Every meeting I am in to discuss how to address the obesity problem among children and teens inevitably touches on the issue of preventing untoward effects - namely, increasing the prevalence of eating disorders. The concern is motivated, in no small part, by the difficulty of identifying, motivating and treating people who are bulimic or anorexic. Another concern is whether teens at high risk for developing an eating disorder will perceive messages and programs focused on preventing weight gain or promoting weight loss as more reasons to 'race to the bottom.'
The Washington Post highlights an Internet-based treatment program for high-risk women: Student Bodies. While a program like this is not a panacea for the possible negative effects of national weight loss initiatives, it is designed as a prevention program for high risk women that might provide a model for adjunctive products and services in a comprehensive weight education effort directed at tweens and teens.
"This study is a very significant piece of research because it demonstrates that one can transfer what's known about risk factors into a program that can be applied at very low cost," said Michael Levine, an eating disorders expert who is a professor of psychology at Kenyon College in Ohio. "And it gives every indication of being able to reduce important risk factors" for eating disorders such as excessive concern about body image and weight.
For social marketers and public health educators, eHealth tools offer the ability to provide tailored interventions to very specific segments of the population. The potential promise of these interventions is that they can provide greater access to evidence-based interventions at reduced costs for both providers and users. As has been pointed out by others, an effective intervention that can reach large numbers of people, even if it has only a moderate effect size (in terms of changing behaviors), can achieve a substantial public health impact.
The Student Bodies program joins other types of eHealth tools that are being developed to address a wide range of health behaviors. A recent review of eHealth sponsored by the DHHS Office of Disease Prevention and Health Promotion found evidence for the effectiveness of eHealth tools to:
- Increase nutrition knowledge in low-income African American women and low-income Hispanic women
- Increase self-efficacy for improving dietary habits in adults
- Increase intention to change eating habits among adults
- Positively affect motivational readiness to change related to eating behaviors in low-income, primarily African American women and physical activity in sedentary adults
- Affect outcome expectations related to healthier eating in adults
- Increase realistic perceptions about food intake
- Improve dietary behaviors among adult supermarket shoppers, adult workers, adults with type 2 diabetes, sedentary adults, low-income (primarily African American) women, middle school students, and elementary school children.
- Increase physical activity in sedentary adults and adults with type 2 diabetes.
The report also notes the importance of employing five criteria (the 5As) in evaluating eHealth tools:
Access. Large numbers of eHealth tools have been developed, but it is not known how many people know about these tools, how many are using these tools outside of research studies and closed health care systems, and how many may be willing to try them.
Availability. Many of the studies utilized convenience samples or required computer ownership. This approach has led to a disproportionate amount of information on Caucasian women with higher education levels. The lack of diversity in the research samples and limited evidence indicating differential effects based on demographics suggest major gaps in knowledge.
Appropriateness. Some tools have been developed that target special populations, and some of these were developed with input from the target audience. These studies show that with careful attention to cultural, literacy, and technological needs, successful tools can be developed for and used by diverse groups.
Acceptability. People like eHealth tools and generally find them easy to use. Although usage seemed to decline over time, the declines were not as steep as those found in the control conditions.
Applicability. Many studies found positive changes in knowledge and intention after just one interaction using eHealth tools. Findings on actual behavior change and health outcomes have been less clear. However, many of these studies may not have provided interventions with enough frequency or intensity to bring about desired changes in these areas, or they may not have used appropriate control groups. Many studies relied on self-reported data to document change.
There is a clear need for developers of these eHealth tools and social marketers to get together for public health change. As yet, I am not familiar with efforts to take these eHealth tools, predominantly created and tested in academic settings, to scale. Clearly it is incumbent upon the sponsors of these research programs, and the grant recipients, to factor in the costs of marketing effective programs and fund them - whether as continuation grants or as a new type of dissemination grant - to fully realize the contributions of this research and eHealth approaches to improving the public health.