Challenging Dogma - Fall 2009

Thursday, December 17, 2009

A Critical Look into Massachusetts Department of Public Health’s H1N1 Intervention; “Flu Facts: What You Should Know” – Jonathan R. Modest

In the midst of one of the most anticipated and severe flu-seasons of this decade, federal health agencies and their state counterparts across the country have spent the last several months grappling with ways to educate the country about the H1N1 flu virus and its new vaccine. Websites and call centers have been established in an attempt to educate as many people as possible about and to suppress the fears of the H1N1 flu, while, at the same time, attempting to urge people nation-wide to vaccinate themselves and their families against what some sources are citing as a “pandemic.” According to Centers for Disease Control (CDC) statistics, between August 30, 2009 and November 21, 2009, there have been 29,348 hospitalizations and 1,224 H1N1 deaths attributed to the H1N1 flu, compared to a total of only 12 reported cases between December 2005 and February 2009 ( 2009). Clearly, statistics indicate that this severe strain of flu is extremely prevalent across populations.
The Center for Disease Control (CDC) defines “swine flu” as, “a respiratory disease of pigs caused by type A influenza virus that regularly causes outbreaks of influenza in pigs…Swine flu viruses do not normally infect humans. However, sporadic human infections with swine flu have occurred” ( 2009). The recent outbreak of swine flu among populations of people around the world has led to interventions on a global scale, in an attempt to combat the virus and prevent its spread. Interventions such as government-supplied vaccines and municipality-organized vaccination clinics and information campaigns are just a few of the many steps that local, state and national officials have taken against H1N1. However, some may argue that one of the biggest challenges with regard to H1N1 is educating people about the virus, how it is spread, who is at risk, and how to get vaccinated.
In an attempt to squash the spread of the easily transmittable and highly contagious H1N1 flu, health departments nation-wide started an array of education and information campaigns.
Locally, in Massachusetts, the Office of Health and Human Services and the Department of Public Health (MDPH) developed its own set of media tools to provide information and education about the influenza A outbreak. One of the state’s primary interventions is a DPH-developed documentary entitled, “Flu Facts: What You Should Know,” which was made available for viewing through Comcast and Time Warner cable “On Demand” menus.
This attempt at education and information sharing fails as an effective public health intervention on the most fundamental levels. At a time when public health departments across the country have the opportunity to “challenge dogma” by using modern-day, dynamic behavior models to help shape interventions that will aid in the diffusion of education and the vaccination of people nation-wide, officials revert back to behavior models that are merely “comfortable” and well known, as opposed to models that truly work.
In development of its “Flu Facts: What You Should Know” documentary, the Commonwealth of Massachusetts used out-dated behavior models to shape its interventions; models such as the Health Belief Model and the Transtheoretical Model, which rely on rational decision-making, while targeting the individual and failing to account for environmental factors that influence the decisions that people make. This intervention fails to draw upon theories such as Advertising Theory and Marketing Theory; both of which have proven very successful in the development of powerful media campaigns. Furthermore, MDPH’s intervention fails to account for and address contextual/environmental factors and the idea of “herd mentality,” while relying on the ability of individuals to make rational decisions, a characteristic which has long been proven to be absent in personal-level health-related decision-making.

Critique Argument I
The first major criticism of the Massachusetts’ H1N1 campaign is the program’s failure to draw from models that have been proven to yield successful media campaigns, such as Advertising Theory and Marketing Theory. Instead, it appears that the intervention is strongly based on the Health Belief Model.
The documentary features 30-minutes of doctors and health professionals discussing H1N1 facts and various prevention techniques; facts that can be easily accessed online in a matter of seconds. The topics discussed include, but are not limited to, H1N1 facts, how to best protect yourself and your family from the virus through proper hygiene techniques and the advantages of the H1N1 vaccine. However, these topics take 30 minutes to explain and, in many instances, are repeated several times by different people during the course of the documentary. The program is boring, repetitious and fails to grab the viewers’ attention, never mind hold it for one-half of an hour.
For those who manage to make it through the full thirty minutes of “Flu Facts: What You Should Know,” several important factors become evident. First, officials who developed this “intervention” relied too heavily on the Health Belief Model, the Theory of Reasoned Action and the Transtheoretical Model, while failing to reference more successful behavior models such as Advertising Theory and Marketing Theory. This documentary spends too much time attempting to persuade it’s viewers that the perceived benefits of good hygiene and healthy behaviors (e.g., washing of hands, avoiding those who are sick, staying home if one does not feel well, getting vaccinated against H1N1, etc.) outweigh the perceived barriers. Furthermore, the program spends too much time and effort trying to move people from the pre-contemplation and contemplation stages of change to the later stages of action and maintenance with regard to healthy practices.
In doing this, the Massachusetts Department of Public Health fails David Ogilvy’s “fourth commandment” of advertising, as explained in Chapter 5 of his book Confessions of an Advertising Man. The Commonwealth could learn a lot from Ogilvy, as he stresses that “You cannot bore people in buying” (Ogilvy 1963). In this case, you cannot bore people into practicing the healthy behaviors that will prevent contraction of the swine flu, and you certainly cannot bore people into getting vaccinated. This intervention will not work if people are too bored to listen to and absorb the information being presented. Asking a series of health professionals to answer common questions about the swine flu in the form of a thirty minute educational program that appears immature in its production techniques does not constitute a successful, attention-grabbing media intervention.
In addition to boring its audience, the creators of the documentary fell victim to a common mistake, another violation of Advertising Theory and Marketing Theory, that ultimately renders many media-driven public health interventions unsuccessful; the promise of health as a product. According to Chapter 6 of Michael Siegel and Lynne Doner Lotenberg’s book Marketing Public Health: Strategies to Promote Social Change, Siegel and Lotenberg argue that,
…in defining the public health product in a campaign to promote a public health program or policy, the practitioner may need to go beyond simply offering health as a benefit to society…The product is not health for society’s members, but something more basic, more compelling, and more at the core of the American policy makers’ value system. The product is the preservation of freedom, independence, autonomy, and control for society. (Siegel and Lotenberg 2007)
Here, Siegel and Lotenberg explain that it is essential for public health interventions to employ a promise that is much more compelling than that of god health in order for the intervention to have a greater likelihood of success. The promise is the core content of any advertisement and making the right promise may be the difference that leads to buy-in, “What really decides consumers to buy or not to buy is the content of your advertising, not its form. Your most important job is to decide what you are going to say about your product, what benefit you are going to promise” (Ogilvy 1963). Perhaps the documentary would have been more successful if it strayed from the value of health and focused on a more fundamental core value.

Critique Argument II
The second major issue with MDPH’s H1N1 documentary is its failure to take into account the importance of the environment. Successful public health interventions are characterized as interventions that capitalize on the importance of context/environment and how these factors may help or hinder the intervention’s target population,
In ecological approaches, the behavior of the individual is viewed as guided by layers of influences including the family, proximal social influences such as social networks or neighborhoods, organizational influences such as worksite or community systems or healthcare systems, and larger social influences such as government, policy, or large economic structures. (Fisher 2008)
In this case, contextual/environmental factors were not considered with respect to two critical aspects of this public health campaign; within the media presentation itself, as well as the availability of the campaign to its target population.
As mentioned above, the documentary provides facts on how to best avoid H1N1, including washing of hands, avoidance of people who may be infected, vaccination, etc. The prevention techniques discussed in the documentary were the “textbook” techniques of how to avoid and/or prevent the spread of a virus as common as the seasonal flu. These are all very helpful techniques, but appear to address H1N1 prevention in a “cookie-cutter” manner, while failing to reach out to various groups that may be threatened by H1N1 in a variety of different manners. For some people who rely on public transportation, for example, avoiding people who are infected with H1N1 may be impossible. Further, remaining home for one week until symptoms improve may also prove difficult for individuals who rely on working every hour for which they are scheduled. Moreover, access to vaccine sources may be difficult for many families and/or cultures that do not have access to primary care physicians or other health care providers. Teachers have different risks than those who work in an office, while pregnant females may need to know very different information from their male counterparts, or compared to those who reside in, or work in homeless shelters. The importance of contextual/ environmental factors in health is explained in I. H. Yen’s article “The Social Environment and Health: A Discussion of Epidemiologic Literature. Yen summarizes the three important roles of the environment in health and health behaviors,
First, areas have characteristics that are more than the sum of the individuals living in them. For this reason, areas exhibit a patterned regularity of disease rates over time even though individuals come and go. Second, there are features of areas that strengthen or weaken social support and social cohesion, and these have important implications for the health of residents in those areas. Third, the social characteristics of an area are not simply a result of geographic location but rather of such features as socioeconomic status, public services, behavior, and culture. (Yen 1999)
These factors must be taken into account when designing a public health intervention with a diverse target population. The same risk factors and prevention techniques may not apply across the many diverse societal groups.
Additionally, in college dormitories and other densely populated areas, large populations of people in small areas place people unknowingly and uncontrollably at risk with little that can be done to control the situation at the individual level, “Colleges and universities are critical players in the coordinated response to pandemic influenza. They will not only be affected as individual institutions, but they can also become sites of transmission because of dormitory-style living arrangements” (Uscher-Pines 2007). Therefore, for a intervention to focus on the “textbook” influenza preventative measures instead of providing creative, alternative approaches to avoiding the virus based upon possible environmental barriers, indicates that those who created “Flu Facts: What You Should Know” failed to account for the contextual/environmental factors that affect target populations. It is important to remember that for a media campaign/public health intervention that is targeting such a large population, not everyone has equal access to hand sanitizers, primary care physicians or other health care providers.
The second example of DPH’s failure to account for contextual/environmental factors can be seen through the limited manner in which the documentary was made available for viewing.. Information on this intervention states,
“Flu Facts: What You Should Know” is now available for viewing on Comcast and Time Warner cable as an “On Demand” viewing option. This 30-minute program features information on H1N1 (swine) flu and answers many frequently asked questions about flu prevention and treatment…From the On Demand menu, click “Searchlight,” then “MyLifeOnDemand,” then “My Local Health,” then “MDPH,” then “Flu Facts. ( 2009)
Instead of making this program available to as wide of a population as possible, MDPH stored the program in the On Demand menus of only two local cable providers. While Comcast accounts for a large percentage of local cable customers, there is still a large population who may not have Comcast or Time Warner, or may not even have cable television in the home at all. This ultimately results in the intervention not reaching a potentially large segment of the targeted population. This intervention also assumes that people know how to access the On Demand menu, which may not be the case.
While media campaigns have proven to be successful methods of reaching large numbers of people within a population, developing an intervention that does not account for the contextual/environmental factors and challenges of their target population results in a failed attempt at a public health intervention.

Critique Argument III
The third major issue with MDPH’s H1N1 intervention builds on a factor first mentioned earlier in this paper. MDPH’s documentary plays on the fact that people are going to make rational, individualistic decisions when it comes to attempting to avoid H1N1. However, countless sources have proven that rational decision-making on the individual level is not something that occurs when dealing with an individual’s health,
To illustrate this process, consider this example. You’re walking past a restaurant and you see two people standing in line, waiting to get in. “This must be a good restaurant,” you think to yourself. “People are standing in line.” So you stand behind these people. Another person walks by…and joins the line. Others join. We call this behavior herding. It happens when we think something is good (or bad) on the basis of other people’s previous behavior, and our own actions follow suit. (Ariely 2009)
The example provided by Ariely clearly delineates a major downfall of MDPH’s H1N1 media intervention. It fails to address the fact that people may not make decisions rationally, but, rather, based on the actions of others.
In the case of MDPH’s intervention, it seeks to target only a few individuals at a time. “Flu Facts: What You Should Know” is not being aired during prime time on a major local television network or being played as a preview in a theatre before a movie. If accessed at all, it is being played in living rooms and is viewed by limited groups of people. Taking this factor into account, it is clear that MDPH did not consider the likelihood of rational, individualistic decision making and the theory of “herd mentality” when creating this intervention. Stating the facts and suggesting swine flu prevention techniques is certainly educational; however, it is not necessarily practical or applicable in the fast-paced, opinionated setting that is society. For example, MDPH can repeat the benefits of a H1N1 vaccination several times; however, if one person in a social group believes that it is unsafe and convinces his/her friends the same, this documentary is suddenly unsuccessful and all of the points raised in it become moot.
Instead of targeting just one or a couple of people at a time, MDPH needs to develop a media campaign that sends important H1N1 facts and information out to the masses. Attempting to harness the idea of “herd mentality” is crucial for a successful intervention, however, MDPH’s strong reliance on the rational decision-making of the individual and failure to employ the idea of “herd mentality” proves detrimental to this intervention.
Targeting as large a group as possible should be the first and foremost goal for MDPH in its attempt to create a successful H1N1 intervention. There is no larger population to channel than the population concerned about swine flu. Therefore, people must reach a “tipping point,” a point where there is enough momentum for these prevention techniques to be carried out by the masses. The more often that people hear the preventative measures and the larger the population of people that hears them, the more likely the ideas and suggestions will stick and the more likely it is that people will make rational, preventative decisions, “Ideas and products and messages and behaviors spread just like viruses do” (Gladwell 2000). However, these actions will not occur at the individual level and the tipping point, the point at which these measures truly catch on across a mass population of people, will not occur unless “herd mentality” is considered in the creation of an intervention.
Instead, MDPH created a documentary that was never placed on a publically accessible television station. They relied too heavily on the fact that people will behave rationally after hearing the methods of practicing proper hygiene and avoiding infected individuals. They failed to take into account the idea of “herd mentality” and that people act in similar ways to the group to which they belong.

Proposed Intervention
MDPH’s “Flu Facts: What You Should Know” campaign has many weaknesses. However, if one stops to attend to each one of the intervention’s flaws, it is possible to turn it around to create a much more successful, wide-reaching intervention that could truly capture the attention of populations across the state. In fact, one of these interventions exists on a much larger scale. The Center for Disease Control created a webpage ( SocialMedia/Campaigns/H1N1/) which is returned as the top suggestion when “googling” “H1N1 Facts.” Upon clicking on the website, a vast array of social media interventions are presented, including buttons, eCards, Twitter blogs, podcasts, RSS feeds, social networking sites, text messaging applications, web pages that are mobile phone compatible, CDC-info and many other features. This robust media campaign addresses each one of the major shortcomings that were identified in MDPH’s H1N1 intervention and is extremely broad in scope.
The first critique of MDPH’s intervention examined its use of the Health Belief Model instead of theories such as Advertising Theory. In applying David Ogilvy’s above-cited quote to public health interventions, the path is simple; MDPH must create a campaign that does not bore people. Creators of this intervention need to design an eye-catching, attention-grabbing media campaign that gets the point across in a fraction of the 30 minutes. This was accomplished by the CDC on its website. Podcasts that do not exceed 6 minutes are available on the CDC website and equally short videos filled with color, music and vivid images are available on its website, as well as on YouTube,
Online video sharing is a popular and powerful activity for exchanging information. Anyone with Internet access can upload, share, view and comment on video footage, and this new ability to participate in video sharing is becoming immensely popular…. CDC encourages the strategic use of online video-sharing sites to effectively and inexpensively reach individuals with personalized and targeted health information. CDC not only participates in YouTube, the most popular video-sharing Web site, it also develops and hosts short consumer-friendly videos on the CDC-TV Web site. ( 2009)
Here, the CDC does an effective job in reaching out to people in a manner that attracts people’s attention and gets the point across quickly, without boring the target population.
Furthermore, MDPH uses the core value of health as a promise in its documentary. In many circumstances, it was discussed that if certain preventative measures are taken, people will remain healthy. However, MDPH should have used a more recognizable and compelling promise, such as that of control. The CDC did exactly that; it created podcasts and short videos that communicate a much different story. Instead of claiming that regular hand washing and getting vaccinated yields better health, the CDC used the message that hand washing and vaccination against H1N1 give an individual and his family control over a virus that has seemingly become “uncontrollable.”
The second critique argues that MDPH fails to take into account contextual/ environmental factors, both in the content of the documentary itself as well as in its method of releasing the intervention to the general public. The first issue within this critique could very easily be addressed by targeting different “groups” of individuals. The CDC identifies information for specific groups, including those who work or reside in shelters; health care providers; state, local, tribal and territorial health officials; laboratorians; pharmacists; parents and caregivers; educational institutions; various sub-groups of people at high risk for flu complications; and many others ( 2009). By addressing such a large variety of specific groups and providing H1N1 tips and recommendations for each group, the CDC illustrates that it understands that various contextual/environmental factors exist across populations and that there cannot be a “cookie cutter” approach to preventing and combating H1N1.
The other major contextual/environmental issue in MDPH’s intervention is its failure to make the documentary available to as broad a target population as possible. Instead of placing the documentary on the On Demand menu of only select cable companies, MDPH must make the documentary and its information available to broader groups through use of the robust social networking possibilities that exist today, such as cellular telephones, internet web sites, etc. The CDC capitalized on the existence of such possibilities by providing H1N1 media through eCards, Twitter blogs, podcasts, RSS feeds, social networking sites, text messaging applications, web pages that are mobile phone compatible,
Since April 2009, the Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services (HHS) have been working together to provide consumers and partners with social media tools that provide information about the ongoing 2009 novel influenza A (H1N1) outbreak. Widgets, mobile information, online videos and other tools reinforce and personalize messages, reach new audiences, and build a communication infrastructure based on open information exchange. ( 2009)
By flooding all of these media sources with information regarding H1N1, the chances of reaching a majority of the population becomes extremely realistic. Those who do not have cable television may have computers or cell phones through which this information can be accessed.
The final critique assessed the failure of MDPH’s campaign to address the issue of rational decision-making and the idea of “herd mentality.” Ideally, MDPH should have created an intervention that reaches large groups of people at the same time and does so repeatedly. By exposing large groups to the same messages over and over again, the population will reach a “tipping point.” More and more people will act based on the behaviors of others and hand washing may become more widespread. In addition, if more people understand the safety and benefits of the H1N1 vaccination, this too could lead to a greater number of people getting the vaccine. The CDC attempts to address this issue by using the variety of media and social networking tools available to the public that aid in getting people to behave as a group. This is seen through the use of CDC-sponsored Twitter blogs and Facebook pages.

As seen through the specifics of the CDC’s media campaign against swine flu, it is possible to develop a public health intervention that is both wide-reaching and successful. The Massachusetts Department of Public Health had the opportunity to create a robust and successful media campaign to help educate and combat H1N1, but failed as a result of its adherence to outdated behavior models and its reluctance to acknowledge successful, modern models and theories. “Flu Facts: What You Should Know” failed to acknowledge theories such as Advertising Theory and Marketing Theory. The documentary did not address the contextual/ environmental factors that ultimately aid in the shaping of decisions, and it relied too heavily on rational decision making. All of these factors compounded together leads to an unsuccessful public health campaign.

Works Cited
Ariely, Dan. Predictably Irrational. New York: Harper Collins, 2009.
Fisher, Edwin B. “The Importance of Context in Understanding Behavior and Promoting
Health.” Annals of Behavioral Medicine. 2008: Vol. 35 Issue 1. Obtained from Academic Search Premier on 1 December 2009.
Introduction . In: Gladwell, Malcolm. The Tipping Point: How Little Things Can Make a Big
Difference. Boston: Little, Brown and Company, 200. pp 3-14.
Chapter V: How to Build Great Campaigns. In: Ogilvy, David. Confessions of an Advertising
Man. New York: Atheneum, 1963. pp 89-103
Chapter 6: Marketing Public Health-An Opportunity for the Public Health Practitioner. In:
Siegel, Michael, MD, MPH and Lynne Doner Lotenberg, MappSC. Marketing Public Health: Strategies to Promote Social Change. Sudbury: Jones and Bartlett, 2007. pp 127-152.
Uscher-Pines, Lori. “College and University Planning for Pandemic Influenza: A Survey of
Philadelphia Schools.” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. September 2007. Obtained from Health Reference Center on 25 November 2009.
Yen, I. H. and S. L. Syme. “The Social Environment and Health: A Discussion of the
Epidemiologic Literature.” Annual Review of Public Health. 1999. Obtained from Academic Search Premier on 25 November 2009.

Labels: , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home