Media Grand Rounds: Current Media Studies
Study Table Of Contents
Targeting Adolescent Hearing Loss from MP3 Player Use
Screen Time, Mental Health and Physical Activity
Teenagers Wanting Medical Advice – Is MySpace the Answer?
Influencing Adolescents' Display of Risky Behavior on Social Networking Sites
Sexual Harassment and Social Networks
Targeting Adolescent Hearing Loss from MP3 Player Use
Vogel, Ineke et al. “Strategies for the Prevention of MP3-Induced hearing Loss among Adolescents: Expert Opinions for a Delphi Study”. Pediatrics 2009; 123:5:1257-1268.
P: Patient or Problem
I: Intervention or Interest
C: Comparison
O: Outcome
Question: What are effective health interventions to prevent MP3-induced hearing loss in adolescents and which stakeholders have the greatest potential to effect prevention strategies?
Question Type: Descriptive/Causation
Study Design: Observational
The authors used a Delphi study consisting of multiple iterations of open-ended questions on potential hearing conservation behaviors in teen users of MP3 players. The Web surveys were transmitted first to experts on music-induced hearing loss and then to stakeholders in research, education, health, community and the music industry.
The initial round of questions targeted research experts (n=7) and solicited responses on potential protective behaviors, likely factors determining whether teens would perform these behaviors, external interventions to increase these behaviors, and identification of parties who should be involved in hearing-loss prevention campaigns. The subsequent 2 rounds of questions (n=30) targeted at the broader range of stakeholders involved rating the behaviors and interventions on a relevance scale (e.g. “how relevant is a 90 dB maximum volume limit to this issue?”) and then on a feasibility scale (e.g. “How feasible would an intervention of limiting volume to 90 dB be?”). The 3rd round allowed the 2nd round participants review the group’s highly rated items (on relevance, feasibility or both) and re-rank their agreement with the group’s response.
The qualitative analysis of the potential behavioral changes and health prevention measures showed that the behavioral changes adolescents could make to conserve hearing were relevant but not feasible. Such changes include users limiting their total daily listening time, limiting their own maximum volume, using special earphones, and limiting frequency of exposure to high volume music. The only behavior that was both relevant and feasible was “Adolescents need to be aware that listening to high-volume music may cause hearing loss.”
Only 2 of 17 prevention measures external to adolescents were rated relevant and feasible:
1) MP3 player manufacturers should be encouraged to produce safer products; and
2) Efforts to launch public health campaigns designed to increase public knowledge of the hearing loss risks associated to high volume music and to educate on preventive measures.
One measure rated as highly relevant but with weaker consensus was that all players are equipped with a noise limiter.
Commentary by Mary Beth Miotto, MD, FAAP
The paper addresses a real-life clinical issue that is attracting attention in both the medical community and the music entertainment industry. Increasing numbers of young adults are showing hearing loss at equal or greater levels than their parents. The authors’ attempts to measure the effectiveness of intervention across disciplines are a first step to real action. It is discouraging that many of the most relevant interventions showed little feasibility in practice, the relatively simple and low-cost measure of public education on hearing conservation showed the greatest potential benefit.
The main limitations of the study were the size and breadth of the expert panels. The data was not sufficient to enable detailed analysis based on the field of the individual participant. The authors take steps to analyze the data with these limitations in mind, but this weakness does reduce the usefulness to clinicians. In addition, there were a number of key stakeholders notably absent from the panel, namely parents, adolescents, and the manufacturers and retailers of the MP3 players. As one relevant intervention was volume level limitations on the MP3 players, the music retail industry should hold a key seat at the table. While regulating the industry may be a feasible intervention in the Netherlands (where the study was done), US retailers may be more amenable to voluntary changes if they are invited into the discussion earlier in the process.
Many new models of MP3 players are being produced with optional noise-limiting controls. The iPod Nano 4G and others offer parents and consumers a password-enabled volume control feature. In addition, 2 small US manufacturers offer noise-limiting ear buds and other major headphone manufacturers such as Bose are integrating noise modulation into their product lines. As pediatricians encounter teens in the office, discussion of MP3 hearing loss prevention may be easily woven into questions on media use and leisure activities. Physicians might also consider spearheading or joining community education campaigns on this important risk.
Screen Time, Mental Health and Physical Activity
Hamer et al. "Psychological Distress, Television Viewing, and Physical Activity7 in Children Aged 4 to 12 Years". Pediatrics 2009; 123:1263-1268.
PICO:
P: Children aged 4-12 years living in Great Britain
I: Impact of screen time and physical activity on psychological distress
C: screen times' negative impact on psychological distress vs. physical activity's positive impact on psychological distress
O: high screen time and low physical activity were associated with the highest psychological distress in an additive pattern
Question: Are television and screen entertainment (TVSE) time and low physical activity independently associated with psychological distress?
Study Design: parental reported retrospective survey
Using a sample from the Scottish Health Survey, data was collected from 1486 children age 4 to 12 years during the calendar year 2003. Trained interviewers were sent into homes to conduct the surveys. Parents provided the answers to questions about their children using the Strengths and Difficulties questionnaire (SDQ). In addition, parents reported the number of hours per week of TVSE and frequency of sports or active play (defined as at least 15 minutes of activity). In an attempt to control for confounding factors, parents were also asked to complete the Scottish Index of Multiple Deprivation Questionnaire (investigating household income, housing, education, etc).
Statistical analysis was completed using an analysis of variance technique testing the variables against TVSE. Additionally, TVSE, the SDQ score, and physical activity were studied via linear regression. As hypothesized, TVSE and physical activity level were found to be independently associated with psychological distress. Furthermore, high TVSE and low physical activity had a synergistic effect increasing psychological distress. The highest SDQ scores were found in the most sedentary children (TVSE of greater than 2.7 hours per day correlated with a 24% increase in SDQ). However, the increase in SDQ nearly doubled (46%) when combined with low physical activity.
Commentary by Elizabeth Murray, DO MBA
There is a perception that sedentary lifestyles and obesity are solely American problems. This study offers a look into what other developed countries are experiencing and shows that screen exposure and lack of activity rates are likely not that different than those experienced by American children.
With regard to study design, self-reporting (or in this case parental reporting) is often plagued with reporter bias. However, the Scottish Health Survey is completed every 3-5 years and would likely be considered a familiar data collection device similar to the Census. Sampling was based on postal code and address which would group subjects by geography instead of a truly random sample, thereby potentially introducing further bias. In addition, there is no control for parental behavior. That is, poorly behaved children may be allowed more screen time if it "keeps them happy".
While there are no p-values reported for the data, the confidence intervals for all aspects of the regression imply significance. However, it is difficult to tell what exactly is a "session of activity". The authors state that it must be at least 15 minutes in duration. It is possible that one child could have eight 15 minute sessions per week while a different child could have eight one hour sessions per week. The authors report that they have demonstrated the validity of the activity data because of a subset of the population (768 children) who had lower pulse pressures (likely blood pressures) in the setting of higher levels of activity (p<0.5). Judging physical fitness on blood pressure alone is an overstatement of the power of a one time reading of one vital sign.
Mental health issues are becoming more and more prevalent (or perhaps more recognized) in the Pediatric population worldwide. This study aims to show a link between not only physical activity and mental health but the compounding effect of screen time on mental health. It offers providers yet another "open door" into the discussion with parents by giving us a new twist on an issue we have been discussing with parents for a long while. As we have seen, appreciating the benefits of activity on physical health has not been enough to encourage parents to turn off the screens and get the children playing. Perhaps an understanding of the impact of activity on a child's mental health will provide the last needed encouragement for parents. In other words, putting a new twist on an old theme may be what finally gets those screens turned off and our kids moving more outside.
Teenagers Wanting Medical Advice – Is MySpace the Answer?
Versteeg, KM, Knopf, JM, Posluszny, S, Vockell, AL, Britto, MT
Arch Pediatr Adolesc Med Jan 2009, 163 (1) 91-2.
Descriptive study characterizing the content of asthma-related groups on MySpace
Over half of all teenagers regularly use social media sites and some join health related interest groups. To better understand the role of social media among teens seeking health information, a group of researchers from the University of Cincinnati recently studies asthma-related content on the popular social networking site, MySpace. Data was collected for 2 weeks using asthma as a keyword search. Researchers collected and analyzed data from MySpace groups composed of a main group web page and forums. Each forum discussion is made up of a thread of question or comments on a topic. Because of the dynamic nature of social media, sites were visited once and information was recorded on a data collection form.
Information on an asthma-related groups main page was classified as relating to medication, lifestyle, diagnosis, or other. Reviewers classified forum posts as asking a question, answering a question, providing advice, sharing a personal story, providing a link to an external site, advertisement or other. Questions were further classified as relating to medication, lifestyle, diagnosis or other.
One hundred eighty eight publicly available asthma groups were found but only 19% were found to be directly related to asthma. Of 317 forums reviewed, 195 were asthma related. The highest proportion of posts shared a personal story (42%), typically about diagnosis, triggers, problems and experiences. Many followed the format “I used to have really bad asthma until….” 15% of posts asked a question and 5 provided advice. More than half of the questions and half the advice related to another asthma topic including alternative treatments, physicians, hospital visits and social situations. Medication was the subject of 40% of questions. Links in posts were 73% commercial in origin and only 40% were considered relevant to asthma.
The researchers conclude that asthma-interest groups on MySpace contained little clinical information and many posts contained significant clinical misinformation.
Commentary By Bryan Vartabedian, MD, FAAP
Teens are increasingly engaging in the social media space. Socialization creates an opportunity for children with similar chronic diseases to come together and share their experiences. While we might consider this to be positive, this study demonstrates that the information available through the social media site MySpace is potentially unreliable or commercially derived. While sharing of health information online may prove to have some benefit for adults, this study shows that among teens, online social activity may have negative implications for health.
Given the descriptive nature of the study it isn’t clear what degree of emotional support these teens gained from online networking. I suspect that this may be a benefit not adequately assessed or described here.
The author’s concluding remarks suggest that their findings are worrisome as adolescents are increasingly turning to the internet rather than their health provider for information. While I would agree that misinformation from any source should is unfortunate, the idea of patients taking personal control of their own chronic conditions should always be encouraged. In the era of participatory medicine, we are no longer the sole providers of information for teens and parents. It is our job to help patients develop new media literacy.
The social media space represents a new and unique opportunity for health professionals to interface with teens. Further studies like this are needed to understand the types of misinformation that are propagated among teens. Such studies can help us understand where to focus as we be begin to focus our attention on new media literacy.
nfluencing Adolescents' Display of Risky Behavior on Social Networking Sites
Moreno, Megan et al. "Reducing At-Risk Adolescents' Display of Risk Behavior on a Social Networking Web Site". Archives of Pediatric & Adolescent Medicine 2009; 163:35-41.
P: Patient or Problem
I: Intervention of Interest
C: Comparison
O: Outcome
Question: Among at-risk adolescents using social networking websites, does an on-line intervention reduce references to sex and substance use?
Question Type: Causation
Study Design: Intervention and Observation
Using the social networking site (SNS) MySpace, Moreno et al viewed 190 web profiles of 18- to 20- year-olds who had documented references to sex and substance use. The aim of the study was to observe the effect that an e-mail from a physician would have on references to sex and substance use in the on-line profiles of at-risk adolescents.
The authors used the MySpace search engine to randomly select 190 18-to 20- year olds, living within an at-risk zip code whose on-line profiles were set to public viewing and who had repeated references to sex and substance use.
An email authored by "Dr. Meg" was sent to 95 of the adolescents, which stated that she had viewed their web profiles and was concerned about their openness regarding sexual issues and substance use. She advised that they revise their profiles to better protect their privacy and provided them with information on sexually transmitted diseases.
The 190 web profiles were revisited 3 months after the interventional email and re-graded for sexual and substance use references. The percentage of adolescents who decreased their references to zero were 13.7% for sexual references vs. 5.3% in the control group and 26% for substance use references vs. 22% in the control group. Additionally, 10.5% changed their profile settings from public to private compared to 7.4% in the control group.
Commentary by Corinn Cross, MD, FAAP
There were many limitations to this study. The sample size was small and the confidence intervals were quite wide. However, the results are promising that fairly low-cost interventions of this type could have a positive impact. One must keep in mind though that decreasing references to sex and substance use on a web profile does not necessarily correlate with decreasing risky behavior itself.
The age range of its subjects also limits the study. The study focused very narrowly on late-adolescents or young adults 18-to-20 years of age. Although it was necessary for the study’s authors to choose this population, since MySpace limits its browse function to profiles of users ages 18-years-old or older, this age group is at the upper age limit of most pediatric practice populations. How effective similar interventions would be on the younger adolescent population is unknown. Interventions in this younger age group might be even more effective. Given their increase risk of being the target of on-line predators, encouraging this younger population to appropriately manage their personal information in order to maintain their privacy on-line is imperative.
The most statistically significant result in this study was the reduction of sexual references by females in the interventional group as compared to the control group. It is possible that many adolescents do not realize how exposed they actually are to strangers when they use social networking sites. If this is the case, discussing with adolescents, particularly females, about how to maintain their privacy could help to decrease their risk of being target of unwanted attention.
With the high use of social networking sites by teens, it seems that these sites have become a common part of adolescent life. Given how prevalent these sites have become it is necessary for us as pediatricians to discuss on-line activity with our adolescent patients. We should question our patients as to where they are hanging-out on-line and what information they are displaying about themselves as well as counsel them about how to stay safe on-line. This study opens the door for more research on how to use this new media venue for outreach programs targeting teens and young adults. It also reminds us that the best way to influence adolescents is to be where they are.
Sexual Harassment and Social Networks
Ybarra ML, Mitchell KJ “How Risky Are Social Networking Sites? A Comparison of Places Online Where Youth Sexual Solicitation and Harassment Occurs” Pediatrics 2008;121;e350-e357
P: Patient or Problem
I: Intervention of Interest
C: Comparison
O: Outcome
Question: Do 10 to 15 year-old youth receive unwanted sexual solicitation on social networks?
Question Type: Descriptive
Study Design: Observational
The authors used the CDC sponsored Growing up With Media Survey to evaluate sexual victimization and harassment on social networking sites. There were 1588 participants 10 to 15 years old who used the internet in the previous 6 months in 2006. One outcome measure was unwanted sexual solicitation on the internet, defined as unwanted requests to talk about sex, provide personal sexual information or do something sexual. Another measure was for internet harassment, defined as rude or mean comments, or spreading of rumors. Four percent reported unwanted sexual solicitation on a social network site compared to the total 15 percent of all those surveyed. Nine percent reported harassment on social networks compared to 33 percent of those surveyed. The authors also reported locations of victimization. The 15% who experienced sexual solicitation in the previous year reported Instant Messaging (42%), chat rooms (31%) and Social Networks (27%) as the top three situations. The 33% who reported harassment sited Instant Messages (55%), Social Networks (27%) and online games ( 24%) as the top three locations. The authors concluded that sexual solicitation and harassment are not wide spread. Prevention efforts should focus on psychosocial issues and not internet applications.
Commentary by Jeff Hutchinson, MD, FAAP
This paper addresses the question of sexual solicitation and harassment with social networking. The good news is that most kids are not harassed or solicited. The Jan 13th NY Times article by Brad Stone, “Report Calls Online Threats to Children Overblown” reports similar findings from an Internet Safety Task force. The same information may also be interpreted as proof that any solicitation of minors is unacceptable and by eliminating social networks one means of solicitation could be eliminated.
Shows like NBCs “To Catch a Predator” and cases like Megan Meier’s involving MySpace create the public outcry for something to be done to prevent sexual predators and online harassment. The American Academy of Pediatrics endorses media education and emphasizes advocacy for children. Pediatricians can educate teens and parents how 1 in 7 who use the internet may experience solicitation and 1 in 3 may be harassed. The more prevalent online harassment should be incorporated into the same discussions about bullies and seat belts when providing anticipatory guidance. The authors rightly approach the topic by questioning the effectiveness of restricting social networking as the solution these problems. They endorse evaluating and addressing the behaviors and the underlying risks.
Discussing instant messaging(IMing) should receive more attention. IMing is limited to known friends and can be in or outside of social networks. IMing followed by chat rooms had a higher percentage of sexual solicitation than social networks. Being harassed was reported during instant messaging more often than when using social network sites. Technology and access will continue to evolve and users will utilize whichever method draws them. As one area of technology is addressed by legislation, young people who are potential targets will have already moved to another technology. Cell phone instant messaging, “texting” is just one example.
If the research demonstrated incident after incident of solicitation or victimization on social network sites, there would truly be a rallying call to address the technology. Instead it demonstrated that most of the inappropriate behaviors are typically from known individuals through instant messaging. It emphasizes the need for parental monitoring and questioning of teen and preteen behaviors. The internet has indeed produced a convenient way for interaction that can be positive or negative. We are beyond the point of taking that communication away. The internet is a tool that can cause harm if used improperly or provide support for individuals who feel alone. It also allows an additional outlet for normal developmental behavior. The key to using any tool is proper education and training.
This paper is a call to improve the technology to protect those we can but more notably to bring out into the open the behavior of some young people. We need to provide tools for young people to prevent solicitation or harassment in the current digital age. Part of media education during a clinic visit should include the questions, “Do you have a social page?” “Is it private or public?” Parents of pre-teens should ask to see the web pages and be suspicious if the patient is embarrassed or refuses to share. Computers should be in common areas so inappropriate pictures and teen’s reactions while online can be monitored. During a clinic encounter when a teen is seen without the parent for part of the visit the teen should also be asked, “Do your parents know you have a page?” These questions can start the dialog and may uncover a young person who has been affected negatively. Fortunately, it will more often provide the opportunity for preventative education where pediatricians can play an important role in the health of children and adolescents.
All articles edited and reviewed by Gwenn Schurgin O'Keeffe, MD, FAAP, COCM Web site and Blog Editor-In-Chief,July 14, 2009
