Calling the Sugar Plum Fairy Fat and Other Ways To End Up on the Naughty List!

Back in the mid 1990's I first began getting interested in public health. One of my first areas of interest was around eating disorders, especially among female athletes. Many of you may remember the book that sparked my interest, "Little Girls in Pretty Boxes".

This book focused on body weight/image pressures among female athletes in elite gymnastics and figure skating. The book is heartbreaking, following several athletes along paths of injury and disordered eating...many of which lead to permanent injury or death. Even though the book is almost 15 years old, I sometimes wonder if we've even learned anything from those stories.

On NBC's Today Show this morning, Jenifer Ringer was a guest. She is a New York City Ballet principal dancer, currently playing the Sugar Plum Fairy in The Nutcracker. Her name has been all over the blogosphere in the past week after a critic for The New York Times Dance Section wrote that "she looked as if she'd eaten one sugar plum too many".

In response to the outrage over his comments, the critic (Alastair Macaulay) published a second editorial five days later called "Judging the Bodies in Ballet". His primary argument- judging the body is fair game in ballet. "If you want to make your body irrelevant to criticism, do not choose ballet as a career". And I would assume that he would argue that the same goes for gymnastics or figure skating, where the body is actually part of the art form. But if that is true, how does the cycle of pressure and expectation ever get broken? Are you asking for criticism if you choose to participate in one of these sports?

In public health, we often make much more headway by changing laws/policies versus changing any one individual's opinion. In that spirit, there have been some systemic changes that have made these types of sports safer for young female athletes. For example, a minimum age limit for Olympic competition was enforced (even though some countries have cheated), hoping that it will help with wear and tear on young bodies that can not yet handle the intense training. Changes have been made to make the equipment safer. For example, after many serious injuries occurred on the women's vault in gymnastics, their pommel horse was replaced with a "vaulting table" that was more appropriately sized and padded.

So minimum ages and safer equipment are wonderful, but what will help with the unrealistic body image problem? In her Today Show interview, Jenifer shared that the New York City Ballet has all types of bodies on the roster, including hers that is more "womanly". I guess that's a good start. If ballet companies can model variety and acceptance and strength for their audiences (including aspiring ballerinas), that can begin to change perceptions of what is "normal". And the outrage shown by readers of the critic's comments. I guess that's a good start too.

Shame on you Mr. Macaulay for picking on the Sugar Plum Fairy.

In Honor of World AIDS Day: Can Celebrity "Digital Deaths" Prevent Real Deaths from HIV/AIDS?

Kim Kardashian, Ryan Seacrest, and Lady Gaga are all dead! No, not really...but they are considered "Digitally Dead" for today- World AIDS Day (December 1st). These celebrities and many more joined forces with a charity co-founded by singer Alicia Keys called Keep a Child Alive. The charity provides treatment, love, and support to families affected by HIV/AIDS.

For today's campaign, celebs were pictured in coffins, featured in "last video testaments", and pledging to stay digitally silent on their social media accounts (i.e., on Facebook and Twitter) until their lives were "bought back" by donors reaching a minimum of one million dollars total. Although the images of celebs in coffins were a little creepy, Keep a Child Alive co-founder Leigh Blake says:

"We're trying to sort of make the remark: Why do we care so much about the death of one celebrity as opposed to millions and millions of people dying in the place that we're all from? Its about love and respect and human dignity."

It is an interesting concept for a health communication/advocacy campaign. Usually when campaigns advocate via social media, it is done by bombarding their followers with messages and links to donate or sign up to assist the cause. Here, the campaign is trying to motivate donors by having an ABSENCE of the celebrities' voices. How powerful is that absence? Will the public really miss reading celebs tweets and facebook status updates? Apparently so. As of tonight on Twitter, Kim Kardashian had 5,467,107 followers and Ryan Seacrest had 3,683,658 followers. So whether we like it or not, the voices (and silences) of these celebrities matter in our communities.

While I do think the campaign will have large reach, I will say that their coffin posters left room for improvement. I've analyzed health communication campaigns on this blog before, and the key is always- "What is the cue to action? Does the audience know what they are supposed to do after seeing the poster/brochure/PSA?" Well- when I first saw this poster of Kim Kardashian, I had no idea what it was about. I had to Google and read the narrative about the World AIDS Day campaign for Keep A Child Alive. For this blog post, I had to blow the image up over 100% to read the text on the bottom of the poster. It reads,

"Kim sacrificed her digital life to give real life to millions of others affected by HIV/AIDS in Africa and India. That means no more Facebook or Twitter until we buy her life back". Then the charity website and text number were provided to accept donations. In future campaigns, they would want that text to be much bigger. It should not take the audience several minutes, a Google search, and a magnifying glass to figure out what they are supposed to do to help poor Kim get out of that coffin.

Overall, I give this campaign a B+ for creativity in using the "absence" of social media messages and targeting celebrities with a huge following and reach to potential donors.

Text Messages and Public Health: Can They Remove Barriers for "Calling" 9-1-1?

Text messages are a great time saver. You do not have to have a long conversation with someone...instead you can just send a quick message like "I made it home safe!" or "Can you pick up milk on your way home?" These text messages work well to support our busy lives, but can they also be incorporated into effective public health interventions and systems?

This week, the Federal Communications Commission (FCC) announced that it is looking into letting citizens report crimes via text message. An article posted by Wired discusses the possibility and highlights some of the "barriers" that this new strategy could help to address. First and foremost, it could allow citizens to report a crime without being overheard if they were in dangerous situations (e.g., kidnapping, robbery). The FCC specifically pointed to the 2007 shootings at VirginiaTech and reported that texts could have allowed emergency personnel to respond more quickly and with a better understanding of the circumstances inside the campus buildings.

While at first glance, it may seem surprising to use text messaging for 9-1-1 reporting (due to potential logistical considerations and challenges), it would not be the first time that texts were being integrated into public health interventions and emergency response systems. For example:

• Text messages are used to disseminate key health messages to various priority populations. E.g., The Text4Baby campaign allows mothers to self select into their program by texting "Baby" to the program number. The mothers then receive weekly text messages (timed to their due date or baby's birth day) regarding key health issues for their babies (e.g., nutrition, immunizations, etc).

• Many workplaces and college campuses have signed up for emergency response systems that will send out automatic alerts to email and phones (via text message) during a crisis (e.g., shooter on site).

In the case of using text messages for "calling" 9-1-1, I wonder about how texts could influence a well documented social psychology barrier to calling for help. Those of you that took a social psychology course in college may remember the name "Kitty Genovese". She was a woman who was murdered outside her home in Queens, NY in 1964. At least one dozen people heard or observed her attack (lasting approximately 30 minutes), but there was much delay in anyone calling for help. A NY Times article running two weeks after her death was entitled, "Thirty-Eight Who Saw Murder Didn't Call Police". This case is widely discussed as an example of the "Bystander Effect", which is used to explain why many people do not help in emergency situations when others are present. Some hypotheses about the effect are that we just do what others are doing (i.e., nothing to help), we assume someone else is already calling/helping, or we assume that others are more qualified to help. Perhaps it is also too much trouble to call 9-1-1? They require a lot of information, we have to stay on the phone, etc. Perhaps a more "passive" option to report the information (like text messaging) would decrease resistance and the bystander effect?

In addition to the great potential with this strategy, there are also several barriers that must be addressed in the planning:

• Costs (equipment, training, staffing)
• Regulation and Oversight: Will text message support be required or voluntary at emergency centers? Who will conduct a formative and ongoing evaluation of the system?
  
• Interpretation of messages: Operators will need special training to (quickly) interpret and respond to text messages. Texts are often written in short hand, so you would need someone very skilled to decipher them accurately. It may also be time consuming to support the texting back and forth that may be required to receive all relevant information from the "caller" in order to dispatch an appropriate response.

Even with the barriers noted above, it does seem like text messages are a viable option to consider in order to increase timely and safe 9-1-1 reporting. However, the 9-1-1 system will need to think critically to develop the type of infrastructure that can keep up with our ever changing and expanding communication technology.

No Matter How Graphic The Images, Fear Based Messages Will Continue To Be Ineffective For Prevention

All over the news in the past week, we have seen samples of the new graphic images being proposed for addition to cigarette packages. They include corpses and people dying of cancer. However, just because these images and warnings are larger and more graphic, does not mean that they will be effective in smoking prevention.

A story ran today on Boston.com called "Will graphic cigarette warnings help- or hurt?" Two experts in tobacco prevention are quoted regarding their concerns about the new images. Gregory Connelly of the Harvard School of Public Health points to the results coming from Canada after using similar images. Smokers there simply purchased sleeves to cover up the images on their cigarette packs. Also, the smoking rate did not go down. The second expert is a wonderful professor of mine from the Boston University School of Public Health, Dr. Michael Siegel. Dr. Siegel writes regularly regarding this topic on his blog, "The Rest of the Story: Tobacco Analysis and Commentary". In the Boston.com article, he states "I do not actually think it's going to have much of an impact". His argument- the images are too late. The smokers are seeing the images after they have already purchased cigarettes. And (drum roll please....) people already know smoking is bad for them.

As someone who grew up during the "This is your brain. This is your brain on drugs. Any questions?" era...I wonder why we have not made much progress since then? Numerous studies have shown that scare tactics (or fear appeals) are not effective for preventing or producing sustained reductions of Alcohol, Tobacco, or other Drug use among youth. In addition to the issues outlined above, there is another problem with the fear based approach:

Although the fear based messages may increase knowledge (e.g., if they did not know it already, smokers will learn that cigarettes are bad for them from the graphic images)- knowledge does not equal behavior change. Especially when you are dealing with an addictive behavior. Addictive behaviors like smoking and drug use are impacted by much more than a rational weighing of pros and cons. There is the biological component of addiction, local-state-national prevention policies, social norms around the behavior, consequences experienced (or not experienced), ease of access to the substance, social support for quiting, money to support the addiction, etc. As you can see, knowledge alone will not change this kind of complex behavior.

Many of the most successful prevention strategies around this and other public health issues will continue to be a refocus from increasing individual knowledge to changing an environment that supports the behavior. In other words, laws that create smoke-free workplaces and crack down on establishments that sell cigarettes to underage kids will always be more effective at keeping the population healthy versus trying to educate (or scare) one individual at a time.

Kids, Gender Identity, and Bullying: Moms Fight Back

Last week on Facebook, no less than ten friends posted a link to the Nerdy Apple Bottom website post "My son is gay". The post was written by the mother of a 5-year old boy who dressed as Daphne (from Scooby Doo) for Halloween. She talks about his arrival at school in his costume and the harsh reaction received...mostly from other parents. She documents her internal reaction to this reception, which prompted much discussion and cheering among my Facebook friends:

"If you think that me allowing my son to be a female character for Halloween is somehow going to 'make' him gay, then you are an idiot. Firstly, what a ridiculous concept. Secondly, if my son is gay, OK. I will love him no less. Thirdly, I am not worried that your son will grow up to be an actual ninja so back off".

As of tonight, this post had 41,311 comments.

Coincidentally, the November 15th edition of People Magazine runs a story called "A Tale of Acceptance". The story profiles a Seattle mother named Cheryl Kilodavis who also has a 5-year old son that likes to dress up as a girl character. When the behavior began three years ago, she and her husband discussed it and decided to let him dress how he liked. In order to help other kids accept him, Cheryl decided to write a children's story. She calls her self-published book, "My Princess Boy".

Cheryl first shared the book at her son's school. The vice principal loved it and put copies in all the classes. Cheryl soon had orders from nine other schools and now that there has been so much press coverage, the family is searching for a publisher and trying to keep up with the book requests.

Of course, not all of the press has been positive. A New York Times article late last week discussed some therapists' concerns about these young boys being "outed" by their parents by having their pictures posted on YouTube, blogs, and talk shows. Some commenters wonder why these mothers do not protect their children from ridicule by making them dress in costumes that are more gender appropriate.

The discussion of bullying and suicide over the past few months has seemed to provide a real "teachable moment" for this country. People want to talk about it (as evidenced by the 41,000+ comments on the Nerdy Apple Bottom site). People want to teach kids how to respect themselves and each other. Therefore, they seem fascinated by "My Princess Boy", which uses words and illustrations that can allow even the youngest children to participate in the discussion around personal expression and acceptance. These blogs and books and support from children's schools can really help to change the social norms around what is "normal" behavior and dress. We must be creative in designing a way to evaluate these normative changes. Hopefully we will see a reduction in negative outcomes for students (e.g., reports of bullying, rates of depression, and suicide). But hopefully we will also see a reduction in risk factors further up stream, like attitudes around acceptance and gender roles.

Marie Claire Blogger vs. Mike & Molly: A "Heavyweight" Fight

Last week a blogger for Marie Claire Magazine named Maura Kelly posted an article called, "Should 'Fatties' Get a Room? (Even on TV)?" The post is focused on a new fall sitcom for CBS called "Mike & Molly". I must disclose that I have not watched this show, but have read that it centers on a couple that meets at an Overeaters Anonymous Group. Ms. Kelly takes a strong position that this show is "promoting obesity" and is grossed out by having to watch two obese people make out (or do anything else, like walk across a room).

As you can imagine, this post has been met with quite a reaction, including 3,195 reader comments (as of tonight) that prompted Ms. Kelly to post an update (aka apology). The update apologizes to those readers that were offended (many of which state that they have since canceled their Marie Claire subscription) and offers that perhaps her strong reaction to these overweight actors comes from her own history as an anorexic. The gist I get from the comments, is that most readers do not feel the apology is sincere and expected a better response from Marie Claire (that would include firing Ms. Kelly and/or making it clear that they will not support this type of discrimination). There has also been a strong response from the celebrity community, including Sharon Osborne on "The Talk" who said that she was appalled and wondered about what Ms. Kelly would think of her. Sharon admitted that she's 30 pounds overweight...should she not be allowed to kiss her husband or walk across the room?

According to the Centers for Disease Control and Prevention (CDC), 34% of adults are overweight and about the same percentage are obese. If approximately 70% of our adult population is overweight or obese, why don't we have more characters that accurately reflect what people actually look like and the challenges that they face? Hasn't there been some effort to portray more diverse characters in other ways (e.g., race and ethnicity)? Why would being overweight be so offensive to the viewing population? And is Mike & Molly really the first show to do this? Growing up, I was a fan of the sitcom "Roseanne" (1988-1997). The primary couple on the show (Rosanne Barr and John Goodman) were very overweight and struggled quite openly with weight, diet, and exercise on the show. Perhaps my memory is fuzzy, but I never remember hearing that viewers were horrified by these characters showing affection on the show.

Ironically, as I was getting ready to put this post together today, I caught the Oprah show. She had on Portia Di Rossi who discusses her battle with Anorexia and Bulimia in her new book "Unbearable Lightness".

Portia spoke about her breakout role in Ally McBeal in the 1990s. Many of you may remember the media headlines at that time calling the three female leads "Scary Skinny" (which they were- Portia was down to 82 pounds at one point). Ironically, she specifically discussed her fear about a scene where she seduces her boss in her lingerie in the law office. Although she was skeletal and sick looking, did we hear from viewers or writers that they were "grossed out" to watch her make out with her boss on the show?

So what is best for viewers? What messages regarding "normal" should we be sending to viewers? If actors are too skinny, the concern is that the image is not realistic and it is causing young girls to have eating disorders trying to achieve this ideal. However, when a show like Mike & Molly is showing characters that accurately represent 70% of the population, there is also controversy. From a public health perspective, I would say that characters should accurately reflect the viewing population- people tend to respond to people that they can relate to. If you are creating a health communication product (e.g., poster or brochure), you test it with the target audience to make sure that they connect to the images. If you are concerned about "promoting obesity", then have the characters modeling healthy behaviors. For example, Mike & Molly are attending an Overeaters Anonymous Group, which means they are taking steps to improve their lifestyle.

I for one, would be very happy to see more realistic characters on television. I would also like to see research on how those characters can be used as a health communication tool to promote positive body image and health behaviors among the viewing population.

Hollywood's "Dilemma": Should "Gay" Jokes Be Censored?

Recently I went to see "The Social Network". We watched several movie trailer previews, including the Ron Howard directed film "The Dilemma". The preview included a scene with Vince Vaughn exclaiming to a conference room full of colleagues, "Ladies and gentlemen...electric cars are gay". He goes on to clarify that he does not say "gay" to mean happy, instead he compares its level of "coolness" to your parents chaperoning a school dance. I leaned over to my husband and whispered, "I thought they were taking this scene out of the trailer?". I guess it had not yet been pulled (and was instead being seen by millions, as The Social Network was #1 at the box office that week).

The controversy regarding this quote began several weeks ago. CNN's Anderson Cooper was one of the first to draw attention to the preview when he appeared on the Ellen DeGeneres Show. His argument (especially in light of the recently publicized suicides involving gay children/teenagers) was that we must "make those words unacceptable cause those words are hurting kids". In addition, the Gay & Lesbian Alliance Against Defamation (GLAAD) put out a statement on the situation:

"When 'gay' is used as a pejorative, it frequently sends a message- particularly to youth and their bullies- that being gay is wrong and something to laugh at. We invite Vince Vaughn to work with us and help insure that gay youth and those perceived to be gay aren't put in harm's way by such jokes".

Last week, Vince Vaughn addressed the above concerns with his own statement that highlighted his feelings that the "gay joke" should be kept in the trailer and in the movie:

"Let me add my voice of support to the people outraged by the bullying and persecution of people for their differences, whatever those differences may be. Comedy and joking about our differences breaks tension and brings us together. Drawing dividing lines over what we can and cannot joke about does exactly that; it divides us. Most importantly- where does it stop?"

ABC's The View also discussed this during its "Hot Topics" show yesterday. I was actually pretty surprised that there seemed to be consensus and support for Vince Vaughn's statement. How can you censor a "character"? This was not about Vince making homophobic statements...but it was the statements of his character. What if the character is a jerk? Then he/she will sound like a jerk. Whoopi Goldberg spoke about recently watching "Roots" on TV and how much of the message was lost due to the censoring of the racist language.

I can see both sides of the argument on this one. Of course, people of all ages look to celebrities and movies to be role models and to confirm (or break) social norms. Therefore, statements using "gay" as a pejorative can absolutely influence the beliefs of an audience. However, I also understand the slippery slope of censorship and the concern that stories can no longer be told with the same honesty and depth of characters. It is also unclear how this censorship would be overseen and enforced. Can we always tell the difference between a statement of someone's beliefs and their attempt at a joke? And just because something is intended as a joke, does that really mean there are no consequences? If your boss "jokes" about how your clothes fit...it is still sexual harassment.

With tomorrow being "Spirit Day" to combat anti-LGBT bullying, it seemed very timely to toss this "dilemma" out to my readers for comment. I look forward to your thoughts.

Courteney and David: A Poorly Designed PSA That Makes Me Want to "Scream"

So Courteney Cox and David Arquette are having a tough week. First they announced their separation and now I have to highlight the poor design of a recent public service announcement (PSA) in which they starred. I must say- they made a much better team on the set of their "Scream" movies.

A recent Newsweek article entitled "Can PSAs End Domestic Violence?" discussed the Cox/Arquette PSA and outlined the challenges of using this particular health communication channel to address the public health problem of domestic violence. The article quotes a wonderful professor of mine (thank you Dr. Emily Rothman for posting this link), so I decided to check the PSA out for myself. Overall, my impression was not good. Let's compare the PSA to some best practices and/or guidelines and see how it holds up. A great resource on this (and all aspects of program planning) comes from the Community Toolbox:

1. PSA Length
A typical PSA runs about 30 seconds. This video runs 1 minute, 50 seconds. And the viewer does not even know what the video is about (cue a random segment about "furry" sex) until the timer hits 1 minute, 25 seconds. They could have very easily lost viewers by that point (either due to boredom, confusion, or because they were offended by the "furry" segment).

2. PSAs Should Have a Clear Message and Call To Action (i.e., what do you want the viewer to do after they see your video?)
So I was a little surprised that the video did not include any specific hotline numbers. In case the audience included victims of DV, you would think that it would be a priority to list those resources. Instead, the only "action" that I could see outlined was how to donate to "OPCC"...and it was unclear what that organization was. So I followed the instructions at the end of the video that gave their Facebook address. Again, there is a huge logo that says "OPCC" (still not sure what that is, so I probably won't give money) and finally (in much smaller writing) some hotline numbers on the left. I went one more step and went to the Ocean Park Community Center (OPCC) website, where it still wasn't immediately clear how this organization supported domestic violence prevention. Apparently, this PSA was to support one of the community programs called Sojourn (a women's shelter)...but geez- how hard was that to figure out!!!???

3. Like any good health communication product, there should be a clear target audience
I have no idea who the audience was for this PSA. This is a direct result of the lack of a clear "call to action". This video had no idea who they expected as an audience or what they wanted those individuals to do. Before the video starts, we are told "this is not for kids" (again- due to the "furry"). So kids are excluded as a possible audience- which is a shame because young adults are also victims of domestic violence. I'm assuming that domestic violence victims themselves are not the audience, since the video did not include any links to DV hotlines/shelters. I doubt the audience was supposed to be DV perpetrators, because I doubt that they would be giving donations. So maybe the intended audience was just potential donors? It is unclear.

4. Evaluation
Ahh! I know I'm a broken record about this issue on my blog. As Dr. Rothman states in the Newsweek article, "there haven't been that many well-designed, rigorous evaluations of the ad's effectiveness". The OPCC spokesperson says that it has been effective because "people are talking about the ad" (how do we know?) and Facebook traffic was up (as of tonight, just 365 people had "liked" the page). But even if "talk" is increased, is that really changing the attitudes or behaviors that were (maybe) targeted by this PSA? If they had clearer goals and a call to action (e.g., The audience for this PSA is women who are victims of DV and the behavior we want to see is an increase in calls to our hotline)- it would be much easier to evaluate. And that evaluation would go well beyond "awareness".

Giuliana and Bill: A Reality Show Addressing the Real Stigma of Infertility

Talking about infertility makes people uncomfortable. Those struggling are uncomfortable because it is extremely personal. Perhaps they feel like they've failed at something that should come naturally...something that seems easy for everyone else. Perhaps it is difficult to explain why they cannot bring themselves to go to a friend's baby shower. Perhaps people at work ask them "when are you going to have a baby?"...not realizing that it is an incredibly painful question because they have been trying for years.

With this as the current state of affairs, you can imagine my surprise to see Giuliana and Bill Rancic come on The View two weeks ago and tell their story about trying In Vitro fertilization (IVF) and suffering a miscarriage. Their ordeal is also documented on their reality show: Giuliana & Bill. I just finished watching my DVR copy of their season premiere which follows them on their IVF cycle. What I really appreciated was the honest display of how difficult the cycle was. Were they both on board with this next step? How scary were the bags and bags of medication!? How would they coordinate their work schedules to make it happen? How could they keep it a secret from their work colleagues and their families? Who would stay home with Giuliana for her 48 hour bed rest? And of course it was difficult to watch them get the happy news of "you're pregnant!" at the end of the episode, since we already knew what was to come nine weeks later.

But what I really want to talk about are the huge strides they've made in reducing the stigma of IVF and miscarriage in just a few short weeks since they've come forward. I've spoken in previous posts about the importance of celebrity role models in reducing stigma of various conditions. Besides their appearance on The View and their very honest portrayal on their show, they have also partnered with key professional organizations like Fertility Lifelines and Resolve- The National Infertility Association. They have created a PSA for Fertility Lifelines encouraging couples to visit a fertility specialist. They offer statistics to help normalize the struggle to conceive and to build a community by letting viewers now that they are not alone.

Just three days ago, Access Hollywood reported that actor Kelsey Grammer came forward to say that the pregnancy he and his girlfriend had just announced in August had ended in a miscarriage. It is hard to imagine that the culture is changing this quickly...in all my entertainment news watching, I can count on one hand how many celebrities have shared this type of story.

I also think that having a "spokescouple" increases the effectiveness of their message. The stigma of infertility so often falls to the woman. "What is wrong with her?" The woman also has to endure the physically and emotionally difficult treatments. Having a couple remind us via this PSA that it can be 50/50 as to which person (or both!) is leading to the infertility helps take the stigma off the woman alone.

This situation also makes me think about the systems (or lack there of) that exist to support couples once they make the choice to see a specialist. Are these types of specialists/procedures even covered by their health insurance? Is it difficult for couples to take time off of work to deal with the physical/emotional demands that come along with this process (which is so often completely inflexible in its scheduling)? Are human resource departments/managers supportive of making accommodations and/or keeping this information confidential for their employees? Are there enough mental health professionals that specialize in infertility to help couples/individuals with the emotional challenges that go along with the physical?

As more couples wait longer to have babies and science moves forward to offer more treatments for infertility, we're going to have to grapple with these questions on a broad system level. However, that conversation is easier to have when stigma is reduced and more couples come forward to ask for what they need and offer to help each other.

Bullying: Is Technology Helping Us or Hurting Us?

Like many of you, my heart broke when I heard about the suicide of Tyler Clementi last week. Unsure of exactly how I wanted to focus my blog on this topic, I took a little time and read the comments coming through on Facebook and Twitter. I talked to colleagues and friends. And something that really struck me was that many people expressed that technology was the problem. All this new technology can only lead to bad things. Right? I agree that new technology has played a large part in our discussions around bullying the past few years. There seems to be an assumption on the part of the bullies that they can be protected by technology- that their identity can be kept "anonymous" in the cyber-world. Perhaps more kids bully online because it is easier to insult or hurt someone at that distance- versus right to their face. Of course, these hurtful comments or videos now have a much broader reach. They can be disseminated through the school, city, state, or even country in just minutes. And you can't take them back. I also think that technology is evolving so quickly that we don't always understand the new boundaries for privacy.

But even with all the new challenges and channels to bullying that technology brings, I still do not believe that it is the root cause. As a friend of mine tweeted this week (yes- Beth G you get a shout out here) "Thinking on the Tyler Clementi case. Tired of hearing that technology is to blame. I'm pretty sure Dharun Ravi and Molly Wei are, actually". Let's not forget the role of personal responsibility- I believe that gets lost when the blame falls squarely on technology.

So with all of that as a backdrop for this discussion, I decided that I wanted to focus my blog on how technology can also help us to combat bullying and help those at risk for suicide. Risk for suicide can increase among those who feel isolated and disconnected from resources. They can also suffer when surrounded by social norms that do not support help seeking for the resources that they need.

So I wanted to present these resources that have gone viral in just the past few days. I can't help but think about all the isolated kids/teens they may reach:

1. MTV launched an Iphone application to combat bullying called "Over the Line". Users can post a bullying scenario that they've experienced and other users can vote if it was "over the line". This has the potential to help promote positive norms/limits regarding how we treat each other. The peer support online may also encourage users to ask for help.

2. MTV was also involved in the launch of "Love is Louder". This "movement" has begun primarily in response to anti-gay bullying and suicides among LGBT youth. Viewers (and celebrities) can upload videos of support for these youth. It has been described as a way to channel the sadness and anger we all feel following these events. Again- this has the potential to build peer support among individuals that may be at risk. It also introduces celebrities or role models to support positive social norms.

3. Columnist Dan Savage has organized the "It Gets Better" campaign. The goal is to reach out to lesbian, gay, transgender and bisexual youth who may be the victims of bullying and remind/assure them that things will get better. This campaign has also attracted many celebrity supporters telling their stories (e.g., Tim Gunn from Project Runway was featured on many of my friends' Facebook pages today).

4. Four days ago, Ellen DeGeneres posted "An Important Message" on YouTube regarding the recent suicides of LGBT youth. As of tonight, there had been 235,627 views of that video. She pledged her support and encouraged all of us to have zero tolerance regarding bullying and the loss of these kids/teens.

So that's the complicated story. Technology brings new prevention challenges to bullying. But it can also build peer networks and deliver resources to those in isolation. It can bring the voice of celebrities or other role models into the discussion, which can be a strong influence on kids/teens. I urge us not to write off all technology in light of recent events.

For example, if anyone reading this blog needs help- please call the National Suicide Prevention Lifeline: 1-800-273-TALK (8255). Their technology even allows for Veterans to chat with an online counselor. Amazing!

Evaluating 90210 & Public Health Interventions: My Perfect Fantasy Job

Cases in Public Health Communication & Marketing is an online, open-access journal (coming out of the George Washington (GW) University School of Public Health and Health Services) which focuses exclusively on case studies from the fields of public health communication and social marketing. The journal's mission is to promote the analysis of real-world experiences and practice-oriented learning. They have recently published Volume 4 (Summer 2010) which includes several case studies focused on Entertainment Education and the work of Hollywood, Health, & Society.

Hollywood, Health & Society (HH&S), is a program of the USC Annenberg Norman Lear Center, and provides entertainment industry professionals with accurate and timely information for health story lines. Funded by the Centers for Disease Control and Prevention (CDC), The Bill & Melinda Gates Foundation, The California Endowment, and the Health Resources and Services Administration's Division of Transplantation and Poison Control Program, the program recognizes the profound impact that entertainment media have on individual knowledge and behavior. These professionals (who totally have my perfect job!) focus on Entertainment Education (EE), which is a communication strategy that involves embedding health or social messages into entertainment programming that can influence knowledge and attitudes, and promote healthy behavior among television drama audiences. The two cases highlighted for the GW publication included a The Bold and the Beautiful (daytime soap opera) storyline which promoted bone marrow donation and a (new) 90210 (nighttime young adult soap opera) storyline which highlighted a main character with bipolar disorder.

What is really fantastic about the case descriptions (beyond the collaboration and prep work that went into creating these accurate and engaging story lines) was their discussion of how to evaluate their efforts. Evaluation is (unfortunately) sometimes an afterthought for public health interventions. Or evaluation is poorly defined as simply measuring satisfaction- "Did the viewers "like" the episode?" Despite the complexity of evaluating health communication efforts, these case studies were quite thorough. For example, with the 90210 episode, they looked not only at exposure (i.e., how many watched the episode or saw the accompanying PSA on bipolar disorder) but also at help-seeking behavior following the episode. They documented calls/contacts to their partners (e.g., SAMHSA Health Information Network and the Child and Adolescent Bipolar Foundation (CABF). The evaluators also collected qualitative feedback from volunteers and teens who visited the CABF online chat rooms after the episode aired. "As expected, visits to the chat rooms increased shortly after the episode aired. Remarkably, traffic and participation in the chat rooms continued for months after the episode and PSAs aired".

It is always validating to see that watching TV can be more than a mind numbing couch potato activity...it can be educational and essential for shaping and measuring social norms around important health issues.

Health Intervention Reality Shows: Are Participants Rescued or Buried Alive?

Last month I wrote on my Facebook wall "that hoarding show on TLC is both horrifying and fascinating". From the quick responses to my post, it is clear that I am not the only one feeling this way. Therefore, I was really interested in stories recently posted on the TIME website discussing how these types of shows can be harmful for the individuals that are featured.

There have been a slew of reality TV shows focused on staging interventions with individuals with a variety of mental illnesses/addictive behaviors. Some examples are "Hoarding: Buried Alive" (TLC), "Hoarders" (A & E), "Intervention" (A & E), and "Celebrity Rehab with Dr. Drew" (VH1). In one TIME article called "For Hoarders and Addicts, Drama is Trauma- Not Therapy", the author presents the argument that the needs of the mentally ill and addicts are the exact opposite of the formula of successful reality TV shows. Recovery for these individuals takes time and empathy and reality TV shows are looking for conflict and quick fixes within the hour allotted.

In all fairness (since I haven't seen all the reality shows in this category), I must say they are not all created equal. For example, A & E "Hoarders" seems to be much more of quick fix with cleaning crews clearing out houses over a two day period (which is very traumatic for the owners). In contrast, TLC's "Hoarding: Buried Alive" cleans out over a longer period and the individuals are more active participants/leaders in their own clean out. With the TIME article noting that effective clean outs for hoarding are a year on average, you have to wonder about the trauma of being confronted on camera about your "abnormal" behavior and then forced through a quick clear out. Also, the behavior of hoarding (or drinking or drug use) is usually just the tip of the ice berg, as it is a symptom of a larger problem. For example, I recently watched one episode of "Hoarders" where the woman shared that she began hoarding after surviving childhood sexual abuse. The therapist assigned to her clean out said "let's not talk about that right now". Therefore, I wonder about the long term repercussions of bringing out these emotions and not providing individuals with the support they need.

On the other hand, there could be potential positive outcomes from these individuals being featured on such a reality show. The primary outcome that I think of is access to resources. Many of the families/individuals featured are in great financial peril (often as a result of the money needed to continue with their addictions). The show is able to link them up with leading experts in their condition, offer ongoing care, assist them with legal concerns, etc. It remains to be seen whether these positives outweigh potential dangers.

Can Foursquare get youth to "check in" to STD testing?

As technology and social networking continue to expand, it is logical to think about the connection to public health. We need to think specifically about its use among priority populations already using it- like youth. It has just been announced that Foursquare will team up with MTV for their "Get Yourself Tested" (GYT) campaign. I'll back up quickly for those that are not familiar with Foursquare. It is a mobile application that allows users to "check in" at locations in order to explore a new city, link up friends, etc. There is also a "competitive" nature to the application which offers "badges" and other titles to individuals which visit the most spots.

Foursquare and GYT have teamed up to offer the first cause-related badge for users who visit STD testing sites. The goal of offering the badge and allowing users to announce it in a public setting is to reduce the stigma of STD testing. This is a common public health strategy- to focus on reducing a specific barrier to a health behavior. In this case, planners are hoping to reduce stigma by normalizing STD testing.

The article does not mention how the program will be evaluated. It seems simple enough to track the number of people who obtain the GYT badge (which I assume is just based on self report). It would be interesting to have some kind of follow up with users to find out:

1. Why they decided to get tested (was it due to exposure to the GYT materials/foursquare badge?)

2. Was this the first time that they were tested? I.e., is this campaign actually initiating a new action among youth? Or is it only attracting youth that have already bought into this behavior?

3. Is there a certain demographic most influenced via Foursquare? How is this similar/different than the changes they are documenting using more traditional channels like PSAs/posters, etc?

I know many of my friends/followers are Foursquare users- what do you think of using the application for "causes" and other public health initiatives?

"Health Fashion" Police

It is the day after the Emmy Awards, so most of us have fashion on the brain and are eagerly awaiting E! Fashion Police. As a result, I thought it was very timely to discuss "Health Fashion". The idea came to me this weekend in two ways. First, as I saw new fashion merchandise (modeled by celebs like Jordin Sparks and The Jonas Brothers) in the form of "TXTING KILLS" thumb bands to reduce texting while driving. Next, I read a fabulous new article in the September 2010 issue of Health Promotion Practice called, "Undressing Health Fashion: An Examination of Health-Cause Clothing and Accessories".

The article provides a great overview of the history of health fashion, including its beginnings in 1953 with the first Medic Alert bracelet. It then proceeds to discuss the use of colorful ribbons to support causes (e.g., AIDS, deployed troops, etc) over the past 30 years. However, the authors really highlight the Lance Armstrong/Nike release of the yellow Livestrong wristband in 2004 as the event that created an explosion of Health Fashion and Cause Marketing.
Health Fashion is sorted into one of three categories:
1. Wearables: Worn by the consumer (e.g., Nike Livestrong wristband)
2. Usables: Items that are directly consumed or that utilize health fashion symbols in manufacturing/packaging/marketing (e.g., United States Postal Service breast cancer stamps)
3. Displayables: Items that are displayed in homes/offices/cars which use health fashion symbols (e.g., Swarovki pink ribbon holiday ornaments)

The article also does a nice job giving an overview of how this merchandise becomes a hot trend. It introduces the reader to Everett Rogers' Diffusion of Innovations theory and how innovators and early adopters (often well known/respected in the community) can disseminate messages or material throughout their community/society, etc. Many of you may be familiar with this theory after reading Malcolm Gladwell's "The Tipping Point".

However, the key question on this blog (and happily in the article as well) is: "Are these initiatives effective?" In order to make that call we have to define what we mean by "effective". The article points out that many campaigns (e.g., Go Red for Women) define their goals as raising awareness. Therefore, if they survey women pre and post campaign and they report an increase in knowledge of facts such as "heart disease is the number one killer of women"...then they can say that the campaign was effective. However, if they had defined their goals in terms of behavior change (e.g., more women will visit their doctor for yearly blood pressure checks), it would be unclear if their goals were achieved.

Another way "success" or "effectiveness" has been defined for health fashion has been focused on the revenue generated by the sale of these items. If the Livestrong wrist bands or Avon's "Kiss Goodbye to Breast Cancer" lipstick line raise significant funds for their charities, then we can consider them successful....right?

Here are some questions regarding effectiveness raised by the article...with my own two cents (okay- more like five cents) thrown in:
1. Are we achieving saturation point with the marketing of health fashion? Does anyone even know what color wrist band supports what cause?
2. How will increasingly knowledgeable consumers affect the sale of these items? It is much easier to find out what percentage of your donation/purchase is actually going to the charity vs. to the corporation.
3. How have social networking sites like twitter/facebook affected the adoption/dissemination of health fashion and cause marketing? Support for a cause can be almost instant and celebrities can quickly call on their twitter followers, which in some cases number over one million. Are consumers being as thoughtful/careful when it is so easy just to click their support?

What are your questions?

Teen Moms and Teachable Moments

For one terrible minute on Monday night, my remote control found itself on ABC Family's "The Secret Life of the American Teenager". The show is completely unrealistic in showing 15 year olds pregnant and parenting with the maturity and vocabulary of people in their 30's. However, my remote control has recently become stuck on a reality show of the same topic on MTV called "Teen Mom". Now this is quite a leap of faith for me, as I pretty much gave up on MTV after its early quality reality shows (Season 3 of Real World with Pedro, anyone?) turned nasty and staged and scandalous. But according to a recent NPR story, I am not the only one thinking that this new show has some value and "reality". The Kaiser Foundation has funded reproduction of the series so that it can be distributed to schools, non-profits, and social service organizations that are working to reduce teen pregnancy.

The educators mentioned above believe that "Teen Mom" helps create and capitalize on a teachable moment. This is defined as "a moment of educational opportunity...a time at which a person, especially a child, is likely to be particularly disposed to learn something or particularly responsive to being taught or made aware of something". One reason to buy into this theory is based on the idea that modeling is important. People learn from watching each other. What high school students see other high school students doing is very important. Therefore, seeing the realistic struggles of the four girls on the show could help them think about potential consequences of teen pregnancy. We see the relationships with their family or the baby's father crumble. We see them working and paying bills in addition to waking up at all hours to a screaming baby. We hear about how one girl lost the father of her baby in a car accident before the child was born...now she is a single mom.

Of course anyone who reads this blog on a regular basis knows that I need to mention that this show is being used in schools as an educational piece. And of course an educational piece is not a silver bullet because it cannot address all the complex risk factors for teen pregnancy which include things like economic disadvantage and growing up with teen parents yourself. However, I think it is a step in the right direction. It is definitely an improvement in the quality of MTV reality shows. It also shows these girls in a pretty "real" light without being preachy or fear-based. Check it out and let me know what you think.

The NFL is making pretty posters- but what are they doing to change the CULTURE of playing with head injuries?

Hot off the presses! Check out the new poster produced by the NFL which now hangs in every locker room in the National Football League. This poster represents a new effort within the sport to educate and protect its players from head injuries. However, I would argue that these strategies (and the others that I will outline) will not do anything to help the problem until a culture shift begins on the player level.
I was inspired to write this blog post after reading an editorial by Michael Wilbon in the Washington Post (thanks to my husband for making me a PTI fan). Mr. Wilbon compares these posters to the Surgeon General's warning that appears on each cigarette package. I completely agree- and they will be just as ineffective. Straight education and "fear-based" messages are not capable of changing behavior.

My first concern is regarding the layout and content of the poster itself. In any good health communication piece, you want the target audience to quickly and easily understand what you are trying to say and what you hope they will do after viewing the piece (i.e., what is the "call to action?"). The NFL poster fails in multiple areas:

1. It is not quick: It took me almost 5 minutes to read it thoroughly.
2. There are too many goals/calls to action (at least three by my count): 1- Education about the facts and symptoms of concussions; 2- How/why to refer yourself; 3- How/why to refer a teammate.
3. It uses some "fear-based" messages (e.g., head injuries can cause early onset dementia).

I highly doubt that this poster was tested with the target population (NFL players)- which is always the best way to produce effective health communication materials. Perhaps the players would have pointed out the obvious oversight that the photographs on the poster are not NFL players (but instead children and those playing other sports).

The posters are being rolled out in conjunction with other prevention strategies. For example, there have been policy changes (either under consideration or already active) regarding how quickly a player can come back after a concussion, how much contact/hitting can take place in practice, etc. They are also reviewing new data regarding the safety of different types of helmets and supporting a coaches committee dedicated to the discussion of player safety.

But what about the players themselves? Are they ready to sit out games? Will they support their teammates sitting out games? From many stories heard from the fields and locker rooms- players have not yet bought into this "new system". For example:

Last November (2009), Ben Roethlisberger of the Pittsburgh Steelers sustained yet another concussion. It was ultimately decided (by his physicians) that he could not play in a key game versus the Baltimore Ravens. The result- he did not receive support from his teammates. Hines Ward told the media that support in the locker room was "50-50" regarding if Ben should play. He talks about how other players have played (and would have played) through a concussion. He also discussed how they would lie to physicians in order to be cleared for play.

So while it is great to have committees and make posters, until the players are on board and feel supported by their teammates to put their health first (without consequence or retribution), these other measures will not truly be effective. A culture change must come first- and it must start with the players.

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?

Pale Is In...Fake Tan Is In...Are Celebrities Encouraging Us to Stay Out of the Sun?

I was talking to my friend Elana today. Like me, she heard that the UV Index was 5 and dove for the sunscreen. We both have fabulous, sensitive skin that we protect from the sun. She said, "pale skin is pretty in these days..." After a quick mental inventory of what I've been seeing on E! News, I totally agree.

Back when I was preparing for prom in the mid to late 90s, a trip to the tanning salon was definitely in order. And according to recent news stories like "Keeping Teens Out of Tanning Beds", this is still a public health problem. However, I would venture to say that our celebrity role models are focusing less and less on baking in the sun. The two trends that I see from celebrities on the red carpet are pale skin and sunless "fake" tans. Both of which appear to be much less harmful than the old fashioned baby oil and tanning scenario!

One trend that has been picking up momentum the past few years is the fake tan. My girl Giuliana Rancic seems to "glow" each evening on E! News and on her reality show "Giuliana & Bill". She has said, "I can't live without my bi-monthly St. Tropez skin-finishing appointment". We also see this "glow" on celebrities like Jennifer Lopez. The other trend we've been seeing more and more of (which I'm really excited about) is the natural pale skin. And they aren't afraid of pairing that skin with blush colored dresses! We saw that with Anna Kendrick at the Oscars and Dakota Fanning at the Runaways premiere. I'm especially happy to see this trend with these younger actresses, since we know that teenagers and other individuals learn by observing the behavior of others (see: Social Learning Theory).

I always hear about how celebrities (insert Paris Hilton and Lindsay Lohan here) are terrible role models with their drinking and partying. We hear about their broken relationships and smoking and bad fashion. But in this one area, I will defend them. I think they are openly promoting alternatives to outdoor tanning and tanning beds. Since tanning can lead to skin cancer, I think this is a great step in health promotion. Fake sunless tans are in...and beautiful pale skin is definitely in. So grab that SPF 60 ladies! We are on trend!

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..."

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 ;)