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.