Mobile Helping Rural Communities in Jordan

February 26, 2011

Earlier, I discussed how mobile health applications can provide benefits to underserved and marginalized communities in developing nations.  Recently, I was referred to an article showing how this is already happening.  In Jordan, women in Bedouin communities lack access to medical care for various reasons, including culture (women cannot seek outside help without their husband’s permission) and the lack of physicians in their communities.

The program is set up in such a way that women can text questions to central contact numbers, and can select which topic they need to address.  Their questions are answered by physicians via return text messages, and the messages can be read so that even women with low levels of literacy can receive the information.

The article includes a few points that are especially interesting to me:

  • The first is that even women in poor, rural communities have access to mobile phones.  I suspect this will increasingly be the case in other developing nations as mobile technology becomes more accessible and less expensive, and Jordan may be blazing a trail for other countries to follow.
  • The second is that the program was developed to address barriers to care: low literacy levels, low educational levels, and the fact that women are not culturally empowered to access care even though they will often be responsible for coordinating care for themselves and for their children.  Previous research has shows that one of the best ways to improve a family’s health is to educate and empower women.  Jordan’s program seems to working on the same principle, and stands to provide broader benefits as a result.
  • The third is that the program is aimed at a broad community, including poor and rural residents, as opposed to being limited to those who may already have other resources available.  Although text messages will not be able to address healthcare inequalities by themselves, a program that aims to provide benefits to those without access–and that has been well-received by members of the targeted community–may be an important step in that direction.

Mobile health, via SMS or low-cost smart phone applications, is a powerful tool to improve the health of marginalized communities either in developing nations or in the United States.  Pilot projects such as this program in Jordan are worth our attention, and may be worth replicating.

Making Health Care For Children Social

February 14, 2011

In one of the more exciting chats engaged by the Health Care Social Media (#HCSM) group on Twitter, the gathering began discussing how to integrate social media for better health care for children. Many of the ideas proposed there got our blogging team thinking about ways to create a framework that taps the enthusiasm of youth for gaming and social tools while recasting health care into their lives. Our consensus was that this effort, in whatever form it ultimately takes, should ideally begin early and embrace the sick and healthy alike. What follows is an initial snapshot of what this kid-focused program could look like. We invite your ideas to expand and improve what we have carved out here.

One of the most important points of agreement relates to design. Specifically, whatever is conceived must have buy-in from children and that requires their input.  Whether considering their health-based goals (e.g. to feel better, be stronger, etc.) to the types of social media support they prefer, each of these choices should be driven by youngsters themselves.  By front-loading any health care initiative with pediatric patient opinions, success is more easily ensured. Moreover, it is important to know where parents and children are in their health knowledge, so a needs assessment should be performed at the start.

Secondly, the aim of such ventures should be long-term outcome improvement. This includes healthy patient goals too. By starting early and measuring impact on child-based health goals through social media tools and support, lasting influences can be accurately measured. What may be a short-term goal may evolve into a different health goal as the child progresses and develops. Whatever the source of the initial engagement, that first step which ignites health care interest may be supported through social tools. Moreover, enhancing health care goals becomes easier when supported by parents, so the long-term view should incorporate their involvement.

Given the differing needs and interests of children across their age groups, consider the following age junctures below where social media may be harnessed for better health care:

Children 4-9
For this age group, parents will likely play a larger role in governing what tools, social or otherwise, will be integrated for their child’s care. That being said, children are often early adopters of technology and report what they like (and don’t like) to their parents. That is a perfect opportunity to begin brainstorming ways to marry the love of tech with improving health.  Imagine any of the following:

  • Counting games that embrace technology could be tied to daily meals (e.g. how many fruits have you eaten today?) and associated with praise from cartoon characters.
  • Gaming exercise and nutrition: Creating games that allow for peer-to-peer competition revolving around healthy behavior can provide the right kind of competition. This can even include providing philanthropy toward a larger goal (e.g. Club Penguin’s Coins for Change)
  • Integrating cartoons and web comics into storylines that still focus on plot, but weave in healthful messages (e.g.  Phineas & Ferb turn the tables on Candice by adopting healthy behaviors that outsmart her)

Children 10-12
For this group, the “coolness” factor is paramount, so integrating healthful behaviors into games they already play is crucial for buy-in.  Granted, tweens should be consulted to determine how a social media program should be designed to cater to their needs. However, given that it is easier to swim downstream, we favor building in health-oriented pursuits into tween-approved games and already popular web venues.  Asking tweens how to incorporate their health-based goals makes this task easier and more likely to succeed. Expanding on this idea, if every social aspect of a child’s life were examined for health-oriented inclusion, there are plenty of ways to impact their idea of health:

  • Summer Camp: maintain networks of friends post-camp to encourage healthy behaviors, and in the case of children with pre-existing conditions, support positive disease maintenance activities. Providing music card rewards, game points or bragging rights to the “healthiest” camp group can be built into the design as incentives.
  • Video Games: Earning points for adhering to a disease treatment regimen, or enhancing one’s clout on a gaming site for such behavior is an easy tie-in.
  • Texting: Harnessing this activity with check-ins that support disease treatment compliance or physical exercise are possibilities. One can imagine a scavenger hunt involving texting to report location-based clues that earn points/rewards.

While the ideas noted above can also be applied to the teen audience, their sophisticated entertainment palette also allows for greater innovation.

  • iPhone/Android phone apps:  Tying in healthful regimens to apps to earn tickets to sport/music events can encourage healthy behavior.
  • YouTube: This medium can be championed to encourage teens to design their best PSA on anti-smoking, anti-drug, unprotected sex, etc. Contests involving PSAs can be created to earn teens iTunes music cards and other sought after rewards.
  • Online communities: Group-based incentives involving trips or donations toward a favored charity can be aligned with healthy behaviors that require group achievement in some healthful measure.
  • School-based communities: By tapping a teen’s sport or social group colleagues, their encouragement regarding healthy goals could be mutually supported and measured—support that could also include rewards for positive team behavior. For example, tennis member Sandy needs help with her serve. Fellow team member Jennifer practices with Sandy who records her pal’s help for team points.

As previously mentioned, parents can get the ball rolling early with their kids. As a start, parents should ask pediatricians for their suggestions of recommended web sites that bear  positive health messaging. Yet, as is often the case, it may be the children who end up being the driving catalyst for improved family health.  Accordingly, not only should the health of children be measured, but that of their parents too.

While the outline above is just a sketch of what can be done using social media for improved health care among kids, we invite everyone to chime in about what they’d like to see.

When is Health Care Advertising Acceptable?

February 13, 2011

Last week’s #HCSM chat focused on health care and advertising–an appropriate choice, given that the chat took place during the SuperBowl.  If you read through the transcript, you will note that I am not a big fan of advertising in health care.  My main concern is this: most health care decisions are difficult and involve balancing risks and benefits, but advertising is designed to craft easily-understood messages that influence behaviors.  This is especially concerning to me in light of the rapidly increasing healthcare costs.  Any advertising that encourages increased resource use and increases the costs of care (especially if the best available evidence does not necessarily support it) is inherently in conflict with ethical medical care.  The more advertising we see for expensive meds that do not offer improved outcomes over older or generic meds, or for aggressive treatments that do not improve outcomes over conservative care, the more costs will continue to rise and quality of care will lag behind.  Although physicians must order tests, recommend treatments, and prescribe medications, pressure to pursue more aggressive and costly care is enhanced by the effect of advertising on the public.

Having said that, I do think that there is a role for advertising in health care.  There is one field where I think mass media communications/advertising strategies can benefit the greater good: public health.  Public health practices focus on preventive care, risk reduction, and health promotion.  Behavior changes at the individual level can prevent or lower the risk of developing disease or the complications of chronic illnesses.  This benefits individuals’ health while also looking to reduce the costs of chronic disease management.  Over time, this would stand to reduce health care spending overall and start bending the cost curve in a more sustainable direction.

Advertising works by influencing behavior.  To make public health advertising successful, it would be necessary to both craft the right message and make it visible to the public during key times (prime time television?  Super Bowl?).  If public health campaigns were given the necessary public support (and the appropriate funding) to be successful, then that would be a health care advertising campaign we should support.

Measure Twice, Tweet Once

February 1, 2011

I confess I’ve been the lagging indicator on this blog for any number of reasons. My goal was to post a multipart examination of how to measure outcomes in Social Media (SM). In my genius moment, I wanted to interview a number of experts in outcomes measurement, market research, and users who would share their knowledge and expertise. Two trusted colleagues took the time to respond to my questions and thoughts on outcomes and SM. This is a starting point for this discussion.

I do not view SM in and of itself as a major driver of change in healthcare (HC). It is a tactic, a tool, and one element of any number of strategies (e.g. marketing, sales, awareness, listening, etc.). In my estimation, SM is a powerful tactic within a learning strategy. Measuring outcomes in SM will aid in understanding what works, what doesn’t, and why. With that knowledge we will be able to create strategies that include targeted SM in HC to drive change through learning and application of knowledge. And further analysis of hard clinical outcomes can follow.

The best definition I could find on outcomes is from a statistical glossary:
“An outcome is the result of an experiment or other situation involving uncertainty.

We are uncertain what works in HCSM, the degree to which outcomes are a function of other variables, and why.

The two colleagues I asked to help me with outcomes are:

Derek Dietze is the founder and owner of Improve CME ( During the past 10 years Derek has focused on measuring outcomes in CME and finding unique ways to measure learning.

Scott Fishman is a well-regarded market researcher and principal of Ethos Lifescience Advisors (, which supports market development in the life sciences, and provides guidance on the clinical and commercial value of new technologies.

Derek and Scott each looked at the topic in a slightly different fashion but overlapped in some critical areas. I will share their comments and thoughts before my own.

Derek offered the following regarding HCSM:

“For many years, we in the CME community have agonized about how to measure the effects of learning interventions on performance change in healthcare professionals and patient outcomes in practical, objective ways within reasonable budget limitations.

While methods and means to do this have come some distance, I’ve discovered that you really have to walk before you run with respect to measurement, both in an individual organizational sense, and in a community of practice sense. I’ve found it most productive to build on a strong foundation of simple measurement, easily understood by the consumers of the results, than advance to higher forms of measurement based on experiential learning. So initially, we focused on measuring changes in knowledge, confidence, and intention to change behavior (called “competence” by many in the CME community). These are still our staple forms of measurement, but now we have advanced to self-reported performance change and self-reported observations of patient outcomes based on CME activity participation. We are also piloting studies using national scope medical claims data to objectively measure performance change for national scope CME initiatives.

While ultimately the goal might be to measure how the use of SM results in better patient and community health, I would recommend starting at lower measurement levels, such as changes in knowledge, attitudes, confidence, and intention to change behavior among those interacting through SM. An article by Moore et al 2009 provides a good frame of reference for measuring changes in physicians and other healthcare professionals, and the Transtheoretical Model may prove to be of some help with respect to changes in patients.

Initially, I thought of SM as an “intervention” (like an educational intervention or activity in CME) when it’s focus is bringing about increases in knowledge, reshaped attitudes, and intention to change behavior. While I suppose it could be considered an intervention or “treatment” for the purposes of measurement, I realize it has many other functions that might be measured. SM seems to be a facilitator, and also has empathic and emotive characteristics, given its relative immediacy and potential frequency of use.”
A reasonable starting point for measuring the outcomes of social media (SM) in health care would be to clearly define:
• The different characteristics/uses of SM in healthcare
• What reasonably might be expected to change through its use in each of those circumstances
• In whom those changes are expected to occur, and
• What’s important about outcomes for the people/organizations invested in the results.

Scott Fishman responded to HCSM and some specific questions with this response:

I asked Scott:
Should our outcomes be qualitative or quantitative? Would you use combinations? Would we want to measure just clinical outcomes? His answer:

“Definitively both. Clinical outcomes measures are obvious and you’ll find them in any clinical paper or meta-analysis of a given condition. But there will also be references to “softer” metrics such as QOL scales, and I would suggest incorporating such measures. Of course, you will have to deal with the issue of generally accepted (e.g. “faces” pain scale) vs. novel metrics. The latter are also useful, but will need to be correlated with improvement in quantitative clinical and accepted QOL measures, which is another whole task in itself, and has the potential for either an “aha” moment or to entirely
undercut your hypotheses.”

Scott also addressed the health care provider (HCP). What would we measure there to determine outcomes in SM?

“Fewer phone calls from unsatisfied or frustrated patients. Shorter visits. Fewer changes in medication or dosages, less agita, fewer slaps from, and more incentives provided by insurers. Then, of course, there are all the “I’m a good doctor I have healthy patients” social acceptability measures.”

I asked him to address the question of what measures are most appropriate for patients?

Happiness. Does the patient feel better holistically? Do we see improvements on ADL scales? Of course we can measure condition-dependent clinical improvement (e.g. Hemoglobin A1c, BP, memory performance, and health). Are patients satisfied with their health care provider? Change in the number of days of lost work. Hospital admissions.
I might also include the quality and content of communications between HCP and patient as a potentially valuable measure for the effect of SM on outcomes.”

Both Scott and Derek have started the discussion that I would like to continue with you.

In healthcare SM’s most powerful application is as part of a learning strategy. HC is driven by knowledge and application of knowledge to improve an outcome. Knowledge is the locus for medicine. The physician is an intermediary in knowledge and treatment. Add to that these evidence-based conclusions about learning:

• Adults want to learn solutions to problems they already have (and, conversely, they seldom learn solutions to problems they do not have),
• Adults want to participate in their own learning, and
• Instruction for adults must respect the multiple demands in their lives.

Derek added the following comment:
“Mark, these measure a patient’s PERCEPTION of their own knowledge level and how it might have changed, which I admit may be valuable. However, when measuring physicians, I don’t trust them to self-evaluation whether they are knowledgeable. Instead I ask knowledge questions to test their knowledge. Anyone of use may be confidently misinformed or have incorrect perceptions regarding our illness/disease. A really simple way to validate correct knowledge (without making the patient feel like they are being tested), is to use “clinical assertion” agreement scale questions. Make a correct statement about a disease or condition, then ask for their level of agreement with the statement using a Likert scale or semantic differential.”

If we accept the fact HCSM is first and foremost a learning tool I believe Derek has presented a way to begin to understand HCSM strength and its potential. We can observe what happens to those patients engaged in SM with a HCP or others. Has the patient (caregiver)/learner: improved/increased knowledge, gained confidence, and intention to change behavior.
Patients get ill, get a diagnosis, and want to avoid an illness*. All of these are triggers to begin a process of learning. They come into the moment with a specific set of information. Patients will surf, call, read, tweet, FB and more. At some point they either stop adding to their personal compendium of knowledge because they have changed or are satisfied they have the knowledge they need. They have closed a personal knowledge gap. If we can measure changes in that gap comparing those who use social media against those who don’t in HC we can begin to understand SM as a learning tool and its value. We can compare it to non SM learning.

Areas of inquiry we may ask patients, caregiver, and HCP using SM in HC are:
• What is their current level of knowledge regarding the illness/dx/treatment you are seeking information on?
• Has their knowledge or understanding changed?
• Which formal and informal information of the following sources provided the greatest knowledge to them? (e.g. web sites, physicians, friends, others with similar conditions, networks on FB, tweeting, chat rooms)
• Based on what they have learned, how are they changing their behavior and/or approach to your care and management? What actually happens when we measure longitudinally from intent to behavior?

This is not an exhaustive analysis of HCSM and outcomes. It is a starting point to an open source discussion. What are your thoughts on how to measure outcomes in SM? Can we determine its relative value within HC? Are strict clinical outcomes the only measure we should make? This is one hypothesis on SMHC and outcomes. How can we dive into this area and improve it?

*I am fascinated by the idea that those patients who are heavy users of HCSM represent a small subset of all patients and are patients who are pre-disposed to learning etc.

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