http://publichealthliteracy.blogspot.com/

The Silly Bandz craze reminds me of how malleable we humans can be and, as Dan Ariely says, how predictably irrational we are in our daily lives (Predictably Irrational, Harper Collins, 2008).   A human trait that we haven’t been able to capitalize on in most of our efforts to influence and “change” public health behaviors.
In The Tipping Point ( Little, Brown, 200) Malcolm Gladwell writes about an intriguing human phenomenon – the almost magical point at which a behavior among a small group becomes a trend, and sometimes an epidemic. For example, the resurgence in popularity of the almost dead shoe brand, Hush Puppies, – starting with kids buying them in resale shops in the Village, and ultimately becoming hip in Manhattan’s bars and clubs in the mid 90s; or the drastic change in ideation about among youth on the island of Micronesia over the past 30 years – it now being viewed as a statement of their spirit of experimentation and rebellion.
It’s not a new question, but I’ve been thinking about it again as I work on an obesity project here in NYC - How do we put this daily human phenomenon to work in public health?
We need to be using what commercial and social marketers have known for decades – convince people, rather covertly, to take their cues from the healthier role models, thought leaders and behaviors around them.  If the messenger is as important as the message, who should be delivering messages about healthy lifestyle, in what voice?  What would it take to instigate a word-of-mouth, “The red coats are coming” style epidemic of healthy eating and activity.  Clearly the top-down, expert driven messages about the risks of overweight and obesity, how to count calories and how much to exercise, have not worked.

The main culprit – is not complex language- as we know. It is the health and science concepts.

AND it is also the format or approach of the teller.

Take for instance the front page NYT story today “Debating Just How Much Weed Killer Is Safe in Your Water Glass”

I read the title as a bad joke – surely NO LEVEL IS SAFE THANK YOU.

But alas the story’s title was not written to be rhetorical.

The entire story is indeed an homage to the “dueling expert” approach to journalism.

State a problem and it’s common sense, person on the ground interpretation (atrazine in my drinking water is a bad thing), but then undermine any conviction I might have in the well-reasoned value of science, by presenting a list of debating experts and their debatable facts.

This is a long-lived journalistic writing strategy – you cover a story by presenting opposing viewpoints.

At best it’s “high-minded” and in some past demonstrated a commitment to an informed, thinking public, coming to their own decisions. (See Herbert J. Gans, Democracy and the News,

But what about at it’s worst? What if the story telling becomes the main goal. And controversy and uncertainty make a good story?

From a public health literacy perspective taking a topic that the public is already very interested in ( the safety of drinking water), and formulaically fashioning stories that are more about what the journalist wants to ( or is told to ) write about, is doing very little for allowing the public to acquire facts and think through risk and possible ways to reduce risk.

A more sociological or cultural approach to journalism about health and environmental issues would include some elements that would make it easier for readers to understand, interpret and act.

To the journalism professor and theorist this notion is abhorrent. “That’s what you can find in your blogs and other user – driven communication and media.”

Well – maybe that’s the point. Old, who/what/when approaches to journalism may very well be a primary reason for the proliferation of popular self publishing. Someone has to step up and present important information that may help us understand and participate in public discourse in ways that will lead us to healthier and safer lives.

We know from general media reports, and out own intercepts here in NYC most residents have heard about and understand the basic hygiene recommendations promoted for reducing risk of contracting swine flue:

• Wash hands thoroughly and frequently with soap and water
• Avoid contact with people who are obviously sick
• If you get sick with any cold or flu, stay home from work or school; avoid contact with others as much as possible     

New York City Office of Emergency Management     http://www.nyc.gov/html/oem/html/home/home.shtml

 “What should I do to keep from getting the flu? 
First and most important: wash your hands. Try to stay in good general health. Get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food. Try not to touch surfaces that may be contaminated with the flu virus. Avoid close contact with people who are sick.” 

CDC   http://cdc.gov/h1n1flu/swineflu_you.htm

A concept that is hard to find in the BASIC information for the public is the story of public health and global health surveillance. The CDC site does refer to “EpiAid teams” being deployed, and “many epidemiological activities are taking place” and “active surveillance in the countries where infections in humans have been identified.”

But knowing what we know about low health literacy among the majority of adults in the US, and the complex concepts embedded in understanding surveillance, it’s safe to assume that people do not understand surveillance in ways that will help them place the current outbreaks in context, and help understand their risks better.

Why is public health surveillance important information for advancing public health literacy?

I was reading the NYT story (Saturday 5/3/09) “Questions Linger Over the Value of a global Illness Surveillance System” and “Flu Outbreak in Mexico May Be Smaller Than Feared”  and in these well written pieces the journalists are telling the story of how the surveillance is unfolding – what kinds of information health experts and epidemiologists had early on in the swine flu outbreak, what they know now, and what information they’re expecting to have soon.

With a bit of science health literacy (that’s how I describe my literacy in that area), the stories put the outbreak into clearer, relative perspective. Key elements:

• There is an “expensive and evolving illness surveillance system constructed over the past decade.”
• The WHO plays a key role in global health surveillance and it has “ an extensive intelligence network of hundred of its own offices and thousands of experts.”
• The carefully follow up on reports anywhere in the world of clusters of acute respiratory illness (in this particular case). On April 17^ththey uncovered a report “of an unusual case of pneumonia death in Mexico that was reported to be similar to those in China during an outbreak of SARS.”
• Multiple international organizations plan on “measures of cooperation.”
• One article concludes “ early warnings of even relatively mild, new flu strains are important.”

I think it’s vital to begin to tell the story of public health surveillance in a clear understandable manner.  Without some understanding of this, and other science concepts, the public has limited ways to talk about and understand this and future outbreaks.

Question of the Day:

• Do you agree or disagree that this is an important message to get out?
• What could the information look and sound like?

I’ll rely on Paulo Freire’s concept of transformative education (his theories grew directly from his work with the poorest and most marginalized populations in Brazil).  I’m taking the liberty to substitute (health lit) for education below.   In Pedagogy of the Oppressed and elsewhere, Freire convinces that meaningful education will always lead to a dialogue about power, agency and history. Education is transforming and it leads to action.

Achieve a critical  conscientiousness and this creates social critics.  This is precisely what a broken health system (the state in Singleton’s comment, I suppose) needs. Individuals with adequate health literacy can and do become critics of the system.  They realize more of what they need and begin to ask, or demand it.

The second concept I will lean on is that of collective action for a common good. In the 1980s and early 90s “informed health consumerism” was hot.  This was at a time of growing managed care and radical changes in the health care system and health care coverage. We run into problems with the “informed consumer” approach in that it only truly works well for members of a society who have standing in a commercial system – the middle and upper classes.    And so, the smart consumer model often winds up blaming the victim – “He didn’t stop smoking so why is he surprised he’s developed lung cancer.”  Or, “She is obese and her diabetes is her own doing.”

If health care is simply another commodity (which I believe it is not), then buyer beware.   If we look at how health system changes actually occur, they are very often propelled by collective action.  Less often are they the right-minded action of state leaders ( politicians and corporations).

Think back to the late 1980s in HIV and AIDS health care in the US.  After a major effort on CDCs part to “educate” the public about risk, it became clear that communities of gay men were going to be more ready, willing and able to educate on the community level. CDC started diverting its funds directly to community-based organizations (We wrote about this in a case study in our book, Advancing Health Literacy). The more information communities had the more they were able to design outreach, education and mobilization that changed the very face of all aspects of AIDS research and education right to this very day.

A final thought – urging people to take more personal responsibility for their health rarely yields desired results.  As you point out, it makes for good right-wing conservative framing, but it doesn’t make for good public health. It’s so much finger pointing.   So seems to me that we should find out more about why urging people to take on more personal responsibility – being better health consumers falls flat.

Here’s something I’ve been learning in my recent field work:  I was leading a series of focus groups with overweight adults living in inner-city NYC.  The goal was to figure out how to frame messages about obesity and obesity prevention.   We found that the personal responsibility message fell flat – people had been trying unsuccessfully to lose weight for years.  They were personally failing and felt that way.   But when we turned the groups’ attention to the super-sized culture, the preponderance of fast food and junk food stores in their neighborhoods, and the lack of healthy eating option in the inner city, the issues of food equity and social injustice propelled people to feel a new energy about the topic.

Henry Giroux writes, in his preface to Literacy Reading the Word and the World, (by Paulo Freire and Donaldo Macedo): “ …. literacy …. becomes the central pedagogical and political mechanism through which to establish the ideological conditions and social practices necessary to develop social movements that recognize and fight for the imperatives of a radical democracy”  (Freire & Macedo, p.6).

With adequate health literacy we can place ourselves in culture and society and see ourselves as actors and agents of change.

http://www.nytimes.com/2009/06/28/health/research/28cancer.html?pagewanted=1&_r=1&hp

The article is a nod to what many of us have been up against for years – think outside the narrow, incremental box of small – minded studies and you either don’t even try for a federal grant or you court a foundation with the vision and pockets to support you.

Is there any cause for optimism?

Chris

A 2003 paper by Andrew Singleton is critical of the role of self-help in ‘empowering’ men. Singleton notes the limits to self-help for men who are anything other than mainstream middle-class, and his description of the ideal men’s health self-help consumer sounds identical to the ideal health-literate man: a man who is motivated to access and utilize health information in pursuit of ‘the good life’.

In answer to a question from me about men’s health, Singleton has explained how the notion of ‘privatizing’ health, in the sense of making it an individual’s responsibility, is consistent with neo-liberal ideology:

“As a sociologist, I think that the best approach is structural change rather than reliance on individual action. Individual action suits a neo-liberal ideology in that it focuses on the consumer, but health care is a state, not an individual issue, because those who need it the most are the ones you take the least care (i.e. lower SES, men, etc.) In any case, I think that men don’t make good, responsible consumers. It is the opposite: notions of real masculinity are about being bad health consumers.”

This really challenges my thinking about health literacy, as:

a) I agree with him that — based on my discussions with Australian males of all ages and socio-economic groups, and particularly those in lower SES groups — it is difficult to find men who are actually interested in taking more responsibility for his own health or who is even particularly receptive to health-related information;

b) Singleton’s view seems to conflict with the prevailing ideology of health literacy (prominently advocated by Kickbusch and others), which alleges that health literacy is a key element of empowerment and building social capital, and seems to incorporate the assumption that people will want to have a high level of health literacy; and

c) Public health advocates, particularly those working on issues such as tobacco and obesity, have been strong advocates for structural and policy reform, as an acknowledgement that people’s decisions (and indeed, their available choices) are the products of the physical, social and economic environment in which they live. In contrast, the “individuals must take responsibility for their own health and that of their children” line has been used by politically conservative decision-makers, and by industry, as an excuse not to make the sorts of structural/policy changes that have been shown to be important for population-wide change.

Singleton’s position suggests to me that perhaps health literacy — particularly in its broad sense, rather than just literacy in a clinical setting — needs to be viewed more realistically, and even harshly, as something that will have only a limited role for people who are not at least ‘middle class’.

To the extent that we expend our energies in working out ways to improve people’s health literacy, and talk about the importance of doing so, are public health advocates simply being complicit in supporting the very ideologies that many of us have been arguing so strongly against?

- Margo Saunders
Public Health Policy Consultant
Canberra, Australia

I might be feverish.  But I don’t have a thermometer ( tossed out the old one with mercury in it long ago – science literacy) and not feeling as though I need to go around the corner to get a new one just yet.  But will go look up the symptoms of HINI – which I’m now going to google as “swine flu symptoms” ( fundamental literacy).

I quickly skip by twitter posts like – “I think I have swine flu. I’ve been laffing alot today and have started snorting like a pigg. But rather land at CDC’s site: (civic literacy – choosing what are scientifically vetted, trustworthy sources of info):

What are the signs and symptoms of this virus in people? The symptoms of this new H1N1 flu virus  in people are similar to the symptoms of seasonal flu and include fever, cough, sore throat, runny or stuffy  nose, body aches, headache, chills and fatigue. A significant number of people who have been infected with  this virus also have reported diarrhea and vomiting.  Also, like seasonal flu, severe illnesses and death has  occurred as a result of illness associated with this virus.”
http://www.cdc.gov/h1n1flu/qa.htm Accessed 5/20/09).

Hmmm.
Maybe I will go get that thermometer.

I’m going to seize the opportunity today to try to notice and list the health literacy skills I use over the course of the day to figure out if the miserable sore throat I’ve woken up with is simply that ( and not the H1N1 virus):

1. No fever – therefore using what I’ve heard on TV (civic literacy) as a symptom – high fever – and deciding I don’t meet this criteria ( at this point);
2. No coughing – again using my civic literacy – what I’ve gathered from TV coverage and signs about coughing and sneezing into your sleeve to gauge whether I meet this criteria.
3. Drinking tea – rather than my Starbucks this am. Must be cultural literacy at work – I grew up in a household that only drank tea when we were sick.
4. Emergency Room vs Physician – idly thinking that if I do wind up needing some medical attention what would I do? The emergency rooms in NYC are backed up because of resident concerns, so pretty unlikely that I’d do that….. (civic literacy again – what I’ve heard in the media and what I know about how the emergency health care system works).
5. Info reconnaissance – time to turn on the morning news shows….

8:22 AM -
Decide not to go to work. I could manage, but definitely don’t want to spread whatever I have – civic literacy. But realize that so many people CAN’T STAY HOME FROM WORK.

9:20 AM
Took the dogs out for their walk and met up with the dog run folks in the park. In passing, along with discussions of dog poop and dog sitting woes I mentioned my bad cold – no appreciable steps backward from anyone. But as I turned to continue to crawl home one woman did call out “You know they closed a private school a few blocks away – that flu thing. Feel better.”