The Chief Public Health Officer's Report on the State of Public Health in Canada 2014 – Digital technology as a tool for public health

Digital Technology as a Tool for Public Health

Highlights

  • Technology can be used in numerous ways to improve, promote and monitor health.
  • Within the field of public health, technology can be a tool for researchers, public health professionals, communities and individual Canadians.
  • The ubiquitous nature of computers and their related technologies can play a key role in implementing and delivering health promotion and prevention programs.
  • Social media is an emerging and rapidly changing technology that lends itself to key areas of public health, particularly those that involve the sharing of information, such as improving health literacy and surveillance.

As technology has evolved, so has its use and application to public health. The telephone has gone from being a tool to transmit electrocardiograph data early in the 20th century to a way for patients to receive health information and advice from health professionals remotely, via telehealth systems.Footnote 345,Footnote 346 Canadians have become accustomed to the technology that routinely surrounds them when they access health services or programs, from computerized health information systems and electronic medical records to diagnostic tools and treatment equipment. Personal computers and mobile device apps are used to connect with health-related information and tools. Behind the scenes, scientific researchers make use of technology to develop new methods and tools for public health and also to create new technology itself.

Technology can provide public health professionals, communities and individuals with a wide range of tools to address issues of public health more efficiently and quickly in a more connected way. As technology continues to advance, its role in public health will also change. The vast range of available technologies will continue to be used in educating, informing, training and communicating with both the public and public health professionals; in surveillance and data collection for detecting infectious disease outbreaks; in monitoring of chronic disease and injuries; in monitoring and evaluating programs; in making transparent and evidence-based decisions; to improve the speed and accuracy of diagnoses; and in providing new and more effective treatments. New and innovative uses of technology for public health will also emerge as the field continues to grow and evolve.

This section presents just some of the ways in which certain digital technologies can be and are being used to address several key functions of public health.

Health promotion and protection

Health promotion is a core function of public health. Public health practitioners and professionals work with communities, agencies and individuals to develop and implement programs and interventions aimed at positively influencing health behaviours.Footnote 347

EHealth interventions

Once a program or intervention is developed it must then be delivered. Technology can help by providing the means through which such programs and interventions are offered. In particular, eHealth interventions allow public health to benefit from current technologies.Footnote 348

A literature review assessed the ways that particular types of eHealth interventions, are being used to encourage the adoption of health promoting/protecting behaviours.Footnote 348

EHealth is defined as "health services and information delivered or enhanced through the Internet and related technologies."Footnote 349

EHealth interventions can take numerous forms and address a vast range of issues.Footnote 348 To provide a manageable and focused assessment, the review excluded eHealth interventions involving telehealth, telemedicine, television or radio, use of electronic health records, gaming or videogames, and personal wearable devices, and interventions were narrowed to include traditional public health functions.Footnote 348 The literature identified studies in the United States, the Netherlands, the United Kingdom, Australia and Canada that used websites and web portals; email and text messaging; goal setting; assessment and monitoring/tracking; risk assessments; online training, counselling/motivational interviewing; tailored feedback and peer and expert advice; and social network sites, live chats and discussion boards as intervention tools.Footnote 348 The public health issues addressed through the interventions included diet, nutrition, healthy weights, increasing physical activity, smoking cessation, sexual health promotion, immunization uptake, substance use reduction and general and/or multiple lifestyle issues.Footnote 348 The intervention approaches were classified into three categories: web-based; mHealth (mobile technologies, such as cell phones, tablets etc.); and computer-based (stand-alone computers without Internet, such as a computer kiosks or CD-ROMs).Footnote 348

The studies included in the review mostly targeted adults from the general population as well as adolescents, college/university students and adults in workplace settings.Footnote 348 A large number of the studies targeted youth in relation to improving healthy eating and physical activity.Footnote 348 Young adults were also most often involved in studies related to sexual health such as increasing screening for sexually transmitted infections (STIs) and adopting healthier sexual behaviours.Footnote 348 Employee interventions targeted multiple lifestyle behaviours, mostly related to healthy eating and increasing physical activity.Footnote 348 Only a few studies analyzed interventions with seniors; one examined seniors' use of mobile phones and another focused on a web intervention, with both aiming to increase older adults' level of physical activity.Footnote 348 In light of the aging demographic in Canada, the increased use of the Internet among those over 55 years of age, the lack of interventions for this population and the promise shown in the above studies, this is a potential area for growth.Footnote 348

Canadian studies focused mostly on web-based or online (enhanced and/or interactive websites or web portals) programs and on one texting intervention.Footnote 348 The studies addressed a variety of health topics: uptake of vitamin C, reduction in alcohol use, reduction in smokeless tobacco use, increase in physical activity, general health-seeking behaviours, reduction in drug use and increased access to information on sexual risk behaviours and testing for STIs (see the textbox "Using technology to increase testing for sexually transmitted infections"). Interestingly, over half of these studies targeted adolescents and young adults.Footnote 348

Using technology to increase testing for sexually transmitted infections

In 2011, Ottawa Public Health launched the Get Tested. Why Not? campaign targeting 15 to 29 year olds. The campaign focuses on increasing STI testing for chlamydia and gonorrhea, as well as increasing access to health information. The campaign uses a bilingual, youth-friendly website to provide information and answers to questions about STIs. Website visitors are able to assess their risk for STIs and their appropriateness for testing. They can then download a testing requisition form directly from the website and use it to have a biological (urine) sample submitted to any local participating laboratory. Although visitors are advised to follow-up with their regular doctor or at a sexual health centre immediately should they have any symptoms, this approach eliminates the need to visit a primary care provider before being tested.Footnote 350 After the first year of the campaign, surveyed participants indicated gaining more knowledge, such as information about services for STI testing and risks of contracting STIs, and felt that they would change their behaviours, such as asking partners to get tested and to use condoms.Footnote 350 In 2013, Ottawa Public Health launched a new sister site to Get Tested. Why Not? called Sex It Smart. The intent is to support safer sex practices by not only encouraging testing to prevent the spread of STIs but also increasing access to free condoms. Individuals/agencies can go online and order free condoms that will be mailed directly to their home or prepared for agency pick-up.Footnote 607

Overall, study results indicated that eHealth interventions are feasible in controlled settings and that individuals are generally open to using technology to monitor and improve health behaviours, attitudes and beliefs.Footnote 348 In some cases, certain features of the technology, for example, brief, relevant and positive text messages, were better at enhancing engagement.Footnote 351

The effectiveness of interventions varied based on the health topic. Alcohol use reduction/prevention studies and sexual health studies showed mostly positive and significant outcomes, whereas smoking cessation and multiple risk factor studies showed both positive and negative outcomes, depending on the type of intervention.Footnote 348 The eHealth intervention studies associated with the most positive and significant outcomes were those that mixed components (e.g. website plus face-to-face support), tailored components to individual needs (personalized feedback or advice) and integrated behaviour change theory, irrespective of health topic.Footnote 348 In addition, many studies showed effects over the short term (less than 6 months), but longer-term results were lacking.Footnote 348 In assessing the level of effectiveness of such interventions, reported study limitations such as self-reported outcome measures, limited ability to generalize of results due to small sample sizes, high attrition rates and loss to follow up must be kept in mind.Footnote 348

As with other uses of technology as a public health tool, accessibility should be taken into account to ensure equitable program and service delivery. For example, in all but one of the mHealth intervention studies, participants had to have a cell phone, and in some cases, a data plan.Footnote 348,Footnote 352 Using text messaging can potentially marginalize populations with low literacy levels or without access to a mobile phone.Footnote 348 Interventions need to match the target population and be integrated into the pool of public health interventions.Footnote 348 EHealth strategies need to deliver health information through culturally and socioeconomically acceptable formats; increase skills in delivering accessible health information; and engage online social network members who assume leadership roles as well as trusted people (e.g. elders).Footnote 348,Footnote 353 To address health equity concerns, factors that need to be considered include lack of physical access to technology; lack of meaningful access (information needs to be designed to reach and appeal to diverse populations); language abilities and eHealth literacy skills; age; disability; and cultural relevance of tools.Footnote 348,Footnote 354 It is critically important to engage end users in co-designing interventions to ensure relevance, uptake and sustained use of eHealth interventions.Footnote 348

There is definitely room for careful application of eHealth interventions in public health in Canada, with attention needed to address challenges to health equity. There is also a need to support further research of eHealth applications in the Canadian context.Footnote 348 New interventions, including some that have already been implemented, continue to be developed (see the textbox "ImmunizeCA").

ImmunizeCA

Immunization is one of the great success stories of public health.Footnote 355 The reduction in the number of cases of vaccine-preventable diseases in Canada has been key in contributing to improved overall health and increased life expectancy.Footnote 355 All Canadian provinces and territories have a recommended immunization schedule for their residents and a system for recording those immunizations.Footnote 356 However, it can be difficult for individuals to keep track of, and manage, their own immunizations or those of their children, which may lead to missed or incomplete immunizations. In March 2014, the new ImmunizeCA mobile application (app) was released to help Canadians track and manage their immunizations and records more easily.Footnote 357

ImmunizeCA is a bilingual app developed with funding from the Public Health Agency of Canada through collaboration between the Canadian Public Health Association, Immunize Canada and the Ottawa Hospital Research Institute.Footnote 357 The app provides access to personal immunization records, schedules and information specific to Canadian children, adults and travellers.Footnote 357,Footnote 358 It is customizable to the user's age, gender and home province or territory allowing the information to be tailored to their particular situation.Footnote 359 In addition to storing personal records it allows quick, easy access to reliable, expert information about immunization schedules, vaccine-preventable diseases and vaccines.Footnote 358 It also allows people to manage appointments and provides alerts for disease outbreaks in the area.Footnote 358

The new ImmunizeCA app is available for Android, iPhone and BlackBerry systems and can be downloaded for free from Google Play, iTunes and BlackBerry World.Footnote 358

Looking at the way in which technology is being used to encourage health-promoting and protecting behaviours, it is clear that the potential exists to improve use of social networks.Footnote 348 Some individual health behaviours and resulting chronic conditions, such as smoking and obesity, have been shown to be "contagious" to some degree, that is, they tend to "spread" within social networks.Footnote 360-362 If an individual has social connections to others who smoke or are obese, they are more likely to smoke or be obese themselves.Footnote 360-362 Knowing this, social media in particular could be used to identify public health programs and interventions and target individuals, rather than an entire network, with the intention that individual change will spread to others.Footnote 360

Education and awareness

Improving health literacy

Public health uses education and awareness programs to influence health behaviours and increase knowledge so that Canadians are better able to manage and understand their own health and that of others.Footnote 2 However, to play a role in managing one's own health requires a certain degree of health literacy, that is, the ability to access, understand and apply the relevant health information.Footnote 267 The Canadian Council on Learning found that 60% of all Canadians over the age of 15 do not have the necessary level of health literacy to obtain, understand and act on health information or make appropriate health decisions.Footnote 363,Footnote 364

Health literacy is "the ability to access, understand, evaluate and communicate information as a way to promote, maintain and improve health in a variety of settings across the life-course."Footnote 267

Public health can use technology in various ways to improve Canadians' knowledge and awareness of their health. One way is to use technology as a tool to improve health literacy. A main component of health literacy is the capacity to obtain the basic health information needed to make appropriate health decisions.Footnote 365 Although information on its own is likely insufficient to bring about a change in behaviour, it is still a necessary component. Social media has the potential to help Canadians get that information.Footnote 366

Social media refers to interactive "websites and applications that enable users to create and share content or to participate in social networking."Footnote 367

The Internet is an extremely common source of health information in North America.Footnote 366,Footnote 368 A 2012 survey found that three-quarters of adults in the United States searched for health information online in the previous year.Footnote 369 In Canada, 70% of home Internet users searched for medical or health information online in 2009, up from 59% only two years earlier.Footnote 368 With more than 200 million monthly active users worldwide on Twitter and more than one billion on Facebook, social media is positioned to connect millions of Canadians with important public health information.Footnote 370,Footnote 371

Although social media is popularly believed to be the domain of younger people, research in the United States found that almost two-thirds of Internet users aged 50 to 64 years and almost one-half of those aged 65 years and older were using social networking sites such as Facebook and Twitter in 2013.Footnote 372 Consequently, it only makes sense that health organizations reach out to this ready-made audience.Footnote 366

Aside from its built-in user base, social media has a number of features or aspects that make it an effective means of sharing health information. For example, minimal effort is necessary to share information in real time.Footnote 373 Organizations can take advantage of the existing infrastructure, which may make using it inexpensive.Footnote 373 The multidirectional nature of the communications allows for quicker and more extensive distribution of the information than traditional methods.Footnote 373

Simply having access to the information, however, is just one aspect of health literacy; the user must also be able to understand and evaluate the information to make appropriate health decisions.Footnote 267 The information and approach must therefore be adjusted to users’ levels of reading and comprehension.Footnote 366 In addition, knowing how family, social context, culture and education play a role is key.Footnote 374,Footnote 375 These influences can affect how individuals receive health information, perceive health problems, express their symptoms and their views on what, and by whom, treatment should be provided.Footnote 375Footnote 376

Exclusive reliance on text in health messages can be a barrier to health literacy.Footnote 377 Online health information providers should also consider alternative and complementary media formats—photographs, illustrations, animation, video, live seminars and interactive games—and learning environments that allow Canadians with literacy or language issues to more easily understand the information (see the textbox "T2X: Getting the message to teens").Footnote 374,Footnote 377

T2X: Getting the message to teens

Funded by the National Institutes of Health in the United States, Teen 2 Xtreme (T2X) is a website (www.t2x.me) developed for teens to use social networking to improve health literacy.Footnote 378-380

The website is intended for teens only and includes content written both by teens and professionals.Footnote 378,Footnote 380 Visitors can learn more about relevant health and life issues such as nutrition, sexual health, smoking, stress and violence and others.Footnote 378,Footnote 380 The site uses numerous interactive resources including blogs, video sharing, text messaging, games and chats to get the information out.Footnote 378,Footnote 379

Teens can chat 24/7 and in real time with health experts, participate in online health-oriented social networking and access educational campaigns that allow them to text keywords to a designated number and receive a response on their mobile devices with customized content on the T2X website.Footnote 378 Current educational campaigns include Talking to Your Doctor, ReThink Your Drink (which discourages consumption of soft drinks), Pertussis, Meningitis, Stop Bullying and Smoking Prevention.Footnote 381 Members participating in a particular campaign complete a pre- and post-test of their knowledge of the topic and their change in intention about a related health behaviour. Results so far are positive.Footnote 381 For example, among teens participating in the ReThink Your Drink campaign, post-tests showed a 21% improvement in knowledge, 26% change in attitude and 19% change in intention for positive behavioural change.Footnote 381

The strength of social media is the ease with which users can exchange information, rather than merely passively receive one-way statements.Footnote 382 Dynamic back-and-forth interchanges can take place with peers or with healthcare professionals. People find it helpful to discuss symptoms, treatments and concerns with their peers with similar health issues or similar questions.Footnote 377,Footnote 383 Social media allows Canadians to do so from the comfort and privacy of their own homes. This allows them to ask questions they might be too embarrassed to ask their doctors.Footnote 377 Communicating with people with whom they perceive they share a problem can help patients open up.Footnote 377 In addition, it may be easier to understand information shared by peers than the jargon used by some healthcare professionals.Footnote 377 People can connect with each other where otherwise they may never have due to barriers in geography, distance or the rarity of their condition.Footnote 383 This access to a broader range of information can increase their knowledge and help them make better, more informed decisions about their health.Footnote 377,Footnote 383 Even between peers the information exchange can go beyond text to include photos or video. For example, a fertility specialist in the United States asked one of his patients to produce a video showing her self-administering her daily in vitro fertilization (IVF) injections. The video was then posted on YouTube for other patients to watch to help them overcome their fears and gain confidence in their own abilities.Footnote 377

The aspects of social media that make it well suited as a positive tool for health literacy are also its main drawbacks. The speed and range of messages that pass through social media, along with its largely un-moderated format, create potential risks.Footnote 374,Footnote 377 The risk of spreading inaccurate, biased or incomplete information or misinformation is considerable given that basically anyone is allowed to post anything they want.Footnote 366,Footnote 374,Footnote 377 The source of the information may be missing, thus preventing assessment of the credibility of the information.Footnote 374 The information may be correct, but written in such a way that it could be misunderstood and have negative health consequences.Footnote 366,Footnote 374 The viral nature of social media then allows this information or misinformation to spread very quickly, especially during times of public anxiety or fear.Footnote 366,Footnote 374

Health organizations may also consider privacy issues and the value of employee time as reasons against adopting social media as a tool for public communication.Footnote 384 They must also be careful not to cross the fine line between providing general information and giving specific medical advice in a public venue.Footnote 384

Some of the risks associated with social media can be lessened, however, by building trustworthy websites and by monitoring and moderating content. Official websites such as those of the Public Health Agency of Canada, the United States Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) can be promoted to Canadians as trustworthy and credible. The content of social media websites should be monitored to prevent spam, malicious content or privacy violations without eliminating the individual user's ability to freely post content.Footnote 374

Social media tools are only of use if people are able to access and use them, which not all Canadians can.Footnote 377,Footnote 385,Footnote 386 Barriers to access include cost, location, low literacy levels, disability and factors that relate to people's capacity to use these technologies appropriately and effectively.Footnote 377,Footnote 386 These are the barriers faced most often by some of the most vulnerable Canadians who are also some of those most in need of improved health literacy. They include older Canadians, people living in low-income households and those living in remote and northern communities, which may include First Nations, Inuit and Métis people.Footnote 387

Moving past the barriers requires improving access to technology and, when necessary, tailoring the information and messages to those with limited health literacy. In terms of access, one solution is to make the technology publically available in schools, libraries and health clinics or doctors' offices.Footnote 377 In fact, most schools and libraries already offer public computer use; some may also have staff on hand who can assist or instruct users.Footnote 377 Placing accessible computers in clinics or other places used for health-related reasons would allow people to access information that may be pre-screened or recommended by knowledgeable staff.Footnote 377 For those with low general literacy or physical limitations that may make traditional browsing difficult, touchscreens with visual cues and icons could help eliminate those barriers.Footnote 377

Surveillance

Surveillance—the collection, analysis and reporting of data in order to track and forecast health events and determinants—is central to any public health system.Footnote 325 Through surveillance public health officials can identify and respond to public health threats, create practical, evidence-based policies and programs, and meet Canada's international public health obligations.Footnote 325

Global health surveillance

Just as the Internet and social media can provide individuals with important information, they can also be a source of invaluable data for public health professionals and official organizations around the world. Global health surveillance has changed, and it continues to adapt in light of the worldwide influence of the Internet.Footnote 389 Information can flow freely and rapidly, allowing for the quicker detection of outbreaks and speedy dissemination of information between officials and to the public.Footnote 389 In addition, the sources of information available online provide a different perspective to that offered by traditional health reporting.Footnote 389

"Public health surveillance is the ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know and linked to prevention and control."Footnote 388

The Internet and social media's value as surveillance tools lies in the fact that changes in information and communication patterns on the Internet can act as an early-warning system for epidemics and outbreaks or other changes in population health.Footnote 389-391 Conversely, public health officials can use data about the information being shared by the public to target public health campaigns, educate, correct misinformation and alleviate fears.Footnote 390,Footnote 392 This is what WHO did during the days following the Japanese tsunami in 2011.Footnote 393 Social media was used as a communication tool to allow WHO to manage critical health information being shared with the public after the incident (see the textbox "Fukushima radiation threat: Informing the public through social media").Footnote 393

Fukushima radiation threat: Informing the public through social media

During the Japanese tsunami and Fukushima radiation emergency of 2011, WHO used social media to manage the global health crisis. Because some people were afraid of possible radiation poisoning from the damaged Fukushima nuclear reactor following the tsunami, they began drinking wound cleaner in the hope that the iodine in it would protect them. Others took iodine pills. WHO became aware of this through social media three days after the tsunami. The organization turned to Facebook and Twitter to warn the public that drinking the wound cleaner could be harmful and that they should see a medical professional rather than self-medicating with the iodine pills.

Three days later, WHO observed via social media that misinformation about iodine was leading people in China to hoard iodized salt and some people to consume seaweed or seaweed supplements for their iodine. Once again, WHO turned to social media to address the behaviour, tweeting that neither seaweed nor salt contain enough iodine to help against radiation poisoning and that, in fact, consuming too much iodized salt could cause poisoning. Just two days later, the success of WHO's social media communications was evident when it was reported that Chinese consumers were trying to return their salt to retailers.

Social media facilitated the speed and ease with which WHO was able to respond to this particular global health crisis and continues to be used by WHO to educate, build awareness and clarify rumours.Footnote 393

In addition to informal web and social media posts of members of the public, public health surveillance can make use of online secondary data such as news reports, expert newsletters and aggregate information that has already been synthesized, analyzed and/or reported.Footnote 390,Footnote 394 A number of Internet surveillance systems that use a more selective approach and choose high quality, expert-curated secondary data sources are in use. These include the Global Public Health Intelligence Network (GPHIN), developed in Canada in 1997, and HealthMap, developed in the United States in 2006.Footnote 389,Footnote 390,Footnote 394 These systems use an automated process to monitor and analyze online sources, facilitating early detection of global public health threats (see the textbox "Global Public Health Intelligence Network").Footnote 389,Footnote 390,Footnote 394-396

Global Public Health Intelligence Network

The concept of Internet-based surveillance is not new. One of the earliest systems to be developed was the Global Public Health Intelligence Network (GPHIN), which was launched in 1997 as part of WHO's Global Outbreak and Alert Response Network (GOARN).Footnote 389 GPHIN is an electronic public health early-warning system developed by the Public Health Agency of Canada to help identify globally significant disease outbreaks and other health threats from around the world by taking advantage of the existing globalized virtual communications.Footnote 389,Footnote 390,Footnote 395 GPHIN's aim is to disseminate timely alerts to help control outbreaks, the spread of infectious disease, contamination of food and water, bioterrorism, natural disasters and exposure to chemical agents and nuclear materials.Footnote 396

This global surveillance initiative is an Internet-based surveillance system that monitors open source information, such as news wires, discussion groups and websites, in nine languages and retrieves relevant reports.Footnote 395,Footnote 397 These reports are reviewed by a team of multidisciplinary analysts who apply their interpretive and analytical skills to identify and flag to GPHIN members those public health events that may have serious public health implications.Footnote 397 GPHIN's state-of-the-art reporting techniques proved crucial in the early stages of the 2003 SARS outbreak.Footnote 389

Syndromic surveillance

Syndromic surveillance, just as its name suggests, aims to track symptoms associated with a defined syndrome, such as influenza-like illness or acute respiratory illness, rather than depending on laboratory-confirmed disease data.Footnote 398-400 Traditionally, this surveillance is carried out through reports from official sources such as emergency departments or primary care providers.Footnote 398,Footnote 401 Nowadays, however, members of the general public can also contribute directly to these data through social media.Footnote 399,Footnote 402 While people discuss their symptoms, illnesses and state of health with others in open forums, they are providing additional information for these surveillance systems.Footnote 399,Footnote 400

One area that has benefitted from the use of social media-based syndromic surveillance is influenza monitoring. Although diagnostic tests can be used to identify individual cases of influenza, the prevalence of influenza in the population at any given time can only be estimated.Footnote 402 Those estimates often rely on syndromic surveillance to capture symptoms related to influenza-like illness (ILI). However, not all people experiencing symptoms will visit an emergency department or physician, so traditional methods do not capture these data.Footnote 401 In addition, traditional systems rely on a limited number of sentinel sites for reporting and delays are frequent.Footnote 401 Capturing user-generated ILI-related information on the Internet may provide a more complete real-time picture of influenza trends and cases.Footnote 401-403

Google has taken that concept and created Google Flu Trends (GFT).Footnote 403,Footnote 404 The idea behind GFT is that people with ILI perform search queries on their symptoms to find information that helps them self-diagnose. GFT tracks the search queries looking for keywords and phrases related to ILI. In fact, the estimates of influenza activity from the system have been shown to be highly correlated with data reported by official public health organizations around the world (see Figure 5).Footnote 403,Footnote 404

Figure 5 Canadian flu activity and Google Flu Trends, the week of September 28, 2003, through the week of March 30, 2014Footnote 405-408

Text Equivalent - Figure 5

Figure 5 Canadian flu activity and Google Flu Trends, the week of September 28, 2003, through the week of March 30, 2014

Figure shows historical Google search-based flu estimates for Canada compared to official surveillance data on influenza-like illnesses gathered through FluWatch.

* Influenza-like illness per 1,000 patient visits.
† Estimates based on Google search data.

As good as these web-based systems are, however, they are not as accurate as traditional systems and can lead to incorrect estimates.Footnote 409 In 2009, GFT greatly underestimated the prevalence of ILI at the beginning of the H1N1 pandemic in the United States.Footnote 410 Despite altering its algorithm after Pandemic H1N1, GFT severely overestimated peak flu levels for early in 2013 in the United States.Footnote 409 Yet even with their limitations, systems such as GFT can still provide useful information. However, they are not meant as a replacement for traditional surveillance and reporting systems, but rather, they should be seen as complimentary to them. In fact, research has shown that a combination of data from both GFT and the CDC in the United States produced better estimates than either system on its own.Footnote 409

As people's Internet browsing behaviours only record proxy measures of influenza, they cannot measure other influenza-related data such as healthcare usage or the clinical spectrum of cases.Footnote 401 This type of data can be collected, however, by having individuals use an Internet-based questionnaire to record their specific symptoms and healthcare usage over time.Footnote 401 These Internet-based cohort systems have been implemented in several European countries, namely Belgium and the Netherlands (under the name "Der Grote Griepmeting"—the Great Influenza Survey), Portugal ("Gripenet") and Italy ("Influweb").Footnote 401 These systems have been shown to provide results in line with those from traditional surveillance methods and may be able to detect increased influenza activity more rapidly.Footnote 401 Such systems can work alongside traditional systems to provide complementary additional information.Footnote 401

Infectious disease outbreaks and trends are not the only things that can be captured through the mining of Internet and social media activity. People's online searches, discussions and postings can also provide information useful in identifying issues surrounding chronic diseases, including mental illness.Footnote 411,Footnote 412 For example, social media mining can show pockets of poor mental health or mental illness in communities, thereby allowing the relevant health service to develop early intervention strategies.Footnote 412 Researchers in Taiwan found suicide to be correlated with lottery sales as an indirect indicator of feelings of hopelessness at the social level.Footnote 413 A South Korean study tested the hypothesis that social media data such as weblog contents are more promising sources to gauge the public mood than activity such as lottery sales. The study found a significant association between social media data and the national suicide rate and resulted in a predictive model that could potentially be used to develop new models for use in forecasting and prevention of suicide.Footnote 414

Continuing efforts

This section has only touched on a very small piece of the picture in terms of the countless possibilities for the relationship between public health and technology. For instance, the idea of technology as a public health issue itself, such as the dangers of texting and driving, the impact of social media on mental health or the change in youth interaction via social media as it relates to bullying, also needs to be addressed as technology continues to permeate more and more of Canadians' everyday lives. In addition, this report has not explored the very important ethical, legal and privacy concerns surrounding the use of social media as a source of data. These are legitimate concerns that must be brought to the forefront of any planning and discussions around this topic.

There are endless ways in which public health and technology do, can and will come together. Although the role of technology in public health in the future is as yet unknown, Canadians can take a cue from today and try to plan for and guide the relationship.

Public health can:

  • support continued research into new technologies or the use of existing technologies as tools for public health;
  • evaluate the efficacy of tools to ensure that technologies are not adopted under the assumption that all are beneficial or worthwhile;
  • consider any barriers that may exist for the user or the recipient, such as language, culture, literacy level, geographic location, etc., to avoid potentially increasing any health inequalities when implementing technology-based tools; and
  • ensure implementation of technologies in programs and policies is flexible, open, and responsive to new developments given the rapid rate at which technologies change.
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