LITERATURE REVIEW ON EFFECTIVENESS OF THE USE OF …

[Pages:63]LITERATURE REVIEW ON EFFECTIVENESS OF THE USE OF SOCIAL MEDIA

A REPORT FOR PEEL PUBLIC HEALTH REBECCA SCHEIN, PHD(1), KUMANAN WILSON MSC, MD, FRCS (2) AND JENNIFER KEELAN, PHD (3)

(1) ASSISTANT PROFESSOR, CARLETON UNIVERSITY, OTTAWA, ONTARIO, CANADA (2) CRC (PUBLIC HEALTH POLICY), UNIVERSITY OF OTTAWA, OTTAWA, ONTARIO CANADA. (3) ONT MOHLTC CAREER SCIENTIST, ASSISTANT PROFESSOR, CENTRE FOR INNOVATION IN COMPLEX CARE & SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF TORONTO, TORONTO, ONTARIO,

CANADA

TABLE OF CONTENTS

EXECUTIVE SUMMARY ...........................................................................................................................................3 BACKGROUNDER ON SOCIAL MEDIA USE .........................................................................................................4 RESEARCH METHODS ..............................................................................................................................................6 RESULTS......................................................................................................................................................................7

POTENTIAL APPLICATIONS, CURRENT USES, AND UTILITY OF SOCIAL MEDIA FOR HEALTH COMMUNICATION................9 "INFODEMIOLOGY" AND "INFOVEILLANCE" .............................................................................................................14 CIRCUMVENTION OF ADVERTISING REGULATIONS THROUGH SOCIAL MEDIA ..............................................................18 FEASIBILITY ............................................................................................................................................................. 20 CHALLENGES / PITFALLS......................................................................................................................................21 SUMMARY ................................................................................................................................................................23 RECOMMENDATIONS.............................................................................................................................................25 REFERENCES ............................................................................................................................................................27 APPENDICES ............................................................................................................................................................. 32 1. STATS CAN DATA ON CANADIAN INTERNET USE.......................................................................................................32 2. SOCIAL MEDIA PLATFORMS...................................................................................................................................35 3. ANALYSIS OF INCLUDED ARTICLES..........................................................................................................................36 4. CASE STUDIES.......................................................................................................................................................52 5. COMPETING WITH VACCINE-CRITICAL MESSAGING..................................................................................................61 6. INFOVEILLANCE / INFODEMIOLOGY: WHO IS SICK ..................................................................................................63

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Executive Summary

Preliminary data from the field suggests that social media is becoming a powerful addition to the health communicators' toolkit. Although there is a great deal of interest in using social media as a tool for public health communications, the research evaluating its utility is still in its infancy. As of yet, few research studies have examined the broader utility of social media for the adoption of health promoting and protective behaviours. One of the chief conclusions of this report is that there is a paucity of peer-reviewed studies testing the utility of social media interventions for desired outcomes. Instead, research has focused on documenting the range of health-related behaviours and the content of health-related discourse on these platforms. Observational studies show an abundance of both informal health conversations related to public health issues and organized health-related activities on leading social media platforms such as YouTube, Twitter, and Facebook. The quality of health information available to users on these platforms is highly variable raising some concerns that social media users are exposed to unopposed viewpoints that counter core public health recommendations and contemporary medical science, such as those opposing immunization and promoting smoking.

Social media is currently utilized by public health organizations both as a broadcasting platform to amplify messages from traditional media sources (e.g., radio, television, print media) and as an entirely new way of collaborating and co-creating content with target audiences. In the latter approach, organizations have had to adapt their communications strategies to incorporate usergenerated content and feedback. The process of engaging users to co-create content, to rate, rank and comment on communications, more so than the resulting message, is increasingly perceived to give a heightened authenticity to messages, improving trust in, and building users' relationships with, organizations. Social media, unlike traditional media campaigns, provides novel opportunities to embed and interject public health messaging into the daily online conversations of Canadians. In the future, it will also allow public health communicators to deliver a range of health promotion messages and self-monitoring tools through mobile applications, an innovation that will potentially increase the reach to those without computers, and will allow public health messaging to penetrate the day-to-day health conversations and activities of Canadians. The adoption of social media by leading public health organizations reflects a widespread sense that these tools are increasingly necessary to reach demographics who are abandoning traditional broadcast technologies (e.g., telephones, television) such as teens, or a significant portion of the public who are rapidly transforming the manner in which they interact with experts.

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Backgrounder on Social Media Use

In the era of the 24-hour news cycle, the traditional once-a-day press conference featuring talking heads with a bunch of fancy titles has to be revamped and supplemented with Twitter posts, YouTube videos and the like. The public needs to be engaged in conversations and debate about issues of public health, they don't need to be lectured to." -Andre Picard, The Globe and Mail, June 9, 2010

Statistics Canada data indicate not only that more and more Canadians are using the internet at home in their daily lives (see Appendix 1 for a review of internet and social media usage trends), but that they are engaging in an ever more diverse array of online activities (1,2,3,4,5). These activities reflect the growing integration of online tools into Canadians' personal and professional lives and the shift from static "Web 1.0" platforms to the dynamic, interactive, and collaborative qualities of Web 2.0. In addition to evidence of the accelerating popularity of online platforms like Facebook, Twitter, and YouTube, new data also suggests that organizations can increase feelings of trust and loyalty through social media use (5). Such trends are already generating widespread interest in the use of Web 2.0 and social media platforms in research, policy and practice. The precise boundaries defining these terms, however, are still emerging within the literature. As the number, diversity, and inter-operability of new web-based and mobile platforms continue to proliferate, the characteristics and subcategories denoted by the term "social media" will need to be further disaggregated and refined.

There is general agreement, however, that the new media environment is characterized by interactivity, usergenerated content, and multi-

As of August, 2007, there were roughly 1200 Facebook communities advocating for cures for different diseases. The Canadian Cancer Society's Facebook community includes, as of the time of

directional communication flows.

this writing, 14,730 members from around the

Broadly, the transition to Web 2.0

world (6, p.105).

marks a shift from a "one-way

conversation" to a "multi-way conversation," in which users participate as both creators and

consumers of web content (7,8). The nature of the content produced by users varies considerably

across platforms, from passively collected data that can be fed back into the system and reflected

back to users in word clouds or other popularity metrics, to content actively created, propagated,

and iteratively revised by users in wikis, blogs, and video-sharing or social networking sites, on

RSS feeds, or through the creation and circulation of "widgets," "gadgets," and "badges" that

can be embedded in sites across the web (9, p.63). As Turnbull notes, the user behaviours

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enabled by Web 2.0 architecture have shifted the boundaries between experts/informationproviders and laypeople/information-consumers: information is increasingly "... created and cocreated by users in a dynamic, collective manner" (8, p.57). Eysenbach began using the neologism "apomediation" (apo: separateness, detachment) to describe the way new online platforms allow users to bypass formal intermediaries, expert gatekeepers, or other middlemen: users do not act entirely without guidance, but rely instead on peers, web tools, and the aggregate knowledge generated by new collaborative platforms (10).

The term "social media" is used somewhat loosely to describe an array of new Web 2.0 platforms. Although they are not always clearly distinguished in the literature, the interactivity associated with "social media" should be differentiated from more generalized forms of online user engagement. For instance, many websites invite users to input their own information, customize the layout and look of a page, prioritize certain kinds of content, or keep track of their own online activities over time. Social media, by contrast, is characterized by interactivity across multiple horizontal connections, which produce in aggregate a mutable, collectively generated user experience (11, see also Appendix 2 for a description of the most popular social media platforms). Even within a single platform, users make use, to varying degrees, of the opportunities afforded for collaboration and social networking. YouTube, for instance, can be used simply as a broadcast medium for propagating a movie trailer or public service ad. It is only when other users begin to link to, remix, repurpose, and discuss posted content that YouTube's character as a social media platform comes fully into view.

Social media platforms are being studied by health researchers and mobilized for a variety of purposes: recruitment for clinical trials; professional development and training for clinicians; inter-professional communication and coordination; training simulations; health social networks and health and illness support groups; health advocacy and fundraising for health organizations; development of interactive, self-management tools and plugins to popular social media platforms; public health messaging; infectious disease monitoring.

This report targets original research, case studies, reviews, and commentaries related to public health communication, although there are at times significant overlaps between this subfield and those listed above. In addition, we summarize information from online sources related to notable public health campaigns (extracted from podcasts, interviews, PowerPoint presentations, and key public health organizations' websites).

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Research Methods

We conducted a systematic literature search of multiple databases, chosen for their coverage of a range of relevant disciplines, including medicine, public health, psychology, business / marketing, and related social sciences using the keywords "social media" (health databases) or "social media" AND "health" (social sciences/business/periodical databases). Between July 14 and July 16, 2010, we (JK and RS) executed keyword searches (See Figure 1 for the list of databases searched and the keywords utilized and the process of article selection and exclusion). Search results (n=551) were imported into the reference software Endnote and combined into a master database for analysis. The final set of articles (n=39) was analyzed using the following categories: article type, research methodology, and major themes. The reviewer wrote a brief description of each article and, where appropriate, identified any new references (snowball) cited that may be relevant to this report (see Appendix 3). Snowball references were then compiled and vetted using the same procedure as articles found through the database searches. Reviewed papers were also ranked for relevance from "low" to "high" as they related to the core objectives of this report.

Figure 1: Search strategy and inclusion criteria. Exact duplicates were identified and eliminated as well as articles written in languages other than English. Article abstracts were reviewed for their social media and health/public health communication content by both JK and RS. A subset of articles was reviewed in parallel by both (JK and RS) and the results showed 100% agreement in the application exclusion and inclusion criteria. Articles that appeared to fulfill both criteria were selected to be reviewed in full. When there was any doubt, articles were selected for full review. Articles without an abstract were also reviewed in full. During the secondary round of analysis, we excluded articles where, despite the abstract, there was no useful content related to health communication or social media. Again, agreement between the reviewers was validated by a parallel review of a sub-sample of articles (by JK and RS).

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Results

Of the 39 articles we reviewed, we ranked 17 articles as highly relevant, 14 articles of medium relevance and 8 articles of low relevance. Most of the articles included in this review were original research articles. 22 of the included articles were classified as original research articles, while 10 were classified as commentaries (or opinion pieces), 4 as reports (including recommendations for action) and 4 as reviews (overviews of the utility of social media) (Appendix 3). Of the twenty-two original research articles, thirteen were case studies either of specific social media interventions or examined discourse, content, and activity on specific platforms. Nine used content analyses to capture current social media behaviours and characterize the quality and reception of health messaging on the platforms (12-20). The most frequent mainstream platforms studied were YouTube, Twitter and Facebook while some studies utilized custom interfaces with social media capabilities (21). One consistent finding of these observational studies was an abundance of both informal health conversations related to public health issues and organized health-related activities on leading social media platforms such as YouTube, Twitter, and Facebook. The quality of health information available to users on these platforms is highly variable, raising some concerns that social media users are exposed to viewpoints (in some cases unopposed by public health experts) that counter core public health recommendations and contemporary science, such as platforms with a significant discourse opposing children's immunization or promoting smoking.

The single controlled intervention study in our review failed to isolate the social media component of the communication campaign to assess its precise impact on issue awareness or measured outcomes, such as improved exercise and diet (21). Thus, one of our chief findings for this report was a paucity of peer-reviewed studies testing the utility of social media communication interventions for desired outcomes (e.g., increased issue-awareness, changes in the public's health competency, or adoption of desired behaviours). When controlled research included an evaluative component, the results were often confounded by a failure to isolate the intervention from other communication strategies. A limitation of many social media case studies was the complex and multi-faceted social media interactions described. This made it difficult to identify the boundaries of a particular intervention and to determine how the results of these studies could be generalized from one health issues to a broader public health context (i.e., does social media work well for particular outcome categories such as improved literacy and awareness but not for necessarily for behavioural change?). The literature also provides limited insight into how the utility of social media might vary depending on the particular public health objectives governing an intervention ? for example, are there differences in the way social

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media influences public opinion and action during epidemics as opposed to in a campaign for chronic disease prevention?

Nonetheless, a significant number of articles reviewed (28) outlined the potential applications of social media for public health communications (9,11-15,17,20,22,23,25-37) asserting that the participatory web is rapidly transforming the way the public relates to medical professions and how average citizens seek out and consume medical information (10,16,39). A small body of public health researchers have focused their attention on the potential for harnessing these platforms to health protection and promotion objectives and are exploring the role social media can play to increase the reach and relevance of public health messaging. These researchers are beginning to articulate a framework to outline the utility of these platforms and to identify lessons learned from social media campaigns in the private and public sectors.

Five major themes were extracted from the article set. They consisted of the following, in order of frequency:

Themes

Frequency*

I. Potential applications

28

II. Current uses of social media for health communication

21

III. Infodemiology / Infoveillance

5

IV. The utility of social media for health communication (and potential pitfalls)

4

V. Circumvention of advertising regulations through social media (e.g., Tobacco

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advertising, junk food advertising to children)

Table 1: Thematic domains identified in the literature review. *Number of articles that met this criteria-Some articles matched >1 category so the sum of hits will exceed the total number of articles reviewed; identified themes occurring at least twice are listed in the table).

In addition to the major themes, we identified several case studies of public health campaigns using social media that illustrate the opportunities and challenges in utilizing these platforms for public health communications. The thematic domains are described below and the selected case studies in Appendix 4.

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