Public Health considerations in designing strong e-Public Health interventions

1. Public Health considerations in designing strong e-Public Health interventions B. R. Simon Rosser, PhD, MPH, LP Professor and Director: HIV/STI Intervention and Prevention Studies (HIPS) Program Division of Epidemiology and Community Health University of Minnesota School of Public Health

2. Overview • Presentation (15 minutes): • What is public health and e-Public Health? • How does e-Public Health view the Internet? • What are some examples of e-Public Health priorities? • Exercise (10 minutes): Working in e-Public Health • Group Discussion (20 min) • What are the social, ethical and policy implications of using Internet technology to advance Public Health • Wrap-up (5 min)

3. Teaser • Why do rich people live at the top of hills and lake side while the poor live in crowded slums? (Hint: Miasma Theory) • How many of you believe that • Women should suffer pain in childbirth because it is part of the natural course of things (consequence of “the fall” in Genesis). • Men wounded in battle should suffer pain because it is their natural role of soldiers to hurt and be hurt? • How many of you have ever got sick by eating at a bad restaurant or drinking bad water? How did you suspect it was the food or water, and not the air? • Who is the “father” of epidemiology who in 2003 was voted the greatest physician of all time?

4. A Brief Introduction to Public Health • Born in England in one of the poorest parts of town subject to flooding and cholera. • 1847, Introduced ether and chloroform as an anesthetic. • Personally gave Queen Victoria anesthetic during childbirth. • In 1854, an outbreak of cholera occurred on Broad Street in Soho, London. Dr. John Snow, 1813-1858

5. The Soho Cholera Epidemic, 1854 • Cholera, a fast-spreading epidemic, leading to widespread mortality. Large populations fled when cholera broke out. • At the time everyone thought it was spread by bad air (Miasma Theory). • John Snow went door-to-door, interviewing neighbors. He discovered 61 deaths had all got their water from the public water pump on Broad Street. People nearer the pump got sick first. Everyone not sick drunk from a different pump. • He concluded cholera (a) was spread by bad water not bad air; and (b) got the pump closed down. The cholera epidemic stopped. • As a side note, Dr. Snow only drank boiled water for the rest of his life.

6. Public Health • Public Health is defined as “organized community efforts to ensure conditions in which people can be healthy. Activities that society undertakes to prevent, identify, and counter threats to the health of the public.” • Schneider, M-J. (2000). Introduction to Public Health. Gaithersburg, MD: Aspen. • Principle: Because a focused intervention is typically more effective than an unfocused one, Public Health interventions typically focus in one of three areas: • 1° prevention: Promoting health and preventing disease (in those who don’t have it so they never get it); • 2° prevention: Preventing disease progress (in those at risk e g. by early detection); • 3° prevention: Preventing effects of disease in those with it (reducing morbidity and mortality).

7. e-Public Health • So is there a way of using the Internet to advance health? • e-Public Health is defined as “The promotion of health and prevention of disease at the community or population level using Internet-based research methodologies, interventions and policies. An emerging sub-discipline, e-Public Health encompasses online health promotion strategies for the public or targeted communities, the study of how Internet-use and e-communication may change health risk, and also the health promotion and disease prevention of virtual communities.” • Rosser, B.R.S., Oakes, J.M., Bockting, W.O., Babes, G., Miner, M. (2007). Capturing the social demographics of hidden sexual minorities: An Internet study of the transgender population in the United States. Sexuality Research and Social Policy, 4(2): 50-64.

8. Social Cognitive Theory (individual health) (Bandura) P (person) B (behavior) E (environment) • Principle of reciprocal determinism: Behavior is determined by a mutually reinforcing relationship between a person’s cognitions, actions, and the environment. • => Change the environment and/or the person’s understanding, and you must change the other dimensions

9. Application to Public Health C (community) B (behavior) E (environment) • Principle of reciprocal determinism: Health risks and behavior are determined by a mutually reinforcing relationship between a community’s understanding, behavior, and the environment. • => Change the environment and/or the community’s understanding, and it will change health behavior

10. Application to e-Public Health C (community) B (behavior) E (environment) • Offline health behavior is influenced by a mutually reinforcing relationship between a community’s understanding, their online behavior, and the Internet environment. • => Change the Internet environment, the virtual community’s understanding, or their online behavior and it must change health.

11. Principle: Think in multiple paradigms • What is the Internet (when approached from an e-Public Health perspective)? Tool (Method, technology) Environment (Structural, Virtual) Community (culture, communication) FFI: see Pequegnat, W., Rosser, B.R.S., Bowen, A., Bull, S.S., DiClemenete, R.J., Bockting, W.O., Elford, J., Fishbein, M., Gurak, L., Horvath, K., Konstan, J., Noar, S., Ross, M.W., Sherr, L., Spiegel, D., Zimmerman, R. (2007). Conducting Internet-based HIV/STD prevention survey research: Considerations in design and evaluation. AIDS & Behavior, 11:505-521.

12. Internet as a tool/technology The Internet as a tool may promote health by • Improved survey techniques (e.g., automated randomization, skip patterns, probes) • More rapidly contacting people at risk (e.g., email) • Increasing access (e.g., mass alerts) • Increase understanding (e.g., webcam, visuals) • Improve ways of communication (e.g., telemedicine, web-based distance nurse triage). But how are Internet tools changing your health risks?

13. Internet as environment The Internet as an environment may change health behavior. - Every house with Internet now has the same health dictionary and access to health information and misinformation, and health sites. How is this changing “traditional” health-seeking practices (e.g., doctor visits vs health websites)? - “Internet 2” is a project the U of M is participating in (PI: Kevin Peterson) designed to link most family practice clinic EMR data in the US and UK to instant upload that can be used to track health risks and identify rear cases (e.g. Bird Flu). - How do webcams of experts coming directly into your home change what health you attend to? - Is this really a cool, new, neat, teen buddy, or is a child molester stalking my child? How does child safety change when the Internet is perceived as dangerous? - In the Internet environment, person, place, and time all become more relative. • How long is too long? Time is changing. What was an acceptable wait physically (e.g., 15 min wait for a doctor) is an unacceptable wait for the same information to come up via the Internet. • Most people search only 1-2 sites for an answer. Are we replacing the “most expert” information with the “most accessible” information. • Early software to block sexually explicit words from computers also blocked out health information (e.g., “breast” for “breast cancer).

14. Internet as community/culture To be credible, health researchers need to learn the rules of online communication as it has it’s own culture (language, social rules, in- and out-groups). • People tell the truth more easily online; they also lie more. “surfing” and “lurking” is more acceptable. • More direct, symbolic language (, LOL, FAQs) changes how we communicate, which changes the messages we send. • Blogs are replacing traditional news sources. • “Virtual communities” organized around certain issues are common. What are the health risks and benefits of being part of online communities?

15. Cutting edge in e-Public Health Intervention Research Environment: Ensuring healthy web environment and structural interventions. Community: Promoting virtual community health Technology: Designing e-tools to promote health and prevent disease

16. EXERCISE Now, in pods, • 1. Ask how the Internet, Internet use, and online cultures may be changing the risk for the disease or health risk you are proposing to study. • 2. Discuss innovative ways to use the Internet – as tool, environment, and/or culture - to change: • Awareness of the health risks • 1°: Prevent persons from getting the disease • 2°: Target populations at increased risk of the disease, and those exposed who may not know it. • 3°: Target populations with the disease.

17. Steps and strategies in designing strong e-Public Health interventions

18. Exercise:Step 1. Identify your motivations(Why do you want to develop interventions, or be part of a team developing interventions?)

19. Real World Motivations Why do people design interventions? • Make a difference: Passion for improving health/preventing disease • Respond to a need: See a need but there’s no or insufficient response • See an opportunity: A funding agency releases funds and calls for proposals • Fill a gap: There’s a lack of online Public Health interventions for this. • Address a need better: There’s something the Internet would do much better than conventional. • Test an idea: You see something online/offline and realize that there’s amore effective, better way to do this online.

20. Strategy 1. Follow your passion Read through the following issues, what resonates for you? • Predators are going to Myspace and soliciting sex with minors. The FBI is working with Myspace to intervene but wants to know the best intervention. • After Virginia Tech, where a student committed multiple homicides, a University wants to develop a effective method of immediately warning all students and shut a university down. What’s the best online methods? • Uninsured persons are using Internet searches to seek health information, but how can they tell if the information is accurate? • A plane passenger is later diagnosed is a multi-resistent strain of TB (MRTB) and may have exposed others on-board. Health authorities advise the airline to locate everyone on that flight and provide essential information on MRTB, urgently. • Online offers for effective and ineffective health-enhancing products reach hundreds of thousands of people daily. How is it changing Americans’ view of health, sex, and what is normal? • You want to meet that special someone. What’s better: to date, conventionally, or use an online site that “matches” you against a data base of thousands of potential partners? How is “instant match” changing Americans’ expectations in a relationship and view of relationships? • How can we assist rural populations, the homebound, the disabled and persons with chronic disease use online resources to overcome isolation? • How important is it for health that we “treat” the digital divide? Are communities without Internet access doomed to poorer health? How can we change this? • Because shame is a powerful barrier for persons with stigmatized health behaviors and illness, they may seek help online. How can we best help alcoholics, compulsive online shoppers, severely depressed, and phobic persons through online interventions? • You friend refuses to go see a health professional about an infectious disease. Should we have a system where the health professional comes to them (virtually)? Do we need webcams in every computer?

21. Strategy 2. Recognize your strengths For a productive focused career, you need the ability to recognize your strengths. An interventionist maybe passionate about • a population • a health issue • an area to advance health • a strategy to influence health (e.g., Internet) What would you be happiest building this quarter?

22. Step 2. Dare to Dream…but ground your dreams is in the DO-able 3 Logical Areas to Design e-PH interventions include: • a. translational research – taking something that has proven effective offline and developing online equivalents. • b. e-interventions – identify the strengths of the Internet and apply it to health. • c. hybrid interventions – use the Internet as part of a broader strategy/intervention particularly where it is better. (e.g., mass screening for an outbreak)

23. Translational (to Internet) Research • There’s a whole world of offline Public Health interventions that would reach more people or people would be more open to receiving if they could be done effectively online. • There’s another whole area of Public Health (e.g., contagious disease) where public safety is less at risk if the intervention could be online.

24. BUT… • Principle of translational research: Not all theories work in all situations / translate across environments. Challenges include: • Adaptation (maybe the intervention changed so much it no longer reflects what originally worked, or we took out the “active” ingredient • Hawthorne effect (maybe the intervention never really worked but only seemed to) • Selective translation (maybe I did not transfer the “active” ingredient. • Environmental/population specific theory (maybe the theory doesn’t apply).

25. Step 3. Define the big picture/objective • Write out* the broad, long-term objective: • E.g., Public Health:“To reduce high risk behavior among those at greatest risk for <<health condition>> and • E.g., Science: “to advance knowledge in how to build effective e-Public Health interventions.” * Good practice is to boil this down to one sentence that communicates the key idea.

26. Step 4. Write out achievable aims • Step 2. Write out 1-3 key goals that are the logical place to start. These are called the specific aims. • E.g., “Develop an Internet-based <<health promotion/disease prevention>> intervention for <<target population>>.

27. Exercise: Backwards Brainstorm Imagine for a moment that you’ve worked very hard in this course and developed a great e-Public Health intervention. It’s so good that people are in awe of it. Now, identify the characteristics of that good intervention…

28. Exercise: Name characteristics of effective interventions

29. Step 5. Define the Characteristics you want your intervention to have

30. Characteristics of effective interventions Source: Rosser, B.R.S. (2004). Unpublished table from: Men’s INTernet Study II (MINTS-II) for HIV Prevention.

31. Step 6. Identify a theory to guide how to build the strongest intervention THEORY is like the foundations of a building, or the blueprint of a design document. Choose a blueprint (theory) appropriate to what you are trying to do. Critical questions to ask: • Should it work? Is your proposed intervention based on a convincing theory of behavior change? • Has it worked? Is there evidence showing this approach has worked in other (offline) settings? • Does it pass the “smell” test? Would it work for me?

32. How to choose a strong theory: Use the ecologic model. At least 5 levels of influence determine health behaviors: Public Policy/Structural Community factors Institutional factors Interpersonal relations Intrapersonal factors Source: K. R. McLeroy et al., (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15: 351-377.

33. Intrapersonal-based theories Depression as a public health issue.

34. Individual level theories Public Health has taken many individual level theories, often hybrids, and applied them to behavioral change. Examples include: • Stages of Change Model (Prochaska) • Information, Motivation, Behavioral – IMB - Model (Fisher and Fisher) • Health Belief Model (Janz and Becker) • Motivational Interviewing (MI)

35. Interpersonal-based Theories

36. Summary In this unit, we • Identified key concepts in public health approaches to health promotion • Reviewed a tool-community-environment model of understanding the Internet • Identified a 6-step model to formulating an e-PH intervention.

37. Next Units • 2.1 examines Internet technology • 2.2 reviews examples of e-Public Health interventions.

38. For further information, contact: B. R. Simon Rosser, PhD, MPH, LP Professor and Director HIV/STI Intervention and Prevention Studies Program Division of Epidemiology and Community Health University of Minnesota School of Public Health 1300 South 2nd Street, #300, Minneapolis, MN 55454 Phone: (612) 624-0358. Email: rosser@umn.edu HIPS Program