Health information technology use among foreign-born adults of Middle Eastern and North African decent in the United States

Abstract

Health information technology (HIT) use among foreign-born adults of Middle Eastern and North African (MENA) descent living in America is an understudied population. They are currently categorized as “White” in the United States (US) on federal forms. The purpose was to uncover the prevalence of HIT use among MENA immigrants compared to US- and foreign-born White adults before and after adjusting for other factors. The 2011–2018 National Health Interview Survey data (n = 161,613; ages 18 + years) was analyzed. HIT uses evaluated were searching for health information, filling prescriptions, scheduling appointments, and communicating with healthcare providers via email (last 12 months). Crude and multivariable logistic regression models were used to estimate the odds of each HIT use, any HIT use, and all HIT uses before and after adjustment. The most common HIT use was looking up health information, with 46.4% of foreign-born adults of MENA, 47.8% of foreign-born White, and 51.2% of US-born White adults reporting its use (p = .0079). Foreign-born adults of MENA descent had lower odds (OR = 0.64; 95%CI = 0.56–0.74) of reporting any HIT use, but no difference in reporting all HIT uses compared to US-born White adults in adjusted models. This is the first study to explore HIT use among Americans of MENA descent. Patterns of HIT use among adults of MENA descent differ from White adults. Results contribute to growing body of literature showing the health of Americans of MENA descent differs from White Americans. A separate racial/ethnic identifier is needed to better capture HIT uses among populations of MENA descent.

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Health information technology use among foreign-
born adults of Middle Eastern and North African
decent in the United States
Alexandra Smith
University of Texas at Arlington https://orcid.org/0009-0007-9770-802X
Tiffany Kindratt (  tiffany.kindratt@uta.edu )
University of Texas at Arlington https://orcid.org/0000-0003-3513-5290
Research Article
Keywords: Health information technology, Middle Eastern and North African, Arab American, National
Health Interview Survey
Posted Date: October 26th, 2023
DOI: https://doi.org/10.21203/rs.3.rs-3491745/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Health information technology (HIT) use among foreign-born adults of Middle Eastern and North African
(MENA) descent living in America is an understudied population. They are currently categorized as
“White” in the United States (US) on federal forms. The purpose was to uncover the prevalence of HIT use
among MENA immigrants compared to US- and foreign-born White adults before and after adjusting for
other factors. The 2011–2018 National Health Interview Survey data (n = 161,613; ages 18 + years) was
analyzed. HIT uses evaluated were searching for health information, lling prescriptions, scheduling
appointments, and communicating with healthcare providers via email (last 12 months). Crude and
multivariable logistic regression models were used to estimate the odds of each HIT use, any HIT use,
and all HIT uses before and after adjustment. The most common HIT use was looking up health
information, with 46.4% of foreign-born adults of MENA, 47.8% of foreign-born White, and 51.2% of US-
born White adults reporting its use (p = .0079). Foreign-born adults of MENA descent had lower odds (OR
= 0.64; 95%CI = 0.56–0.74) of reporting any HIT use, but no difference in reporting all HIT uses compared
to US-born White adults in adjusted models. This is the rst study to explore HIT use among Americans of
MENA descent. Patterns of HIT use among adults of MENA descent differ from White adults. Results
contribute to growing body of literature showing the health of Americans of MENA descent differs from
White Americans. A separate racial/ethnic identier is needed to better capture HIT uses among
populations of MENA descent.
BACKGROUND
The use of health information technology (HIT) has become progressively popular as development in
technology has advanced. HIT use involves accessing the internet to seek healthcare information,
consulting with healthcare professionals, and searching other health-related inquiries. Individuals and
healthcare providers have increased technology use as a mode of communication and education to seek
and provide information outside of oce visits.1 With an advancement in HIT use, there is interest about
who is using it, how often, and for what means. Previous studies have sought to identify characteristics
of individuals using HIT and potential purposes. Manganello (2017) found regardless of self-report health
understanding there was an increase in HIT use.2 Gandrakota (2021) found similar results in their study
of HIT use from the years 2012 to 2018. They also found sociodemographic differences; older individuals
and individuals that identied as a racial or ethnic minority used HIT less compared to Non-Hispanic
White adults (hereafter, White).3
On a national level, studies have been conducted to examine differences in HIT use based on
sociodemographic factors and found that HIT use differs by age, gender, sexual orientation, education
attainment, nativity status, and race/ethnicity. Younger adults, women, sexual minority groups, adults
living with chronic conditions, and racial/ethnic minority groups are more likely to report HIT use
compared to their peers.4–7 Black, Hispanic, and Asian adults are less likely to report any HIT use
compared to White adults.8,9 Regarding nativity status, other research has reported that foreign-born

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Hispanic adults are less likely to report HIT use compared to US-born Hispanic and US-born White
adults.10 Research has been conducted to evaluate HIT use as a potential predictor of preventive service
utilization. Kindratt and colleagues (2019) evaluated how HIT use was associated with inuenza vaccine
uptake and found that any HIT users were more likely to receive an inuenza vaccine compared to those
who did not report any HIT use.11 Other studies have reported that HIT users were more likely to report
receiving recommended cancer screenings, pneumonia vaccines, and HIV testing compared to adults who
reported zero HIT use.11–15
Theoretical/Conceptual Framework
Previous studies evaluating HIT use fail to account for the disparities that exist among populations who
lack representation on a national level, specically adults of Middle Eastern and North African (MENA)
descent. The lack of studies on MENA Americans is because this population is dened as “White” by the
federal Oce of Management and Budget. The White population comprises individuals who were born in
or trace their heritage to countries located in Europe, the Middle East, and North Africa. Adults of MENA
descent are considered White on surveys such as the National Health Interview Survey (NHIS) and the US
Census Bureau. Despite this classication, research studies have found that the lived experiences and
health of this population differs from White adults.16 This can lead to a lack of representation, support,
and federal funding. The MENA community is not always perceived as "White" by society and can face
discrimination due to race, appearance, and cultural practices. Awad and colleagues (2019) noted that
MENA individuals can experience trauma and discrimination after major events like 9/11, and major
political changes.17 Regarding health, studies have reported that MENA adults are more likely to report
psychological health concerns,18,19 comorbid diabetes,20 and disabilities,21–24 less likely to report
receiving immunizations and cancer screenings,25–27 less likely to receive a diagnosis for dementia,28
and less likely to receive recommended follow-up care compared to White adults. 29,30 Although studies
have found that HIT use may contribute to improvements in healthcare utilization and management of
the chronic conditions that disproportionately affect this population, patterns of HIT use among the
MENA population remains unknown.
To the authors’ knowledge, there are no current studies that analyze HIT use among foreign-born adults
of MENA descent. Our aim was to estimate and compare the prevalence of HIT use among foreign-born
adults of MENA descent compared to US- and foreign-born White adults before and after adjusting for
covariates.
METHODS
Data Source and Participants
Secondary data from the 2011–2018 NHIS were analyzed. The NHIS conducted by the National Center
for Health Statistics collects health information about the US population. Data are collected in a face-to-

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face interview at the home of the participants throughout the year. Questions are asked about the family,
one sample child (17 years or younger), and one sample adult (18 years or older) at each household.
Starting in the year 2011 questions were asked to the sample adult about HIT use. Our sample included
161,613 participants aged 18 + years (n = 1,264 foreign-born MENA, n = 4,516 foreign-born White, and n =
155,833 US-born White). Data were analyzed using the complex sample design features in SAS 9.4.
Variables
Independent Variable
The independent variables were created from NHIS question cards accessing race, ethnicity, and region of
birth. Participants selected their race (White, Black, American Indian/Alaskan Native, Asian, Other) and
identied if they were Hispanic or Latino. Participants were asked their birthplace (one of the 50 states,
Washington DC, military base overseas, or US territory). Individuals not born in the US they were asked “in
what country were you born?” All responses were divided into 10 world regions (US, Europe, Russia,
Middle East, Africa, and others). Individuals born in the “Middle East” or “Africa” were categorized as
foreign-born adults of MENA descent and compared to US- and foreign-born White (from Europe or
Russia).
Dependent Variable
From 2011–2018, the NHIS consistently measured HIT use in a series of four questions. The questions
included assessed whether the participant (no, yes) used the internet during the past 12 months to look
up health information, ll a prescription, scheduled medical appointments, or communicate with a
healthcare provider by email.31” Questions were analyzed individually and collectively as “any” HIT use
and “all” HIT use based on previous studies 11,32.
Covariates
Covariates included age (18–44, 45–64, 65 + years), sex (male, female), highest level of education (less
than high school, high school diploma or GED, some college or associate degree, bachelor’s degree or
higher) and chronic conditions. Chronic conditions were evaluated in two ways. Diabetes, heart disease,
cancer, and asthma were identied as four of the top ten leading causes of death in the US.33 Studies
have found that that the burden of these chronic conditions differs from White adults20,30,34 and people
with chronic conditions (e.g., diabetes) are more and less (e.g., cardiovascular disease risk) likely to report
HIT use compared to other adults.35,36 Participants were asked whether they have ever been told by a
healthcare provider that they had diabetes, coronary heart disease, cancer, or asthma.31 A dichotomous
variable (no, yes) was created for each chronic condition. Then, a combined variable was created to
indicate whether participants had one or more (no, yes) of the top chronic conditions.
Institutional Review Board

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This study used secondary data that did not include any identiable information and were publicly
available. Therefore, our institutional review board deemed this study not subject for review or approval.
RESULTS
Table1 provides the sociodemographics, top chronic conditions, and HIT uses. The MENA population
was younger, with 50.1% of foreign-born adults of MENA descent ages 18–44 years compared to 38.3%
of foreign-born White and 41.6% of US-born White adults (p = .0001). A greater amount of MENA adults
were men (54.1%) compared to US- and foreign-born White adults (48.5% and 45.6%, respectively) (p
= .0111). More foreign-born MENA adults had a bachelor’s degrees or higher level of education (50.2%)
compared to US- and foreign-born White counterparts (32.5% and 42.3%, respectively) (p < .0001). Fewer
foreign-born adults of MENA descent reported any top chronic conditions (21.0%) compared to foreign-
born (23.8%) and US-born White (31.7%) adults (p < .0001). Fewer foreign-born adults of MENA descent
reported all HIT uses (48.9%) compared to US- (53.6%) and foreign-born (50.3%) White adults (p = .0102).
Specically, foreign-born adults of MENA descent were less likely to report looking up health information
and lling prescriptions online compared to US- and foreign-born White adults (both p’s < .05) yet were
more likely to schedule appointments with a healthcare provider online compared to other groups (p
= .0274). Only 2.9% of foreign-born adults of MENA descent reported all HIT uses compared to 2.2% of
foreign-born and 2.5% of US-born White adults.

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Table 1
Weighted sociodemographic and health information technology (HIT) use characteristics, NHIS 2011–
2018, n = 161,613.
US-born Foreign-born 
 White
n =
155,833
Column %
 White
n =
4,516
Column
%
MENA
n =
1,264
Column
%
p-value
Sociodemographic Characteristics
    
Age     .0001
18–44 years 41.6  38.3 50.1 
45–64 years 36.8  34.9 35.8 
65 + years 21.6  26.7 14.1 
Sex     .0111
Male 48.5  45.6 54.1 
Female 51.5  54.4 45.9 
Highest level of education     < .0001
Less than high school 8.9  8.9 8.6 
High school diploma/GED 26.2  20.3 18.3 
Some college/Associates 32.5  28.5 22.8 
Bachelor’s degree or higher 32.5  42.3 50.2 
Top Chronic Conditions
    
Any Chronic Conditions
(%yes)
31.66  23.83 20.99 < .0001
Diabetes
(%yes)
9.02  7.31 8.44 .0089
Coronary heart disease
(%yes)
5.28  5.47 3.72 .0200
Cancer
(%yes)
11.59  9.70 5.04 < .0001
Asthma
(%yes)
13.54  7.26 7.62 < .0001
Health Information Technology (HIT) Use
Any HIT Use
(%yes)
53.6  50.3 48.9 .0102
Note. All US- and foreign-born groups are non-Hispanic.

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US-born Foreign-born 
Looked up health information on the internet
(%yes)
51.2  47.8 46.4 .0079
Fill a prescription
(%yes)
9.0  6.8 4.8 < .0001
Schedule appointment with health care provider
(%yes)
6.8  7.4 10.2 .0274
Communicate with health care provider by email
(%yes)
8.6  8.1 10.4 .2358
All HIT Uses
(%yes)
2.49  2.23 2.89 .5393
Note. All US- and foreign-born groups are non-Hispanic.
Abbreviation. MENA=Middle Eastern and North African.
Table 2 provides associations between race, ethnicity and nativity and
any
HIT use. Foreign-born adults
of MENA descent had 17% lower odds (95%CI= 0.70-0.92) of any HIT use compared to US-born White
adults. Results remained statistically signicant when adjusted for age, sex, and highest level of
education, and any top chronic condition (OR= 0.64; 95%CI= 0.56-0.74).
Table 2. Unadjusted and multivariable associations between race, ethnicity, and nativity status and any
health information technology use, NHIS 2011-2018, n=161,613.
 Any Health Information Technology (HIT) Use
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
US-Born
(reference)
 
  White 1.00 1.00
Foreign-born  
  White 0.89 (0.81-0.96) 0.79 (0.72-0.87)
  MENA 0.83 (0.70-0.92) 0.64 (0.56-0.74)
Note. US- and foreign-born groups are non-Hispanic.
Abbreviations. CI=condence interval; MENA=Middle Eastern and North African; OR=odds ratio.
aUnadjusted model
bMultivariable model adjusted for age, sex, and highest level of education, any top chronic conditions.

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Table 3 provides associations between race, ethnicity and nativity and
each specic
HIT use. Statistically
signicant associations were found for looking up health information online and relling prescriptions. In
the unadjusted model, foreign-born adults of MENA descent had 18% lower odds (95%CI=0.71-0.95) of
looking up health information online compared to US-born White adults. Results remained statistically
signicant after adjusting for age, sex, highest level of education, and any top chronic conditions
(OR=0.67; 95%CI=0.58-0.78). Foreign-born adults of MENA descent had 49% lower odds (95%CI= 0.34,
0.76) of lling a prescription online in the past 12 months compared to US-born White adults. Results
remained statistically signicant after adjusting for age, sex, highest level of education, and any top
chronic conditions (OR= 0.54; 95%CI= 0.40-0.73). There was a statistically signicant difference between
foreign-born adults of MENA descent and US-born White adults for scheduling medical appointment
online in the past 12 months (OR=1.55; 95%CI= 1.15-2.08) in the unadjusted model. However, results were
attenuated and no longer signicant in the adjusted model. There was not a statistically signicant
difference (OR= 1.24; 95%CI= 0.93-1.65) in communicating with a healthcare provider by email.
Table 3. Unadjusted and multivariable associations between race, ethnicity, and nativity status and each
specic health information technology use, NHIS 2011-2018, n=161,613.

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 Look up health
information online
Fill a
prescription
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
US-Born
(reference)
   
  White 1.00 1.00 1.00 1.00
Foreign-born    
  White 0.88 (0.82-
0.96) 0.80 (0.73-
0.87) 0.74 (0.61-0.90) 0.74 (0.65-0.85)
  MENA 0.82 (0.71-
0.95) 0.67 (0.58-
0.78) 0.51 (0.34-0.76) 0.54 (0.40-0.73)
 Schedule
appointments
Communicate with health care provider by e-
mail
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
US-Born
(reference)
   
  White 1.00 1.00 1.00 1.00
Foreign-born    
  White 1.10 (0.91-
1.32) 1.08 (0.95-
1.23) 0.94 (0.78-1.13) 0.91 (0.80-1.03)
  MENA 1.55 (1.15-
2.08) 1.07 (0.86-
1.34) 1.24 (0.93-1.65) 1.07 (0.87-1.31)
Note. US- and foreign-born groups are non-Hispanic.
aUnadjusted model
bMultivariable model adjusted for age, sex, and highest level of education, any top chronic conditions.
Table 4 provides associations between race, ethnicity and nativity and
all
HIT uses. There were no
statistically signicant differences between foreign-born adults of MENA descent and US-born White
adults in the unadjusted (OR=0.86; 95%CI=0.54-1.36) or multivariable (OR=0.92; 95%CI=0.58-1.46) model.

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Table 4. Unadjusted and multivariable associations between race, ethnicity, and nativity status and all
health information technology uses, NHIS 2011-2018, n=161,613.
 All Health Information Technology (HIT) Uses
Model 1a
OR (95% CI)
Model 2b
OR (95% CI)
US-Born
(reference)
 
  White 1.00 1.00
Foreign-born  
  White 0.77 (0.46-1.30) 0.78 (0.46-1.31)
  MENA 0.86 (0.54-1.36) 0.92 (0.58-1.46)
Note. US- and foreign-born groups are non-Hispanic.
Abbreviations. CI=condence interval; MENA=Middle Eastern and North African; OR=odds ratio.
aUnadjusted model
bMultivariable model adjusted for age, sex, and highest level of education, any top chronic conditions.
DISCUSSION
The purpose of this study was to estimate and compare the prevalence of HIT use among foreign-born
adults of MENA descent to US- and foreign-born White adults. An overview of our key ndings is
presented below.
We found that foreign-born adults of MENA descent were less likely to report
any
HIT use compared to
other groups. However, there was no difference in
all
HIT uses compared to US- and foreign-born White
adults. We cannot compare these ndings to other studies with MENA populations in the US.
Furthermore, there is limited research on the patterns of HIT use among adults of MENA descent living in
their geographic region of origin. Adults from the MENA region are heterogeneous in many factors,
including their internet use. Internet use has been reported to be as high as 99% among residents in
Kuwait and Qatar but much lower in Palestine (70.6%) and Jordan (66.8%).37 Data from the 2019 US
Census indicated that large populations of MENA immigrants in the US are from Iraq (20.7%) and Egypt
(17.1%).38 Internet use in these countries has been reported as 76% and 58%, respectively, with
differences by age, gender, and income within country of origin.39 For instance, among older ages (ages
60+ years), HIT use has been reported as only 41% in Iraq and as low as 9% in Egypt. With 26% of our
sample of MENA adults ages 60+ years, this may have contributed to our nding that any HIT use was
lower than White adults. The research specic to HIT use in the MENA region is limited. Most studies

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have described recommendations for creating systems for electronic medical records and mobile
applications and fail to account for the perspectives of individual users.40,41 Two studies in Lebanon
evaluated patient perceptions of the usefulness of patient-portals for communication with healthcare
providers. Results indicated that patients supported its use for scheduling and communication with
healthcare providers, yet no comparisons were made to other populations.41 In our study, the prevalence
of HIT use for scheduling appointments and communicating with healthcare provider by e-mail was
higher among MENA adults than White adults. MENA adults were more likely to use the internet to
schedule appointments than US-born White adults in the unadjusted regression model; yet ndings were
no longer signicant after adjusting for age, sex, education, and chronic conditions.
When we looked at each HIT use specically, foreign-born MENA adults were less likely to look up
information online and rell prescriptions. Some reasons for this disparity could be language and
underuse of prescription medications among the MENA population. Although English is the most widely
spoken language in the US, the incidence of bilingual households is increasing.42 Recent data from the
US Census indicates that Spanish is the most widely spoken language other than English. Between 2006-
2010 and 2017-2021, the greatest increase in language spoken at home other than English was Arabic at
roughly a 70% increase.42 Although several reputable websites with health information in the US are
available in Spanish, fewer are available in Arabic or other languages representing countries in the MENA
region. The CDC offers several multilingual health educational printouts on emergency preparedness,
health conditions, healthy living, and others. Of the 1,030 health educational printouts available there
were 48 only available in Arabic, 14 in Somali and only one in Turkish.43 Although website services are
available to translate (e.g., Google Translate), heterogeneity in culture, context and linguistic dialects are
often not captured with standard electronic-based translation services. We also found that foreign-born
MENA adults had 0.54 times lower odds of lling prescriptions online compared US-born White adults.
Studies have reported that MENA individuals are less likely to use prescriptions, which may be due to lack
of access, barriers in communication with healthcare providers due to language, or cost.44–46 Since
younger adults are more likely than older adults to report HIT use in general, there may not be a need for
relling prescriptions online among those who are healthy and do not need everyday prescriptions. Yang
and colleagues found that adults ages 18-24 less likely to need prescriptions than adults ages 75 and
older who were less likely to use the internet for any purpose.47
These ndings underscore the need for research to examine HIT use among MENA populations both in
the US and abroad. Overall, we found that the disparities in HIT use among MENA adults compared to
White adults are similar to patterns among other racial/ethnic minority groups (Black, Hispanic) and
White adults.8,9,47 Without an ethnic identier for MENA Americans, baseline estimates for all health
topics cannot be determined. In 2023, the Oce of Management and Budget published a proposal to
include a separate checkbox for MENA individuals on the 2030 decennial census and other required
federal forms.48 A corresponding comment period was opened for 90 days so that members of the public
could indicate whether they supported the addition of the checkbox. During the rst month of the
comment period, 71.49% of all comments posted mentioned the addition of a MENA checkbox and of

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those, 98.89% indicated support for including it.49 The addition of the checkbox will not only allow for
baseline health data to be collected for this population, but it will also allow for funding opportunities for
linguistic services to be provided. Among the comments reviewed, 55% mentioned a need for a MENA
checkbox to support language and linguistic services.50 The ability to provide resources for linguistic
services is important to developing culturally tailored health education materials and ultimately
increasing the ease of access for more HIT use among MENA Americans.
Strength and Limitations
Despite not being able to describe HIT use among all MENA adults in the US due to the lack of an ethnic
identier, a strength of this study was the ability to combine multiple years of nationally representative
data to begin to uncover the patterns of HIT use among the foreign-born MENA population. This method
has been extensively to evaluate health behaviors and chronic condition patterns among the foreign-born
Middle Eastern population, and more recently expanded to include the North African population. It is
important to acknowledge that the results are limited to foreign-born MENA adults only since we are
unable to disaggregate US-born MENA adults from the White category. Another strength of the study was
the ability to evaluate several HIT uses from the adult sample. The NHIS pilot tested the HIT use set of
questions in 2009 and incorporated it as part of its annual question core in 2011. The original set of
questions included a question on HIT use for communication with people using chat groups. However,
this question was removed in 2018. The question was part of a supplemental set of questions sponsored
by the Assistant Secretary for Planning and Evaluation to Health and Human Services to address
provisions of the Affordable Care Act of 2010.51 This limited our assessment of HIT use for
communication purposes to only its use for communication with healthcare professionals. The questions
on HIT use did not assess the purpose of and frequency of HIT use. Future studies can expand on these
questions to get a broader assessment of HIT uses among this population. The data were cross-
sectional. Because of the small samples of foreign-born MENA adults surveyed each year, we combined 8
years of data to provide robust estimates of HIT use in a cross-sectional manner. This method has been
used previously to examine MENA health;19,21 however, it limits our ability to access trends in HIT use to
ensure adequate power with our sample sizes.
NEW CONTRIBUTION TO THE LITERATURE
In summary, this is one of the rst studies to evaluate HIT use among MENA Americans. This study
makes an important contribution to the research literature by adding MENA Americans to the discourse
on racial/ethnic health disparities in HIT use. Our results highlight that patterns of HIT use among MENA
Americans are more similar to other racial/ethnic minority groups than White adults. By masking MENA
Americans under the White classication, the health information seeking behaviors cannot be
determined. Without an ethnic identier, this group will remain unnoticed and eHealth efforts for primary,
secondary, and tertiary prevention among this population will continue to be omitted.
Declarations

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Acknowledgements: None
Contributions:Smith A: writing – original draft (lead); formal analysis (lead); software (lead);
methodology (supporting). Kindratt T: conceptualization (supporting); methodology (lead); software
(supporting); writing – review and editing (lead).
Competing Interests: None
Personal Financial Interests: None
Employment Interests: None
Other Competing Interests. None
Funding: This work was partially supported by the National Institutes of Health, National Institute on
Aging [R03AG070177]. The content is solely the responsibility of the authors and does not necessarily
represent the ocial views of the National Institutes of Health.
Data Statement: Data for this project are publicly available online from the National Center of Statistics
(https://www.cdc.gov/nchs/nhis/1997-2018.htm).
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