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 ;)

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!