
a lexicon or glossary of terms for health words for each Asian American,
Native Hawaiian, and other Pacific Islander language. In addition,
Federal agencies should provide guidelines, standards, or a process
for creating quality online translated materials.
Think through what you are translating. Often times
there are Web sites or phone numbers that are translated. If you
are going to translate it, think through how people will respond.
They will call this number or go to this Web site. But what if
the Web site is only in English and the 1-800 number is only answered
by an English-speaking person? If you have language capacity,
say so. If you don't, you could add that callers will need an
English speaker to call for them. I think there is often an assumption
that you can just take the English piece and just automatically
translate. But you actually need to go through and think about
if you were in a non-English reader's shoes and looking at this.
What would I end up experiencing?
It is important to do focus group testing even before
the messages are developed, preferably in the native language.
Being able to get that input before you start is important because
I think it's often difficult once you already have it set in English
to expect the translated version is going to automatically work
with the target community. If possible, focus group test the materials
after they have been translated. So basically, get the folks that
are supposed to be benefiting from these materials involved with
the materials development. Find out if your messages make sense
and if your information addresses the needs of the community you're
trying to reach.
If you are working with translators, you want to be
able to develop your own lexicon or glossary. Otherwise, different
translators will come up with their own translations for terms
and concepts that don't have a standard translation. Different
documents with different translations can end up defeating your
purpose by confusing your readers.
Then another practical thing is just to recognize that
there is an expansion of text when it comes to translation. Folks
need to think about expanding the format or cutting out some information
instead of just making the font size smaller.
Linda Okahara, Asian Health Services
The following three resources offer examples of guidelines,
standards, and translation services used by other organizations:
- NSW Multicultural Health Communication Service in Australia
offers translation guidelines and checklists. (See http://mhcs.health.nsw.gov.au/health-public-affairs/mhcs/index.html).
- The Minnesota Department of Health developed the Translation
Protocol: A Guide to Translating Materials for Limited English-speaking
Communities,28 which covers checklists,
examples of translations that have gone wrong, lists of qualified
translation agencies, and how to find a qualified translator.
(See http://www.health.state.mn.us/communityeng/multicultural/translation.pdf).
- The Interagency Working Group on Limited English Proficiency
offers a clearinghouse of information, tools, and technical assistance
for Federal agencies, recipients of Federal funds, and community-based
organizations and individuals regarding meaningful language access
to Federal and federally assisted programs and activities. (See
www.lep.gov).
The following examples, taken from the Minnesota Department
of Health's Translation Protocol, offer a humorous look at
translations gone awry, while underscoring the importance of accurate
translation.
- The name Coca-Cola in China was first rendered as Ke-kou-ke-la.
Unfortunately, the Coke company did not discover until after thousands
of signs had been printed that the phrase means "bite the wax
tadpole" or "female horse stuffed with wax" depending on the dialect.
Coke then researched 40,000 Chinese characters and found a close
phonetic equivalent, "ko-kou-ko-le," which can be loosely translated
as "Happiness in the mouth."
- In Taiwan, the translation of the Pepsi slogan "Come alive with
the Pepsi Generation" came out as "Pepsi will bring your ancestors
back from the dead."
- Also in Chinese, the Kentucky Fried Chicken slogan "finger-lickin'
good" came out as "eat your fingers off."
- The American slogan for Salem cigarettes, "Salem?Feeling
Free," got translated in the Japanese market into "When smoking
Salem, you feel so refreshed that your mind seems to be free and
empty."
For online translated materials, interviewees recommended
providing users several options, ranging from PDFs to graphical
displays to entire Web sites that require a language plug-in for
browsers. Intermediaries also suggested developing bilingual materials
to prevent English-language documents from being separated from
their translations.
For the Web site or printed materials, intermediaries recommended
using photographs of Asian Americans, Native Hawaiians, and other
Pacific Islanders living in America. Many confided that they would
rather throw away than distribute free materials that they felt
were inappropriate for their community. Interviewees suggested that
agencies either contract with Asian American, Native Hawaiian, and
other Pacific Islander intermediary organizations to produce their
materials or contact them for photographs or graphics. They were
very pleased that ODPHP asked for their opinion and review prior
to finalizing and printing materials. In addition, intermediaries
recommended translating quality audiovisual materials for their
communities.
I'd like to see some collaborative effort to take quality patient
education materials that are audiovisuals and translate them for
nonreading or nonliterate people, especially for cultural groups
that are immigrants. It's nice if we could have something that
can be played back on a computer screen and even distributed on
CD-ROMs as well so that they could be distributed. I've just heard
over and over again that pictures are really important. The overall
health literacy issue is such that the reading level and pictures
of patient education materials needs to be brought down to what
people can use.
Margaret Allen, Hmong Health Information Promotion Project
Some general usability issues that suggested a need for further testing, as demonstrated by the following concerns expressed by intermediaries:
- Some users were inexperienced or annoyed with PDF files. Users need to be warned that a link will open a PDF file.
- Some users did not have a language plug-in installed
for their browser. Users need to be warned that they need a plug-in
to view the site properly.
- Many users desire more choices for sorting the information presented.
- Some labels or links were not descriptive enough to match user expectations.
- Providing more instructional content on sites would help users determine where to go to get the specific information they are seeking.
Intermediaries recommended that the next phase
of the project address the following user preferences:
- Disaggregate Native Hawaiians and other Pacific Islanders from Asian Americans at the very least. The best scenario would be to have a separate section for each of these three groups.
- Review the quality of the translated materials that the site links to. Many interviewees would like to know how the materials are rated or reviewed.
- Provide access to local organizations. Most intermediaries get calls from community members wanting to know how to access health services in their area.
I do get calls from around the country like, "do you know of anything in St. Paul?" And if I can't find it pretty easily on the Internet, then I'll just tell them to call the health department over there only if I know someone there.
Gem Daus, Asian and Pacific Islander American Health Forum
Local resources?If that is possible, that would be superb.
So if I lived in Chicago, I would know where to go in Chicago
for culturally competent mental health treatment or services.
It would be nice to know which organizations are service providers.
Dr. DJ Ida, National Asian American Pacific Islander
Mental Health Association
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Section 7 - Conclusion
For the purpose of designing cultural usability, we will keep the definition simple and operational. We will view culture in terms of attributes belonging to a target audience that distinguish it from other target communities. Therefore, we view culture as the collective of identifiable behaviors, practices, conventions, signs, symbols, artifacts, values, and beliefs that characterize a group. The practice of cultural usability requires that the designer identify the target audience's relevant attributes and design accordingly for them.
Albert N. Badre1
ODPHP studied "cultural usability" as defined by Badre for 2 of
the 15 special population sections of www.healthfinder.gov:
- American Indians and Alaska Natives
- Asian Americans, Native Hawaiians, and other Pacific Islanders.
In our investigation of Asian American, Native Hawaiian, and other Pacific Islander populations, ODPHP gathered significant information about various audiences, attributes of health information that are important to these audiences, and their reasons for visiting health-related Web sites.
ODPHP validated the approach of an English searchable database for intermediaries of Asian American, Native Hawaiian, and other Pacific Islander populations. They were interested to learn there is a central location where they can go for quality translated materials. They shared with ODPHP their frustrations about the lack of such materials. Intermediaries recommended that Federal agencies consider developing a health or medical lexicon or glossary as well as standards or procedures for translating materials.
As more materials are collected for these audiences, intermediaries suggested that separating Asian Americans, Native Hawaiians, and other Pacific Islanders into three distinct categories ultimately provide the best service to each of these communities.
The tools presented in appendix
B and appendix C are designed to be
building blocks or foundations for better understanding what Asian
American, Native Hawaiian, and other Pacific Islander intermediaries
want to accomplish on healthfinder® and other health information
Web sites.
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1Badre, A.N. Shaping
Web Usability: Interaction Design in Context (Boston: Addison-Wesley),
2002.
2Hsu, L.D. Understanding
Our Users: How To Better Deliver Health Information Online to American
Indians and Alaska Natives (Washington, DC: Office of Disease Prevention
and Health Promotion), November 2002. Available online at http://odphp.osophs.dhhs.gov/projects.
3Tagalog and Japanese resources were not advertised as part of our collection because the majority of Japanese and Filipinos in the United States speak English.
4 Office of Management and Budget, Executive Office of the President. Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity. Federal Register Notice, October 30, 1997. Available online at http://www.whitehouse.gov/omb/fedreg/ombdir15.html.
5Lai, E., and Arguelles, D. The
New Face of Asian Pacific America: Numbers, Diversity, & Change
in the 21st Century (San Francisco and Los Angeles: Asian Week
and UCLA's Asian American Studies Center), 2003.
6U.S. Census 2000. Of the 12 million, 10.2 million stated that they were Asian only, whereas 1.7 million identified themselves as being Asian in combination. The 72-percent increase of 72 percent factors in people who identified themselves as Asian alone or in combination.
7Centers for Disease Control
and Prevention, Office of Minority Health. Asian American Populations.
Available online at http://www.cdc.gov/omh/Populations/AsianAm/AsianAm.htm.
8South Asian Public Health
Association (SAPHA). A Brown Paper: The Health of South Asians
in the United States (Silver Spring, MD: SAPHA), October 2002.
The Executive Summary is available online at http://www.sapha.net/execsum.pdf.
9Centers for Disease Control
and Prevention, Office of Minority Health. Native Hawaiian &
Other Pacific Islander (NHOPI) Populations. Available online
at http://www.cdc.gov/omh/Populations/NHOPI/NHOPI.htm.
10President's Advisory
Commission on Asian Americans and Pacific Islanders. Asian Americans
and Pacific Islanders: A People Looking Forward; Action for Access
and Partnerships in the 21st Century. Interim Report to the President
and the Nation (Rockville, MD: White House Initiative on Asian
Americans and Pacific Islanders), January 2001. Available online
at ftp://ftp.hrsa.gov/aapi/interimreport3.pdf.
11Hurtado, M.P., Swift, E.K., and
Corrigan, J.M. (eds.), Committee on the National Quality Report
on Health Care Delivery, Board on Health Care Services. Envisioning
the National Health Care Quality Report (Washington, DC: The
National Academies Press), 2001.
12Ong, P., and Miller,
D. Economic Needs of Asian Americans and Pacific Islanders in
Distressed Areas: Establishing Baseline Information (Los Angeles:
Ralph and Goldy Lewis Center for Regional Policy Studies, UCLA School
of Public Policy and Social Research), July 2002. Available online
at http://lewis.sppsr.ucla.edu/research/workingpapers/EDAREPORT.pdf.
13National Asian Women's
Health Organization. Empowering Avenues for Community Action:
The National Collaborative for Asian American Women's Mental Health.
Available online at http://nawho.org/file_depot/0-10000000/0-10000/9950/conman/Mental+Health+Fact+Sheet.pdf.
14Spooner, T. Asian-Americans
and the Internet: The Young and the Connected (Washington, DC:
Pew Internet and American Life Project December 12, 2001. Available
online at http://www.pewinternet.org/reports/pdfs/PIP_Asians_Report.pdf.
15President's Commission on Asian Americans and Pacific Islanders. As-yet untitled report, forthcoming.
16Pacific Islanders Are
World's Fattest. BBC News, November 29, 2001. Available online
at http://news.bbc.co.uk/1/hi/world/asia-pacific/1682477.stm.
17The Health of the Hawaiians: E
Ola Na Kin. Pacific Health Dialog: Journal of Community Health
and Clinical Medicine for the Pacific 8(2) September 2001.
18National Center for Health Statistics.
Health, United States 2001 (Hyattsville, MD: U.S. Public
Health Service, Centers for Disease Control and Prevention), 2001.
19Hurh, W.M., Kim KC.
Uprooting and Adjustment: Sociological Study of Korean Immigrants'
Mental Health, 1986-1988 (Macomb, IL: Western Illinois University),
1988. Available online at http://www.radcliffe.edu/murray/data/ds/doc1143.htm.
20National Institute of
Diabetes and Digestive and Kidney Diseases. National Diabetes
Statistics Fact Sheet: General Information and National Estimates
on Diabetes in the United States, 2000 (Bethesda, MD: U.S. Department
of Health and Human Services, National Institutes of Health), NIH
publication no. 02-3892, 2002. Available online at http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm
(accessed May 2003).
21Nguyen, Thang. Interview by Leslie Hsu. Tape recording. Arlington, VA, March 20, 2003.
Allen, Magaret. Interview by Leslie Hsu. Tape recording. Stratford, WI, April 3, 2003.
22Spoehr, Hardy. Interview by Leslie Hsu. Tape recording. Honolulu, HI, March 25, 2003.
23Hsu, L.D., et al. Student Leadership
in Public Health Advocacy: Lessons Learned from the Hepatitis B
Initiative. American Journal of Public Health. August 2003
(in press).
24National Heart , Lung,
and Blood Institute. Cardiovascular Risk in the Vietnamese Community:
Formative Research From Houston, Texas (Rockville, MD: U.S.
Department of Health and Human Services, National Institutes of
Health), March 2003. Available online at http://www.nhlbi.nih.gov/health/prof/heart/other/vietnamese.pdf.
25National Heart, Lung,
and Blood Institute. Cardiovascular Risk in the Filipino Community:
Formative Research From Daly City and San Francisco, California
(Rockville, MD; U.S. Department of Health and Human Services, National
Institutes of Health), March 2003. Available online at http://www.nhlbi.nih.gov/health/prof/heart/other/filipino.pdf.
26The Hepatitis B Initiative
Web site, http://www.hepbinitiative.org.
Accessed May 28, 2003.
27Papa Ola Lokahi. Native Hawaiian
Health and Wellness Summit and Island 'Aha: Issues, Trends and General
Recommendations, Honolulu, March 1998.
28Minnesota Department
of Health, Communications Office. Translation Protocol: A Guide
to Translating Materials for Limited English-speaking Communities
(St. Paul: Minnesota Department of Health), November 2000. Available
online at http://www.health.state.mn.us/communityeng/multicultural/translation.pdf.
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