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Mobilizing For Health The future of cell phones and public health Rena Greifinger MS Candidate 2009 Harvard School of Public Health Independent Study Center for Health Communication May 2009 Table of Contents Executive Summary…………………………………………………………………………….... 3 Section 1 Setting the stage.…......................................................................................................... 4 Section 2 Examples from the field …………………………………………………………….. 11 Section 3 Big thinkers in mobile ………………………………………………………………. 17 Section 4 Is mobile the answer? ……………………………………………………………….. 29 Section 5 Discussion …………………………………………………………………………… 32 References ……………………………………………………………………………………… 35 2 Executive Summary Mobile phones are becoming prolific in society, both in industrialized and non-industrialized countries. Of all of the developments in new media, mobile is the only one that seems to be narrowing the digital divide rather than widening it, making it a crucial tool in improving the health of poor and hard-to-reach populations. Organizations around the world are beginning to implement mobile technology into their health behavior interventions and are seeing rising success. In diabetes and other chronic disease management, mobile phones are being used for medication alerts and health reporting. The technology is being used to send sexual health and HIV/AIDS information in places like downtown San Francisco and rural Africa, as part of ongoing testing, counseling and prevention services. In the US, applications involving GPS technology, video games, and persuasive technology are all being tested for their effectiveness in influencing health behavior and applicability on mobile phones. Through published research and interviews with key leaders in the mobile health field, this paper will outline the benefits of mobile technology and the barriers to integrating mobile fully into public health campaigns. Despite the enormous work already being done and a host of new technologies on the rise, most experts will agree that mobile phones on their own will not serve as primary tools for influencing health behavior. A comprehensive and integrated campaign that incorporates mobile will be most effective, but mobile alone faces too many barriers to fostering social norms on the wide-scale. In fact, many argue that the ways in which public health advocates are able to place health messages in broadcast media cannot be applied on cell phones because of society's growing resistance to mobile marketing. This paper will address two key research questions: 1) What are some examples of how organizations around the world have harnessed mobile technology to improve the health behavior of disease-specific and target populations? 2) What lies in the future for mobile technology and health? Is mobile the answer we have been looking for? 3 Section 1: Setting the Stage This section provides a broad overview of mobile phone use across the world, laying the foundation for the case studies and arguments revealed later on in this paper. It provides an introduction to the use and growth of mobile technology in the fields of health and development, and provides a ―state of mobile‖ analysis to help the reader understand where and how mobile has penetrated society. 1.1 Introduction There is continued debate as to whether mobile phone technology can be used to spearhead a new era in development, or whether it is only providing a ‗quick-fix' for solving global problems that eventually must be solved with large-scale, cross-sector policies. Some say that the technology is widening the digital divide -- exacerbating socio-economic inequalities because disparities in access to information, literacy and human capital are pervasive. This paper will provide an in-depth look into the ways that public health and development organizations are using mobile phones to improve service delivery, efficiency and access to care. It provides case- based scenarios of what the future holds for mobile, and the opinions of experts in the field on how mobile will and will not be beneficial for public health media campaigns. Harnessing technology, particularly mobile phone technology, for health and development is vital to solving some of the world's most pressing problems. However, no single technology will work on its own. An integrated, targeted and intentional campaign that is grounded in formative research is the only mechanism by which public health advocates will be able to influence positive health behavior in individuals and influence social norms on the wider scale. Most of the successful interventions outlined in this paper are not reinventing the ways that information is disseminated, but rather leveraging technology to more effectively disseminate data that already exists. For instance, information that used to be provided in a wallet card or brochure that can be dropped, forgotten or ignored, is now provided in a text message that is constantly with someone and able to be stored for long periods of time. Using light-weight technology such as RSS feeds (really simple syndication), organizations that typically disseminate information via the web and print materials can almost simultaneously get that 4 information out on the mobile platform. This helps organizations integrate their media use and streamline their services across all segments of the population. 1.2 Mobile Use Around the World Mobile phones are becoming fully integrated into our society. In 2002, mobile phone subscriptions took over fixed landline subscriptions worldwide, across geographic regions, gender, income and age [1]. Since 2000, the number of mobile phone users across the world has tripled [16]. There are currently 3.5 billion mobile phones used in the world, with ubiquity in both developed and developing countries [15]. More people have a mobile phone than don't, making it the most prolific source of communication in existence today. In the United States over the last two decades, mobile phones have gone from being a luxury to a necessity for the majority of Americans. In 2007, the NHIS found that one out of every six (17.5%) households in the United States did not have a landline, but did have wireless telephones. In the first half of 2008, the percentage of wireless-only adults grew from 13.6% to 16.1% [22]. In 2006, mobile phones became the first technology to have more users in developing countries than in developed ones, with 800 million mobile phones sold in developing countries over the last three years [20]. The 2007 information and communication technologies (ICT) index reports that Sweden has the most relative access to telephones, computers and communications networks, and that South Korea places second. Nordic states and high-income countries in Europe, Asia and North America also score highly. However, the most dramatic growth is being seen in developing countries such as Pakistan (ranked 127 th), Saudi Arabia (55th), China (73rd) and Vietnam (92nd). Technology has aided in economic growth in all of these countries [21]. 1.3 SMS Short messaging services (SMS) is one of the fastest growing mechanisms for communication worldwide. Otherwise known as a text message, the SMS sends messages of up to 160 characters between mobile phones, and is an application built into most phones across the world. Billions of messages are sent every year. A 2005 Mori poll in Great Britain found that 84% of respondents were mobile phone users and 62% used SMS [2]. In the Philippines in 2003, the average user sent 2,300 messages, making it the world's most fervent texting country [1]. Evidence suggests that SMS alerts have a measurable impact on and greater ability to influence behavior than radio 5 and television campaigns [27]. The most successful initiatives in mobile phone use and health have built on the use of phones that people already use and applications, like SMS, that are already widespread [15]. Ninety-five percent of phones in the United States are text-capable. In 2007, 7000,000,000 SMS text messages were sent in the United States [23]. Of the 254 million mobile subscribers in the U.S., over 100 million use SMS and 41 million Americans are reported to send SMS messages everyday [25]. Over 80% of 18-27 year olds use SMS. Some of the applications already popular with SMS technology include surveys and polls, games, product promotion, voting, subscriptions and donations. Sending one SMS message typically costs about $.015 per message. Many plans will allow users to pay a set fee, around $20.00 per month, to be able to send an unlimited amount of text messages. 1.4 Paying for Mobile In the United States and Europe, the standard way of paying for a mobile phone service is through a monthly charge, with one-year contracts. Often this includes a certain amount of texts and phone call minutes per month, with added charges if the minimums are surpassed. In order to sign up for such a service, people need to show proof of address, income and bank account information. Since most people in developing countries don't have these, mobile phones are used on a prepaid system whereby people buy minutes in advance, and can control how many they use over a period of time. This keeps mobile technology cheap and accessible. In addition, the prepaid system allows people to pool money for minutes and share one mobile phone. In Africa, for instance, rates of mobile phone subscriptions are low, but these numbers do not account for phone sharing in groups. ―The impact of mobile extends well beyond what might be suggested by measuring the aggregate number of subscriptions‖ [1]. This could be beneficial in getting messages out to groups of people at one time. However, it poses a potential barrier to disseminating health information to individuals when people want to keep their health information confidential. While Americans are apt to paying for health and wellness, through gym memberships and preventative care for example, they are found to be less willing to pay for health services 6 delivered by phone [25]. ―Securing reimbursement from the government, private insurers, or other third-party payers – which together cover nearly 90 percent of all U.S. health care costs – will be necessary if wireless applications are to become an integral part of the larger health care landscape‖. For those individuals who want to opt-in to a mobile health plan, to receive medication alerts for instance, the question of who pays will continue to be debated. However, the dependence on opt-in technology in general creates a barrier for public health advocates to broadcast messages via mobile phone, the way they have in the past using radio and television. 1.5 Who is using mobile? Mobile phone use is highest among adolescents, young adults, people of low socioeconomic status and low level of education, and those who rent homes or frequently change address [23]. In a global survey [19] of mobile technology use among high performing non-governmental organizations (NGO), 86% of participants said they are using mobile technology in their work. Those in Africa and Asia are more likely to be using mobile technology, due to limited Internet access. Ninety-nine percent of mobile users say that the technology is positive. In their review of SMS-based behavior change interventions, Fjeldsoe et al (2009) write that ―mobile telephone use is associated with lower levels of self-rated health, higher BMI, and engaging in health- compromising behavior. Therefore, SMS presents a prime delivery channel for health behavior change interventions because it has high penetration in populations of lower socioeconomic position and populations with poorer health‖ [23]. In the United States, 30% of the population does not have regular access to the Internet, and therefore lacks access to email. This population is mostly poor, non-English speaking, and suffering from a range of health problems that can be mitigated through behavior change. Approximately 85% of the U.S. population is using mobile phones throughout all segments of society. Moreover, underserved populations are using text messaging in the place of Internet. For example, Hispanics and African Americans use text messaging 3-5 times more than the general population [28]. For underserved populations, those most targeted by public health initiatives, text messaging may be the only resource for accurate health information. Since mobile phone usage is just about equal across socioeconomic strata, mobile has the ability to lessen the digital divide that has been exacerbated by the Internet. 7 1.6 Benefits of Mobile The key benefits for those implementing mobile-based interventions are time-savings, the ability to mobilize large groups of people quickly, and easily contacting previously hard-to-reach audiences. Mobile phones have very low start-up costs meaning that people living in resource- poor settings are still able to access them. SMS is transmitted between mobile phones so a fixed landline is not needed. It is fast, private, and messages can be stored. In addition, messages can be sent from one phone to many phones simultaneously. This one-to-many capacity makes it cheap and easy to send mass messages about health. Text messages also leave a record whereas telephone conversations do not. Lastly, messages are asynchronous, meaning that an individual can choose where and when to read them. In addition, once pilot projects are shown to be successful, they will be easy to take to scale and replicate. In its study of current and future successes in the mobile health field, the UN Foundation and Vodafone Partnership [27] identify key, evidence-based guidelines for harnessing mobile technology successfully for health delivery. These include: Forging strong partnerships between companies and organizations Targeting interventions to specific demographic groups Maintaining a focus on usability Building a long-term funding plan Setting measurable goals Collaborating with other mHealth organizations 1.7 Barriers to Mobile There are some barriers to using mobile phones that should be addressed before any health intervention takes place. Primarily, mobile access is more expensive than fixed landline access because one is paying for coverage rather than connection. Many smaller-scale organizations that are implementing mobile phone interventions rely on subsidized services or donations from telephone companies. The sustainability of these programs, therefore, becomes problematic when organizations look to scale up. In most non-industrialized countries, the cost of an outgoing 8 phone call from a mobile device costs anywhere from $0.50 (Brazil) to $1.30 (Nigeria) [1]. However, receiving phone calls and text messages is normally free, so program planners should investigate whether costs to individuals will be involved when planning an intervention. Secondly, access to electricity is a major problem in many parts of the world. To resolve this, people have come up with clever ways to charge their phones. For example, one person taking the whole community's cell phones to a central location to charge them. This of course leads back to one of the original problems of confidentiality if people are sharing phones or sending them out of the village with one person. Language and literacy pose a third barrier. While phones are now designed to accommodate most of the world's languages, many indigenous languages and spoken-only languages are not included. With a world-wide illiteracy rate of 20% [6], highly concentrated in developing countries, text-based interventions may not prove useful. Many countries in the world are far more advanced than the U.S. when it comes to cell phone technology, speed, variety and cost. While most of the rest of the world uses a single cell phone standard, permitting widespread interoperability, the U.S.'s reliance on several networks makes this very difficult. No single mobile service provider in the United States can provide coverage across the country. Many rural areas continue to lack coverage and even parts of metropolitan cities have very little to no reception. Though improving steadily, it will take years before this country sees ubiquitous, high-quality cell phone coverage [25]. Lastly, SMS only provides room for 160 characters so conversations are not feasible. SMS is great for delivering small amounts of information like test results, blood-glucose levels, weight and medication alerts, but lack the capacity to facilitate deeper discussion between patient and provider. Messages could become cryptic and difficult to understand. 1.8 Measuring Impact While mobile phones have become a popular mechanism for achieving health and development goals, there is still a long way to go in terms of measuring impact. To date, there are very few 9 examples of robust, systematic evaluations of mobile technology as a mechanism for change. While it is rapid and easy to produce output measures such as number of calls/texts made, amount of information given, etc., it is less easy to attribute good health outcomes and changed social norms to the initiation of mobile phone use. This warrants further collaboration between groups, who often work in isolation, in order to share best-practices and empirical data. 10 Section 2: Examples from the field This section will highlight how organizations around the world have harnessed mobile technology to improve health behavior and health outcomes for target populations. The case studies provide a closer look into how mobile phones are being used as part of larger health behavior change interventions that include patient alerts and reminders, two-way communication between patients and providers, anonymous information about sexual health and testing, and support around preventing negative health behavior such as smoking. 2.1 Sexual Health Many sexual health clinics use SMS to improve their services and help patients better adhere to services. SMS is used for appointment reminders, provision of STI test results, communication of sexual health information and assisting with contacting partners after an STI diagnosis. SEXINFO In response to rising gonorrhea rates among African American young people in San Francisco, Internet Sexuality Information Services (ISIS) and the San Francisco Department of Public Health have teamed together to develop SEXINFO [4]. This is a text messaging service that provides sexual health information and referrals to youth and social services. This is an opt-in service whereby young people text the word SEXINFO to a phone number and are then given a list of codes that they can choose from to find out more information. For example, ―B2 if u think ur pregnant‖. Between April and October 2006, the service received 4500 inquiries, over half of which led to more information and referrals. The top three messages accessed were: 1) ―what 2 do if your condom broke‖, 2) ―2 find out about STDs‖, and 3) ―if u think ur pregnant‖. Similar services are operating in Australia (sxtxt), and the U.K. (youthnet.org) [13]. The developers at ISIS have tried to rigorously evaluate and modify the SEXINFO service, to ensure that the service is clear, comprehensive and easy to use. For instance, in a 2007 investigation of how teens in San Francisco were using the service, they discovered that some youth found the number of questions and responses overwhelming. ISIS therefore cut the number of questions from eleven to four and provided single-digit responses, rather than double-digit responses. Usage increased by over 100% [19]. SEXINFO is now working with community organizations in Washington DC and Toronto, Canada to roll out the service more widely. A study in Amsterdam [3] found SMS to be highly useful in providing information for hard to reach sex workers. A computer program was developed so that messages could be sent in bulk to provide information on sexual health, or sent individually to remind women of medical 11 appointments. 2,641 sex workers were reached through this program, half of whom would not be reached through traditional methods. In Nigeria, Learning About Living is a joint program between One World, UK, Nigerian NGOs, the MTN Foundation and the Nigerian Department of Education [14]. Like the examples above, young people can text sexual health and HIV questions to a number and receive immediate, anonymous responses. In the first day, the service received 1,000 texts. Developers remark that the service eliminates the stigma associated with sex and HIV, and reduces the fear that teenagers have in asking for information. In their study of access to and perceptions of mobile phone use to promote adherence to HIV medication and safe sexual behavior in Peru, Curioso and Kurth [5] found that cell phones are effective tools for supporting medication adherence and HIV transmission risk reduction in people living with HIV. Participants were enthusiastic about cell phone interventions. They were particularly interested in receiving SMS messages about behavior and voice messages about reminders. In a pioneering program in Singapore, the world's most populous Muslim nation, renowned ―Dr. Love‖ launched an SMS-based sexual health education campaign in July 2007 [12]. Citizens can send a message with a sexual health question to a panel of volunteer doctors who will either answer the question directly or post it on a website that compiles sexual health information. Text to Change (TTC) is a non-profit organization, founded in 2006, that develops ICT systems on mobile phones to promote health education and adherence to medication for people living with HIV/AIDS in developing countries [16]. In Uganda, the organization reached out to 15,000 mobile phone users on the HCT provider network. Users received an interactive text message in the form of a quiz question about HIV, to which they are asked to respond. If they answer correctly, users are rewarded with free HCT services and entered into a prize draw. The application was responsible for a 40% increase in participation in HIV/AIDS counseling and testing services in Uganda [27]. In Mexico, the Zumbido project connects people living with HIV in a mobile-phone-based social networking network, where participants can text one another about the daily challenges they are 12 facing. Project developers found that participants established meaningful relationships with one another, and overcame the traditional barriers of communication posed by stigma and discrimination. In a follow-up survey after the pilot study, participants noted feeling less isolated, more connected to a social network and better connected with their families [17]. In Cape Town, South Africa, TB specialist Dr. David Green's ―On Cue‖ project sends reminders to patients to take their medications. Patients' phone numbers are loaded onto a central database and every half hour, the server reads the database and sends personalized messages out to patients. In a trial with 138 patients, there was only one treatment failure. This program is now being rolled out through South Africa [18]. 2.2 Diabetes Of all the literature on the use of mobile phones in patient-provider relationships, particularly in industrialized countries, the majority of studies have been done with young people living with diabetes. There are two main reasons for this. First, texting is becoming an ingrained part of teen culture. Over one third of American teenagers and 80% of British teenagers report using text messaging as a regular mode of communication [6]. Second, diabetes management often takes close and regular communication between patient and provider, and is based on small amounts of Sweet Talk Sweet Talk is a mobile phone intervention that supports youth with type 1 diabetes. Informed by social cognitive theory, the program addresses goal setting, and self-efficacy [6]. Sweet Talk has a database of text messages that include information and reminders about insulin injections, exercise, healthy eating and blood-glucose testing, that are automatically sent to patients based on their individual profiles and self-management goals that they devise with their providers. They receive weekly reminders of their goal and daily reminders from the database. Occasionally they receive text ‗newsletters' with topical issues and are encouraged to send messages when they have questions about self-management. The questions that are deemed particularly relevant for the youth as a whole are anonymously sent to everyone, in order to build community and avoid peer -to-peer networking that may cause exclusion or bullying. One of the key results from Franklin's study on Sweet Talk [6] were that while the intervention was designed to deliver passive support, most participants were active in submitting messages themselves. The study implies that mobile phone interventions with diabetes patients will not only increase patient health outcomes, but also increase efficiency on the provider-side. For instance, sending text message alerts about appointments will help avoid the telephone tag that often ensues when patients and providers try to reach out to one another. One of the limitations of this study was that over 52% of the text messages being sent back to providers came from the same two 13 participants. data that can be communicated easily. For instance, patients can keep their providers aware of the weight and blood-glucose level, while providers can send reminders to young people to take insulin injections. 2.3 Child Maltreatment Many interventions aimed at reducing child abuse and neglect utilize home visiting programs where social workers work directly with parents in helping them to be involved and non-violent with their children. Mobile phones make it easier to maintain communication with parents who are hard to reach because of high mobility, unpredictable schedules and limited landline access. One parenting program, Planned Activities Training (PAT), demonstrated that the addition of cell phones to the normal intervention increased its impact and improved outcomes [8]. Cellular Phone-Enhanced PAT (CPAT) has two functions: weekly phone calls between visits between the social worker and parent, and daily text messages. The text messages include ideas for activities in the community, parenting tips and riddles. They also receive a daily text asking about their use of PAT, interactions with their children and how the children are behaving. Some parents responded and others did not. They were more likely to respond when asked a direct question. All of the parents, even those that did not send messages back, said in the evaluation that the texts were very helpful. 2.4 Smoking Among young adults in particular, there is great need for innovative smoking cessation programs that incorporate mobile phone technology. Most cigarette smokers begin smoking during their teenage years, with 80% having their first cigarette before turning 18 years old [9]. Those interventions shown to be effective in adults, including nicotine replacement therapy, are less successful with young people. Most young smokers are occasional or episodic smokers, meaning their habits are influenced by environmental triggers like alcohol use and peer influence. Interventions must be tailored to complement the ‗high-risk' times that young people are likely 14 to smoke. Between one-third and one half of college-age smokers report a desire to quit and prefer a ‗cold turkey' method of quitting [11]. In a large randomized control trial (RCT), Rodgers et. al. [9] enlisted 1700 young smokers who intended to quit, in a mobile phone intervention program that would complement traditional service provision. Based around a set quit date, the youth received personalized text messages with cessation advice, support and distraction from cravings. The information included symptoms of quitting, tips on managing cravings, nutrition and weight-management information, breathing exercises and motivational support through success stories. Youth with similar characteristics and quit days were put in touch with one another as ‗quit buddies' to facilitate social networking and peer support. The youth could also access information and advice based on their own needs by texting the service proactively. Over time, the intervention was lessened to one or two texts per week, rather than five per day. The program elicited powerful results. It doubled the quit rate after six weeks and was consistent across age, gender, income level and geographic location. In their comparison of the impact of texting on smoking cessation between Maori and non-Maori groups in New Zealand, the same investigators [10] found that a mobile-phone based cessation program was successful in recruiting young Maori and was effective in demonstrating short-term self-reported quit rates in both groups. In a study from the U.S. a web and SMS based smoking intervention with college-age smokers used behavioral self-regulation theory to inform its development [11]. In the initial stage, participants identified a long list of characteristics using a web-based survey that outlined specific situations where cigarette cravings were strongest. They identified a quit day and contact details for friends and family who can send text messages as part of the social support component. Participants can log their daily number of cigarettes online and send SOS text messages when they are having cravings and want coping messages to be sent back. Participants were sent coping messages and tips for managing cravings, during the high-risk times of day identified in the initial stage. After six weeks, 34% of the participants had quit smoking. The social support and SOS mechanisms, however, were underused. 15 2.5 Disaster Relief Mobile phones are becoming more widely used in disaster situations, both during and in the aftermath. They provide a fast, low-cost and effective way of notifying people of impending disaster on a wide-scale, as well as in individual communication between loved ones, relief workers and victims after disaster has occurred [19]. The speed with which a mobile telephone system can recover from a disaster is directly correlated to the effectiveness of relief services and the recovery of the economy. Therefore, governments must work closely with telecommunications companies to ensure that the best protocols and recovery systems are in place, in the case of large-scale disaster. In Iraq, the World Food Program (WFP) sends text alerts to refugees from Syria who receive food aid, when it is time to come and pick up their deliveries [19]. Telephones without Borders (TSF), an NGO based in France, provides emergency relief assistance using telecommunications, when disasters strike all over the world. From earthquakes in Peru and Bangladesh, to civil wars in the Middle East and Africa, the organization aided in 17 disaster-relief missions in 2006 and 2007 alone [19]. The organization started in the late 1980's to provide disaster victims with three minute phone calls to reach loved ones. Now, they have expanded to setting up entire telecommunication systems in areas hardest hit by natural and man- made disaster. 2.6 Violence Prevention In the weeks following the volatile Kenyan national elections in 2007, Oxfam Great Britain partnered with a number of international multilateral agencies to provide text message alerts of planned attacks to communities and gangs, in order to prevent the violence. Text messages were sent to a ‗nerve center' run by Oxfam and subsidized by the national telecommunications agencies, to report potential attacks. The ‗nerve center' then sent out alerts to local authorities and police, who were able to prevent the violence in many local communities and displacement camps. An example of a text reads, ―The situation in Narok south is bad. People have camped at the catholic church in Mulot and there are fears that they may be attacked tonight.‖ [19]. 16 The restaurant business has caught onto a new trend in marketing food to consumers by placing advertisements and coupons as close to those people as possible – on their mobile phones. Large chains such as Denny's, Starbucks, and McDonald's have all used this mechanism to market to consumers, and studies are beginning to show how successful this can be. In a 2008 Nielson study, data demonstrate that 51% of mobile phone subscribers who saw an ad on their mobile phone in the last 30 days responded to it [31]. One company, Buffalo Wild Wings, has experimented with peer-to-peer mechanisms, asking customers for the email addresses and phone numbers of their friends and family so that they can send customized invitations to eat their buffalo wings. Section 3: Big thinkers in mobile While Section 2 highlights the successful work being done to improve patient outcomes using mobile, Section 3 approaches the second research question of what lies in the future for mobile and health. The section outlines examples of innovative work being done in the field that has enormous potential for growth and development as new applications are invented. The case studies below capture the importance of other technologies, such as GPS and video games, that are beginning to be applied to mobile in industrialized countries and could pave the way for new avenues into the public health arena. According to the Nokia Research Center, user interfaces of the future will combine personalized and adapted functions with those of data-sharing and Internet services. They will incorporate an individual's unique characteristics (e.g. location, environment, activities) with personal needs (e.g. preferred services and applications) so that the device is fully integrated into their daily activities. This research focuses on how the user experience meets cultural preferences; mixed reality technologies in conjunction with multimodal interaction and immersive communications; and media representation. For instance, a traveler arriving at a hotel in another country will be able to access accurate and immediate translations into the local language, on the mobile device. The natural and professional gestures that we engage in daily, such as trading business cards and documents, will become ever-more effortless using mobile. As more of our personal information is documented on web-based applications, the more the messages that we receive on our mobile phones will be adapted to meet our desires and needs. The commercial industry will look to capitalize on this technology by marketing products to people in their target populations. By harnessing those 17 same tools, public health advocates can target their mobile marketing messages about health behavior to the groups that will benefit most from them. 3.1 Project Masiluleke "Mobile phone or cell phone industry operators appears to be the fastest growing communications industry - when Vodacom started operations in 1994, it connected 10,000 subscribers on it"s first day, by June 2006 had 20.4 million subscribers. Cell- C started up in 2001 and 2 years later passed had 3 million subscribers, MTN in June 2006 reported having 11.2 million subscribers. Mobile service providers also seem to have developed relatively (compared to fixed line Telkom) innovative ways of encouraging subscriptions, having more pre-paid than post-paid customers by far. In fact, the mobile phone industry has come closest to universal service" [20]. There are over 150 million mobile phone users in Sub-Saharan Africa alone [16]. Roughly 40% of the population in South Africa uses mobile phones, with mobile phone lines covering 90% of the nation. While there are under 9 computers per 100 inhabitants, 11 Internet users per 100 inhabitants and 10 fixed telephone lines per 100 inhabitants, there are 71.6 mobile phone subscribers per 100 inhabitants in South Africa [20]. Research in South Africa demonstrates that close to 80% of respondents said that cell phones improve their relationships and that they would rather call than travel far distances to visit family and friends. Another 26.5% say that cell phones have been useful in emergencies. Usage is almost equivalent between women and men, with the large majority of users under the age of 40. Project Masiluleke Masiluleke which means ―to give wise counsel‖ and ―lend a helping hand‖ in Zulu, has brought together a renowned group of organizations working across mobile technology, design and health care, to combat the HIV/AIDS and TB epidemics that plague South Africa. Frog Design, Praekelt Founation, iTeach, National Geographic, MTN and Nokia, have teamed up to use the ubiquity of cell phones to provide HIV and TB education. Currently in South Africa, MTN provides an application whereby individuals can send free ―Please Call Me‖ text messages to their networks. This was implemented because in the past, people would place a phone call and then hang up the phone so as not to incur charges. The person on the other end would have to then call back. The networks were not able to handle this type of traffic so decided to offer people free SMS messages that alerted people to call. Since this message only takes about 50 characters, messages about testing and treatment for HIV and TB are now tagged onto the end. The messages link cell phone users to local call centers, who then refer people to testing sites and health care providers [26]. The project is currently sending one million text messages per day. Since the project's inception, calls placed to HIV testing sites and call centers have tripled in volume [27]. 18 3.2 Mobile Commons Mobile Commons is a New York-based company that helps organizations integrate text messaging into their advocacy campaigns, websites and customer relations management (CRM). At a Save Darfur rally in Central Park, the company set up a system called mCommons whereby attendees could text a message to a phone number to opt-in and then text their email addresses to sign petitions. Twenty-five percent of the crowd opted in, meaning the campaign team did not have to send hundreds of staff members into the crowd, hounding people for often-illegible signatures. mConnect, another application developed by the company, allows advocacy groups to embed phone numbers into pre-recorded audio messages and text messages so that users can easily be directed to the information they need. For example, during John Edward's 2008 Presidential campaign, the campaign team sent out text messages to everyone on their phone list and directed them to a voice-recorded message from the candidate. They then heard a message from Edwards about the campaign status and updates, with directions on how to connect directly with the campaign fundraising hotline. When it comes to consumer safety, most of the trusted information about the health effects of food and other non-food products are found online. However, most people do not have the Internet or a computer at the point of purchase. Mobile Commons has contributed to a number of public health applications aimed at improving consumer knowledge and informed purchasing power. One such application is called FishPhone. FishPhone comes out of recent public health attention to the dangers of consuming certain types of fish, particularly for children and pregnant women. Often, information about the dangers of fish and which types of fish to look out for, is hard to remember. Therefore, with the help of Mobile Commons, the Blue Ocean Institute launched this application to inform consumers about the health and environmental impact of eating different kinds of fish. With FishPhone, someone buying fish at the store can text the word FISH and the name of the fish they are looking to buy to the number 30644. He or she will then receive a message from the Blue Ocean Institute with information about that fish and alternatives to buying it if it poses environmental or health concerns [1]. An application built upon the same model will allow consumers to text the name of a plastic bottle that they are purchasing to access information on the dangers of a carcinogenic substance, 19 Bisphenol A (BPA) that has come to the public's attention over the last few years. Z Recommends is an online blog that posts important information about baby bottles for parents. The company has now gone one step further by making this information available via text message (text ZRECS and the name of the bottle to 69866) so that parents can access this reliable information at the point of purchase. Other applications currently being tested by the New York City Department of Health and Hygiene will allow asthmatics in the city to text their location to a phone number that will send a message with information about air pollution in that neighborhood. New York City and Mobile Commons have also teamed up to develop mobile interventions targeting specific groups such as new mothers with reminders to attend post-natal care appointments, diabetics with platforms to monitor their blood glucose levels, smokers with cessation interventions and injecting drug users with information on where in the city they can find clean needles. Mobile Commons founder Jed Alpert believes that mobile phones are a great way to reach poor people who often do not have access to the Internet, but nearly always have a cell phone close by. He says that mobile phones allow organizations to access useful information from people, rather than always pushing information on people the way traditional media messages are disseminated. He cautions, however, that mobile is not a stand-alone intervention. It is part of an overall marketing universe that spans all forms of media, both commercial and non-commercial. The important distinction from mainstream media is that here, people have their mobile phones in hand all the time. The information that they are receiving is in real time, and therefore highly effective in influencing people's choices. Alpert believes that mobile is not the phone itself or even the text message. Mobile is a technology platform – a dashboard on which people connect with the technology sector. It provides the best way to reach a poor person and a rich person, replicates face-to-face interaction, and provides people with up-to-date and immediate information that will aid in their personal choices and behaviors. Alpert also stresses in his book chapter, Texting for Health, the importance of using applications such as FishPhone to collect important data about consumer choice. Not only is the Blue Ocean Institute able to build consumer awareness about fish, but it is also able to draw conclusions, 20 make predictions and write new guidance to meet consumer needs, based on the questions that people are asking them. 3.3 Kiwanja.net Kiwanja.net provides consultancy, workshops and advice to local, national and international non- profit organizations in developing countries. It's flagship applications nGOmobile and FrontlineSMS have caught the attention of mobile gurus and mainstream media all over the world. Through their Mobility Project, Kiwanja.net is taking mobile applications development away from the limited scope of the desktop computer and putting them onto mobile phones, which are ubiquitous in the regions where they work. Based on the MIT Courseware model (web-based publications of all MIT course content), the objective is to develop easily accessible and implementable teaching aids that will allow educational institutions to develop mobile phone programming courses into their curriculum. FronlineSMS allows people to send and receive text messages in large groups. The program is innovative, particularly in developing countries, because it does not require an Internet connection, works on all phone plans, is lap-top based, stores all of the phone numbers and messages that live on a local server, and is scalable to large groups of people. The application has been used for disaster relief, conducting surveys, organizing protests, health care information, emergency alerts and human rights monitoring. 3.4 Dodgeball As innovations emerge in the world of mobile, particularly with the application of GPS technology, the line between online and real-life social networking is becoming increasingly blurred. For instance, websites such as www.dodgeball.com provide a link between one's online social network and his/her real-life social network. After sending Dodgeball a message with your whereabouts, it will let all of your friends know where you are, as well as let you know which of your friends are in a ten block radius. As Dusan Belic writes on mobile technology website intomobile.com, ―DodgeBall relies heavily on SMS to allow users with virtually any mobile phone to schmooze while on-the-go‖. 21 This type of application is promising for health behavior change campaigns that wish to capitalize on the power of social networking and peer-to-peer motivation. Behavioral economics professors at Yale University [34] study the power of ―commitment contracts‖ in influencing individual healthy behavior. The concept is based on two basic assumptions about human behavior: 1) People don't always do what they claim they want to do and 2) Incentives get people to do things. ―For example, if you do weight loss, if you give someone a payment for losing weight, that has an impact. But a far bigger impact is a stick for not losing the weight or not keeping it off. So for example, some of them had done commitment devices where if you don't lose the weight and keep it off, some embarrassing photo of you is posted online. And it worked—the evidence suggested that for the same financial incentive, if there is a penalty or carrot that's equal, the penalty worked better ―[35]. ―Studies of all kinds of human frailties are revealing how to help people change — not only through mandates or financial incentives but also via subtler nudges that preserve our freedom to make choices while encouraging us to make better ones, from automatic-enrollment 401(k) plans that require us to opt out if we don't want to save for retirement to smart meters that warn us about how much energy we're using. These nudges can trigger huge changes; in a 2001 study, only 36% of women joined a 401(k) plan when they had to sign up for it, but when they had to opt out, 86% participated‖ [37]. The behavioral economists have also shown how people appeal to conformity. If someone is told that their neighbors use less electricity than they do, they will begin to use less electricity. For similar reasons, obese people hang out with other obese people and successful weight loss usually happens in groups. ―We are a herd-like species‖. Public health advocates therefore have to create a social norm of opting-out rather than opting-in. People are more likely to quit smoking, lose weight, and use electricity when it takes action to say no, rather than to say yes. In order for mobile phones to truly develop as health behavior change tools, it is crucial to develop this sort of incentivized social networking structure. 3.5. Video Games Nicco Mele, webmaster for the 2004 Howard Dean Presidential campaign and Institute of Politics Fellow at the Harvard Kennedy School, believes that when investigating opportunities to embed health messages into mobile and other technology platforms, video gaming cannot be 22 ignored. With an enormous audience made up of young people, and increasingly being applied on mobile phones, video games provide a unique and effective venue for placing targeted messages about health behavior. Health messages are already starting to penetrate video gaming culture, even in some of the most unlikely places. Along with messages espousing drug use and irresponsible sexual activity, demonized in the public health field, Grand Theft Auto has included nutritional education in its recent ―M17+‖ rated video game Grand Theft Auto San Andreas (GTA San Andreas). In the game, players eat to maintain their strength and stamina, but if they overeat they develop a beer belly. In this case, they have more trouble finding a girlfriend, are dissed by passersby and run slower – threatening their ability to escape from the police. To avoid this, players must work out at a gym and make healthier eating choices. These somewhat redeeming messages about nutrition are of course compounded by other negative messages. For instance, players have to spend money on food and the food at fast food joints is less expensive than it is at healthier establishments, mimicking real life. Furthermore, players have to drive out of the city to the suburbs to find healthier foods, meaning they are spending more money on gas. Lastly, players are allowed to fast for 48 hours or force themselves to throw up in order to reduce the size of their gut, which could lead to the encouragement of eating disorder behavior in youth [29]. Alternate Reality Games (ARG) provide another avenue for exploring health messages and mobile technology because they use the real world as a platform for multi-media games that tell a story. This story can be manipulated and changed by players in real-time. Players interact directly with characters in the game, solve problems and puzzles and work together collectively to analyze a story and create real life activities online. Phones play a major role in ARGs and Internet is essential. In May 2009, the U.S. Centers for Disease Control and Prevention (CDC) and Hawaiian emergency preparedness organization Coral Cross will launch an ARG that mirrors a potential global threat and need for emergency preparedness – pandemic flu. Based in Oahu, Hawaii, the game will allow players to experience what it would feel like to be in the middle of a flu outbreak and how to manage the situation [30]. The game is being launched as part of a larger 23 campaign package that includes television and panel discussions with the Hawaii State Department of Health. Coral Cross hopes to ―address the impact pandemics will have on local communities and social structures while providing a truly immersive experience for the participants‖. Sense Networks Jed is a twenty-nine year old, gay lawyer who recently moved to the Castro neighborhood of San Francisco. He has his first date tonight with Greg, a thirty year-old musician who he met on PlanetOut.com, a popular internet dating website for gay men. Jed wants to take Greg out of Castro and into the city, away from the regular crowd. He is nervous, however, because he does not know the city well and does not want to end up taking Greg to some lame bar without any customers, or worse yet, a place that is (uncharacteristically for San Francisco) not gay friendly. Luckily, Jed's nerdy IT friend introduced him to a new application for his mobile phone called CitySense. Now logged onto CitySense, Jed can see where the hot spots are in the city tonight, what bars are crowded and which ones have people just like him inside. He is feeling lucky tonight! The scenario above sounds like something we won't see for decades, but in fact it is a technology already being pilot tested in San Francisco. Sense Networks Inc. is a New York -based company that tracks mobility across geographic locations, using GPS and WiFi technology, in order to make predictions about people's movements and desires. Based on the concept of ―Search‖ espoused by Google [38], the idea is that the more we know about people's movements between places at different times, the more we can anticipate their needs. ―Search‖ works in a similar way. It employs three components: the Crawl, the Index and the Query Processor (QP). The Crawl continuously searches the web for words and word associations on every single website. These are then compiled in the Index. The QP then runs analytics on the Index in order to draw conclusions about what people are looking for, so as to better meet their needs through search results. One of the company's applications Citysense, for instance, answers the timeless question of ―Where is everybody going out tonight?‖ Based on health mapping technology and GPS, the application shows users where there is usual and unusually high activity in the city and which nightlife spots have the most activity, all in real time. It is the antidote for that pit in your stomach when you take your date to an empty bar. The key technology shift here is from 24 searching to sensing. The user does not have to change any behavior; rather, the technology is able to sense where crowds are gathering in a city and project this information on a heat map that appears on the mobile phone. Jeff Schmidt, Director of Business Development at Sense Networks, explains that the company is built off of academic research conducted by Columbia's Tony Jebara and MIT's Alex (Sandy) Pentland. The researchers study and analyze patterns of human behavior. Schmidt explains that the ways in which people handle their cell phones are indicators of disease trends. The researchers are able to look at the epidemiology of diseases and study the movement of those diseases in population groups, by studying cell phone patterns. In South Africa, for example, Sense Networks is developing an application that will look at location data (e.g. co-location, travel habits and movement of populations) in aggregate and predict how the data indicate direct spread of disease. For instance, tuberculosis (TB) is an air-borne virus that requires very intense and constant treatments, so there are clear patterns to follow in patients that have TB. Sense Networks will soon be able to see the people that TB patients co-locate with and will therefore be able to predict where the disease will spread. The implications of this are that health care could be implemented earlier and road blocks could be developed to stop the spread of the disease. There are two ways to collect this type of location data. The first is through a registration method in which patients will agree to be followed and monitored, in order to aggregate where people are going. The other way is to determine cases by going to clinics and identifying them as hubs and spokes, and watching flow to and from those areas. This would warrant a partnership with a local mobile phone company. The data is aggregated and kept anonymous, so individuals need not worry that their identities will be disclosed. Shortly after the release of CitySense, the Centers for Disease Control and Prevention (CDC) contacted Sense Networks to discuss the possibility of using their applications for disaster response initiatives. For instance, if there is an earthquake in L.A., the CDC would like to know where people are going for food, shelter, water and aid so that they better equip those sites with survival kits in the future. 25 In looking forward at the potential to use this type of mobile technology in public health, Schmidt remarks that the gold standard of mobile marketing is the concept of receiving a coupon on your mobile phone when you are walking by a certain shop or store. ―In our opinion, this is never going to happen. You are walking by every store and get a million text messages -- it's a kind of SPAM. The idea is that the phone will have a profile of you so you get messages that you want to receive. It would have to be very unobtrusive. In Brazil, twenty percent of marketing is done over mobile. It is more intimate than the computer screen, and places like Africa, you find mobile-only communities. Eventually, we will see more movement from the desktop to mobile, simply based on convenience. That is where the industry is going‖. Sense Networks is using its data as tools for marketing and advertising. It is providing an analytics platform with the capability of flattening longitudes, latitudes, and unique identifiers to identify attributes, patterns, clusters, segments, and features that will provide intelligence. ―Where you go and what you do is a better indicator of anything than demographic data will give you‖. 3.6 Persuasive Technology In their Stanford University lab, Dr. B.J. Fogg and his colleagues are studying computers as persuasive technologies, in other words, captology. They are working on the hypothesis that, like human persuaders, computer products such as websites and mobile phones can be used to influence people's attitudes and behavior when it comes to health, business, safety and education. Some computing products are developed solely for the purpose of persuasion, like online smoking cessation and weight loss websites. Fogg deems these under the category of macrosuasion. More often, however, products that are built for purposes of productivity, entertainment or communication, also act as persuasive technologies. These products, falling under the category of microsuasion, include ebay's rating system whereby people are motivated to be honest when reviewing customers. Like Yale's behavioral economists, Fogg is acting on the behavioral theory that humans are motivated by the commitments they make to themselves and other people. Websites and other technological innovations are appearing everyday and persuading us to act in certain ways. As public health advocates, we must continue to use these 26 same innovations to help people develop the attitudes, intentions and commitments to make positive health choices. 3.7 Text novellas Here is something novel – pun intended. YouthNoise, a social networking website for socially- conscious teens, and Virgin Mobile USA, have teamed up to deliver ―Ghost Town‖, a text message-based novella about a homeless teenager [33]. The novella is delivered in two 160 character text messages per day for five weeks, complemented by a website that hosts full profiles, blogs and interactive discussion between the novella's characters. The characters even each have a MySpace page. Character Profile: GHOST Favorite Song: Stairway to Heaven My Heroes: Marshall Faulk, Adam Marchelletta, Kurt Warner, Torry Holt, Isaac Bruce My Philosophy: I like the Golden Rule. You treat others the way you want to be treated. I believe in fair play, and that you shouldn't pick on people smaller than you. Issues that I Care About: Addiction, Poverty, Teen Suicide, Tolerance, War Ways I Volunteer: Sometimes I mentor new freshmen on the team. I also read to some kids at an assisted living center last year for civics and it was a lot of fun, but it was really sad, too. My Goals: I just want to make it day to day. Keep playing football. Maybe work with kids somehow. More About Me: I don't know, anything else, ask. NOISEname: greyghost07 Hometown: St. Louis Country: United States Sex: M Age: 17 New school year Advanced chemistry sounds kind of hard, but otherwise I think this year could be a good one. I hear you have to buy safety glasses or something though. Might have some trouble there. Roach'll probably figure that one out. He always does. Read Ghost's full blog. MySpace Profile: http://www.myspace.com/greyghost07 Ghost Town is a type of ARG applied directly onto the mobile phone. It taps into young people's desires to socially connect with one another and create a community around a controversial topic, while having the space to develop their own online identities. The novella had over 10,000 subscribers who were notified by Virgin Mobile when the series began and at the end of the 27 series, were asked for input into how to continue it in the future [36]. The text novella presents an innovative integration of mobile and online media. Young people are kept constantly engaged through SMS messaging directly to their mobile phone, and offered the opportunity to interact on the Youth Noise website. Once on the website, the youth are immediately taken on a journey through the lives of homeless youth, in order to raise their awareness of the problem and build their motivation to activate around the cause. As with most projects, the young people must already be Virgin Mobile customers and must opt-in to receive the novella's messages. 28 Section 4: Is mobile the answer? Ethan Zuckerman, editor of Global Voices Online and Berkman fellow for Internet and Society, holds a number of strong opinions about the use and potential abuse of mobile phones in reaching public health outcomes. When pressed on how we in public health can challenge the commercial industry as they flock consumers with advertising over mobile phones, he deeply sighs and gives the signal to calm down. ―This is all unproven hype,‖ he says calmly. ―People do not want ads on their phones. They want to hear stories, follow their friends and build a personal brand. That is the content that they want, not advertising, and so that is the content that you should give them‖. As we have seen all over the industrialized parts of the world, social networking websites such as Facebook, MySpace, and Bebo, have swept people up, young and old, in a groundswell of vicious momentum. People are yearning to connect with one another through narrative, profile-building, shared causes and groups. Zuckerman believes that in order to harness the impact that social media has made through the Internet and transfer it onto mobile phones, the public health industry has to reverse its paradigm of pushing content onto people. For even if people are opting into an intervention, for medication alerts for instance, they will at some point throw up their hands and refuse to receive those messages anymore. ―People do not want to be SPAMed over the phone‖. One of the barriers that we are continually coming up against as we think with our social marketing caps on, is the inability to broadcast messages widely onto mobile phones. Mobile phones are fundamentally individual-to-individual interaction, with few mechanisms to achieve the one-to-many paradigm that the Internet has mastered. Twitter, a new social media platform built on the idea of the SMS, is the first mobile broadcast mechanism for which the one-to-many paradigm could be orchestrated on mobile phones. It is too early to tell, however, whether Twitter will take off running or peak early and slowly disintegrate. The only instances in which people are accustomed to receiving mass text messages is either when the phone company is shutting down and therefore alerting its customers, or when the government has a message for the public. This is often seen as an abuse of power. ―It's like the government stepping in and acting as the voice of God‖. 29 As Zuckerman, Alpert and many others have highlighted, mobile phones are not powerful as singular health behavior change tools. It is just one tool in a very complicated media environment. However, when paired with other mediums like radio, television and the web, the phone can become a unique and dynamic part of an integrated package. For instance, in countries of Africa where community radio is the most effective form of broadcast media, radio show hosts and DJs can take callers' questions through text messages and calls, but then shout out the responses over the radio and on the station's blog. Stations can make deals with the phone companies so that when people call or text in with questions about health, they do not have to pay for those calls and texts. Something as simple as subsidizing the phone calls that people make could be a greater public health intervention than trying to infiltrate people's inboxes with positive health messages. Zuckerman believes that the paradigm of sending text messages as part of a public health intervention is not effective unless it is viral – unless the people that receive those messages are passing them onto others who are then passing them onto others. This is the power of the peer-to- peer network that social networking platforms have been able to capitalize on. Peer-to-peer interaction via mobile phones is on the rise, particularly in countries such as Kenya where political unrest has spurred civilian action. During the 2007 uprisings following a botched election, hundreds of thousands of Kenyans were drawn to the streets in protest, after receiving text messages from the government telling them not to riot. Receiving these mass messages from the ruling government, complemented by a string of viral text messages from citizens wishing to organize, incited the people toward action. Another example of peer-to-peer interaction in Kenya is fostered through Safaricom's M-PESA application [32]. M-PESA is a service that allows one to transfer money to somebody else, whereby the phone system acts as banker. Money can be transferred to retail outlets, restaurants, taxi drivers, supermarkets and banks via a system that looks a lot like buying phone cards. Ken Banks, founder of Kiwanja.net is also frustrated. Through his work in rural Africa, he witnesses the everyday potential to leverage mobile technology to improve health care delivery 30 and efficiency, and how this potential is being squandered. ―There is so much low-hanging fruit‖ he explains. ―We have such a tendency to build big, sexy solutions to global problems and neglect to concentrate on the cheap and feasible solutions that already exist. Big, 3G, interactive ideas will interest donors who want to get their hands on something new and exciting – the next big thing. They are not interested in using basic, old technologies, even if they are being used for innovative purposes. It will be a long time before a rural farmer in Malawi can tap into such networks and benefit from these "sexy" ideas‖. Banks goes onto talk about the fundamental problem of lack of communication between community health workers and hospitals in rural Africa: ―As soon as the community health worker walks out the door, he/she loses all connectivity with the hospital. He/she may be gone for five weeks at a time and then has no way to update patient data from the field or ask important questions. They don"t even need fancy phones and internet to do that. All they need is SMS but SMS is not sexy so no one will fund the $500 dollars per year in contracts and $15 per phone. I keep reading these experts saying that we need to figure out what works. We know what works but we don"t see it replicated anywhere. We need to change our system and our thinking away from discovering the next big things and toward making better use of the things that we have. There is so much that we can do right now that we are not doing.‖ Banks is not as concerned with the future of mobile because he is consumed by what we can do with mobile right now. ―Frontline SMS can be downloaded anywhere, anytime. It's not clever and I am proud of that. Yet for some reason, nobody has replicated it. Until the iPhone comes to Africa, we have to do what we can do right now‖. 31 Section 5: Discussion It is clear that tremendous work is being done around the world to improve health care, health behavior and health outcomes, using cheap, easy and innovative technologies. In a media fragmented world, where new technologies are being developed everyday, it is difficult to imagine what the future will bring and how society's attitudes toward these applications will change. It is important to note that no single media intervention, whether it is mobile phone or other, will work on its own in influencing health behavior change. A comprehensive and integrated approach, that incorporates new and social media alongside broadcast media, is the most effective way to ensure that health messages are delivered and received. From the testimonies of the experts highlighted in this paper, it seems that a counter-marketing approach is not the answer for public health. While many worry that the commercial sector will begin to bombard people with incentives to engage in negative health behavior, individuals will react defensively to these types of SPAM-like messages. The fear is over-pronounced and we should instead investigate how mobile phone technology can be integrated as part of larger media campaigns, rather than as the primary tool. It is still too early to tell. In America Calling: A Social History of the Telephone to 1940, Philip A. Reed investigates how people responded to and integrated the use of the telephone in their lives, and how the telephone influenced social shifts in human behavior, gender roles and normative thinking. Reed's analysis documents these changes over 65 years (1875-1940), allowing him to dig into the complexities of emerging technologies and give technology educators a framework within which to make predictions about other innovations as they ensue. His ultimate conclusion was that the consumer decides which uses of technology will dominate and which will not. As public health advocates continue to investigate ways in which to harness these technologies for social marketing purposes, both an eye and an ear should always be kept close to the consumer and the beneficiaries of our campaigns. 32 References 1. Kaplan, W. A. (2006). Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Globalization and Health, 2, 9. 2. Lim, M. S. C., Hocking, J. S., Hellard, M. E., Aitken, C. K. (2008). SMS STI: a review of the uses of mobile phone text messaging in sexual health. International Journal of STD & AIDS, 19, 287-290. 3. Van den Oever & van Mens L. The Combined Use of Internet and SMS Targeting Hard to Reach Sex Workers Working as Escorts Abstract. AIDS 2006 – International AIDS Conference, Toronto 2006. 4. Levine, D., McCright, J., Dobkin, L., Woodruff, A. J., Klausner, J.D. (2008). SEXINFO: a sexual health text messaging service for San Francisco youth. American Journal of Public Health, 98, 3, 393-395. 5. Curioso, W. H. & Kurth, A. E. (2007). Access, use and perceptions regarding Internet, cell phones and PDAs as a means for health promotion for people living with HIV in Peru. BMC Medical Informatics and Decision Making, 7, 24. 6. United Nations Literacy Decade. UNESCO. Retrieved on February 27, 2009 from: http://portal.unesco.org/education/en/ev.php- URL_ID=13197&URL_DO=DO_TOPIC&URL_SECTION=201.html. 7. Franklin, V. L., Greene, A., Waller, A., Greene, S.A. & Pagliari, C. (2008). Patients' engagement with ―Sweet Talk‖ – a text messaging support system for young people with diabetes. Journal of Medical Internet Research, 10, 2. 8. Bigelow, K.M., Carta, J.J., & Lefever, J.B. (2008). Txt u ltr: Using cellular phone technology to enhance a parenting intervention for families at risk for neglect. Child Maltreatment, 13, 4, 362-367. 9. Rodgers, A., Corbett, T., Bramley, D., Riddell, T., Wills, M., Lin, R-B., Jones, M. (2005). Do u smoke after txt? Results of a randomized control trial of smoking cessation using mobile phone text messaging. Tobacco Control, 14, 255-261. 10. Bramley, D., Riddell, T., Whittaker, R., Corbett, T., Lin, R-B., Wills, M., Jones, M., & Rodgers, A. (2005). Smoking cessation using mobile phone text messaging is as effective in Maori as non-Maori. The New Zealand Medical Journal, 118, 1216. 11. Obermayer, J.L., Riley, W.T., Asif, O., & Jean-Mary, J. (2004). College smoking-cessation using cell phone text messaging. Journal of American College Health, 53, 2, 71-78. 12. Agence France-Presse. Indonesia launches first SMS sex education campaign. Retrieved on March 2, 2009 from: http://www.theage.com.au/news/Technology/Indonesia-launches-first-SMS-sex-education- campaign/2007/07/17/1184559784985.html. 13. Let's Talk About Sex, Baby: Sexual Health Info via SMS. Retrieved on March 2, 2009 from: http://mobileactive.org/lets-talk-about-sex-baby-sexual-health-info-sms. 14. Ask about Sex via Text: Teenagers 'Learn About Living' in Nigeria. Retrieved on March 2, 2009 from: http://mobileactive.org/ask-about-sex-text-teenagers-learn-about-living-nigeria. 15. Why Mobiles and Health? Retrieved on March 2, 2009 from: http://mobileactive.org/wiki/Health 16. Text to Change. Retrieved on March 2, 2009 from: http://www.texttochange.com/. 17. SMS Support Network: Connecting People with HIV/AIDS in Mexico. Retrieved on March 2, 2009 from: http://mobileactive.org/sms-support-network-connecting-people-hiv-aids-mexico. 33 18. Chetley, A. (2006). Improving health, connecting people: The role of ICTs in the health sector of developing countries. Working paper, InfoDev. 19. Kinkade, S. & Verclas, K. Wireless Technology for Social Change: Trends in Mobile Use by NGOs. Washington, DC and Berkshire, UK: UN Foundation–Vodafone Group Foundation Partnership, 2008. 20. Cell phone 4 dev……. 21. Reuters. Mobile phone growth helps poorer states: U.N. March 2, 2009. Retrieved March 6, 2009 from: http://tech.yahoo.com/news/nm/20090302/tc_nm/us_technology_un. 22. Blumberg, S. J. & Luke, J.V. (2009). Wireless Substitution: State-level estimates from the national health interview survey, January – December 2007. National Health Statistics Report, U.S. Department of Health and Human Services. 23. Fjeldsoe, B.S., Marshall, A.L., & Miller, Y.D. (2009). Behavior change interventions delivered by mobile telephone short-message service. American Journal of Preventive Medicine, 36, 2, 165-173. 24. The Search… 25. Alder, R. The Landscape of Texting 4 Health: Technology, Applications, Policy Issues Slide Presentation in Texting 4 Health Conference, February 29, 2008. 26. Pop!Tech Unveils Project Masiluleke: Largest-Ever Use of Mobile Devices for Delivery of HIV/AIDS & TB Care. Press Release retrieved on May 8, 2009 from: http://www.poptech.org/projectMpressRelease/. 27. Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation Partnership, 2009. 28. Alpert, J. & Stein, B. Reach Out and Text Someone in Texting 4 Health. c. 2008. 29. Sex, Carjacking and Nutrition. Retrieved on May 11, 2009 from: http://calorielab.com/news/2005/07/17/sex-carjacking-and-nutrition/ 30. http://www.coralcross.org/ 31. http://findarticles.com/p/articles/mi_m3190/is_16_42/ai_n25455474/ 32. http://www.safaricom.co.ke/index.php?id=745 33. Weinreich, Nedra. Excuse me, my cause is calling. Blog post retrieved on May 12, 20098 from: http://www.social-marketing.com/blog/2006/08/excuse-me-my-cause-is-calling.html 34. StickK. Retrieved on May 12, 2009 from: http://www.stickk.com/about.php. 35. Newsdesk. What Makes Orszag Run? New Yorker Magazine, April 29, 2009. 36. Kaye, K. Virgin Mobile Texts Tales to Take on Teen Homelessness. On Click Z website. Retrieved on May 12, 2009 from: http://www.clickz.com/3623327. 37. Grunwald, Michael. How Obama is Using the Science of Change. Time Magazine. April 2, 2009. 38. Battelle, J. (2005). The Search. Portfolio, New York. 34
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Rice, Cheddar & Spinach Pie
From EatingWell: March/April 2012
This rice, spinach and Cheddar pie is a cinch to prepare—especially if you have leftover cooked rice. If you don't, follow package directions for 4 servings to get about 3 cups cooked rice. Serve with steamed artichokes with light mayo mixed with lemon for dipping.
Makes: 6 servings
Active Time:
Total Time:
Nutrition Profile
Diabetes appropriate | Gluten free | High calcium | Low calorie | Low sodium |View Our Nutrition Guidelines »
- 3 tablespoons extra-virgin olive oil
- 1 small onion, finely chopped
- 3 cloves garlic, minced
- 1 10-ounce package frozen chopped spinach, thawed and squeezed dry
- 3 cups cooked instant or quick-cooking brown rice
- 1 cup diced extra-sharp Cheddar cheese
- 1/2 teaspoon freshly ground pepper
- 1/4 teaspoon salt
- 4 large eggs
- 1/4 cup nonfat milk
- Preheat oven to 425°F. Generously coat a 9-inch pie pan with cooking spray.
- Heat oil in a large skillet over medium heat. Add onion and cook, stirring frequently, until beginning to brown, about 5 minutes. Add garlic and spinach; cook, stirring, 1 minute more. Transfer to a large bowl. Add rice, cheese, pepper and salt to the bowl and stir to combine.
- Whisk eggs and milk in a medium bowl. Stir into the spinach-rice mixture. Transfer to the prepared pan and smooth the top with a spatula.
- Bake the pie until lightly browned in spots, about 25 minutes. Let stand for 5 minutes before cutting into wedges.
Per serving: 340 calories; 18 g fat (6 g sat, 8 g mono); 144 mg cholesterol; 30 g carbohydrates; 0 g added sugars; 14 g protein; 3 g fiber; 309 mg sodium; 300 mg potassium.
Nutrition Bonus: Vitamin A (119% daily value), Calcium & Folate (23% dv)
Carbohydrate Servings: 2
Exchanges: 1 1/2 starch, 1/2 vegetable, 1 high-fat meat, 2 fat
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Recipe Categories
- Total Time
- 45 minutes or less
- Servings
- 6
- Main Ingredient
- Vegetarian, other
- Type of Dish
- Main dish, vegetarian
- Ethnic/Regional
- American
- Health & Diet Considerations
- Diabetes appropriate
- Low calorie
- Low sodium
- High calcium
- Gluten free
- Meal/Course
- Dinner
- Ease of Preparation
- Easy
- Publication
- March/April 2012


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Creators: L. Quilici, S. Quilici Gigli
Contributors: DARMC, R. Talbert, Sean Gillies, Tom Elliott, Jeffrey BeckerCopyright © The Contributors. Sharing and remixing permitted under terms of the Creative Commons Attribution 3.0 License (cc-by).
Last modified Mar 14, 2013 05:08 PM
Collatia was an ancient city of Latium located between Gabii and the Anio fl.
Show area in Antiquity À-la-carte, GeoNames, Google Earth, Google Maps, or OpenStreetMap.
- DARMC location 18354 (750 BC - AD 640)
- Collatia (750 BC - AD 640)
- See Further: BAtlas 43 C2 Collatia
- See Further: FormIt Collatia
- See Further: Smith 1854 (Perseus), COLLATIA
- See Further: Wikipedia, Collatia
Barrington Atlas: BAtlas 43 C2 Collatia
The Barrington Atlas Directory notes: Lunghezza
Quilici, L., S. Quilici Gigli, DARMC, R. Talbert, S. Gillies, T. Elliott, J. Becker. "Places: 422898 (Collatia)". Pleiades. <http://pleiades.stoa.org/places/422898> [Accessed: July 3, 2015 3:25 am]
{{cite web |url=http://pleiades.stoa.org/places/422898 |title=Places: 422898 (Collatia) |author=Quilici, L., S. Quilici Gigli, DARMC, R. Talbert, S. Gillies, T. Elliott, J. Becker |accessdate=July 3, 2015 3:25 am |publisher=Pleiades}}
- History
Edited by Jeffrey Becker on Mar 14, 2013 05:08 PMedited description; added references↑ Compare ↓Edited by Sean Gillies on Oct 20, 2012 07:44 PMLocation updates and tags from Johan Ahlfeldt's (jahlfeldt) Digital Atlas of the Roman Empire in October 2012↑ Compare ↓Edited by admin on Feb 14, 2012 11:55 PMGlobal migration and reindexing of citations and provenance, February 2012↑ Compare ↓Edited by Sean Gillies on Jan 21, 2011 06:10 PMNew locations, coordinates, and metadata from Harvard's DARMC project. See http://atlantides.org/trac/pleiades/wiki/PlaceUpgradesAndMigrations↑ Compare ↓Edited by Sean Gillies on Jan 14, 2011 02:43 PMDetail text updated from former modernLocation. See http://atlantides.org/trac/pleiades/wiki/PlaceDetailsUpgrade


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An Improved Audio Watermarking Scheme Based on Complex Spectral Phase Evolution Spectrum
In this paper, a new audio watermarking algorithm based on the Complex Spectral Phase Evolution algorithm is presented. This is an extension of a previous scheme. Peaks in a spectral representation derived from the Complex Spectral Phase Evolution are utilized for watermarking, instead of the frequency identification technique which was previously proposed. Although this new scheme uses a process which is less complex, it nevertheless achieves a high degree of robustness, particularly against common attacks, which is one distinct advantage over our previous scheme. Similarly, perceptual transparency and accuracy are both very good.
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The impact of oxygen on the transcriptome of recombinant S. cerevisiae and P. pastoris - a comparative analysis
- Equal contributors
1 Department of Chemical Engineering, Autonomous University of Barcelona, Spain
2 Department of Biotechnology and Bioscience, University of Milano-Bicocca, Milan, Italy
3 Institute of Applied Microbiology, Department of Biotechnology, University of Natural Resources and Applied Life Sciences, Vienna, Austria
4 School of Bioengineering, University of Applied Sciences, FH Campus Vienna, Austria
5 Austrian Centre of Industrial Biotechnology (ACIB GmbH), Vienna, Austria
6 Department of Computer Science, UC Davis Genome Center, University of California, Davis, USA
BMC Genomics 2011, 12:218 doi:10.1186/1471-2164-12-218Published: 9 May 2011
Saccharomyces cerevisiae and Pichia pastoris are two of the most relevant microbial eukaryotic platforms for the production of recombinant proteins. Their known genome sequences enabled several transcriptomic profiling studies under many different environmental conditions, thus mimicking not only perturbations and adaptations which occur in their natural surroundings, but also in industrial processes. Notably, the majority of such transcriptome analyses were performed using non-engineered strains.
In this comparative study, the gene expression profiles of S. cerevisiae and P. pastoris, a Crabtree positive and Crabtree negative yeast, respectively, were analyzed for three different oxygenation conditions (normoxic, oxygen-limited and hypoxic) under recombinant protein producing conditions in chemostat cultivations.
The major differences in the transcriptomes of S. cerevisiae and P. pastoris were observed between hypoxic and normoxic conditions, where the availability of oxygen strongly affected ergosterol biosynthesis, central carbon metabolism and stress responses, particularly the unfolded protein response. Steady state conditions under low oxygen set-points seemed to perturb the transcriptome of S. cerevisiae to a much lesser extent than the one of P. pastoris, reflecting the major tolerance of the baker's yeast towards oxygen limitation, and a higher fermentative capacity. Further important differences were related to Fab production, which was not significantly affected by oxygen availability in S. cerevisiae, while a clear productivity increase had been previously reported for hypoxically grown P. pastoris.
The effect of three different levels of oxygen availability on the physiology of P. pastoris and S. cerevisiae revealed a very distinct remodelling of the transcriptional program, leading to novel insights into the different adaptive responses of Crabtree negative and positive yeasts to oxygen availability. Moreover, the application of such comparative genomic studies to recombinant hosts grown in different environments might lead to the identification of key factors for efficient protein production.


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ThermoEnergy, others get $1M for flameless reactor
A joint venture between ThermoEnergy Corp. (OTCBB:TMEN), ITEA, MIT and Georgia Tech dubbed the Unity Power Alliance has received final approval on a $1 million U.S. Department of Energy award to advance the company's pressurized oxy-combustion technology for clean, coal-fired power generation.
The alliance, formed by ENEL, is set to prove that its technology can work at high pressure, which would both simplify and dramatically reduce the cost of the entire system. The first part of the program is the techno-economic modeling optimization, which will be done at MIT. The second part of the program will be to test ITEA's flameless reactor over a range of pressures which will be conducted at Georgia Tech's Carbon Neutral Energy Solutions lab. ThermoEnergy, in Worcester, has been tasked with building the bench-scale testing unit.
The joint venture came together when ENEL saw that ThermoEnergy had its high pressure patent coverage and ITEA had technology that works at a low pressure range. "The beauty of the two is if we can prove - which thermodynamically and kinetically should be easy - that part of (ENEL's SpA and ITEA) technology works at high pressure, it simplifies and dramatically reduces the cost of the entire system," UPA Managing Director and Vice President at Thermal Energy Robert Marrs told Mass High Tech.
There is a lot riding on the project, according to the UPA.
If the team has great success with proving that its technology works, it will move on to a larger, Phase 2 DOE/National Energy Technology Lab award in the $10-20 million range toward the construction of a pilot scale project. The team has a short time frame in which to report results, but is confident it will achieve greater efficiencies to test the reactor at a variety of higher pressures in order to reach Phase 2, according to Marrs.
"The confidence level from a technical perspective is extraordinarily high," Marrs said. "We already have a 15-megawatt plant in Singapore and 5 megawatt in Italy."
The UPA plans to develop and commercialize the pressurized oxy-combustion as a new way to repower existing coal-fired power plants in the U.S. and build new power plants with near zero air emissions. The DOE is anxious to get the technology tried in the U.S. and that has placed a huge challenge on UPA and competitors who have less than a year before they need to apply for the next phase, according to Marrs.
"It is a horse race," he said. "I look forward to the competition."


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