2 Attitudes toward health, healthcare, and eHealth of people with a low socioeconomic position 23 2.1 Introduction Low socioeconomic position (SEP) is associated with a higher prevalence of unhealthy lifestyles compared to a high SEP (Stringhini et al., 2010). Consequently, people with a low SEP are at increased risk of chronic diseases (e.g., cardiovascular disease, diabetes, and obesity) (Drewnowski et al., 2014; Mackenbach et al., 2008; Shishehbor et al., 2006). eHealth interventions such as monitoring devices, online communication platforms, and serious games have been proven effective in changing behavior and promoting a healthy lifestyle in various domains. However, these interventions are less successful in changing the behavior of people with a low SEP due to low reach, less adherence during the intervention or less effectiveness of the interventions (Bull et al., 2015; Busch & van der Lucht, 2012; Busch & Schrijvers, 2010; Michie et al., 2009; Reiners et al., 2019). A crucial factor in facilitating the adoption, and therefore success, of eHealth interventions, is the alignment with a person’s attitude toward using this technology (Garavand et al., 2016; Venkatesh et al., 2003). Moreover, successfully achieving a lifestyle change, a primary goal of such interventions, requires the person to have a positive attitude toward their health and health services (Ajzen, 1991). eHealth is designed to expect its intended users to have a positive and pro-active health attitude. However, considering the growth of current health inequalities, such interventions would have a bigger impact when they can support groups not sharing these attitudes. A multitude of studies point out that people with a low SEP have unfavorable attitudes toward their health, healthcare, and eHealth. For instance, Wardle and Steptoe (2003) found that health attitudes within the low-SEP groups are specifically characterized by a lower consciousness about health and less often thinking about the future. Other studies have identified more passive attitudes toward healthcare (Schröder et al., 2018) and less confident attitudes toward digital health interventions (Choi & Dinitto, 2013) within low-SEP groups. Nevertheless, there is insufficient evidence to inform researchers and designers about these attitudes. The complexity of studying health values within contrasting sociodemographic environments poses various emotional and ethical challenges such as perceived harms, feelings of stigmatization, and anxiety toward research and the research team (Birks et al., 2007; Bonevski et al., 2014; Stuber et al., 2020). As a result, hard-to-reach groups are minimally included in research efforts. Moreover, existing evidence is difficult to generalize toward other contexts. Measurements of attitudes are highly context-dependent and are expected to differ by country, setting, and time (Eagly & Chaiken, 2007). Financial wellbeing and accessibility of health sources, for example, will not have a profound impact within countries that have unemployment
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