The rise of racial minority health apps
Authors: Udani Samarasekera
Journal: The Lancet Digital Health (2022)

“As a Black woman with a chronic mental health illness, racism and lack of cultural competency in health care scares me. Sometimes I am faced with huge barriers when trying to get the support that I need, and I am tired of it…”, tweeted Jasmin Pierre, an American mental health advocate and app developer in early February 2022. Her sentiments are echoed by many Black Americans, according to recent data. Results from the 2020 Survey On Race And Health, a nationally representative survey of US adults by American non-profit Kaiser Family Foundation and digital platform The Undefeated, revealed that one in five Black adults said that they had personally experienced race-based discrimination in the past year. Additionally, two-thirds of Black adults said it was difficult to find a health-care provider who shared their background and experiences, and a quarter said they have never received care from a Black doctor. Black adults were also more likely than White adults to report negative experience with health-care providers, including providers not believing they were telling the truth or refusing to provide pain medication. Such responses from Black individuals are unsurprising given the longstanding and well-documented racial disparities in health and health care in the USA that have arisen from structural and systemic inequities. But while the USA and other countries continue to grapple with this issue, particularly in the wake of the global racial reckoning that occurred in 2020, could digital health be part of the solution? Several Black technology entrepreneurs think so. They have stepped in to try to help address racial health inequities in their communities by designing culturally relevant consumer health apps. The past 5 years has seen a proliferation of such apps in the USA, specifically for Black people and other people of colour. Areas that the apps focus on include increasing access to Black health-care providers, providing mental health support, and improving reproductive care. An example of these apps is Health In Her HUE, launched in 2018 by two Black female entrepreneurs Ashlee Wisdom and Eddwina Bright. Wisdom has expertise in public health and Bright in business. The app connects Black women and women of colour to 1000 culturally competent and sensitive health-care providers across the USA including doctors, midwives, and nutritionists. In August 2021, the app attracted US$1 million in funding to build the platform, mostly from Black-owned companies. In the mental health arena, the Ayana Therapy app founded by Eric Coly, a Senegalese American and mental health advocate, links marginalised and intersectional communities to 200 licenced mental health professionals who might share their race, ethnicity, culture, gender, sexual orientation, or religion. It uses a detailed and culturally sensitive questionnaire to match people with a counsellor. Users are then able to use the app to communicate with the therapist via text messages, phone calls, or video sessions. Another mental health platform is The Safe Place, which is a free app created by Pierre in 2018. It is geared towards the Black community and features mental health statistics and self-care tips including on coping after police brutality and talking to family members about mental illness. “All races go through mental illness, but we also can experience it differently because of our race and social backgrounds”, Pierre writes in her app. “African Americans are 20% more likely to experience serious mental health problems than the rest of the general population. However, many Black people still do not wish to seek professional help for their mental illnesses.” The purpose of the app “is to bring more awareness, education, and hope to this serious issue”, Pierre states in her app. Black doctors and researchers working in racism and health have largely welcomed the rise of health apps for minorities by Black people. Ayana Jordan, Assistant Professor of Psychiatry, Yale School of Medicine, CT, USA, whose work focuses on substance use and mental health in minority communities tells The Lancet Digital Health that the increase in such apps “demonstrates that Black people are attempting to find solutions to the very real need to be seen and treated with humanity in a very racist mental health and health-care system”. Using technology makes sense too. 83% of Black Americans now own a smartphone, according to a Pew Research Center survey in 2021. With the rise of smartphones and social media, Jordan tells The Lancet Digital Health that, “culturally based apps allow people to readily identify Black and other treaters of colour” and find “which providers are safe and can understand and empathise with the Black experience…or minimise the impact of real consequences of being Black and othered in a system not created or meant to integrate your cultural values.” Joia Crear-Perry is President of the US non-profit the National Birth Equity Collaborative and a thought leader around racism and inequity. She thinks the proliferation of health apps directly marketed to Black people in the past 2–5 years is not surprising. “We spend a lot of time and money on technology that we find value in and I am happy to see companies understanding that and creating products that reflect our unique experiences while also making quality health care, particularly for mental health, more accessible to our community”, she comments. Only 5% of active physicians in the USA identify as Black or African American, according to the Association of American Medical Colleges. In view of such statistics, Jordan is overall in support of Black entrepreneurs “responding to the real need for representation in a global milieu where there are so few Black physicians” but she notes some important considerations for these initiatives. She questions whether these health apps utilise evidence-based treatments. Although this is “not mandatory” she says, Black people should be offered options to evidence based practices and “given the opportunity to learn about the latest treatment options, including medication”. Jordan also thinks that there needs to be a way to distinguish self-help support apps from treatment apps where an intervention is occurring or where you can connect to doctors, psychiatrists, or other mental health providers. Importantly, she notes that “if people are feeling unsafe (acutely wanting to hurt someone or themselves), how will the app address that urgency or interface to connect a person to more immediate care?” Although she does not consider these insurmountable concerns, she thinks that they need to be carefully considered by developers. Meanwhile, Crear-Perry thinks that although developing health apps specifically for the Black population is useful and necessary, “it is important that we not reinforce or present harmful narratives that suggest that our bodies are somehow biologically different than other races. They are not. However, our experiences and how the effects of those experiences play out in terms of our health, mental and physical, absolutely need to be reflected in the type of care we receive from our provider or via an app in order for us to feel safe.” She is also concerned about potential exploitation. “Now that Black companies have proven there is a market for this technology…you can see how others are attempting to lean into this space as well.” She is “instantly wary when those involved—and profiting—are not Black people ourselves.” Non-commercial health apps for African Americans have also grown in recent years as researchers try to tackle racial health disparities. These apps focus on health promotion and health behaviour change, are evidence-based, and have a longer history than the newer consumer health apps for the Black community. Areas of health covered include cardiovascular health, reproductive health, HIV prevention, and physical activity and many include or are led by Black researchers. Some, such as the Fostering African American Improvement in Total Health (FAITH!) app, are reporting promising results. Researchers led by LaPrincess Brewer at the Mayo Clinic, Rochester, MN, USA, co-designed the culturally tailored FAITH! app to promote cardiovascular health within the African American church community using an iterative participatory approach between academia and the community. In the pilot study, participants achieved improvements in key cardiovascular health behaviours and factors and in a formative evaluation reported overall high acceptability and satisfaction of the intervention. Such co-designing of apps is key, notes Sherry Pagoto, Professor in the Department of Allied Health Sciences at the University of Connecticut and Director of the UConn Center for mHealth and Social Media, Storrs, CT, USA. “Experts from the target population should be at the design table and developers should heavily engage potential users who are members of the target population throughout the design process. If you aren't co-designing in this way, there is a good chance your app won't be of interest to an entire population of people”, she says. An issue with any app in the health promotion realm, however, is getting users to keep returning. “A major challenge with mobile apps is that they often get downloaded and then ignored. A significant tension exists between in-the-pocket convenience and adherence. Mobile apps are incredibly convenient but getting people to use them enough to produce clinical outcomes has been an elusive goal. All of these factors require a team that has the proper expertise represented”, Pagoto notes. Whether it is an app to link the Black community with Black health care providers, culturally relevant information, or to encourage health promoting behaviours, the common goal is to improve the Black health care experience and reduce racial health disparities. Will these Black entrepreneurs and researchers succeed? Only time will tell. But that the development of these apps is being led by the Black community looks to be a step in the right direction.