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.