Category: Health Communication

What Can We Learn from PR Theories

Let’s talk about these persuasion techniques from the fields of PR and advertising. They don’t just need to apply to consumer marketing or branding—they can inform health campaigns.

Mendelsohn’s Three Assumptions for a Successful Campaign

  1. Target your messages
  2. Assume target audience is uninterested in messages
  3. Set reasonable, mid-range goals & objectives

How to best “assume” (without making an a** out of you and me):

  • Research to understand target audience & inform goals
  • Theory to develop strategies

Thankfully these receiver-oriented sequential steps are based on dominos and not a house of cards:

McGuire’s Hierarchy of Effects (aka Domino Model)

  1. Exposure: Get the message out; alas, if only was enough
  2. Attention: Production values; color; involuntary (orienting response) vs. voluntary (enjoyment)
  3. Interest: Perception of relevance; throw in novelty/something unusual
  4. Comprehension: More attention, more learning; misinterpretation a barrier
  5. Skill Acquisition: Intention doesn’t matter if don’t know how to do the thing
  6. Attitude Change: Opinion-based; attitudes and behaviors don’t always correspond
  7. Memory Storage: Key takeaways of message need to stand out
  8. Information Retrieval: Provide reminders/memory devices (e.g. jingles, slogans, miscellaneous swag)
  9. Motivation: More likely to act if behavior perceived as easy/important/realistic/beneficial
  10. Behavior: Facilitate (e.g. supply, access) brand/behavior loyalty
  11. Reinforcement: Minimize buyer’s remorse/behavior regret
  12. Routine: Assimilate into target audience’s preexisting worldview; become a part of their life (i.e. ultimate goal, difficult)

BRB, I’m going to keep these in mind forever.

Dear Apple, Keep doing what you are doing

The new Apple Watch commercial “Dear Apple” has the world talking after its debut during this year’s Winter Olympics. It’s personal, heart wrenching and most importantly highlights the incredible impacts of it’s less advertised features. This commercial emphasizes that this technology could revolutionize healthcare and provide life-changing health support. It features anecdotes of a car accident survivor using the feature on the watch to call 911 after their phone was thrown from the vehicle and a child with Type 1 diabetes pairing the watch with her glucose monitor that alerts her when her blood sugars are at low levels. While the ad still features its more traditional feature of tracking physical activity, it was nice to see that the more innovative features of its products and it’s direct benefits. While I love a good selfie, it’s reassuring to know that Apple and other technology companies are using their technology for just more than just three dimensional emojis and higher quality selfies. I look forward to seeing what other technology these companies come up with in the future to help us lead healthier lives.

If you haven’t seen the commercial check it out here: https://www.youtube.com/watch?v=N-x8Ik9G5Dg

 

 

Just Trust Me (Part IV)

In the past few weeks, I have illustrated how trust (or lack thereof) shapes the relationship between individuals and healthcare, and how mistrust is historically justified. In this last segment, I want to talk about potential solutions from a social justice standpoint.

Trust is often cited in public health from the angle of paternalism, something that public health is often associated with. When we think of optimal paternalism – using scientific knowledge to influence the health decisions of the general public – we ask ourselves: are we abusing trust, or using it for good?

Public health, while sometimes paternalistic, already stresses to its students the importance of working with oppressed communities as equals to identify and solve problems. Medicine needs to catch up. Many medical students already participate in racial and cultural training, but they need to be trained from a structural angle – to gain an understanding of oppression and policy – too.

We need to support training for healthcare providers that doesn’t shy away from the tough stuff. Hands-on learning, such as tactful poverty simulations, can help. This will allow them to understand things like how the cycle of poverty makes some patients less talkative with authority figures (such as doctors) than others. We need to support minority students in medicine, so that patients can see representation of themselves and feel understood. We need to provide incentives for students to stay in their own communities for residencies. Of course, broad class mobility-enabling policy is the ultimate solution.

Many times, our work seeks to increase trust, but that puts the burden on the patient instead of addressing the reasons behind mistrust. Teaching trust in and of itself is a paternalistic objective: we should instead focus on deserving it.

Sources:

http://commonhealth.legacy.wbur.org/2012/02/minority-doctors-diversity

https://campus.fsu.edu/bbcswebdav/institution/academic/social_sciences/sociology/Reading%20Lists/Social%20Psych%20Prelim%20Readings/IV.%20Structures%20and%20Inequalities/2002%20Lareau%20-%20Invisible%20Inequality.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2156058/

It doesn’t beep at the backseat

In 1993, the National Highway Traffic Safety Administration launched the catchy “Click It or Ticket” campaign to increase seat belt usage by emphasizing the legal consequences of “freeriding” (which is also catchy and I just coined). The campaign was considered largely successful.

In our 21st century, the CDC puts 18-24 year olds as less likely to wear seat belts than older age groups, especially in the backseat. I painfully point out that these youths were likely not cognizant, maybe not even born yet, at the height of “Click It or Ticket.” It may be time for a reboot.

Enter “Buckle Up, Backseat,” a campaign idea to increase seat belt usage in backseat passengers. Tyler Lee, a first-year master’s student studying Strategic Communication, was kind enough to present this proposal to our class today. He described how a strong focus would be on ridesharing vehicles (like Uber, Lyft, or your average taxi) since they are widely used by 18-24 year olds. Tyler and team’s formative research found that attitudes on backseat passenger seat belt usage were notably laxer when in the context of rideshares.

So don’t “freeride” (wink wink, trademark pending), and instead remember to “Click It or Ticket” and “Buckle Up, Backseat.” Catchy phrases have power.

 

Source: https://www.cdc.gov/motorvehiclesafety/seatbelts/facts.html

Just Trust Me: Part III

“You can’t health care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.” -Raegan McDonald-Mosley

Last week, my post scratched the surface of the history of oppression disguised as medical treatment. Today, I want to talk about how this mistreatment, and the historical trauma that ensues, exhibits itself in patient-practitioner relationships.

Many of us have experienced the helplessness of not knowing how much a medical procedure will cost until it’s over. It’s a terrible feeling: it feels like everyone is communicating without you; ‘above’ you. For many non-white and immigrant patients, this feeling lasts for the entire appointment: from scheduling to decision-making to discharge.

Traditionally, there are four types of patient-physician relationships, each with varying levels of patient power and involvement in decision-making. There is also a distinction between patients preferring an active or passive role in decision-making. Acknowledging the relationship between trust and decision-making preference, these researchers suggest that, for black patients, race may impact both: such that a patient who trusts her individual physician “may have residual mistrust of the health care system that limits [her] ability to relinquish decision-making control.” Cultural differences, as well as fear that the doctor does not have one’s best interests at heart, can influence the relationship between patients and their physicians in Hispanic populations as well.

Racial bias, conscious or otherwise, has been found to influence treatment decisions. Black patients are systematically under-treated for pain due to false beliefs of biological differences between blacks and whites: such as black people’s skin being thicker, or blood coagulating more quickly. This is exacerbated by existing power structures between whites and non-whites, as well as between doctors and patients. In over 200 personal stories from black women of their childbirth experiences, NPR found a constant theme of being devalued and dismissed by medical providers.

Read Part IV here.

Sources:

https://www.npr.org/2017/12/07/568948782/black-mothers-keep-dying-after-giving-birth-shalon-irvings-story-explains-why

http://www.pnas.org/content/113/16/4296

https://www.theatlantic.com/health/archive/2014/05/why-many-latinos-dread-going-to-the-doctor/361547/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766485/

http://www.antoniocasella.eu/salute/Emanuel_1992.pdf

Are Mobile Mental Health Apps User-Friendly?

by Kat Caskey

Currently, only about half of those affected by mental illness in the United States will receive any kind of treatment[1]. In the past few years, however, experts have begun to look to remote healthcare options that could improve access to mental health treatment. Perhaps most promising is the growing consensus that mental health apps, or mHealth apps, “have unprecedented potential for improving quality of life and public health outcomes” for the tens of millions of people affected by mental health conditions in the U.S. each year.[2]

Mobile apps have the unique potential to reduce many of the traditional barriers to mental health treatment. For example, mHealth apps can be significantly less expensive than traditional treatment and may be accessed anytime, including during times of crisis, without an appointment. In addition, apps can reduce cultural barriers to care as they provide a “discrete mobile environment” free from social stigma.[3]

Evidence-based mHealth apps have been proven effective at treating a variety of mental health conditions, including posttraumatic stress disorder[4], anxiety[5], depression[6], obsessive compulsive disorder[7], bipolar disorder, borderline personality disorder, and substance abuse[8]. Unfortunately, however, although patients frequently download any of the myriad of mental health apps available in the App store, many are deleted after only a few uses, and a staggering 26% are used only once. One study that surveyed mental health app users found that among the most common reasons for deleting mental health apps included “not engaging” and “not user friendly,” with “ease of navigation” being the top feature that makes eHealth apps for mental health favorable.[9]

What good are evidence-based mental health apps if people won’t use them? These results indicate trouble in the realm of user experience, which considers “user emotions, affects, motivations, and values” as well as “ease of use, ease of learning and basic subjective satisfaction.”[10] Understanding user experience has been identified as “a key step in realizing the role of mental health apps”[11] and reminds us that it is not enough to understand the clinical basis of new health technologies; equally significant is consideration of the best ways to design and implement apps for people with mental health conditions. Ideally, user experience and usability testing evaluations should involve all relevant stakeholders, including patients and providers.[12]

Especially considering the wide reach of mHealth apps, “even minor efforts to further refine the usability and utility of the app” have the potential to decrease app attrition rates and increase user exposure to evidence-based treatment recommendations.[13] As apps designed to improve mental health continue to proliferate, app designers and researchers should continue to investigate how an emphasis on user experience can improve mHealth tools for mental health.

[1] National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/index.shtml.  Accessed February 4, 2018.

[2] Owen, J. E., Jaworski, B. K., Kuhn, E., Makin-Byrd, K. N., Ramsey, K. M., & Hoffman, J. E. (2015). mHealth in the wild: using novel data to examine the reach, use, and impact of PTSD coach. JMIR mental health2(1).

[3] Owen, J. E., Jaworski, B. K., Kuhn, E., Makin-Byrd, K. N., Ramsey, K. M., & Hoffman, J. E. (2015). mHealth in the wild: using novel data to examine the reach, use, and impact of PTSD coach. JMIR mental health2(1).

[4]Rodriguez-Paras, C., Tippey, K., Brown, E., Sasangohar, F., Creech, S., Kum, H. C., … & Benzer, J. K. (2017). Posttraumatic Stress Disorder and Mobile Health: App Investigation and Scoping Literature Review. JMIR mHealth and uHealth5(10).;
Owen, J. E., Jaworski, B. K., Kuhn, E., Makin-Byrd, K. N., Ramsey, K. M., & Hoffman, J. E. (2015). mHealth in the wild: using novel data to examine the reach, use, and impact of PTSD coach. JMIR mental health2(1).

[5] Sucala, M., Cuijpers, P., Muench, F., Cardoș, R., Soflau, R., Dobrean, A., … & David, D. (2017). Anxiety: There is an app for that. A systematic review of anxiety apps. Depression and anxiety.

[6] Lattie, E. G., Schueller, S. M., Sargent, E., Stiles-Shields, C., Tomasino, K. N., Corden, M. E., … & Mohr, D. C. (2016). Uptake and usage of IntelliCare: a publicly available suite of mental health and well-being apps. Internet interventions4, 152-158.

[7] Ameringen, M., Turna, J., Khalesi, Z., Pullia, K., & Patterson, B. (2017). There is an app for that! The current state of mobile applications (apps) for DSM‐5 obsessive‐compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders. Depression and anxiety.

[8] Rizvi, S. L., Dimeff, L. A., Skutch, J., Carroll, D., & Linehan, M. M. (2011). A pilot study of the DBT coach: an interactive mobile phone application for individuals with borderline personality disorder and substance use disorder. Behavior therapy42(4), 589-600.

[9] Smith, D. Motivating Patients to use Smartphone Health Apps. Consumer Health Information Corporation. http://www.consumer-health.com/motivating-patients-to-use-smartphone-health-apps/. Published 2014. Accessed February 4, 2018.

[10] Abrahão, S., Bordeleau, F., Cheng, B., Kokaly, S., Paige, R. F., Störrle, H., & Whittle, J. (2017, September). User Experience for Model-Driven Engineering: Challenges and Future Directions. In 2017 ACM/IEEE 20th International Conference on Model Driven Engineering Languages and Systems (MODELS) (pp. 229-236). IEEE.

[11] Lemon, Christopher. “The User Experience: A Key Step in Realizing the Role of Mental Health Apps.” Psychiatric Times, 7 Feb. 2018, www.psychiatrictimes.com/telepsychiatry/user-experience-key-step-realizing-role-mental-health-apps.

[12] Price, M., Yuen, E. K., Goetter, E. M., Herbert, J. D., Forman, E. M., Acierno, R., & Ruggiero, K. J. (2014). mHealth: a mechanism to deliver more accessible, more effective mental health care. Clinical psychology & psychotherapy21(5), 427-436.

[13] Owen, J. E., Jaworski, B. K., Kuhn, E., Makin-Byrd, K. N., Ramsey, K. M., & Hoffman, J. E. (2015). mHealth in the wild: using novel data to examine the reach, use, and impact of PTSD coach. JMIR mental health2(1).

STOP Act: Implementation and Effects on the Opioid Epidemic in North Carolina

The rise of the opioid epidemic nationwide has led to an increase of attention from both media and policy makers. Here in North Carolina, a recently passed policy is the Strengthen Opioid Misuse Prevention, or STOP Act, which aims to reduce the amount of Opioids prescribed a one approach to tackle the epidemic. The STOP Act was signed into law by Governor Roy Cooper on June 29, 2017, and since then its four stage implementation has been put into effect, which will continue until 2020.

The first step of implementation occurred almost immediately after the law’s passage, on July 1st 2017, requiring Physician Assistants (PAs) and Nurse Practitioners (NPs) to personally consult with a supervising physician. This applied to Pas and NPs at facilities that primarily engage in treating pain, and the prescription will, or is expected to, last longer than 30 days. Additionally, PAs and NPs have to consult with a supervising physician every 90 days for patients for are continuously prescribed opioids.  Providers are also required to provide information on the disposal of controlled substances, both written and orally, when a patient concludes a course of treatment. The second aspect, implemented on September 1st, 2017, requires that pharmacies report targeted prescriptions to the North Carolina Controlled Substance Reporting System within a day of the prescription is dispensed.

The most recent aspect of the STOP Act was implemented on January 1st, 2018, and limits the amount of opioids prescribed for acute pain. Practitioners are not able to prescribe more than five days’ worth of any Schedule II or III Opioid or Narcotic, with an exception to things like pain after surgery, where the prescription cannot for longer than seven days. The final part of the law will be implemented on January 1st, 2020, and will require practitioners to electronically prescribed targeted controlled substances, with a few exceptions.

While it is still unclear what impact the law will have on overdose deaths in the state, it appears that the State government is attempting to address this issue. While more resources could be devoted to mental health services, naloxone access and syringe exchanges, and more programs geared toward injecting drug users rather than only those who use prescription drugs, it’s commendable that a joint effort was reached to combat this ongoing epidemic.

 

Sources:

New! Summary of NC’s new opioids law, the STOP Act: North Carolina Medical Board – https://www.ncmedboard.org/resources-information/professional-resources/publications/forum-newsletter/notice/new-summary-of-ncs-new-opioids-law-the-stop-act

FAQs: The STOP Act of 2017: North Carolina Medical Board – https://www.ncmedboard.org/resources-information/professional-resources/publications/forum-newsletter/article/faqs-the-stop-act-of-2017

STOP Act Provision Takes Effect Jan. 1, Will Limit Opioid Prescriptions: NC Governor Roy Cooper – https://governor.nc.gov/news/stop-act-provision-takes-effect-jan-1-will-limit-opioid-prescriptions

STOP Act Bill Summary: North Carolina Medical Board – https://www.ncmedboard.org/images/uploads/article_images/The_STOP_Act_summary-OnLetterhead.pdf

 

Just Trust Me (Part II)

“Dr. X, or whoever she was, she must have been experimenting on me…she left a big scar on my neck … I don’t want that lady to ever touch me again. I don’t like her and I don’t trust her.

Last week, I introduced the issue of trust in the medical setting and how it may vary across scenarios and patient characteristics. But to truly understand why some patients don’t trust the healthcare system, we absolutely cannot ignore the history of their oppression by its hands.

The most well-known medical violation under the guise of research in the U.S. is the Tuskegee “study,” a 40-year-long theft of human rights that, brilliantly and viciously, utilized both government and community-level networks to recruit black men in Macon County, AL. Most had syphilis. The participants, many of whom had never seen a physician, were not made aware of the dangers, causes, and treatment options for their disease. They were not offered informed consent, nor the option to leave the study, and many died.

But Tuskegee is only the tip of the iceberg. Henrietta Lacks’ cells were cultured without her consent during her battle with cervical cancer in 1951 and are still widely used today. Gynecologist J. Marion Sims ran “practice runs” of his procedures on enslaved women. A common belief in the 20th century was that those who could not pay for medical care, many of them poor minorities and immigrants, “owed their bodies” to science. Harry Laughlin performed forced sterilizations on “socially inadequate” Puerto Rican women until the 1970s. The list could go on.

Today, this unfathomable history is manifested in mistrust in healthcare and scientific research. Evidence suggests that black patients are less likely to trust physicians, are more worried about medical privacy and experimentation than are white patients, and are less likely to participate in clinical trials. Some patients are not fully aware of the history to their mistrust – it is a cultural feeling that has been passed down through generations. This is called historical trauma. In addition, racism is still rampant in the healthcare system, both intentional and subconscious, which I will delve into in Part III. These features make this issue even more difficult to address.

Read Part III here.

Sources:

https://www.extension.umn.edu/family/cyfc/our-programs/historical-trauma-and-cultural-healing/

https://www.ncbi.nlm.nih.gov/pubmed/8918067

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497554/

http://stanford.edu/group/womenscourage/cgi-bin/blogs/familyplanning/2008/10/23/forced-sterilization-in-puerto-rico/

http://time.com/4746297/henrietta-lacks-movie-history-research-oprah/

https://www.npr.org/2010/02/02/123232331/henrietta-lacks-a-donors-immortal-legacy

https://www.cdc.gov/tuskegee/timeline.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1405662/?page=4

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766485/

Just Trust Me (Part I)

Well I’m not trained medically, so I’m taking a lot of what they say on faith.”

This was the response of a 47-year-old man, whose interview was part of a study on patients’ trust in hospitals.

There is no universal definition of trust that will apply to every scenario. Physician training, patient’s racial and cultural background, personalities, and expectations all come into play as their relationship evolves. One recurring theme in the study cited above was “sensing that you are in good hands.” Some mentioned that their trust developed from knowing the sheer amount of training required to be a medical provider. Other patients pointed out that being desperate, or having few other options, accelerates the formation of trust.

The Trust Project at Northwestern emphasizes the role that vulnerability plays in forming trust. Generally, once we come to trust someone, we open up to them; we expose vulnerability. In the healthcare system, it works backwards: being sick, worried, or simply confused by jargon (this is called information asymmetry), the patient often begins her relationship with her provider in a state of vulnerability.

Trust can also vary in different facets of the healthcare system. When we say that a patient has mistrust in the healthcare system, are we referring to his relationship with his provider, institutions like his hospital and insurance company, or the notion of Western medicine to begin with? One study suggests that repeated interactions are a key to building trust, and that patients do not see their providers as interchangeable. These findings suggest that we should enhance continuity, not just access.

Patients with low health literacy may reveal trust in a number of ways. One extreme is blind faith in the expertise of the provider, and another is mistrust and suspicion. One study found that blind trust in physicians was stronger in patients who were older, perceived their prognosis to be uncertain, or sometimes of low SES. Trust in the healthcare system tends to be lower among racial minorities, due to a history of unethical treatment. Could race moderate the relationship between SES and trust? Can these two extremes be reconciled, or even coexist in a single patient?

Read Part II here.

Sources:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/

http://bmjopen.bmj.com/content/2/5/e001389.short

http://www.annfammed.org/content/8/5/440.short

http://www.kellogg.northwestern.edu/trust-project/videos/michelson-ep-2.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518638/

Is the Use of Strava’s Data for City Planning Racist?

By Margot Schein

Strava blends social media and fitness tracking to provide cyclists the ability to track, post, and receive feedback from other users on their activities. Strava Metro aggregates these data on a city level, and for $20,000/year cities can purchase them.1 Seeing the potential to utilize such data, cities around the US have begun to purchase these data to inform their efforts to build better and more bike lanes and paths.

Overall, this kind of data seems promising, and to my knowledge, big data hasn’t been used in this way to provide an evidence base for the creation of bike lanes. In the best case, data-driven development could lead to more people commuting using bikes and more accessible bike paths for those looking for a workout.

But, I have ethical concerns about using big data to guide city planning decisions. Namely, whether data reflect the needs of a city in general, or the needs of a particular subset of a city. In this case, there are good reasons to question how representative of a city Strava users are: wealthier, white males are overrepresented in the app2, and in fact, 77% of users overall are male.3

Cities are thus spending taxpayer money to access data that not only reflects a small portion of ridership2, but also does not reflect the demographics of that city. I wonder: who is being left out? Making bike lanes more accessible to white, upper class men and not to lower-income members of the community (who are disproportionately people of color) could serve to create a larger disparity in terms of both income and health. If bike lanes are not also made available to those who don’t already bike due to safety concerns or distance to a work place, lower-income individuals are essentially excluded from any benefits gained by the purchase of big data. Meanwhile, those who do benefit, gain even more access to work via their bikes and more available paths for workout purposes.

Cities need to be judicious about their use of big data, especially when such data are likely non-representative, accessed using taxpayer dollars, and provide benefits to white people in a city, and not black and brown people. If equity and disparities aren’t considered, well intentioned plans may serve to exacerbate problems. Strava Metro cannot be the only source or data for city planning.

References

  1. Davies A. Strava’s Cycling App Is Helping Cities Build Better Bike Lanes | WIRED. Wired. https://www.wired.com/2014/06/strava-sells-cycling-data/. Published 2014. Accessed January 21, 2018.
  2. Flahive P. Could big data unlock safer commutes for cyclists? Marketplace. https://www.marketplace.org/2018/01/08/tech/could-big-data-unlock-safer-commutes-cyclists. Published 2018. Accessed January 21, 2018.
  3. Jestico B, Nelson T, Winters M. Mapping ridership using crowdsourced cycling data. J Transp Geogr. 2016;52:90-97. doi:10.1016/J.JTRANGEO.2016.03.006.