Health Promotion and New Information Technologies

Health Promotion and New Information Technologies - Page 4

4.3 Monitoring, Informing and Influencing the Course of Societal Change

In some respects, the most enlightening aspect of this study is in discovering what has not happened rather than what has. It has been troubling to discover that there has been little sustained critical thinking within the health promotion community about potential health effects of the new technology, and more particularly the health effects of government policy on the ownership, use and development of the new technologies. In view of the much touted new emphasis on the determinants of health, including such things as income, employment, social support and community membership, it seems incongruous for health promotion not to have a strong and active voice in determining the policies that govern the information technologies that are reshaping the structures of power and of economic and social relations in our society. Health promotion is about people taking control over the conditions and factors that affect their health -- the new information technologies are themselves key examples of such factors in the coming information society.

It is overly simplistic to say that the internet and its applications are just tools for communication, and that the potential advantages and disadvantages of these tools are analogous to those associated with the introduction of any new communications technology. This new technology has the ability to overcome the barriers of time and geography; and in so doing, it can directly attack the communications barriers of culture, language, and social status. As Canadians, we are well aware of the importance of culture and language.

Those promoting the internet in an uncritical way have postulated a kind of computopia; a world in which everyone uses their computers to ride the wave of the internet to the distant locales offering greater access to information, democratized input to decision-making and unlimited potential for addressing our common concerns and problems. Optimists are hopeful that the new information technologies may provide us with the opportunity and capability to grow in consciousness, and to accept others and other perspectives. For the optimist, the internet will automatically allow us to address the barriers of class, status and power that are so important in affecting Canadians' health.

Even if we accept that all of these potential benefits could be realized through using and adopting the internet and associated technologies, this does not mean that we must expect the benefits to flow automatically and without a great deal of effort and concerted attention by highly motivated groups and individuals. There is a need to discuss and reflect upon the more pessimistic or cautious side of these issues. The new information technologies have the potential to undermine our sense of membership and security, our sense of community and relatedness (at least in a physical sense) and thus perhaps, our willingness to help our neighbours.

Further, the cost of accessing the new information technologies, potentially coupled with sheer unwillingness by the elites to be open to sharing decision-making and power, could remain a barrier, making attempts at addressing the determinants of health extremely difficult without concerted effort and adversarial tactics.

The internet encompasses some basic contradictions. It can allow us to be free of barriers of time and geographical space, national boundaries, language and one-way communication. But it has its own barriers of cost, status and power (among groups and individuals within societies, and between the have and have-not societies around the globe). Health promotion requires real people taking time to care for themselves and each other. For health promotion workers and others, the new information technologies may simply result in faster production requirements, more monitoring, less institutional support, less social interaction, and more home office work with its intrusions into family life.

Introducing major new technologies to a society has the potential to produce radical changes in social and economic conditions and relations. It can significantly change culture. In turn, such changes can have major impacts on the health of the population, and on the ability and willingness of the population to engage in health promotion activities.

The internet allows Canadians to have access to other cultures and new ideas in an unprecedented way. It represents a range of opportunities for learning about other ways of doing things and different standards of practice or experience that can be a standard or basis for comparison when reviewing our own efforts, policies, programs and activities. But this enabling and broadening of our cultural inputs also has the potential to be a great contributor to the homogenization of peoples, ideas and cultures. Opening up the communication lines between those who have never spoken before means that we are also opening up new opportunities for competition between ideas and ideologies, and ways in which good ideas that are small and locally appropriate can be subsumed within or overtaken by broader ideas that enjoy a wider and less critical audience.

In researching the expanding culture of the web, the author was repeatedly reminded of the Prime Directive from the popular Star Trek television series--not to interfere in the development of other civilizations. Introducing a free-for-all network of information exchange has the potential to allow cultures to be overpowered and changed irrevocably in a way that makes the globalization impacts of the transportation revolutions of past centuries seem insignificant.

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5. Summary and General Recommendations

The new Information Technologies clearly have great potential to be a health and health promotion resource to individuals and groups across Canada and beyond. However, it may also have the potential for perpetuating health inequalities, and even doing harm to the health and well-being of Canadians if nothing is done to 1) ensure equal access to the internet and to key internet applications, and 2) ensure that safe and useful information is easily identifiable and available in a form and at a cost that makes it accessible to all.

RECOMMENDATION:

For these reasons, we recommend that those active and interested in the field of health promotion work to:

Develop the internet as a means for informing, educating and empowering individuals, practitioners, groups and organizations, and:

• Ensure access for all;
  
• Ensure the availability and accessibility of key information and resources on the internet;
  
• Develop the public's ability to use the internet for self-help and mutual aid;
  
• Work to realize the internet's potential to provide information at varying levels of complexity and in different media formats, and its capacity for two-way communication between information users and suppliers.
  

Some informants articulate concern about the ability to build trust using the new communications and information technologies; others fear increasing social isolation. Some have the view that the use of the new IT can be used to supplement rather than replace older methods of communication. Interesting investigations of these issues are now taking place across the country. At the moment, however, there appears to be little recognition of the unique and non-replaceable benefits such as a sense of identity and social membership, having fun, the building of trust and commitment, tangible sharing of physical resources in common time and space (not just benefits in the realm of communication) that are associated with old methods of communication. Hence there is a danger that the search for cost savings through the use of the new IT could go too far, and replace important and effective activities with those encompassing a narrower scope and vision. In particular, there is a danger that the new IT and the mass media will become the primary communications channels for the masses, and workshops, conferences, long distance telephone calls and so on will become increasingly restricted to the privileged few.

There is also a relative absence of discussion and attention to the implications of the new technology for the structure of power and influence within the field of health promotion, and to the ways in which the new IT will or can reshape relationships between major players. The implications for relations between researchers and those individuals and communities they research are potentially immense, but were not investigated for this study. In general, we need to do much more thinking about how we want this technology to be used, and what the consequences of use are for the field as a whole and the players within it.

Recent studies² of the introduction of computers into workplaces have shown that automating lower level professional jobs can serve to interrupt the traditional learning sequence and career paths for employees within organizations. It can create gaps that make lower level positions dead end, while hurting organizations by cutting traditional forms of communication and recruitment of skills and knowledge, thereby reducing the organization's flexibility and adaptability to change. At a broader level, the internet has some of this same potential. If we do not safeguard all those intermediary organizations and their ability to contribute to major decisions about health policy and the direction of health promotion, then we may inadvertently set ourselves back in a way that could take years to recoup.

Particularly missing in the comments and discussion of the internet and its applications of many informants is the notion that new information technologies can be used as a foundation for social change: for citizens working together to create new knowledge, to build more healthy institutions, more healthy communities, new support structures, new organizations, or more radically, to address the determinants of health at the level of the social system. This means building political power to challenge unhealthy social policies or to challenge the distribution of power and privilege that underlies many unhealthy living conditions. Instead, the new IT tends to be tied to facilitating action on particular projects that usually fit within the mainstream of approved social and economic policy, or that focus on ameliorating difficulties faced by particular sub-populations without challenging the systemic and structural conditions that give rise to those difficulties.

RECOMMENDATION:

We thus feel it is imperative to recommend that government and health promotion stakeholders pro-actively work to:

Strengthen the role of intermediaries (health promotion practitioners, voluntary organizations, community groups) in:

• facilitating and enabling networking and group development;
  
• providing access and training to ensure that all have access to the internet and its resources;
  
• synthesizing information and in developing information for local users and users with special health concerns;
  
• stimulating and supporting local discussion and action on determinants of health.
  

For the most part, key health promotion organizations are preoccupied with getting access to the new information technologies and learning to use them. Electronic bulletin boards, satellite links, Freenets, the internet and the various internet applications all tend to be viewed as more cost-effective or efficient ways of carrying out old communication tasks, and meeting information and communication needs. Where in the past, mass media, publications, conferences and workshops were used by health promotion groups and individuals to obtain and disseminate health promotion information, the internet and other new information technologies are now seen to have potential to be more efficient in meeting these needs. Similarly, the networking that has often been supported through workshops, conferences, summer schools and project grants is seen to be made easier and less expensive by electronic networking. But despite Marshall McLuhan's forewarnings of previous years, there does not, as yet, seem to have been a lot of hard thinking done about the influence that the medium has on the message, nor about the unique ways of working that the new technology makes possible.

The new information technologies are more than a fancy telephone or fax. They are more than a supplement to existing communications and information technologies. They have the potential to fundamentally change the field of health promotion, and more importantly, to change the structure of society and consequently to have major impacts on the health and well-being of present and future generations. Langdon Winner³ has warned that while the new IT may have the potential to democratize, to increase our ability to participate in decision-making, to decentralize political control, and to enable social equality, this isn't an automatic result of introducing new technologies. Progress of this kind is made on the basis of our concentrated efforts to overcome inevitable obstacles. We may end up deciding that a laissez faire approach to the development of the new information technologies is best for the field and for society, but we should decide.

RECOMMENDATION:

We therefore recommend that:

Health Canada, in consultation with such organizations as Health Promotion Research Centres, develop an ongoing process for consultation on the health implications of the new information technologies, with the aim of:

• identifying potential health impacts of increased use of the new technologies, both directly and through their impacts on other determinants of health (employment, income, social networks etc.);
  
• developing research and monitoring strategies;
  
• providing policy and program advice to government and others to ensure positive health impacts.
  

The opportunities to debate and reflect on new technologies are rare, and become even more difficult to initiate the longer the technologies have been established and the more firmly entrenched they are. The point in time at which a technology is introduced is critical in determining a path down which we may be headed for a long time to come. Further, it is important to maintain this debate on an on-going basis, and in a way that allows us to reflect on the impact of the technologies on the processes and activities they are being used to facilitate.

In putting these recommendations forward our aim has been to focus thinking on broad strategies for realizing the potential benefits of the new information technologies. There is still a great deal of room for more specific recommendations aimed at producing tangible short-term results. There is not a shortage of proposed and active projects and initiatives linking the new technologies and health promotion. However, the health promotion community lacks a vision that can provide a frame of reference for more specific strategies and initiatives. We believe this is a dangerous situation. For this reason, we feel that it is imperative to begin the broad process recommended in the above three general recommendations with a call to specific action on the part of Health Canada.

RECOMMENDATION:

Against this backdrop of "findings and general recommendations," one recommendation appears of vital importance and merits immediate action. We thus recommend that:

Health Canada fund a wide-ranging national consultation involving multi-stakeholder discussions, forums and workshops to consider and prepare recommendations regarding:

• how health promotion organizations', groups' and practitioners' access to and use of computer-mediated communications (CMC) can be facilitated while ensuring equitable and cost-effective information access and communication for all;
• how to realize the potential of the new technologies and CMC to support community building, empowerment of citizens, the creation of new knowledge, the development of new policies and programs to address the determinants of health;
  
• health promotion's role in assessing the potential impact of the new information technologies on the determinants of health and the health of Canadians, and in influencing government communication policy to ensure that it is healthy public policy.

Such discussions are needed:

• to prevent potentially negative consequences of the unplanned rapid growth of the new information technologies for health promotion and the health of Canadians, and
  
• to realize the great potential these new technologies have for empowering people, enhancing their health, and developing a more health promoting society.

The above recommendation was sent by e-mail to a number of key informants. We received no opposition to the recommendation as presented, and many very positive and supportive responses. Here are a couple of typical replies.

I agree that the issues you raise as topics for "wide-ranging, multi-stakeholder discussions" are right on. Concerns about these issues are related to the pace at which we are entering the fashionable world of the internet .... This would seem to be a natural for the consortium of centres to get involved in .... If you wanted to think about a network of related discussions across the country sponsored by the centres I'd be prepared to give that a try and feed in to a national workshop or something like that.

Your note of caution around IT hit a chord with me. It's very easy to get caught up in the technology and forget the purpose. I figure though that information technology is here to stay -- we can't be luddites, we need to remember that it's not an end in itself, but a means to an end. It doesn't just provide us with information, but it provides us with a new way of working toward the goals which we have always had. I thought your multi-stakeholder discussion questions were a good beginning. But whose agenda does this go on? Now is certainly the time to have these discussions raised before we get too much farther down the highway. I think the first step is to raise awareness of the potential advantages and disadvantages to health promotion of information technology, so as people begin using the technology more they will be more aware of how to make the technology health promoting.

There are a variety of ways in which the consultation could be carried out. We propose beginning by forming a steering committee to plan the consultation process with representatives from each of the major stakeholder groups.

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Appendix A: Exemplary Uses

What follows are descriptions of internet uses that help reveal its potential for various health promotion objectives. Where possible, I have tried to let the people we have consulted tell their own stories.

Computer Mediated Communication Increases the Amount and Quality of Person to Person Communication.

Several counter-intuitive findings have been made by health promotion practitioners working with the internet. One of the frequently stated concerns about the new information technology is that it will lead to people becoming social isolates relating only to machines. Jim Rankin with the School of Nursing at the University of Alberta who has been developing an on-line health promotion course and is experienced in on-line teaching, has discovered that student taught on-line actually communicate more with him and with each other over course matters than do students in a conventional classroom. Similarly, some fear that when community groups and agencies are linked they will quit meeting face-to-face with a resulting lost of trust, understanding and commitment.

In Toronto, Liz Rykert found that when eight agencies serving the same community where electronic linked on-line, they were able to increase the effectiveness of face-to-face meetings by disposing of the non-essential issues, simple information sharing, announcements and basic logistical issues on-line. The electronic communication strengthened rather than weakened the effectiveness of face-to-face meetings.

Both on-line teaching and community networking need more investigation. It is clear that they can be done in ways that are not facilitative of quality person to person communication as well as produce the beneficial results discovered by Rankin and Sterling and Rykert. It is anticipated that this is an area in which more applied research will be forthcoming.

Potential to Inform the Hard to Reach.

It is clear to anyone who has worked with computer mediated communications over the last five years or more, that the technology is much more user-friendly, eliminating the need to be a "computer nerd" to use it. It is also clear that there has been an immense leap the capability of the technology to produce multimedia communications which are attractive and interesting and interactive to the extent that they can respond to the likes and dislikes of the user. Traditional media used for health promotion communication have never had equivalent potential to interact and adapt to the particular needs and interests of multiple users.

"Networking and support groups are the big health promotion uses of the internet"

"The internet has great potential for training and skilling in health promotion"

Networking and Community Development.

Ontario Prevention Clearinghouse has been involved with three exemplary projects which have both demonstrated the use of the internet for health promotion purposes and provided a basis for learning how to use the internet effectively.

• Along with Simon Mielniczuk of the OPC, Alison has supported and studied the used the internet to promote and facilitate networking of community practitioners, researchers, funders and consultants involved in a number of community initiatives for children (i.e., Better Beginnings, Better Futures, Best Start, Ontario Healthy Communities, Growing Up Healthy Downtown and Brighter Futures and the Health Promotion Resource Centres). The aim is to enable projects to learn from one another and from research in their efforts to develop innovative programs in complex and varied environments.
• Liz Rykert of the Growing Up Healthy Downtown project in Toronto to demonstrate and learn how agencies can work together on-line to share information, make collective decisions and carry out effective and efficient local communications.

In a third project Liz Rykert and Kerrie Duncan are facilitating and analyzing the use of the internet to develop and support social action in relation to recent cuts in provincial government spending in Ontario. Liz describes this project as follows:

The act.cuts.ont conference and it's sister conferences act.cuts.docs and act.cuts. facilitators are all defined spaces used collaboratively to further social action in Ontario. As conferences they are all different in their culture, purpose and participation, however, all have the same features, namely that they can be public, private, or semi public, allow all who are participating to see and learn form each others activities, encourage broad sharing of information by participants to all other participants, remove the middle person from controlling content and instead using a facilitated dialogue to establish the on-line culture ...the group wants to establish to make it happen. Conferences can be grouped and have search engines attached for easy access to the content and promote local skill development by facilitators.

Conferences and the Internet.

Christina Mills identified the 1995 Internet Sun Conference as an example of successful internet conferencing which had a health promotion component to it. Hosted by the Active Living and Environment Program and the University of Regina medical practitioners, recreation specialists, environmental experts, university students, researchers and the general public met in cyberspace for 2 hours. In total 42 people were involved in the conference. More information about the conference is available on the WWW at "http://alep.unibase.com/sunconf.htm". We are awaiting a more complete hard copy conference report.

Another health promotion/environment event involved use of the internet to assist in conference planning and to support networking after the conference. I've included exerpts from Don Petit's e-mail to me regarding the CARE conference and the internet because it contains a number of exemplary lessons that can benefit others.

To promote and design the grassroots conference, we sent out a questionnaire by e-mail to a cross section of health and environment BBSs. The response was modest, but it was also modest in the regular mailed version. It did come in very handy just before the conference, when we were trying to nail down a few participants quickly. It was fast and cheap to send e-mail rather than phone calls across Canada.

Three people helped us who are much more knowledgeable about all this than I am. They are Chris Heald of the West Coast Env. Law Assoc., wcelrf@unixg.ubc.ca who set up our Home Page and after-conference listserv; Mike Hollinshead of Facing the Future, mikeh@ccinet.ab.ca who facilitated/instructed the internet part of the conference along with Chris; and Jim Dixon dixonj@direct.ca who finished off the Home Page after the conference, is putting our post-conference newsletter on it as it is issued, and who helped get out the questionnaire to the BBSs.

Of the seven or eight dedicated members of our group, only myself and one other have made much use of the internet. It has certainly been very useful in staying in touch with two or three of the 50 conference participants who I correspond with regularly. Other members of the group either aren't interested in "computer stuff", live out of town on party lines so can't go on line, or can't afford it. This is quite reflective of the overall response we got from an internet questionnaire that Mike Hollinshead conducted at the conference. I am sure he would be glad to share with you the results of the questionnaire and his many insights on this topic in general.

I have done very little research on the internet because I don't make it a time priority. I do get some information, ususally on our listserv from other members. But searching is time consuming, and sitting in front of a key board and screen for hours on end is a bit boring for me. I actually prefer printed material, and get more from newsletters, magazines, etc. More than enough for me.

One of our CARE members has however done a lot of research on organic farming practices, and has found the internet to be an invaluable tool for research.

(What problems (and solutions) that have been encountered in putting this information technology to work?)

Money, time, techno-phobia. As Mike Hollinshead had pointed out and found repeatedly, it is easy to get people to download info from the internet, but hard to get them to input it. He is working on a variety of approaches to help this situation with some networks he is setting up in Alberta. Talk to him about it he is rather an expert on these topics.

We set up a listserv for conference participants. We started with about 20 members, and it is up to about 40. It has been running since Christmas of last year, and has been quite active until the last few weeks when it has been dead as a doornail. Not sure why. Another group of about 20 from a grassroots conference in the US is about to be added, so that should pick things up a bit. In conjunction with the listserv, we are also publishing a national newsletter by regular mail to about 200 people contacted during the conference. It seems to be getting a better response than the listserv, although time will tell on that one to. Response meaning people sending in articles (some-times by e-mail, sometimes by fax) for it, and letters and e-mail messages of encouragement for it.

The problem I see is that mentioned above: people like to download much more than they want to upload. Therefore interactive communication systems, like listservs (unless they have a very large membership to keep things cooking) have limited value in my experience. However, a service like an internet newsletter, that one could subscribe to and just receive (with options for input of course) would be most welcome and would probably be well-read. Soliciting information from groups for publication in the newsletter would help involve them, but they would probably have to be phoned, faxed and e-mailed to get the input. The internet newsletter should be very short: a few pages sent out perhaps twice a month. Or if longer, well indexed and organized so one could zip to only those articles of interest. I would not suggest putting it on the World Wide Web to be accessed at will?I don't think many people would bother, and it is so slow that many find it frustrating. Just straight text, well indexed. Automatically sent to a mailing list of subscribers.

These ideas are not exactly mind-boggling or sophisticated, but in my experience the average internet user isn't either. The actual potential of the internet for interactive communication and info exchange is realized only by the very few hackers who are in to it. The rest of us just want it to be quick and easy, mostly to download useful information and exchange mail.

Varied uses in the Atlantic Region.

In the Atlantic Region the Community Animation Program has made Internet training a priority for its health and environment groups to encourage networking in the region and across Canada. Usage is likely relatively low now, but this is rapidly changing. Groups use e-mail a lot. They use internet to share their knowledge, share information about upcoming events, promote networking, access new groups and to problem solve. Some examples may help to clarify this. The Newfoundland and Labrador AIDS Committee (NLAC) put parts of a new book they produced on the Internet; as a result several universities in the U.S. picked up the information and now have included NLAC's book on the curriculum. This Committee would like to use the Internet for support groups now conducted over the phone. The Nova Scotia Community Health Promotion Network needed testimonials for some sustainability work -- they put this request on the Internet and got 30 testimonials in a matter of hours.

Informing the Public.

As has been noted, the internet is as yet not accessible to all. It has the same difficulty in reaching people who are poor, illiterate, and socially and geographically isolated people that traditional health promotion information technologies have. However, there are again some counter-intuitive discoveries being made. Unfortunately we were unable to contact Dr. Harvey Skinner who has created an access point to the internet for Toronto Street Kids. As we understand it Skinner has combined access to the internet with many interesting multimedia information programs and very practical on-line information sources (where can a youth get a free shower, how can I get job training). The results are reported to be very good with street youth waiting in line to access the computer resources

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Appendix B: National NGOs Consulted by Phone

Canadian Aids Society
Thanks to: Bob Daly, Stacey Townsend
Provision of Information: planned for fall 1996; some components have sites.

Canadian Association for Health, Physical Education and Recreation; and other "Active Living" Organizations (Active Living Alliance for Canadians with a Disability; Active Living Canada; The Active Living and Environment Program; Canadian Association for the Advancement of Women and Sport and Physical Activity; Canadian Fitness and Lifestyle Research Institute; Canadian Intramural Recreation Association; Canadian Parks/ Recreation Association; Canadian Society for Exercise Physiology, Canadian Sport and Fitness Administration Centre, Franc-O-Forme, Sport Information Resource Centre).

Thanks to: Véronique Duvieusart (CAHPER); Jeff Fitzgerald (CP/RA)
Accessing Information: some;
Provision of Information: established, developing.

Canadian Centre on Substance Abuse
Thanks to: Margot Holly
Accessing Information: all;
Provision of Information: one year; developing.

Canadian Council on Smoking and Health
Thanks to: George Duimovich
Accessing Information: some;
Provision of Information: July 1995, soon moving to own server.

Canadian Council on Social Development
Thanks to: Susan Scrutin
Accessing Information: all;
Provision of Information: have site.

Canadian Hospital Association
Thanks to: Edward Brado
Accessing Information: few; others have e-mail;
Provision of Information: under consideration.

Canadian Institute for Health Information
Thanks to: John Blackmore
Accessing Information: all;
Provision of Information: started.

Canadian Medical Association
Thanks to: Ann Bolster, Dawna Ramsey
Accessing Information: available through dedicated machines;
Provision of Information: from March 1995, expanding rapidly.

Canadian Nurses Association
Thanks to: Susan Hicks, Sandy France
Accessing Information: some;
Provision of Information: e-mail; www in process

Canadian Public Health Association
National AIDS Clearinghouse
Thanks to: Hui Tang
Accessing Information: some;
Provision of Information: under construction.

Heart and Stroke Foundation of Canada
Thanks to: Jean-Charles Côté
Accessing Information: few;
Provision of Information: pilot project.

National Institute of Nutrition
Thanks to: Sheryl Conrad
Accessing Information: fall 1996;
Provision of Information: under construction.

ParticipACTION
Thanks to: Art Salmon
Provision of Information: planned for fall 1996, needs fund-raising.

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Notes:

¹ Gradstein, Dorian S.; Hofman, Michael S.; and Reuben, Yigal; "Health promotion on the Internet," Internet Journal of Health Promotion, Vol. 1, No. 1. 1995.

² Peter Albin and Eileen Appelbaum, "The Computer Rationalization of Work: Implications for Women Workers," Pp. 137-152 in, J. Jensen, E. Hagen, and C. Reddy (editors), The Feminization of the Labour Force: Paradoxes and Promises. Campridge: Polity Press. 1988.

³ Langdon Winner, "Mythinformation," Pp. 98-117 in, The Whale and the Reactor: A Search for Limits in an Age of High Technology. Chicago: University of Chicago Press. 1986.

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