When We Tweet About Health

A few weeks ago, I discovered that not one, but two colleagues in my PhD program— people I previously held in high esteem, had no idea who Amal Alamuddin Clooney was.  I did not think it was possible to not know.  But, like many things in life, whether or not you know who Amal Alamuddin Clooney is and every outfit she wore over her wedding weekend in Venice depends greatly on where you get your information (for Dan and Ilene, that would be the smooth underside of a rock). 

Where we get our health information is not just a matter of self-improvement, but one of public health.  One only needs to look at the current Ebola outbreak to see the importance of accurate and trustworthy sources of information.  As more and more of our conversations and news-seeking occur online, it’s important to understand who is talking about health online and what they’re saying.  With that in mind, I teamed up with a few colleagues* to examine health conversations occurring on Twitter.  Our results were published last month (synergy!).  We especially wanted to know the types of things people tweeted about (like whether it was evidence-based, personal, or commercial), and whether different types of users (like doctors versus patients) tweeted about different things.

Word cloud of health-related tweets in our analysis (Lee 2014).

Yes, Readers, qualitative research is every bit as sexy as it sounds.  We systematically gathered a pile of tweets and categorized each one.  We found a diverse array of health-related user groups posting about a wide range of health topics.  For example, while organizations and businesses use Twitter to promote their services and products, patient advocates are using this tool to share their personal experiences with health.  Most health tweets were claims that users would expect to be supported by some level of medical evidence or shared news, though whether these claims were actually scientifically valid was not examined. 

While our study may not save lives "millions at a time", it is among the first to capture, in depth and breadth, what users are tweeting about health.  It points to the diverse activity on Twitter and the need for helping users, especially patients, make sense of the health tweets out there, by medical professionals, you, me, and even Amal Alamuddin Clooney**.  Knowing about our information sources enables us to know what to do with their information. 

*Colleague is too inadequate a term.  I worked with four wonderful mentors who generously welcomed me and patiently guided me through the whole process. 

**Not actually on Twitter (but I am!  Follow: @superlegitJoy)

Jedi Mind Tricks

Let’s start with an exercise.  Think of the last 2 digits of your social security number.  Got it?  Now, at what year did Albert Einstein emigrate to the United States?

Did you guess 1933?  If so, you are the smarty pants exception to the rule.  Chances are, if your social digits are high, you guessed high, and vice versa.  This is an example of a neat behavioral economics mechanism called “anchoring,” in which our decision making processes are affected by information around us.

In the realm of public health, behavioral economics can help us make the right decisions.  We often know what’s good for us. But we can’t always do what we want to do.  I don’t want to eat a bag of leftover Smart Food by myself.  I don’t even like popcorn.  And yet I do.  As I’ve discussed before, public health sometimes helps us out of these jams by taking away opportunities for us to make mistakes.  But sometimes public health gives us the choice to decide.  Then helps us to make the right decisions. 

(One of my favorite institutions in Brunswick, ME)

One example of this help comes from Dr. Sara Bleich at Johns Hopkins.  In a wicked cool experiment, Bleich and her team posted 3 different messages about soda at neighborhood bodegas. 

“Did you know that a bottle of soda or fruit juice has about 250 calories?” 

“Did you know that a bottle of soda or fruit juice has about 10% of your daily calories?” 

“Did you know that working off a bottle of soda or fruit juice takes about 50 minutes of running?”

Do these statements do anything for you?  Which statement is a bigger deterrent for you?  I’m an easy target, but the exercise one rings most powerful to me.  (Full disclosure: Because of my terribly indiscriminate I'm-a-hungry-grad-student-diet, I'm easily shamed and susceptible to suggestions.  This usually results in buying many overpriced bananas by the cafe checkout counter.)  Bleich and her team tracked the buying behavior of adolescents in the stores over a 6 months period.  They found that the signs worked.  Looking at the 3 strategies as a whole, the odds of buying a “sugar sweetened beverage” (soda or fruit juice) decreased by 44% after they posted the signs, as compared to before.  Looking at the 3 methods separately, the exercise information was significantly associated with a decrease in purchase. 

Even if quinoa and kale aren’t a part of your regular diet, the evidence on the negative health effects of consuming too much sugar (i.e. empty calories), especially in adolescents, is weighty and obvious*.  Yet information alone can’t improve population health.  Public health relies on brilliant folks like Dr. Bleich to figure out the right tricks to employ to help us make the right decisions.

*Never an inopportune time for a DHem plug.  Thanks to Jesse for the reminder.

Counter Culture

Contrary to what my summers at the Center for Talented Youths may suggest, I was not a gifted science student.  Labs made me especially nervous because they put my knowledge to test amidst combustibles and corrosives.  But all that changed in Professor Paul Baures’ Organic Chemistry II Lab.  He was unflappably patient when we asked questions we should have learned in lecture, and unfailingly kind whenever we drained the wrong layer, knocked solutions over, or broke yet another pipette.  Professor Baures created a culture where instead of diluting solutions with water to ‘look right,’ we felt safe and encouraged to work until we got it right.  I even went on to be an orgo lab assistant*. 

(Goggle Gang, 2007.  One of my favorite pictures.)

I hope you have felt the magic of a Professor Baures.  They demonstrate how much setting the right tone and culture matters.  It’s no surprise that positive work cultures are associated with better outcomes.  In the hospital context, that means fewer adverse events and medication errors.  But does that mean we’re all doomed if we don’t have a Professor Baures in our workplaces and hospitals? 

Not quite.  Professor Baureses are rare, precious things.  But public health has figured out interventions that can be implemented on a systemic level to change workplace culture.  These cultural interventions recognize that it’s often not enough to just have a good solution; solutions need to be accepted by the team using them.  The Comprehensive Unit-based Safety Program (CUSP) at Johns Hopkins is one example.  It involves training staff in the science of safety, a lot of talking about safety, learning from defects, and adding tools for improvement.  All this may sound common sensible and maybe even too touchy-feely for the workplace, but the results are astounding.  At Johns Hopkins hospital, bloodstream infections in many ICUs dropped 90% over 18 months after CUSP implementation.  When the program was replicated across the state of Michigan, it reduced hospital deaths by 10%. 

The effectiveness of this CUSP intervention has a few good lessons for public health.  We don’t always do what we ought to do, and when we mess up, it can be hard to speak up and learn from the mistakes.  Public health once again succeeds by focusing not on the individual, but the bigger picture.  By building a culture of safety, interventions like CUSP change the norm of what we should do; the rules become easier to follow when everyone follows them.  With the system in place, every workplace can feel safe and conducive to effective workers, whether you have a Professor Baures on hand or not.   

*Actual conversation I had as lab TA: “Is aluminum chloride corrosive?” “Well, does it burn?”  “Sort of.”  “Wash your hands more often, James.”

I Can Feel It in My Fingers

(Photo Credit: Tiffany Ho via facebook)

Joy's Note:  In this holiday edition, Food & Obesity Expert in Training Michelle Wong takes you on a tour of our local farmer’s market (i.e. where I go for my weekly habit of biscuit & gravy… and vegetables).  A health policy doctoral student at Hopkins with a background in drug policy research and a food blog of her own, Michelle is basically a better version of me*:

I feel it in my toes. Love Christmas Public Health is all around me, and so the feeling grows.

One of my favorite places to see public health in action is on Sunday mornings at the Baltimore Farmers’ Market and Bazaar.  The market, located under the I-83 freeway is a smorgasbord for the senses: a rainbow of color from the vegetables; delicious smells emanating from coffee to pulled pork; and the buzzing of voices interrupted periodically from the rumble of the freeway above.  Stocking up on groceries for the week here, I see public health all around me.

Have you ever notice that the ice cream aisle is usually right in the middle of the supermarket, with the chips and soda aisles next to it, while produce is relegated to the side and the milk and eggs in at the back?  More than one third of Americans are considered obese.  But farmers’ markets like these are an antidote to our startling obesity rate.  Unlike a big box supermarket, cleverly designed to steer you towards the Chunky Monkey, the produce takes center stage here, from hardy winter greens like kale to wispy carrots still crowned by a tuft of leaves.  Sure, there are milk and eggs here, but getting to them is not “treacherous” and doesn’t involve passing the Hot Cheetos aisle.  If you’re craving something sweet, there are slivers of apples from Reid’s Orchards to sample – naturally sweet without high fructose corn syrup.

Leafy greens in hand, I pass by the welcome booth, which offers information on using federal food stamp benefits (the Supplemental Nutrition Assistance Program, or SNAP) at the market. This is the first year that this farmers’ market is accepting SNAP benefits and making the bounty of the market available to everyone. The market even doubles SNAP benefits to make the produce more affordable. Hunger, like obesity, is a very real public health problem. By accepting and doubling SNAP benefits, the market helps to improve fresh food access.

(Romanesco Broccoli; Photo Credit: Michelle Wong)

A little farther ahead, a peculiar looking vegetable catches my eye, Romanesco Broccoli, also known as fractal broccoli. It’s bright green, but instead of round florets, each floret is cone-shaped. I ask the farmer how to prepare such a bizarre vegetable and our conversation quickly turns to his farming methods. He says he tries to avoid synthetic pesticides. Here, public health meets environmental health: synthetic pesticides threaten the health of farm workers, who come in frequent contact with pesticides in large quantities, and those who consume the produce over long-periods of time.  Moreover, pesticides degrade the local ecosystems.

Obesity, hunger, and environmental health— keep your eyes out, because public health really is all around us, even on a sleepy Sunday morning at the farmers’ market.  

*Except that she's a Yale grad.  So no, not a better version of me.

Welcome to the Gun Show

(My flabby gun)

After a few weeks of living in northwestern China, I thought I had gotten used to a lot of absurdity.  Like having lamb for breakfast, deer penis wine with lunch, and doctors who smoke as they examined patients.  Still, watching on the news, in a country of over a billion, the story of a man waving a knife on a street corner, felt absolutely absurd.  It took the police hours to subdue and disarm him.  This, I realized, was what it was like to live in a gun-less society. 

Here in the States, I live in a society where we can hunt, reenact historical scenes, and carry guns in self-defense.  The majority of the US, even gun owners, even NRA members, support mandatory waiting periods, registration, and other gun control regulations.  With so many editorials and statistics floating the interwebs this week, you’ve probably heard that American women account for 84% of all female firearm homicide victims in high income countries (but just under 1/3 of the population); that 6 states don’t have minimum age requirements to possess a handgun*; or that, as David Sedaris so famously wrote in the holiday classic, blind people can go hunting in Michigan and Texas.  You know our policy and enforcement failures.  So instead, let me tell you what public health (policy) is doing well:

(For a recap on why gun violence is a public health problem to begin with, start here.) 

Disarming Batterers:  A number of states actively deny individuals who have restraining orders against them from owning or buying firearms.  It’s a group that is hard for the NRA to rally around, and a 2003 study by Vigdor and Mercy suggests that the laws reduced intimate-partner homicides. 

Surveillance:  Did you know that more people die by suicide than homicides every year? The National Violent Death Reporting System, established in 2002 and run through the Centers for Disease Control & Prevention, serves as a tool for pinpointing and observing trends that helps state and local workers frame and understand where and how violence occurs so they may better prevent it.    

Research in Practice:  These numbers I spit out don’t just stay as numbers.  They’re translated into training programs for counselors, pastors, and physicians to know how to talk about and reduce violence.  Research that evaluate policies help pinpoint and effective interventions so more resources could be directed toward the ones that work, like limiting the number of guns one can purchase per month, or disarming people who have had felony convictions*.

(Standing way too close to fireworks in Baltimore)

What can you do well?  Calling members of Congress pressures them to support gun control measures, educating yourself spreads best practices, and writing a big-a$$ check helps offset NRA contributions and funds worthy programs that reduce violence.

*From David Hemenway’s Private Guns, Public Health.  Again, no funding, just a good book.  

PS. I talk about DHem a lot, but folks at Hopkins, like Daniel Webster ("DWeb") are also doing great things on guns.

Red Light District

(special thanks to Priscilla for inspiring this post)

Is running red lights public health?  Randy Cohen, the New York Times "Ethicist," recently justified it as ethical practice for cyclists in an opinion piece.  Since I once incurred ridicule from peasant farmers in China for forgetting how to ride a bike ("like riding a bike" my foot), I thought it best to turn this question over to 4 great public health minds for their diverse and expert perspectives.  Hit the comments below for your own take.

To start off, their glittering credentials (more complete bios available on their respective post pages):
David Hemenway: Commuter cyclist; PhD in economics, Harvard; currently a big deal in injury prevention
Oliver Hsu: Serious 'gearhead;' MS in Health Policy, HSPH; currently works in healthcare consulting
Amy Lee: Commuter cyclist; MPH in Public Health Practice, UW; currently works in clinical research

Cass Kercher: Non-cyclist, MPH in Occupational Health, Drexel; PhD student in injury prevention & policy at Hopkins

(apologies for my lack of tech savvy, they don't teach this in public health school)

David:  Ride (and run lights) safely and sensibly 

I am most concerned about safety.  In Boston I often run red lights as this turns out to make me safer—for example  if, as is common, there is a car illegally parked up ahead and I will be forced into the motorists lane, so I want to do that when there is no car behind me.  If there were a safe bike lane I would rarely run a red light.  I also, on a rare occasion, will actually use the sidewalk if it is especially dangerous on the street, and it doesn’t affect any pedestrians. ... (Read more) 
 

 Oliver: Respect the rules, or risk causing harm

I'm definitely one of those cyclists who does not run red lights and stop signs. I am an avid gearhead so that may bias my response. I get annoyed when cyclists flaunt the rules, especially, in the back roads of California where vehicle speed is much higher and there are more blind corners. The environment is more dangerous yet that there is less regard for the rules just because traffic is infrequent.  I would disagree that just because a bike is not moving as fast or is as heavy as a car that it is somehow less dangerous than a car. There is still roughly 200 pounds of rider plus bike traveling at 20 miles per hour. ... (Read more)

Cass: Our imperfect laws keep you from hitting me  

As a frequent active commuter (until very recently I didn't own a car and walked nearly everywhere I went in Philadelphia and Baltimore), I am concerned with transportation safety. On more occasions than I can count I have witness cyclists putting pedestrians and motorists at risk while they occupy a lane of travel but ignore traffic laws. Of course, I will admit to crossing the street against a light, but always in the crosswalk of a very empty intersection. ... (Read more)
 

Amy: Rules keep me in check while the right environment makes rule-following easy

I do not run red lights when I'm biking.  Although I think some lights are ridiculous to sit through (especially during rush hour when I'm breathing in car exhaust), I follow the rules because I believe that this is public health.  I am a fairly experienced biker, but I can make mistakes.  Following biking rules helps reduce the temptation for me to make a poor decision when I'm in a rush because it is habit for me to slow down and stop when I see a red light or a stop sign.  This is true for drivers, too, which is why we don't allow drivers to make illegal turns when the roads are completely clear. ... (Read more)

Their individual practices may differ, but David, Oliver, Cass, and Amy all point to the need for better bike infrastructure.  They also recognize that while traffic regulations are designed to keep cyclists from endangering themselves and others but given imperfect regulations, cyclists must also rely on individual discretion in deciding what is safest for them.

Policy Implications: Altering bike infrastructure (e.g. better lanes, more vigilant and sensible enforcement, tolerant bike culture) can improve road safety and behavior for drivers, cyclists, and pedestrians alike.

Photo credits for this post: Kent Dayton via UVM.edu (DHem), and Oliver Hsu, Jim Kercher, and Sasha Tan via facebook (Oliver, Cass, and Amy).