The Comics: A Funny Place to Find Serious Public Health Issues?

On a recent trip to visit my in-laws, I was very happy to find that I had time to relax and read the paper in the morning. For me, the joy is found in reading the comics and completing the word search. So you can imagine my surprise when I sat down to read the comics and found that Doonesbury was discussing a very serious public health issue- sexual assault and harassment in the military. Apparently this storyline has been playing itself out in a series that follows Roz (a female soldier who is worried and seeking help for her friend Melissa). Melissa is being reassigned so that a superior officer can "prey" on her.

According to the Veterans Administration (VA) website, "Both women and men can experience sexual harassment or sexual assault during their military service. VA refers to these experiences as military sexual trauma, or MST". Like other types of trauma, MST can negatively impact a person's mental and physical health, even many years later. Every VA facility has a designated MST Coordinator who serves as a contact person for MST-related issues. Here I'll give a shout out to my favorite public health social worker, Micaela Cohen, who is the field and program development coordinator for the national military sexual trauma program at the VA.

Obviously, sexual assault is a serious public health issue, as it can put soldiers and veterans at a higher risk for negative health effects, such as depression. MST can also affect the rate at which health services are utilized. A recent study published in the journal Women's Health Issues reported that, "the under utilization of specialized PTSD services by younger women could be due, in part, to the fact that a significant proportion of PTSD in female veterans is associated with a history of military sexual abuse. Women with a history of military sexual trauma may not feel comfortable either in mixed-gender groups or using services in which treatment is oriented primarily toward combat-related PTSD."

For years, Doonesbury's author- Garry Trudeau, has been taking these types of statistics and important global issues and using them to shape his comic strip. For example, in 2006, he had his character B.D. wounded as he served in Iraq. In a 2007 interview with Military.com about the storyline, Mr. Trudeau stated, "I originally considered having him die in combat, but I concluded that while that might have caused a brief sensation, it would soon be forgotten. In the alternative, by giving B.D. a life-altering wound, I could set in motion a sustained story arc that tracked the arduous recovery and readjustment issues that a survivor might expect to face. "

Although public health practitioners may come across stories and statistics about the health issues and challenges faced by our service members everyday...the general population does not. And even if they do, I'm not sure that they would feel comfortable talking about it. Therefore, I think that inserting public health and social justice issues into the comics is an innovative idea. The comics are a "familiar" section in the newspaper to readers of all ages. We get to know the characters and follow them for years or even decades. The characters can give us a shared and "safe" way to discuss difficult issues. I just hope that as newspapers continue to struggle and more of us are reading our news online...that we don't forget to read the comics! It might not always be a laugh...it might be something even more important.

iPads and other wireless technology: Forget the fun...will they be the next great public health invention?

iPad mania is sweeping the nation! It even made a cameo in my new favorite show, "Modern Family". In a recent episode, all Phil Dunphy wants for his birthday is an iPad. He is excited to use it for web browsing, eBook reading, and video watching. But what if it could also improve his health?
A great article in The Economist this week called, "When your carpet calls your doctor", examines how the convergence of wireless communications, social networking, and medicine will transform health care.

This concept appears quite realistic for several reasons:

• Doctors are already using and comfortable with the technology. The article quotes a forthcoming report by the California Health Care Foundation that found that two-thirds of doctors are already using "smart phones" (a mobile phone with advanced capabilities such as Internet connectivity). Doctors are also used to turning to their computers and/or wireless devices for programs like Epocrates to review treatment information and decision making tools.

• Wireless technology reduces treatment barriers such as the distance and/or availability of the health care provider. One example of the technology being developed is a device which will be able to contact a doctor when his/her elderly patient is about to take a fall in their residence. The article also quotes successful work being done in developing countries such as Rwanda and Peru. This work has expanded to public health programs in the United States, such as Text4baby. This is an educational program of the National Healthy Mothers, Healthy Babies Coalition (HMHB). Women who sign up for the service will receive free text messages each week, timed to their due date or baby's date of birth.

• This technology is aiming to address barriers and facilitators of Behavior Change, not just an increase in knowledge! The focus soley on education to increase knowledge is the downfall of many public health programs. Knowledge alone will not change behavior. However, check out the programs from the company Virgin HealthMiles. They have begun using online social networks, through which co-workers or family members can cheer on or nag patients electronically, in order to encourage exercise or weight loss. The company is beginning to explore how to increase the level of social support and social/family acceptance that patients receive regarding their recommended treatment. Lack of support in these areas can often be a barrier to treatment success.
  

Of course there are still a few things that remain to be seen about the success of these eHealth programs. What are the privacy implications? Are smart phones (or similar wireless technology) widely available to the populations that most need these interventions (e.g., low socioeconomic status, the elderly, rural residents, etc)? What do my readers think?

Personal Responsibility and Health: Who Should Pay For Your Cheeseburgers?

Last year one of my "friends" on Facebook posted a status that infuriated me. It said "Why should I pay for health care for people who can't stop eating cheeseburgers from McDonald's?" I'm never one to downplay the importance of individual health behaviors like diet and exercise. In the three years since I met my husband he has gone from eating "less than one" (his words) serving of fruits/vegetables a day to at least four or five a day. And I'm sure that was the result of my gentle "nudging" because I was concerned for his health. However, this oversimplification that all acute or chronic illnesses are caused by "overweight people eating McDonald's" is incredibly ignorant. We cannot have a discussion about facilitators and barriers to good health outcomes without considering a person's environment, economic status, profession, family, peers, attitudes, beliefs, knowledge, etc. The list goes on.

There was an interesting article in The New York Times this week, No Matter What, We Pay for Others' Bad Habits, that explores this very issue of personal responsibility. The story had legs on Facebook and Twitter, so I wanted to incorporate it into the blog. And because I follow such thoughtful and interesting people online, I thought I'd include one of their quotes to demonstrate my point above (I removed her name in case she isn't interested in being a blog celebrity):

• "The notion of personal responsibility becomes almost a moot point if we don't have an environment that supports our ability to responsibly make "the healthy choice". As the Institute of Medicine says, "It is unreasonable to expect that people will change their behavior easily when so many forces in the social, cultural, and physical environments conspire against such change".
  

Some thoughts:

• Perhaps the hourly worker would like to make it to his healthy/yearly check-up at the doctor. However, because his job doesn't offer sick time since he's part-time, he could be fired for missing work. Therefore, he decides to miss his appointment, flu shot, blood pressure check, etc....because his paycheck is more important to his family.
  

• Perhaps there are a large number of people in a lower socioeconomic bracket that eat McDonald's cheeseburgers (as my Facebook "friend" noted above)...but maybe that's because there are no Whole Foods or Trader Joe's Markets in their neighborhoods. And maybe they don't have a car to drive to one and/or the bus route doesn't pass those stores. And I know that those $1 burgers are a little less expensive than the $10 Rotisserie chicken that Whole Foods sells.

• Perhaps a parent wants their child to walk or ride their bike to school for exercise, but their neighborhood isn't safe. What if there are no side walks?
  

• And what about the impact of genetic and environmental factors in disease? A strong family history of cancer and heart disease cannot always be canceled out by eating vegetables and heading to the gym. And what about those people that are exposed to dangerous chemicals in their jobs. What about those that now suffer due to exposure to asbestos in their jobs before we knew how bad it was? Do they not deserve health care?
  

Again, I'm not downplaying personal responsibility. Patient compliance, healthy eating, and exercise are incredibly important. But let's not forget the complex systems which influence the health of individuals.

And to end with a Facebook "friend's" status that made me less angry: "I mean, seriously, if you're getting that angry cuz a fellow human being can now go to the 'effin doctor, you probably could use a few moments of self reflection..."

Talkin' Bout A Revolution...Jamie Oliver is much louder than a whisper!

So I just finished watching the premiere episode of "Jamie Oliver's Food Revolution". It is a new show on ABC that chronicles the journey of English chef Jamie Oliver as he tries to change the eating habits of residents in Huntington, West Virginia. Huntington was recently crowned the most unhealthy city in America.
It is obvious that Jamie has good intentions. He has left his family for several months to work on this project. He is especially concerned about the quality of food being served in the Huntington schools. However, my reaction to the first episode was "No, no, no! Stop what you're doing and talk to these people first!"

The most important part of any public health intervention is getting to know the community you are working with. The worst thing you can do is come in as an "outsider" and start barking orders. Some questions you should ask before getting started are: How does this community operate? Who makes the decisions? What are some of the barriers to serving fresh food in schools? What are the USDA guidelines? (which Jamie knows nothing about) Who are the individuals you want/need to get on board with your idea? How do the parents feel about their children's eating habits? How can you get their buy-in? What would be a realistic timeline for assessment/buy-in before trying to implement change?

Jamie went about this all backwards (which may very well have been to increase drama for a TV show, but it is still a great example of "what not to do"). His first day in town he was told he was viewed as an "outsider" by the trusted radio host...and still proceeded to go into the elementary school and lecture the chefs on how disgusting the food is (after only observing them for one day). And he's surprised he's getting push back on his efforts?! The only small victory he has is creating a partnership with "Pastor Steve" at the local Baptist church. Steve is a trusted leader in the community and knows the families and their challenges very well.

Too bad Jamie did not look to better models of this kind of community effort. Shape Up Somerville (Somerville, MA) began as a community based research study at Tufts University targeting 1^st through 3^rd graders in the Somerville Public Schools. Today there is Coordinator working on active and healthy living programs supported by the Health Department and a Taskforce that is a collaboration of over 11 initiatives and 25 stakeholders involved in working on various interventions across the city. Program components include a focus on the school lunch program, local restaurants, walk ability and safe routes to school, etc. (I'll give a shout out here to one of my public health heroes- Julia Bloom- who helped Tufts bring this model to more rural communities across the country!)

Shape Up Somerville represents a strong program that began with a strong base. The original program engaged key stakeholders and did not try to change the community without first finding out how it worked. The community and parent outreach were an obvious key to success...where that aspect is basically forgotten in the "Food Revolution". Jamie just seems like one man on a mission to change. At the end of the episode Jamie is visibly upset and says "they don't know why I'm here". Yeah- that's because you're an outsider lecturing them on how they should raise their kids!

I'll probably watch the second episode where he actually starts to engage the community...how about you?

Technology: Building Social Connections or Breaking Them Down?

Last week, a friend at work told me that she had given up watching TV for Lent. She said "every time I give up TV, my quality of life goes up". I thought of her immediately today as I read this new article in TIME, "Logged on, checked out...of relationships?" The article discusses a study (published in the March issue of the journal Archives of Pediatrics & Adolescent Medicine) which studied adolescents during two periods of time (1988 and 2004). The adolescents who spent more time watching TV or playing video games were more likely to report lower quality relationships compared with those who logged less screen time.
I find this fascinating because I have followed the debate among colleagues and friends regarding the increase in the use of technology and its impact on social connections. For example, kids that may be "outcasts" at school may find friends online. They may have hundreds of Facebook "friends". They may find lots of kids with similar interests by joining "groups" online. However, one has to ask, are Facebook friends "real"? I personally have 355 friends on Facebook, but would only consider about 10 of those people close friends in my day to day life. Is it worth it to focus your time and attention to online activities (as noted above) to the detriment of your "real life" relationships with friends and family?
In looking at how social connectedness can be a protective factor for things like suicide, the question has also come up: "Is it the quantity or quality of relationships that really count?" In research on college students, studies like Healthy Minds are beginning to indicate that it is the quality that counts. However, unlike my previous posts where it has been easy for me to take one side or the other...I'm torn about this issue. The authors of the above study were as well...they note that there is an obvious correlation between online activities and relationship quality, but the causal link is not clear.
Therefore, I believe it is probably some happy balance that is best. Facebook friends and groups are not all superficial and time wasters. People can connect (or in many cases, "reconnect") with friends and colleagues with shared histories or interests. I've seen Friends post a concerning or unsafe status and 20 people jump in with words of encouragement or offers of help...which is wonderful. On the flip side, it helps to turn the computer or TV off and enjoy the world around us...strengthen those connections with those we live with, eat dinner away from the TV, etc. And of course on that note, I'll log off. LOST starts at 9pm ;)

Sesame Street's "Talk, Listen, Connect": A Strong Public Health Program for Military Families

Both academic and popular news sources have been reporting on the health problems experienced by active duty military and veterans (e.g., Post Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). Recently we have also begun to see research looking at the health problems experienced by spouses and children within military families. This January USA Today story highlights two such research studies:

(1) The first study (published in the New England Journal of Medicine) concluded that wives of soldiers sent to war suffered significantly higher rates of mental health issues than those whose husbands stayed home.

For example, wives of soldiers deployed to Iraq or Afghanistan between one and 11 months had an 18% higher rate of depression than those whose husbands did not go to war. When soldiers were deployed 11 months or longer, their wives had a 24% higher rate of depression.

(2) The second study (by the RAND Organization) found that children of deployed parents suffer more emotional issues, particularly if separations are long or the parent at home is troubled.

Based on this data, public health experts can see a clear need to develop interventions not just focused on active duty military and veterans, but also for their families. Therefore, I was happy to see that Sesame Workshop (the non-profit organization behind Sesame Street) has created a program called "Talk, Listen, Connect", which addresses priority issues for this population. I reviewed three brief videos and accompanying literature on this project and was very impressed:

• The "channel" being chosen to reach parents and children is an existing one. Families are already familiar with (and trusting of) Sesame Street, so they are not asking families to bring an unfamiliar resource into their homes. E.g., Elmo is the character used most frequently in these videos, and he is beloved by children. They are used to learning from Elmo.
  
• The videos used various methods for providing information, so it can be appropriate for learners of multiple levels/backgrounds. E.g., Pictures, songs, modeling of conversations between Elmo and his Dad, celebrity cameos (Queen Latifah stars in the third video).
• The creators obviously did research into relevant issues for military families (e.g., the videos address preparing for deployment, adjusting to homecoming, and coping with changes). The third video even shows a child coping with a Dad who came back with TBI- an injury unfortunately too common with these wars.
• The Sesame Workshop is even going beyond education to address real barriers to families staying connected. I was thrilled to see them examining challenges in the environment! They have created Sesame Street Family Connections. It is a little like having a Facebook Family Page. It is a a child-centered online space where both children and adults can interact and stay connected over long distances when everyday communication can otherwise be difficult. Family and friends can post pictures and videos, share messages and artwork, etc. This strategy is attempting to increase connections and family support (and decrease isolation)...which can help reduce associated negative health effects (e.g., depression).
• A plan for outcome evaluation exists! So often, this is left out of public health education planning. Although research about the effects of Talk, Listen, Connect on families experiencing multiple deployments and injuries is forthcoming (as the projects moves through several phases of roll-out). A summary study for the first phase of the project, which dealt with a parent’s first deployment, revealed that the materials helped military parents and children feel better during deployment, and helped them to be prepared emotionally for the deployment process. It also showed that Talk, Listen, Connect is helping parents by giving them the language and tools they need to engage in a dialogue with their children.

Although the details of a formal evaluation still need to be reviewed, I feel optimistic about this program for military families. They have incorporated the latest research (e.g., populations to target, risk/protective factors for adverse health effects, effective communication channels) into the program design. Go Elmo!

"Popular Media Helps Establish the Public Health Agenda" That's What I Said.

"Popular media helps establish the public health agenda". I just read this line in a new article from the March 2010 edition of Preventing Chronic Disease...I thought- that's what I've been talking about. I knew public health and pop culture went hand in hand!
This particular research project was inspired by the CDC/Alzheimer's Association Initiative: National Public Health Action Plan to Promote and Protect Brain Health. The authors conducted a content analysis of the four most circulated Women's magazines (Good Housekeeping, Ladies Home Journal, Women's Day, Family Circle) and Men's magazines (Men's Health, GQ, Men's Journal, Esquire). They conducted a content analysis to see how the magazines described the three strategies correlated with healthy cognitive function (physical activity, healthy diet, and social involvement).
I will say that I was slightly disappointed that there was almost no discussion of the differences in how these issues are presented in Women's vs. Men's magazines. It is always interesting to see how public health issues are marketed differently based on gender. For example, I was fascinated in graduate school to see how cigarettes and smoking have been presented over the years. For example, Virginia Slims cigarettes were advertised in Women's Magazines with slogans like "You've come a long way baby". The products were visibly thin and the slogans focused on being free and empowered.
This content analysis was also interesting however, in that it identified what strategies were being talked about. They found that both types of magazines were focusing on prevention vs. treatment (yay!) Women's articles tended to be longer and were were likely to include contact information (for websites/researchers). It seems the magazines have done their research that women are more likely to seek help for a health issue. They also found that most articles focused on healthy diet, while increasing social involvement was almost never discussed. The authors do not speculate as to why social involvement was not presented. I find that interesting (and a shame) since social support/connection is also a protective factor for other health issues (e.g., suicide).
I think this type of research has great implications for other public health work. How often are pop media channels evaluated for the content/accuracy of their public health messages? How can the evaluation of those channels/messages inform the public health agenda? My message to MPH students: "Study that qualitative analysis textbook!" We're going to be needing researchers that can analyze the content of commercials, magazines, social networking sites...it sounds like a fun job!

If you'd like to check out the article I cited above:
Friedman et al. Cognitive Health Messages in Popular Women's and Men's Magazines, 2006-2007. Prev Chronic Dis. 2010: 7(2).