Health communication: why getting it right impacts us all

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0:01:12.7 Speaker 1: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macro-economic, the social to the environmental, from cities to neighborhoods, states to countries and around the world.

0:01:42.9 S1: On this episode of Population Healthy, we'll hear from four experts who bring their own unique perspectives to the topic of health communication. Health communication are the verbal and written strategies used to influence and empower individuals, populations and communities to make healthier choices. It's a vital part of public health, but in many ways, health communication has become more difficult to navigate for both public health professionals and the public over time. To start us off, we have Ken Resnicow, he's a professor of Health Behavior and Health Education at the University of Michigan School of Public Health, and he's an expert in health communication. First, we ask Resnicow to frame some of the ways we may come across health communication messages in our daily lives.

0:02:25.8 Ken Resnicow: When you think about across the day, all the various health messages, it can really add up.

0:02:30.9 KR: So for example, there's what people see on TV and radio, those are ads that can be both from health organizations, non-profit organizations, or they can be sponsored health content, like a pharmaceutical company promoting a new drug, they may have a campaign to raise awareness about that disease. And then we have the print media, which can be in the large venue, something like billboards, all the way down to small posters and ads and magazines and newspapers. And then we get into the whole digital exposures and there's various places people see health information and health ads, so they can be placed strategically in social media like Instagram and TikTok, individual researchers or government and non-government agencies can buy time and place ads in those venues. Also, people often search for health information. It's one of the most common things we did some studies on searching around COVID, and there are millions and millions of people who searched for COVID on their own, and often they'd land at places like WebMD is a very common landing place, the CDC's website, Mayo Clinic's website, those are some of the big players if you do a health search where people will land. And finally, your providers, your doctors, your allied health professionals, chiropractors and podiatrist, they also can provide health messages. So we're getting hit with messages throughout the day from several angles and several venues.

0:03:53.6 KR: I would like to divide public health campaigns in two generations. The first generation, which I think is largely behind us, but occasionally we still see it was based on the 3Fs, fear, facts and feedback, particularly fear and facts. For 30, 40 years, we really focussed on informing people, empowering people with information. But in the second generation, which I think began 1980s, 1990s, but is much more intensively adhered to now, we're really trying to shift from fear and facts to motivating people by trying to find meaning in the behavior change.

0:04:31.2 S1: Health communicators have certainly learned a lot over the years about what types of messages work and which don't. Resnicow shares some examples of great health communication campaigns and the not so great ones.

0:04:44.7 KR: An example of a campaign that most of us agree failed was the marijuana worse than you think campaign from the early 2000s sponsored by the Office of National Drug Control Policy.

0:05:01.9 Speaker 3: Marijuana can slow your reaction time and impair your judgment. Marijuana, it's more harmful than we all thought.

0:05:11.6 KR: Their core message was, you're underestimating the risk of marijuana, it is much more harmful than you think. It causes car accidents, it causes you to drop out of school, you're gonna get arrested and get in trouble if you smoke on marijuana. And what happened in the evaluation of that campaign, it turned out that exposure based upon pretty rigorous methods, the higher your confirmed exposure, the greater your intentions to use marijuana, so somehow telling youth over and over again, you're underestimating your risk, you're wrong, it's much more harmful than you think turned out to be what we call reactant. It created in the teen a desire to counter or argue with that, no, it's not as bad as that. That's not my experience. And when you create counter-arguing, what you're asking the audience member to do unintentionally is defend marijuana use.

0:06:03.4 KR: So we think one of the ways that campaign failed is it induced counter-argument in the audience, and the second pathway by which that campaign failed is that it gave the impression that most marijuana users are heavy users and are "addicted", but that's not the experience of most youth. So what that did is it established a norm that was inaccurately negative, it actually gave kids the message that more kids are using pot than they actually experience.

0:06:31.9 KR: And when you raise perceived norms, you increase use. The more normative you make a behavior, the more it sends a message to kids it's acceptable and normative. And we think that campaign also failed because of that, what we call meta-message, an unintended communication that is received by the audience without intent directly by the developer of the message. That's an example of, I think, a failed campaign. Now, I'd like to talk about a very successful campaign called The Truth Campaign, funded by money initially through the Florida settlement with the tobacco industry, and then eventually the national attorneys general settlement with the tobacco industry.

0:07:12.0 Speaker 4: Who here would wanna work in a high-paying, recession-proof multibillion dollar industry once they graduate? Alright, keep them up. Now, who wants to work in an industry whose products could potentially be responsible for one billion deaths in the 21st century? Nobody? 

0:07:31.2 KR: The Truth campaign created a smoking prevention model that was truly unique. They decided that they're not gonna get kids to not smoke by scaring them, we're not gonna talk about health consequences, what we're gonna talk about are what's important to kids, autonomy, feeling their generation is special, not acquiescing to White male corporate establishment. So they created a series of campaigns where they basically made the tobacco industry the villain, not cigarettes, but that the industry was dishonest, manipulative, didn't care about them, was ruthless. And through very creative, very high production value ads, they were able to create a very strong anti-tobacco industry sentiment. And what the research has shown is that that anti-industry sentiment was strongly correlated with a desire to not smoke, so they really created a causal pathway that if we could target and create anti-industry sentiment, we can prevent smoking, and they did it successfully through a series of individual campaigns, each with a slightly different message, but all focusing on not health effects, but by smoking, you are acquiescing to the tobacco industry.

0:08:46.9 KR: In general, it requires a diagnostic evaluation of the intervention targets, that means understanding what we call the drivers or the mediators of the behavior. In the case of smoking, we know that perceived risk is a very small determinant of who smokes. On the other hand, normative beliefs, whether or not you feel your peers are doing it, whether or not your peers think it's acceptable and cool, those we know are very strong predictors of smoking uptake, therefore those become our intervention targets. So it usually takes a combination of quantitative research such as analyzing surveys, supplemented by qualitative research, interviewing, in this case, youth about why they smoke or don't smoke, or what they think about kids who smoke or don't smoke, and you combine that quantitative survey data with the qualitative deeper dive data, and usually you take those two sources and you create a causal model and you decide what are the intervention targets we want our campaign to address.

0:09:50.3 S1: And then came the COVID-19 pandemic and all of the myths and disinformation that was added into the mix, COVID made health communication an already difficult tasks even more grueling.

0:10:01.7 KR: When it comes to understanding COVID messaging, I'm gonna talk first about vaccine uptake, but we also could apply this to other COVID protective behaviors such as mask wearing. It's important to understand there's different audience segments. In effect, there are two different vaccine hesitant groups, there's the wait and see group, that's the group that said, "I'm considering it, I'm not against it, but I wanna see more people take it, I wanna make sure it's safe, I wanna make sure there's no nefarious purposes, but if my questions are answered, I'll consider taking the vaccine." Then there's another group that has really been a public health challenge called the Hard No group, that group has said, "Under no circumstances will I get this horrible vaccine, it's unsafe, it's unproven, it's part of an attempt to control us, to poisonous us, it's part of this broader conspiracy generally from the public health left," which is a new phenomena that public health is seen as political, that Hard No group has not been messaged very well.

0:11:05.9 KR: I think we've done a really decent job with the wait and see group, and in fact, the percent of America that has been in the wait and see category has dropped by more than half in the last year since vaccines became available, but the Hard No group hasn't budged. How to message that group is really challenging, and we haven't met that challenge yet. We've come up with some ideas, and there have been some interesting campaigns out there trying to circumvent that autonomy argument by saying, "You're right. You don't need a vaccine. You're strong, your immune system is great, but your grandmother living with you might because she's vulnerable." So this idea of the protector model is something we've used and others have used in some smaller campaigns, not so much nationally, but I think that addresses the fact that the anti or Hard No persona still might wanna protect their family even if they don't wanna succumb to the left, pharmaceutical conspiracy. This gives them and out, it preserves their dignity and their autonomy while still giving them a motive to get vaccinated. But again, I don't think we've done a superb job at counter messaging the Hard Nos, and it's something over the next year or two is gonna be a challenge for us, and many people are working on that sticky problem.

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0:12:31.9 S1: Some of the very people working on the sticky problem of vaccine uptake include health communicators within county health departments. Susan Ringler Cerniglia is the Communications and Health Promotion Administrator and the Public Information Officer at the Washtenaw County Health Department in Michigan. She's also an alumna of the University of Michigan School of Public Health. To understand more about what it's like to be a health communicator during a public health crisis, we asked her about her experiences during the COVID-19 pandemic, and why communicating during a crisis is inherently challenging.

0:13:02.3 Susan Ringler Cerniglia: First and foremost, information and how we process that in a crisis can be very different. We might be feeling particularly anxious, threatened by whatever's happening. And that level of stress can make it difficult to understand, to remember, to really absorb what you're hearing. And that, of course, can be magnified if the information that you're hearing is inconsistent from different sources, even subtle changes in that might cause confusion, might be difficult to wrap your mind around the actionable details. We unfortunately also live in a time where we're absolutely inundated with information, and that amount of information has really changed over the course of our lifetime. We've gone from having, for example, daily local newspapers where there was really a professional staff. Overall, we're now in this time where there's lots and lots of information, we can't necessarily rely on accurate information coming to us, we have to be individually more proactive in discerning and where we're getting that information, whether or not it's reliable. It puts a lot more pressure on the individual. Communications, of course, don't stand or operate independently, for example, if we're sharing early in the crisis, we're sharing a lot of information about the situation, what are we seeing in terms of impact, in terms of data, statistics, where are we seeing the impact? 

0:14:41.3 SC: What is the actionable information that I need to do something? Information isn't gonna be received by everybody in the same way in our diverse communities, and often in our communities that for whatever reason, may not be able to be proactive in terms of time or Internet access and really go to those official sources for information. So you have to have multiple systems to get information out, and we've tried very hard to build our partnerships and our networks, fanning out from, obviously, our staff, our elected officials, our local municipalities and our community partners to really try to get that information out to people through those trusted organizations. Prior to the pandemic, we've been doing a lot of work in engaging communities. We had a network of community leaders that were identified through a process of data and community health assessment to really focus in where we knew health disparities were high, access to traditional information or health opportunities might be low, or it was low in many cases, and we built relationships with some of those leaders. So we were fortunate in the beginning of the pandemic to really be able to rely on them, and then of course, as the pandemic unfolded, we had this shut down essentially, and service delivery change everywhere, so it became incredibly important for us to rely on those networks and to really push reliable and up-to-date information out in as many channels as we could.

0:16:31.8 SC: A couple of the things we did, for example, was make sure that we were always creating written information, as simple and as up-to-date as possible and getting that translated as quickly as possible. Food distribution, you might recall, changed very dramatically. Food pantries weren't necessarily open, and schools, as they were closed down, shifted to this daily food delivery, and that presented an opportunity for us to share written up-to-date information with vulnerable folks. And that wasn't to say we didn't use more traditional means, we had news releases and tons of media interviews that were happening as things unfolded and we would share those, of course, with our staff, our elected officials, our partner lists, and also push out information and adjust information based on what we were hearing from our community partners and contacts, and that foundation really served us well as we moved through the different phases. 'Cause some of the characteristics of each of these phases, and of course, overall, we had this long response. Unlike most emergencies, health emergencies tend to be longer in duration, and you really have to deal with information in a different way because it's not a matter of a immediate explosion and an aftermath, it just keeps going and going.

0:17:58.3 SC: Fast-forward to vaccination, same idea; limited supplies, and really working to get that out where we knew access was different and harder, and information might be harder to come by. Of course, that was also, I should add, combined with higher impact. The pandemic is quite obviously highlighted existing fragments both in the public health system and in the healthcare system, and then people's underlying health. We've seen our communities of color, particularly our Black and Latinx communities locally, be impacted to a greater degree. We've seen that geographically and in areas locally, and so really using that data to bring resources as equitably as possible and as soon as available to those areas was critical, but we couldn't do that necessarily with the staff that we had at the health department. So again, those partnerships, and that work to both fan out information and to situate resources in communities where they're most needed was incredibly critical throughout the pandemic and remains critical.

0:19:17.0 SC: We saw this in the pandemic, for example, there was a lot of demand for incredibly nuanced information or an expectation that we had oodles of people researching questions and establishing data or even going out and enforcing mandates, for example, but that's really not what happens at local public health. We're not a research organization. We are set to provide guidance and guidelines, and that can be hard for folks to understand the role of local public health when we have a situation like this, and hopefully we'll come out of it with a better understanding of the critical need for that investment and what we can accomplish if we're truly proactive and have a robust public health system in place.

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0:20:20.5 S1: Next, we'll hear from Scott W. Campbell, a Professor of Communication and Media at the University of Michigan, his research examines how people use social media in their everyday lives and what benefits or consequences those habits might have. Shortly before the COVID-19 pandemic began, Campbell and his colleagues set out to identify links between an individual's likelihood to believe false health information and where they get their news. When the pandemic began and brought with it mis and disinformation, Campbell and his research team had the opportunity to see some of the things they were studying play out in real time.

0:20:52.9 Scott W. Campbell: We were able to get national survey data from the United States and Singapore and Turkey, and we were able to look at people's uses of different types of media and associate those media uses to various kinds of things, including misinformation beliefs about health. And we asked people about vaccines and whether they thought vaccines caused certain things that they don't cause, that we know that they don't cause, just some basic truth or factual questions about genetically modified foods; it was another area that we asked them about, and so these are just kind of scientifically controversial areas that actually we do know factually this about vaccines, and we do know this about genetically modified foods, and we know that there's also some other information that's out there that's just not true, and so we ask people about their beliefs around these things, and what we found was that people who rely on what we were calling in this study, legacy media, which is mainstream online news media.

0:21:49.6 SC: So an example in the United States would be like MSNBC or maybe AP, the Associated Press, or Reuters, one of the wire services, and those are new sources that have been around for a long time, and those are new sources that we recognize. They're institutions, right? Then we asked people also about social media as a source of news, and we found that people that use the mainstream legacy news sources for news, there was a negative relationship between believing in misinformation, false information about health and using that as a source of news, and this was across all of the countries, between the uses of social media as a news source and the alternative types of websites as new sources about health information and those were positively linked to believing information that's just not true, and it's very consistent across the countries, that shows that it's in pattern.

0:22:38.5 SC: Your information tends to be more accurate if you're using mainstream media, it's the opposite pattern with the other types of media, and we looked at thinking style, so individual differences in how people process information. In this study, we're looking at two, one of them is called faith and intuition, and that's where it... Like it sounds, people rely on their own kind of intuition to interpret information when they encounter it in the news, and another thinking style that people were high on that we found called need for cognition, which is just a need for your information to be very structured and ordered in a certain way for it to make sense to you, so people who were high on these two different types of thinking styles that had nothing to do with the link between believing in misinformation and mainstream news, but it made the situation worse for people that rely on social media and alternative media, so if you need your information to be very structured and ordered, it tells us that these sources tend not to do that in a very constructive way, not in a way that translates into accurate beliefs. The other thing that we might say is that people who rely on their own intuition then maybe are just more gullible, and that mainstream news, it's just...

0:23:48.6 SC: It's more vetted, there's more gatekeepers, there's editors, there's people who are gonna get fired. If a lie generates a bunch of clicks on an alternative website, somebody's gonna get promoted, if that happens on a credible news site, somebody gets fired. The Internet has certainly fueled a paradigm shift in terms of the information ecology out there, and definitely this applies to health information, but before I talk about the Internet, I wanna say it's not just about the Internet, it's also about the media environment around us. I wanna point out that there was a policy shift in the United States in the 1990s that allowed drug companies to advertise directly to consumers, and so that shift goes hand-in-hand along with the change in our media environment that partially explains why there is so much more information that is out there targeted for individual consumers as compared to, say, a couple of generations ago, when we were more in the mass media environment of television, radio, TV, newspapers, also there were regulations that pharmaceutical companies here in the US constrained them from reaching out to consumers directly, and they were just having relationships with doctors, and so that's part of the story.

0:25:00.3 SC: So there is an almost unlimited amount of information that is out there, and on the one hand, it's good, it's empowering because people have more access to information, but on the other hand, the nature of that information ranges between factual and accurate and helpful to absolutely nothing other than persuasive and profit-seeking, and some of them even goes as far as being malicious, disinformation, intentionally trying to deceive people, and so it's a wider ecology of information with much more access to individuals, but you have to have more literacy, I think in this day and age, not only about the drugs and your health, but also about the media and the sources of information that we're using to make our choices, unbiased truth in journalism and in our news, those are ideals. Those... Objectivity is something that you shoot for.

0:25:52.1 SC: It's not something that you can necessarily fully always get. And so I think that we have to recognize that economic and social and political forces, cultural forces and blind spots and constraints and limitations are gonna make it so that we have to have a diverse range of sources of information so that we can kind of fill in gaps with a little bit here and there, and check this against that and have our eyes open about these limitations and still have our trust out there and understand that it's not gonna get perfect. These are unlimited resources, let's not give up on the news, we have to diversify our media diet in order to have a more robust vision of what's out there.

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0:26:38.5 S1: At its core, health communication is designed to reach large audiences, ultimately, however, the messaging all boils down to an individual's choices, and what works best for them. This is an area of expertise for Brian Zikmund-Fisher, a Professor of Health Behavior and Health Education at the University of Michigan School of Public Health.

0:26:56.0 Brian J. Zikmund-Fisher: I'm an expert in the psychology of medical decision-making, and in particular, I study how to make the data of health, whether that's re-statistics or test results, those kinds of data more intuitively understandable to patients, to policymakers and to the public more generally, so that they can use that information to make better health choices.

0:27:17.0 S1: Zikmund-Fisher has some ideas on why communicating to patients can be difficult.

0:27:23.3 BZ: So there's two big reasons why communicating health data to patients or the public is so hard, the first is, lots of the data that people need to understand, involves risk, chances, probability, uncertainty. It's just simply the case that risk is a really un-intuitive concept for most people, so we're having to talk to people about things that they don't really understand conceptually, but they have to understand in order to make good decisions.

0:27:50.2 BZ: The second reason is that all of the data of health, unless you're a health expert, a public health official or a doctor, these data are things you don't generally think about in your day-to-day life, I don't think about electrolyte levels or concentrations of chemicals in my day-to-day experience, but if I have to make a decision, that's dependent upon that data, I'm gonna need help, in order to be able to make sense of the data, even if I have it available to me. So let me give you an example of a personal situation that happened to me that really brought into sharp relief this problem of, you can have data, but you don't necessarily know what it means. When I was in high school, I had a routine blood test drawn and it came back with a platelet count of 45, I won't even bother giving you the units. If I just pause there, I suspect, you don't actually know what that means. Is that good? Is that normal? Is that bad? It's just 45. Now, I know, because I've researched about platelets, normal levels are from 150 to 400, and so 45 is significantly below normal, I also know that if you get down below 10, you're in imminent danger of bleeding internally and dying from that, so 45 is better than that.

0:29:08.3 BZ: But it's obviously not normal, and I needed that contextual information to be able to make sense of what was a piece of data that I had available to me, but that I had no ability to understand what it meant without that extra information. So in high school, I went through a bunch of tests. But we didn't really figure out what was happening, and then 13 years later, when I was in graduate school, and in my doctorate, I was diagnosed with something called Myelodysplastic syndrome, which is a dysfunction of the bone marrow. And what that meant was that my bone marrow was no longer making blood cells like platelets, or red blood cells, or white blood cells the way it should. As a result, I ended up having a bone marrow transplant, which sounds like scary thing, and it is. It's one of the most dangerous procedures that modern medicine has come up with, you wipe out somebody's immune system, you wipe out their bone marrow, and then you replace it with somebody else's and hope it takes because we don't live very long if we don't have a functioning set of bone marrow.

0:30:11.8 BZ: And that meant I was exposed to lots and lots and lots of blood tests. Lots and lots of risks that I had to face, including literally the trade-off between my disease progressing and potentially killing me, versus very significant risks of treatments that also had chances of killing me, and having to make that choice as someone who was trained in my professional life, about risks and decision-making was a fascinating exposure to me of the challenges that all of us face when we have to make difficult medical decisions, when we have to navigate our health risks and environmental risks in our day-to-day life. I remember a day when I was going through the intake process into my bone marrow transplant program, and I went into the room with the physicians and I said, "Hey, I study decision-making, give me data," and they did, and we draw curves up on the board and then we talked about the numbers, and I came out of that day still really struggling with what it all meant and how I could make appropriate decisions, and I remember that day because I also came out of that room going, "If it's this hard for me, and I have every advantage, in trying to deal with this problem, how hard must this be for everybody else, who don't have my familiarity with risks and numbers and processes of decision-making?"

0:31:41.3 BZ: It opened my eyes to the inequities that exist in this space, and then really started me thinking about how can we design better communications, how can we train doctors and patients to be better ready for these moments when they happen.

0:31:57.5 S1: So why is it difficult to communicate about health risks and trade-offs? And for people to make decisions that affect their health? 

0:32:03.0 BZ: Risk is just a hard concept, and I mean we, like, all human beings, we don't like uncertainty. We wanna know what's gonna happen to us. A classic example of this is vaccination, like what do I want? I want to be protected against, let's say, seasonal influenza, but it's not perfect, even if I get vaccinated, I might get the flu, and the vaccine itself has some chances, very small, but they do exist of causing, say, an allergic reaction. I have to trade off the desire protection against the influenza versus the chance that the vaccine might cause an allergic reaction now, maybe that chance is only one in a million people, but if I happen to be the one who has that allergic reaction, I get it, it's not like it's any less because only one person in a million gets it, and that's why risk trade-offs are hard, so somehow, we have to acknowledge uncertainty, know that we can't ever know for sure what's gonna happen, and then look at the chances, not just in terms of numerical probabilities, but also in terms of how important is this to you? And it's that integration of the data of medicine and public health with the values of patients and communities, that is really what good decision-making needs to be.

0:33:26.9 S1: So if someone needs to make a tough decision about their health, how can health communicators design communications that will help them decide? And how can patients advocate for themselves? 

0:33:36.2 BZ: The key for anyone who is trying to communicate this type of information, to patients, to the public, to policymakers, is to be really clear right from the start, what do they need, experts have lots and lots of information that is not actually helpful to the public, it's then helpful to other experts, but if we wanna help people make good decisions in their individual lives or in our society, we really need to do the work of figuring out what they need. Part of that is access to the relevant information, and we've seen a lot of effort done to help give people access to their health information, for example, we now can get direct access to our laboratory test results by logging on to our hospital's website for most people in the United States, that wasn't true 20 years ago, and it changed the way in which we got to talk to our doctors or monitor our own health conditions, we also need to give that information to people in a format that they can understand, it's not just, Oh, here's the numbers, but give them that context to help them know what's normal, what's bad, etcetera.

0:34:44.2 BZ: And we need to help them understand how to use this information to make good decisions, and if that's a patient with diabetes, that might mean talking with them about how they can use the data to understand how their own health behavior is leading to better or worse numbers in, say, their blood glucose, if that's COVID-19 statistics, that might be helping them make sense of when the numbers show that there really is a lot of risk and they need to take more precautions in their day-to-day life, versus when those numbers show that maybe we can be a little bit more relaxed and that that would be a reasonable amount of risk to accept in order to do other things in our life. Again, it's about understanding the users need, we don't have to be complete, we certainly don't wanna bombard them with a fire hose of information, clarifying what the user needs is the best thing that we can do to help people actually be able to accomplish, live their daily lives, and make good policies, that accept risk, but minimize it. My advice to patients is always, be willing to ask questions, ask for information if it's not directly available to you, but more importantly, ask what stuff means. Asking questions like, is that a good number or a bad number? Or, What should I feel about this? Or how high would this need to be in order for you to be worried about it? 

0:36:08.9 BZ: Those kinds of questions are really powerful, they're certainly useful when a patient is talking to a doctor, but they're also useful for when we're thinking about communities, trying to understand the information that's available to them, say about their environment or the health status of a community. We have a role in public health to play, to be the stewards of the information that's available to us, but we can't always know what our audiences understand or don't understand. So my best advice, again, to anyone who is receiving information is be willing to ask those kinds of clarifying questions, 'cause you deserve to know what it means.

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0:36:51.9 S1: On the next edition of Population Healthy.

0:36:54.1 Speaker 8: So nurses have been delivering extraordinary care in hospitals, schools, they've been serving their communities all throughout this pandemic with really no relief, what that has shown us, is that they are at risk for substantial burnout, what we call emotional exhaustion, being tired of being in the workplace, etcetera, I think something that's really important to understand though, is that these concerns pre-dated the pandemic.

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0:37:25.1 S1: Thanks for listening to this episode of Population Healthy, from the University of Michigan, School of Public Health. We're glad you decided to join us and hope you learned something that'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcasts, be sure to follow us @umichsph on Twitter, Instagram and Facebook, so you can share your perspectives on the issues we discuss, learn more from Michigan public health experts, and share episodes of the podcast with your friends on social media, you're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health, visit publichealth.umich.edu/news/newsletter to sign up, you can also check out the show notes in our website, population-healthy.com for more resources on the topics discussed in this episode, we hope you can join us for our next edition where we'll dig in further to public health topics that affect all of us at a population level.

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