Health Promotion and New Information Technologies

NHN Consulting Group

Submitted to Health Canada
Health Promotion Development Division

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Contact: Dr. Mike Nelson
P.O. Box 539, 10-7217 Lantzville Road
Lantzville, British Columbia, V0R 2H0
Phone or Fax (604) 390-1241

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Preface and Acknowledgments

This paper deals with new and rapidly changing technologies and their potential impact on a relatively new and evolving field. The aim is to provide advice that may assist Health Canada and other key players in the field of health promotion to think through and strategically plan their involvement with the new technologies. Here the advice has taken the form of recommendations that for the most part, call on the health promotion community to consult and plan together to ensure that the positive potential of the new technologies to help promote health is realized, and to minimize the possible negative effects.

The recommendations are meant to be taken seriously. However, the reader should recognize that the recommendations have been developed without the author having complete knowledge of what key stakeholders--and Health Canada in particular--have already planned or set in motion regarding the new information technologies and health promotion. This means that the recommendations presented here will likely need to be modified to take account of the plans, strategies and commitments that are already in place or under development within Health Canada and by other stakeholder groups. Whether specific recommendations of this paper are implemented will, in the end, matter less than addressing the basic issues that are the focus of the recommendations. Generating interest, concern with the issues identified, and extensive discussion is the primary aim of this exploratory study.

This work has been a collective effort. Mr. John Horvath of Health Canada had the vision to see the value of the study. He and Dr. Mike Nelson of NHN Consulting collaborated on designing the study. Dr. Nelson oversaw the study and carried out the bulk of the work and writing. However, others made substantial contributions to the writing and investigatory work. Mr. Jerry Hinbest edited and made original contributions to various sections of the paper. Mr. Barry George conducted telephone interviews with national NGOs and produced the initial draft of the section of this report that deals with National NGOs. Mr. Chad Nelson investigated health promotion WWW sites and wrote the companion report on Health Promotion Sites on the Web, as well as providing material for use in this report.

Many people have contributed their time and thought to this paper. The following page lists key informants and focus groups members. Informants for national NGOs contacted in this study are listed in an appendix.

Mike Nelson

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Key Informants and Focus Group Participants

The following people were kind enough to give of their time to help with this study. It is quite possible that others attempted to provide assistance but had their messages go off into cyberspace. A number of problems associated with using e-mail were discovered, some solved, and some not. Suffice it to say I would not be surprised if some efforts to help are unacknowledged as a result. If this is the case I am truly sorry.

CONTENTS

1. Introduction
2. What Are the New Information Technologies?
   2.1 The Internet and Internet Tools
3. Study Design
4. Emergent Issues, Findings and Specific Recommendations
   4.1 Realizing the Potential: Improving Access and Use
   4.1.1 Empowering the Public
   4.1.2 Individual Health Practitioners
   4.1.3 Health Promotion and Social Development Offices
   4.1.4 Public Health Associations
   4.1.5 University Health Promotion Centres
   4.1.6 National NGO's
   4.2 Realizing the Potential: Reinventing Health Promotion's Infrastructure
   4.3 Monitoring, Informing & Influencing the Course of Social Change
   
5. Summary and General Recommendations

Appendix A: Exemplary Uses

Appendix B: National NGOs Consulted by Phone

NOTES: Footnotes

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1. Introduction

Initially, this paper was intended to inform Health Canada policy and program decisions regarding the use of new information technologies in health promotion. It soon became apparent that any assessment of the potential of the new IT for health promotion would be quickly out-dated. The hallmark of the new technologies is rapid change and innovation. This morning's impossible dream is this afternoon's reality. The capabilities of the technologies, their accessibility, and their usage are expanding constantly. At the same time, the field of health promotion is moving quickly to make use of the new technologies, although there are significant variations in the speed of adoption among and within organizations.

If information technology and the extent of its use are changing rapidly, so too is the field of health promotion. The disappearance of the words "health promotion" from the names of government units, decentralization of responsibility for health-care decision-making to regional and community councils and boards, and the concurrent emphasis on the social and economic of determinants of health have created an unsettled environment for many health promotion practitioners. On the one hand, greater responsiveness to local concerns and increased opportunity for citizen participation in health issues is facilitated by decentralization, and action on social and economic conditions to improve health is legitimated by the emphasis on social and economic determinants of health. On the other hand, local power structures are real, and they are not necessarily favourable to greater public participation nor enlightened action regarding the non-medical factors that determine health. Further, the many health promotion practitioners who are employed within the health system may find it hard to feel secure as local decision-makers attempt to integrate and improve the efficiency of what is still viewed as a health "care" system.

Change in the environment of health promotion, and in the use and capabilities of new information technologies make it difficult for this report to claim currency in describing the state of the art of communication. On the other hand, this environment of change also offers the opportunity and the means to develop innovative ways of meeting new and old challenges.

In our estimation, health promotion (and perhaps the health field in general), is at a critical moment in its involvement with the new IT. A critical mass of converts to the new IT has emerged, and there are signs that rapid growth in awareness and use is taking place within the field. At such a moment people are interested in knowing what all the excitement is about: What are the new Information Technologies? What can it do for health promotion? Who is using them for what? What do people need to do to use the new IT? and so on. This is also a time when it is important to think about how the diverse membership of the health promotion field wants to make collective use of these technologies, and what role they want to play in influencing the use, structure and evolution of the technologies to ensure that they have positive impacts on the health of the general population.

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2. What Are the New Information Technologies?

When we talk about the new information technologies we are talking about using computers and various information carrying channels from copper wire to fiber optics to microwaves in order to link people to one another and to information. There are various ways in which the physical linkages are made and managed, and a variety of ways in which visual, auditory and print information can be manipulated, stored, and exchanged. Most important, the new technologies have the potential to search out information and to facilitate communication without regard to the constraints of time and space. They have opened the door to multi-party communication by persons around the world on thousand of topics.

The new information technologies encompass more than the internet. Electronic bulletin boards such as Health Canada's Health Promotion On-Line may or may not be linked to the internet, but qualify under our definition of new information technologies, and are able to offer some unique advantages in terms of privacy, information security and quality control. This said, the main emphasis of this paper is on exploring the use and the potential use of the internet and internet tools for health promotion purposes. The reason for this focus is simple. Boosted by the recent development of user-friendly software and the growth of interesting sites on the World Wide Web, access to and use of the internet is growing rapidly. Most groups, organizations and individuals that have information to distribute, messages to send or exchanges to make, are concerned to be accessible via this medium.

For those unfamiliar with the internet and the tools available for using it, we have prepared the following brief and hopefully reader-friendly discussion of the internet and the main internet tools. Others may wish to skip this section of the paper.

2.1 The Internet and Internet Tools

This material was edited and adapted from Michael Pluscauskas' article, "The Internet and Medicine: Hooking Up and Using the Internet" from Volume 1, Issues 2 & 3 of Canadian Medical Informatics Magazine (April/May 1995).

What is the Internet? The Internet is commonly described as a "network of networks." A computer network can be something as small as a few computers that are linked together in an office to share files and electronic mail (e-mail) -- these are known as Local Area Networks or LAN's. LAN's in turn can be connected to form groups of thousands of computers that are linked across large areas -- sometimes referred to as Wide Area Networks or WAN's. The Internet provides a vehicle for these networks and individual "stand alone" computers to "intertwine" to form a global network. In Canada, it is estimated that over 1 million computer users have some form of access to the Internet; and that the number is growing at a rate of nearly 10% per month. (CA-Net Annual Conference, 1994).

Electronic mail (or E-mail) is still the most common use of the Internet. It allows Internet users to send and receive messages to individuals or groups of individuals from around the world. E-mail can also be used to join electronic mailing lists, on specific topics of interest, known as "listserv's."

Listserv's* are electronic versions of "focus" discussions that usually require joining the group. Access to the listserv may be open or controlled by an individual. This allows for controlled access to information when that information may be sensitive or may require professional judgment. Listserv's often are linked to newsgroups that offer a wider access to information and input to discussion. Listserv's provide an "asynchronous" alternative to Chat lines described below -- in other words, they don't demand that those communicating be on-line at the same time.

Usenet newsgroups* are Internet bulletin boards that are similar to Listserv's but require the use of a piece of software known as a "news reader". Usenet news provides a forum for Internet users from around the world to correspond about common topics of interest. The power of the "Usenet" is the way it enables individuals with similar experience and interests to communicate regardless of time, geographical and even cultural differences.

Telnet provides a tool by which users can "log in" to other computers around the Internet. Through Telnet a person can access other computer sites using their own computer as a terminal. This is particularly useful for accessing medical libraries and other health care database systems that are linked to the Internet.

FTP (File Transfer Protocol) is the method by which specific computer data or "files" are transferred around the Internet. Files can be simple text -- usually known as ASCII files -- or more complex data such as graphics or computer programs, -- known as binary files.

Gopher is a menu driven service that allows people to "seamlessly" access information from around the Internet. Gopher and its counterpart WWW (discussed below) allow users to access information without ever needing to know its precise location. Links to other Internet tools, such as telnet and FTP, can be made through Gopher.

World Wide Web* (WWW or W3) is the newest, and most talked about, Internet service. It provides links to information via "hypertext" and for those who have the proper type of Internet access it can bring "multimedia Internet" to the desktop. Hypertext provides links to other information sources through selected or highlighted words within a text. A person simply chooses the highlighted word to get further facts on the topic of interest. Access to the Web is through the use of a browser (Netscape being the most commonly used at this time). This browser allows newsgroup and e-mail access and is being developed to handle "secure" transmissions.

Internet Search Tools* are more commonly known as "search engines." There are a number of these available at various sites. These are powerful tools that index Web Pages and other sources as they come on-line. Individuals seeking information on the Web perform keyword or title searches to locate where the information is stored.

Real Time Conferencing Tools (IRC Chat/WebChat/Videophone)* are tools designed to facilitate "realtime" communications between Internet users. They allow users to make simultaneous connections to the Internet and carry on discussions that currently are based upon keyboard input that can be viewed by all parties at the same time. Emerging technologies now allow both audio and video to be transferred across the Internet in realtime

3. Study Design

Orienting Questions

The fieldwork pursued the following questions:

• How is the internet being used in the health promotion field today?
• Are there some exemplary uses for others to emulate?
• What are the advantages and disadvantages of using the internet?
• What plans are there to expand use in the future?
• What are the barriers to use or expanding use?
• What role should the new technologies play in the field of health promotion?

Methods

Within a one and a half month period from early-February to late-March of 1996, information relevant to the study questions was gathered by the following means:

1. • Literature Review. Print and electronic literature were reviewed with the aim of:
     
   • identifying leaders (individual, organizations or groups) in the use of new information technologies in the field of health promotion;
   • finding assessments of the new technologies' potential for meeting health promotion information needs;
   • identifying obstacles to the use of new information technologies and the magnitude of same;
     obtaining examples and identifying resources to facilitate use of new information technology in health promotion;
   • obtaining information on the accessibility of the technology.
     
2. Internet search. This involved "surfing" the net, using search engines, and posting to newsgroups in pursuit of the aims listed in "1" above.
   
3. Key Informant consultations. Key informants were persons who could at a minimum, speak knowledgeably about health promotion information needs, and ideally about these needs and the new information technologies. Key informants were contacted by telephone, e-mail and/or fax. Key informants included representatives of:
   

   Health Promotion Centres; all but one were contacted, five provided significant feedback in time for inclusion. Health Canada's Regional Health and Social Development Offices; all but one were contacted and significant feedback was provided by three. Provincial Public Health Associations; all but one were contacted, the majority by fax, significant feedback was provided by four. National Non-Governmental Voluntary Health Promotion Organizations. The following were contacted by telephone: Canadian Public Health Association Canadian Association for Health, Physical Education and Recreation Canadian Association for School Health Canadian Centre on Substance Abuse Canadian Council on Smoking and Health Canadian Council on Social Development Canadian Hospital Association Canadian Institute for Health Information Canadian Medical Association Canadian Nurses Association National Institute of Nutrition Canadian AIDS Society Heart and Stroke Foundation of Canada Health Promotion On-line Atlantic Community Health Promotion Network National AIDS Clearinghouse Ontario Prevention Clearinghouse

4. E-mail snowball consultation. Members of the health promotion community who are on the net were contacted as they were identified through various parts of the study. Members of the on-line community were asked to identify others who would be interested in the study and to provide their e-mail addresses. We then invited the newly identified person to give us their views via e-mail. More than twenty people were contacted through this method.
   
5. Focus Groups. Two focus groups were held; one with the board of a provincial public health association, and a second with staff of a Regional Health Promotion and Social Development Office. These focus groups first identified the information and communications needs and interests of the group, and then involved the group in assessing the potential of internet applications to serve those needs and interests. Time pressure and cost prevented us from carrying out consultations with other health promotion groups that we had hoped to involve in the study. Future study might usefully be directed at the following groups:
   

   national non-governmental health promotion organizations; regional public health units; regional health councils; provincial health promotion or population health divisions; participants in exemplary health promotion projects using the new technologies.

6. A request for consultation on the internet and health promotion was sent for distribution at the February 15 and 16 health promotion conference held in Saskatoon. Stories illustrating success and failure in using the internet to meet health promotion information needs were requested. Only one reply was received from over one hundred participants.

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