Turning the Technology Around

Turning the Technology Around

Smart interventions help kids chat, text, and game their way to better health.

At the annual meeting of the American Public Health Association last fall in Philadelphia, crowds gathered around hawkers peddling the latest in “amazing” new inventions like:

  • The “revolutionary” ActiFry® hot air cooker that repeatedly churned out a pound of crisp French fries with just 2 tablespoons of oil (also great for granola)
  • The “breakthrough” big beige LouseBusterTM scalp vacuum
  • “Risk-minimizing” acrylic (rather than metal) tongue barbells, heralded by the Association of Professional Piercers to prevent damage to teeth

Other intriguing tech-based innovations were discussed more quietly. In backroom academic sessions, with minimal hardware hoopla, public health presentations heralded technology that has been used for years—and increasingly abused, some might say.

When was the last time you heard anything but complaints about kids playing video games, texting, and spending time on Facebook or MySpace? Adults are worried, understandably, about the links between violent video games and aggressive behavior, the dangers of “sexting” (texting sexual content), and privacy protection in the era of social networking. They’re also concerned about physical inactivity due to kids’ obsession with electronic media. According to a recent Kaiser Family Foundation report on juvenile use of entertainment media, average screen time for kids now exceeds seven hours a day!

But the news is not all bad on the kid-tech front. Awareness is growing about how adults can manage, and even take advantage of, electronic media to ensure the well-being of the world’s first-ever generation of digital natives. Kathryn Montgomery, a communication professor at American University and author of the book Generation Digital, says being a kid today means never having known a time without “constant connectivity.” This is a generation that considers e-mail an archaic and slow form of communication, according to the PBS Frontline report on “Growing Up Online.”

“Viral” has a new definition for effective health educators. Communicating with kids increasingly means getting on their screens—literally, the little ones they’re holding in their hands or on their laps. It’s happening already, and University of Michigan faculty and staff are part of public health’s push toward positive apps.


Alison Grodzinski was among the information specialists at the 2009 APHA annual meeting presenting on Web 2.0 interactive platforms in public health. Twelve years as a health librarian has convinced Grodzinski of interactive technology’s “enormous potential to revolutionize ways in which public health workers reach their target populations and improve communication.” Who wouldn’t want to use a collaborative platform that breaks down geographic and logistic barriers, boosts communication skills, and can be, for the sake of total convenience, both “live” synchronous or “on your own time” asynchronous?

At the UM School of Public Health, Grodzinski is the communications coordinator on the core project of the Prevention Research Center (PRC) of Michigan for 2010 to 2014, which is using education and online social networking to fight the spread of sexually transmitted infections (STIs) in a mid-Michigan area that has experienced elevated rates of HIV and STIs, including a recent syphilis outbreak. The idea is to keep teens and young adults thinking and talking about safe sex on their time and their networks, long after in-person education sessions have passed.

More than 19 million new cases of STIs occur each year, and almost half occur in teens and young adults. In Flint, Michigan, the rates of STIs for African-American residents aged 18–24 are high, but testing rates need improvement. The PRC wants to build a buzz around best practices and prevention. Its CDC–funded project is officially called “HOPE: HIV/STI Outreach and Prevention Education.” The HOPE concept was developed by YOUR Center, the lead community organization for the project. The intervention will begin this summer with face-to-face get-togethers focused on healthy-sexuality education in two Michigan counties, Saginaw and Genesee. Along with refreshments, attendees at these parties will get education in STI-prevention methods, condom negotiation, and communication skills. They’ll make plans to reduce their risk. The intervention in Genesee County will add the social technology component. Participants will be invited to utilize blogs, sexual health podcasts, and social networking sites on an ongoing basis, to expand educational opportunities and enhance peer mentoring. PRC researchers and their community partners will analyze responses and outcomes among the two groups.

Marc Zimmerman, chair of SPH’s Department of Health Behavior and Health Education and principal investigator on the HOPE project, says the PRC partnership came up with this model for positive health messages as a way to use “what’s already out there.” With about three-quarters of teenagers now using social media, “natural networks are now online,” Zimmerman says.

Social media and online peer networking are in focus elsewhere at UM as well. Some sample projects:

  • Melissa Valerio and Christy Houle of the Center for Managing Chronic Disease at UM SPH recently looked at the role of Facebook in family managment of asthma.
  • UM medical students working on the Social Media Research Project are surveying what the public—including potential patients—think of physicians-in-training who turn up in unflattering photos or questionable public contexts online. Coordinator Anuja Jain says the goal is “to create policies related to professionalism.”
  • The UM Health Sciences Library recently went into several Ann Arbor public schools to “teach teachers” about online health resources, including wikis and resource-sharing tools.
  • The 2010 annual Depression on College Campuses conference on central campus in March had a session focusing on how technology and online networks can support student mental health.

Meanwhile, the CDC has come aboard the wave as more than a funder: It launched a new website in early 2010 offering best practices for online communication tools, stating, “The use of social media tools is a powerful channel to reach target audiences with strategic, effective and user-centric health interventions.”

Dawning Day 4 Mobile Health

Social networking health interventions are more promising in the U.S. than other places in the world because the Internet is so accessible in this country (about three-quarters of American teenagers use online social networks frequently). But there’s a downside to our networked status: Many other countries skipped ahead of us to build wireless infrastructures that allow great flexibility in the communication of health information. “The creativity and energy that goes into the Internet here goes into mobile in other countries,” said Paul Meyer of the technology firm Voxiva (a Washington, D.C.–based consulting company that provides interactive mobile health information services). He was speaking at one of the many 2009 APHA sessions on mobile health, which is a catchall term (along with mHealth) for any health-related technology that involves cell phones or any wireless data transmissions.

“The U.S. has to catch up to places like Rwanda in mobile health,” Meyer said. And he wasn’t just throwing out the name of a developing country: Rwanda actually has a public-private partnership which uses computers and mobile phones in a national electronic reporting system that eases delivery of public health care at the village level. Similarly, programs addressing 1.2 million TB and HIV patients in Malawi and Uganda, run on a shoestring by FrontlineSMS:Medic, are showing that text messages and cheap mobile phones can extend the reach of community health workers (each installation of their open-source network also requires a laptop and GSM modem).

FrontLineSMS:Medic also helped set up a bandwidth-light text-messaging “distress line” in Haiti in the days after the January 12 earthquake; it received 18,000 requests for food, water, and other forms of help in about a month. (And few people could have missed hearing that the Red Cross texting-based fundraising effort raised more than $32 million in a month for Haiti.)

Imagine if American kids just the age to be obsessed with texting were regularly managing chronic conditions like diabetes by sending glucose readings and photos of what they’re eating for lunch to caseworkers in real time. Electronic medical records could be managed wirelessly, along with operational communications for other population health issues. Attractive scenarios, but there’s a problem in the U.S.: Our mobile communication industry model involves numerous carriers charging independently for data transmission, adding complexity for large-scale health interventions.

One reason to be hopeful about the future of mobile health in the U.S. is the new Text4Baby® maternal and infant health initiative. Sponsored by numerous private and public partners, the nationwide program could never have gotten off the ground without “free messaging services generously provided by participating wireless service providers,” according to the website of the sponsoring National Healthy Mothers, Healthy Babies Coalition. Text4Baby® provides pregnant women and new moms with broadcasts of up to three text messages a week about nutrition, immunization, prenatal care, mental health, car-seat safety, breastfeeding, and more. Expectant parents simply text the word BABY (or BEBE for Spanish) to 511411 and enter their due date. Though not personalized, the messages are timed to coordinate with appropriate prenatal, postpartum, and infant-care milestones through the child’s first birthday.

Closer to home, on a smaller scale but with greater personalization, UM SPH alumna Susan Woolford, MD, MPH ’06, is incorporating tailored motivational text messages into her work with overweight youth in the federally funded MPOWERed Messages project. “It’s all about healthy messages geared to keeping healthy choices at the forefront of their minds,” she says.

As medical director of the UM Health System’s Pediatric Comprehensive Weight Management Center, Woolford has patients who live hours away. Because she believes in the importance of provider-patient communication related to behavior change, she’s turned to electronic messaging to extend contact, boost impact, and bridge geographical distances. She ran a pilot project last year to see if, in between visits, her teen patients would be responsive to receiving text-message reminders to help them keep on track with healthy behaviors and goals. “A large majority enjoyed participating,” she said. “I see it as an adjunct to face-to-face work we do.”

As with the PRC’s social media project, outcomes will be compared from equal-sized groups that do and do not receive the text messages. “Focus groups help us develop messages that are salient to adolescents,” Woolford explained. She’s working with the Ann Arbor–based Center for Health Communications Research to refine participant surveys of their food preferences and habits. Such “tailoring” helps recipients feel that each message was written just for them, even if it was generated by a computer, Woolford believes. (Below: see video explanation of tailoring by UM SPH's Vic Strecher.)

Further down the line, Woolford would love to start using Internet conferencing to communicate with patients.

“We need to interact frequently with the young people we’re working with,” she said. “Weight management is a chronic problem for many adolescents. We need to do everything we can for them.”

Getting in the Game

In the gym affiliated with the UM Pediatric Comprehensive Weight Management Center is something Woolford calls “spectacular.” Several sessions at the APHA annual meeting were devoted to what this spectacular innovation represents. The trend is “exergames” that get young people off their duffs and moving. Most popular is the Wii Fitness suite of active video games, which are inspired by sports as diverse as snowboarding and tennis. Judging from the amount of enthusiasm kids show playing Wii Fitness games, Woolford says she wishes all her patients could afford to have their own. “I love the goals part of the programs,” she says. “Young people step up and enter their weight into the system, and the Wii comes up with an avatar. They see it and say, ‘That is not how I want to look.’ It can be very motivating.”

It can also be a lot of fun. Whether it’s Dance, Dance Revolution, or the virtual reality workouts catalogued in a lengthy Wikipedia entry on “exergames,” it’s a trend that public health can’t afford to ignore. Can there be a better way for kids to spend their daily screen-time limits?

Actually, additional types of “Games for Health” shared the bill at the January 2010 conference of the same name in New York sponsored by the Robert Wood Johnson Foundation and the Serious Games Initiative. Dedicated to “advancing the role of videogames in health and health care,” the conference showcased antismoking games, nutrition and healthy-eating programs, and even games designed around “beating” particular juvenile diseases like diabetes and other chronic conditions. An Apps for Healthy Kids competition (part of Michelle Obama’s Let’s Move! campaign to end childhood obesity) challenges software developers, game designers, and other innovators to develop fun tools that drive children to eat better and be more physically active. The USDA nutrition data set will be the basis of the games.

An award-winning Warner Brothers–built video game called Pamoja Mtaani is at the center of a public-private partnership to fight HIV/AIDS in Africa. With the support of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), this game aims to really turn tables by empowering people with the idea that HIV/AIDS can be the disease of their parents’ generation—assuming young people can stop the spread with safe practices like delaying sex, using condoms, getting tested, and more.

The Facebook page for the American Legacy Foundation’s truth® campaign, along with providing a fearless forum for people to rail out for and against smoking, occasionally links to custom-made video games like Addictor Click and Type or Die. It’s a strategy that fits with the initiative’s mandate to allow teens “to make their own informed choices about tobacco use,” without preaching and judging.

Meanwhile the role of games in education continues to grow. A New York City charter school has been structured completely around educational gaming. Inexpensive iPhone apps help you eat healthier (fish and local food) and demystify the human brain for fun and enlightenment. Scientific American recently quoted astrophysicists at prominent universities who were intrigued by the way newly launched Mass Effect 2 incorporated the concept of dark energy into the action of the game. One role of video games is to stretch what we know about science by using the imagination, they said, heralding tremendous untapped potential in games for incorporating cool science.

Perhaps this kind of attitude is what it’s going to take to meet tomorrow’s adults—today’s e-savvy digital natives—on their own playing field. At the same time we’re selling them on lower-calorie junk food, kinder body art, safer sex, and games that challenge more than their eyes and thumbs, we could probably learn a thing or two from them about the positive po-tential of another brave new world.

By Mary Beth Lewis.

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