Tuesday, October 8, 2013

Public Health Getting Small: The Case of Social Media

Yesterday I made the point that steep budget cuts in public health have caused us to embrace more limited goals over time, and have forced us to use strategies for achieving those goals that have limited impact. Today I am going to explore this in the context of social media.  Social media—Facebook, Twitter, texting, etc.—has been touted as a way for public health to reach more deeply into the community to educate and mobilize in ways we could not in the past.  This article from The Nation’s Health is typical.  But is this really happening because social media is a great way to do public health, or is it because, well, you can have a Facebook page or twitter account for free. According to the National Association of County and City Health Officials, more than half of local health departments have Facebook pages.  But is anyone healthier as a result? To dive into these questions I'll start by talking about what local health departments should be doing, and then contrast it with what we are doing.

In public health we have a clear idea of what we should be doing.  We say that we should be implementing evidence-based practices. The National Association of Local Boards of Health has an excellent guide to the topic .  What this means is that we should be doing things that are scientifically proven to work.  We should not spend a lot of the tax payers’ dollars on things whose effectiveness is questionable.

In looking at the evidence base, most public health researchers conclude that the most effective and lowest cost way to improve community health is through public policy, for example regulations against smoking in public places like bars and restaurants, regulations requiring food handlers to be trained, and regulations requiring inspection of septic systems. While the technology underlying many public health interventions is very effective: vaccines, sewers, seat belts, etc., public policies always accompany the successful implementation of such technology:  kids must be vaccinated to go to school; if you build a house you have to hook up to the sewer or get a septic system; cars must have seat belts and drivers must wear them. Some people are bugged by regulations, but regulations work to protect the health of the public.

Another thing the evidence shows is that broad-based multi-media campaigns to educate and inform the public can be effective in improving public health also. The City of New York’s anti-smoking campaigns are a good example. These campaigns involve many community organizations, multiple media channels and the use of messages shown by research to be effective. Furthermore these campaigns are sustained for long periods of time and are regularly evaluated so course corrections can be made. All of this means they cost money. 

 There aren’t many good examples of such campaigns from Michigan recently.  The Governor’s 4x4 campaign encouraging people to get health screenings was intended to be such an effort, but the financial support was never there in the legislature.  Furthermore, at the end of the day there was no enduring policy change.  When the campaign dollars were gone it was back to business as usual.  MMDHD had a tiny bit of funding for one year under that plan. Our employee who was trying to support the plan by working 10 hours a week on it is now busy helping people get insurance on the Marketplace instead.

We start out trying to convince policy makers to embrace policies that protect the health of the public. If that doesn’t work we switch to broad-based community campaigns to convince the public to alter their behavior voluntarily.  When we can no longer afford effective campaigns, we switch to, well, Facebook pages. 

John’s Hopkins student and experienced social marketer Erica Holt is researching public health and social media.  She recently shared her literature review on the topic. She asked and answered the question…
“Does social media work [for public health] in certain situations, with certain audiences, for certain health outcomes? There’s not one study that I’ve found that shows this is the case, just yet.”

Before I go on, I should say I agree that health departments should have Facebook pages and Twitter accounts.  They should have them for the same reason they have a sign in front of their building, or a phone number.  The thing is, you cannot show that the sign improves health. The existence of the sign is not a sufficient condition for health improvement; it tells you a health department is here, but not whether that health department is doing its job.

In fact MMDHD is listed in a recent issue of the American Journal of Public Health as an innovator because we got into Facebook early.  However, the same article concludes that most local health departments with Facebook pages have fewer than 200 followers! 

There are some evidence-based practices related to social media that Erica Holt missed. But these practices do not support the effectiveness of broad-based campaigns based on free social media alone.  Instead they all involve interventions using social media with people who have already made up their mind they want to make a change—for example text message reminders to diabetics who are already involved in a nutrition and exercise program.  MMDHD’s Facebook page for breastfeeding moms in the WIC program is popular because these moms are engaged with their health and want to learn more.  But texting an over-eater who is not worried about their over-eating has shown no promise so far.  And Facebooking about immunizations on a site with 200 followers isn’t going viral.

One of the most widely cited examples of the effective use of social media by public health is the Zombie Apocalypse campaign the CDC has run for several years.  The campaign was enormously fun for us in public health, and it probably is effective as a curriculum aid. But I wonder what we got at the end of the day.  I still want to know if Americans understand the principles of communicable disease control better, or if they are more supportive of governmental public health, as a result?

Monday, October 7, 2013

The Shutdown: How Cuts Weaken Public Health

We are into the sixth day of the government shutdown of October 2013. Is it affecting the Mid-Michigan District Health Department?  Yes, it is.  We’ll begin the day on Monday morning by working on contingency plans (Instead of doing the work our clients and staff want us to be doing!). If this goes on a couple of more weeks, the State may have to stop reimbursing us for some services. Without that reimbursement we will not be able to pay staff to deliver those services, so the Federal layoffs will start turning into state and local layoffs.  Furthermore, our employees eat and shop locally, and our clients spend their benefits in local stores, so local businesses will soon feel it, too. 

But today I am not going to blog about how bad the consequences of this way of making policy are for the public interest.  Plenty of other writers have got that covered. In this post I do want to make two points:  First, the shutdown is just another in a long series of blows to the ability of American communities to protect the health of the public. Second, these blows have had a cumulative affect that is profound in certain ways. One of the more profound effects of the long decline is that, over time, it causes us to set goals that are more and more limited, and to use strategies for achieving those goals that are less and less effective. Oddly, we are doing this without really acknowledging that it is happening.

To the first point: here is a great slide, first used by my predecessor, Kim Singh. We have continued to update it. It shows funding for what is called Essential Local Public Health Services (ELPHS) in Michigan.

These are funds the State pays local health departments to provide mandated services.  It shows that ELPHS today is 3 million dollars less that it was a decade ago.  But it also shows that funding is 13 million dollars less than would be needed to provide the same level of service, adjusted for inflation!  In other words we only have two-thirds of the inflation-adjusted ELPHS dollars we did a decade ago.  Of course the services are still mandated.

Other cuts, like the sequester, the shutdown, reductions in local funding and the loss of grant funds have had their impact, too. Since 2008, 44,000 local public health jobs have been lost according to our professional organization, the National Association of County and City Health Officials. A dozen of those positions were at MMDHD.

As a local health department loses resources, its ability to carry out its mission is compromised. By this I mean it is forced to set more limited goals, and to use strategies that are less and less effective.  I am going to write about this tomorrow. I’ll be taking as my example the use of social media to educate and inform the community about health issues, in which health departments are settling for what may be fairly ineffective communications strategies that happen to be free.