# data[].attributes.attachment_link.readable_text
Monitoring Editor: Gunther Eysenbach

Reviewed by Peter Schulz, Ari-Matti Auvinen, and Bradley Crotty

S Anne Moorhead, PhD, MSc, ¹ Diane E Hazlett, PhD, MSc, ¹ Laura Harrison, MSc, ¹ Jennifer K Carroll, MD, MPH, ² Anthea Irwin, PhD, ¹ and Ciska Hoving, PhD ³

Abstract

Background

There is currently a lack of information about the uses, benefits, and limitations of social media for health communication among the general public, patients, and health professionals from primary research.

Objective

To review the current published literature to identify the uses, benefits, and limitations of social media for health communication among the general public, patients, and health professionals, and identify current gaps in the literature to provide recommendations for future health communication research.

Methods

This paper is a review using a systematic approach. A systematic search of the literature was conducted using nine electronic databases and manual searches to locate peer-reviewed studies published between January 2002 and February 2012.

Results

The search identified 98 original research studies that included the uses, benefits, and/or limitations of social media for health communication among the general public, patients, and health professionals. The methodological quality of the studies assessed using the Downs and Black instrument was low; this was mainly due to the fact that the vast majority of the studies in this review included limited methodologies and was mainly exploratory and descriptive in nature. Seven main uses of social media for health communication were identified, including focusing on increasing interactions with others, and facilitating, sharing, and obtaining health messages. The six key overarching benefits were identified as (1) increased interactions with others, (2) more available, shared, and tailored information, (3) increased accessibility and widening access to health information, (4) peer/social/emotional support, (5) public health surveillance, and (6) potential to influence health policy. Twelve limitations were identified, primarily consisting of quality concerns and lack of reliability, confidentiality, and privacy.

Conclusions

Social media brings a new dimension to health care as it offers a medium to be used by the public, patients, and health professionals to communicate about health issues with the possibility of potentially improving health outcomes. Social media is a powerful tool, which offers collaboration between users and is a social interaction mechanism for a range of individuals. Although there are several benefits to the use of social media for health communication, the information exchanged needs to be monitored for quality and reliability, and the users' confidentiality and privacy need to be maintained. Eight gaps in the literature and key recommendations for future health communication research were provided. Examples of these recommendations include the need to determine the relative effectiveness of different types of social media for health communication using randomized control trials and to explore potential mechanisms for monitoring and enhancing the quality and reliability of health communication using social media. Further robust and comprehensive evaluation and review, using a range of methodologies, are required to establish whether social media improves health communication practice both in the short and long terms.

Keywords: health communication, social media, review

Introduction

There is an ongoing increase in the use of social media globally [ 1], including in health care contexts [ 2- 9]. When focusing on social media for health communication, it is useful to first outline the general characteristics of social media. Kaplan and Haenlein [ 10] defined social media as "a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of user generated content". They suggested that social media can be classified as two components: media-related and social dimension. The media-related component [ 11] involves how close to synchronous face-to-face communication different types of social media come and how well they reduce ambiguity and uncertainty. The social dimension is based on Goffman's [ 12] notion of self-presentation, whereby individuals' interactions have the purpose of trying to control others' impressions of them.

Social media provides opportunities for users to generate, share, receive, and comment on social content among multiusers through multisensory communication [ 1, 2, 10, 13, 14]. Although the terms "social media" and "social networking" are often used interchangeably and have some overlaps, they are not really the same. Social media functions as a communication channel that delivers a message, which involves asking for something. Social networking is two-way and direct communication that includes sharing of information between several parties. Social media can be classified in a number of ways to reflect the diverse range of social media platforms, such as collaborative projects (eg, Wikipedia), content communities (eg, YouTube), social networking sites (eg, Facebook), and virtual game and social worlds (eg, World of Warcraft, Second Life) [ 10].

The relationship between personality traits and engagement with social media has been reported [ 15]. Gender is a factor in that extraverted women and men are equally likely to engage, but emotional instability increases usage only for men. Age is also a factor in that extraversion is particularly important in younger users, while openness to new experiences is particularly important in older users [ 15]. Lenhart and colleagues [ 16] explored various types of Internet usage among teens and young adults in the United States between 2006 and 2010. During this time, social networking sites experienced the biggest rise (an average of around 50%), and the key shift in use came at age 30 years with almost double the number of teens and 18-29 years old using them as those 30 years and over (73% compared with 39%).

Social media is changing the nature and speed of health care interaction between individuals and health organizations. The general public, patients, and health professionals are using social media to communicate about health issues [ 2- 9]. In the United States, 61% of adults search online and 39% use social media such as Facebook for health information [ 7]. Social media adoption rates vary in Europe; for example, the percentage of German hospitals using social networks is in "single figures", whereas approximately 45% of Norwegian and Swedish hospitals are using LinkedIn, and 22% of Norwegian hospitals use Facebook for health communication [ 8]. Recent UK statistics reported Facebook as the fourth most popular source of health information [ 9]. There have been many applications of social media within health contexts, ranging from the World Health Organization using Twitter during the influenza A (H1N1) pandemic, with more than 11,700 followers [ 4], to medical practices [ 3] and health professionals obtaining information to inform their clinical practice [ 5, 6].

To explore the diversity in form and function of different social media platforms, Keitzmann and colleagues [ 17] presented the "social media ecology", a honeycomb framework of seven building blocks that are configured by different social media platforms and have different implications for organizations such as health care providers. In developing their model, they have drawn on Butterfield [ 18], Morville [ 19], Webb [ 20], and Smith [ 21]. The building blocks are (1) identity: the extent to which users reveal themselves, (2) conversations: the extent to which users communicate with each other, (3) sharing: the extent to which users exchange, distribute, and receive content, (4) presence: the extent to which users know if others are available, (5) relationships: the extent to which users relate to each other, (6) reputation: the extent to which users know the social standing of others and content, and (7) groups: the extent to which users are ordered or form communities. Thus organizations, including health care providers, need to recognize and understand the social media landscape, where the conversations about them are already being held, and develop their own strategies where suitable [ 17]. Similarly, Mangold and Faulds [ 22] highlighted that social media is changing the relationship between producers and consumers of a message. This suggests that health care providers may need to take a certain degree of control over online health communication to maintain validity and reliability.

In this paper, social media for health communication refers to the general public, patients, and health professionals communicating about health issues using social media platforms such as Facebook and Twitter. Currently, there is a lack of information about the uses, benefits, and limitations of social media for health communication among the general public, patients, and health professionals from primary research. The objective of this paper was to review the current published literature to identify the uses, benefits, and limitations of social media for health communication among the general public, patients, and health professionals and to identify current gaps in the literature to provide recommendations for future health communication research. This is important in order to establish whether social media improves health communication practices.

Methods

This review paper followed the PRISMA guidelines [ 23] and used a systematic approach to retrieve the relevant research studies. The review included all study designs in order to identify the best evidence available to address the research objective. The literature search was conducted on February 7, 2012, using the following 10 electronic databases: CSA Illumina, Cochrane Library, Communication Abstracts, EBSCO Host CINAHL, ISI Web of Knowledge, Web of Science, OvidSP Embase, OvidSP MEDLINE, OVIDSP PsycINFO, and PubMeb Central. The searches were performed using the following defined search terms: "social media" OR "social network" OR "social networking" OR "Web 2.0" OR "Facebook" OR "Twitter" OR "MySpace" AND "Health". From the above database searches, 9749 hits were identified. Manual searches were conducted in the Journal of Medical Internet Research (January 2002 to February 2012) where 24 papers were identified; thus, 9773 papers were identified in total. The papers' titles and abstracts were screened for relevance, duplication, and the selection criteria. The inclusion criteria were (1) primary focus on all communication interactions within and between the general public and/or patients and/or health professionals about health issues using social media, (2) including the uses and/or benefits and/or limitations of social media for health communication, (3) original research studies, (4) published between January 2002 and February 2012, and (5) all study designs. The exclusion criteria were (1) studies not in English, (2) literature reviews, dissertation theses, review papers, reports, conference papers or abstracts, letters (to the editor), commentaries and feature articles, (3) studies only on Web 1.0 ( ie, traditional Internet use), and (4) studies with a primary marketing or advertising focus. In total, 98 original research studies that included the use, and/or benefits, and/or limitations of social media for health communication among the general public, patients, and health professionals were selected for this review [ 24- 121] (see ). Excluded studies and the reasons for exclusion are listed in Multimedia Appendix 1. Two researchers (AM, LH) independently reviewed and evaluated the studies and reached consensus on the inclusion for the analysis. The interrater reliability between them was 0.90, indicating strong agreement [ 122]. Any discrepancies were discussed with reference to the research objective until consensus was reached.

Results

The 98 selected studies are summarized by study design, social media tool/application, study purpose, participants/sample and sample size, measurement tools, results, conclusion, and use of social media in Multimedia Appendix 2 [ 24- 121]. The diverse studies included the use of a range of social media tools/applications, the most reported being Facebook, blogs, Twitter, and YouTube (the full list is provided in). The study samples included blogs/forum discussions in which the participants were the general public, patients, and/or health professionals ( Multimedia Appendix 2). There was a wide range of health topics, but the most frequently reported on were sexual health [ 45, 46, 70, 104, 107, 115, 117], diabetes [ 47, 60, 68, 110, 116], flu/H1N1 [ 54, 57, 58, 111], and mental health issues such as stress or depression [ 48, 83, 101].

Table 1

Facebook (n=13)

Farmer et al (2009) [ 37], Ahmed et al (2010) [ 51], Greene et al (2010) [ 60], Bender et al (2011) [ 78], Egan & Moreno (2011a) [ 83], Egan & Moreno (2011b) [ 84], Frimmings et al (2011) [ 86], Gajara et al (2011)[ 88], Garcia-Romero et al (2011) [ 89], Jent et al (2011) [ 92], Kukreja et al (2011) [ 95], Lord et al (2011) [ 99], Sajadi & Goldman (2011) [ 105]

Blogs (n=13)

Adams (2008) [ 26], Kovic et al (2008) [ 29], Lagu et al (2008) [ 30], Tan (2008) [ 32], Denecke & Nedjl (2009) [ 36], Keelan et al (2009) [ 41], Kim (2009) [ 42], Adams (2010) [ 50], Clauson et al (2010) [ 53], Hu & Sundar (2010) [ 61], Sanford (2010) [ 71], Shah & Robinson (2011) [ 109], Marcus et al (2012) [ 119]

Twitter (n=8)

Chew & Eysenbach (2010) [ 54], Scanfeld et al (2010) [ 72], Heavillin et al (2011) [ 91], Kukreja et al (2011) [ 95], Sajadi & Goldman (2011) [ 105], Salathe & Khandelwal (2011) [ 106], Signorini et al (2011) [ 111], Turner-McGrievy & Tate (2011) [ 112]

YouTube (n=7)

Freeman & Chapman (2007) [ 24], Fernandez-Luque et al (2009) [ 38], Lo et al (2010) [ 67], Tian (2010) [ 74], Chou et al (2011) [ 80], Sajadi & Goldman (2011) [ 105], Fernandez-Luque et al (2012) [ 118]

MySpace (n=5)

Moreno et al (2007) [ 25], Moreno et al (2009a) [ 44], Moreno et al (2009b) [ 45], Versteeg et al (2009) [ 49], Ralph et al (2011) [ 104]

PatientsLikeMe (n=4)

Frost et al (2008) [ 28], Wicks et al (2010) [ 75], Doing-Harris & Zeng Treitler (2011) [ 81], Frost et al (2011) [ 87]

Wikipedia (n=3)

Clauson et al (2008) [ 27], Morturu & Liu (2011) [ 100], Rajagopalan et al (2011) [ 103]

Quitnet / online smoking cessation support group (n=2)

Cobb et al (2010) [ 55], Selby et al (2010) [ 73]

Physician rating website (not specified) (n=2)

Lagu (2010) [ 65], Kadry et al (2011) [ 93]

Daily Strength (n=1)

Morturu & Liu (2011) [ 100]

ArboAntwoord (n=1)

Rhebergen et al (2012) [ 121]

Social media (tool not specified) (n=30)

Chou et al (2009) [ 35], Jennings et al (2009) [ 40], Takahashi et al (2009) [ 48], Avery et al (2010) [ 52], Colineau & Paris (2010) [ 56], Corley et al (2010) [ 57], Ding & Zhang (2010) [ 58], Hwang et al (2010) [ 62], Kim & Kwon (2010) [ 63], Kontos et al (2010) [ 64], Lariscy et al (2010) [ 66], Orizio et al (2010) [ 69], Rice et al (2010) [ 70], Adrie et al (2011) [ 76], Baptist et al (2011) [ 77], Bosslett et al (2011) [ 79], Dowdell et al (2011) [ 82], Friedman et al (2011) [ 85], Hanson et al (2011) [ 90], Kishimoto & Fukushmima (2011), [ 94], Lariscy et al (2011) [ 96], Liang & Scammon (2011) [ 98], O'Dea & Campbell (2011) [ 101], Omurtag et al (2011) [ 102], Selkie et al (2011) [ 107], Setoyama et al (2011) [ 108], Shrank et al (2011) [ 110], Veinot et al (2011) [ 115], Weitzman et al (2011) [ 116], Young & Rice (2011) [ 117], O'Grady et al (2012) [ 120]

Web 2.0 application (not specified) (n=11)

Scotch et al (2008) [ 31], Timpka et al (2008) [ 33], Hughes et al (2009) [ 39], Lupianez-Villanueva et al (2009) [ 43], Moen et al (2009) [ 44], Nordqvist et al (2009) [ 47], Ekberg et al (2010) [ 59], Nordfeldt et al (2010) [ 68], Lau (2011) [ 97], Usher et al (2011) [ 113], Van Uden-Kraan (2011) [ 114]

Discussion

The 98 research studies in this review provided evidence that social media (most reported applications were Facebook, Blogs, Twitter, and YouTube) can create a space to share, comment, and discuss health information on a diverse range of health issues such as sexual health, diabetes, flu/H1N1, and mental health issues [ 24- 121]. Social media attracts a large number of users thus creating a platform for mass health communication [ 35] with identified uses, benefits, and limitations for the general public, patients, and health professionals.

Benefits of Social Media for Health Communication

Numerous benefits of using social media for health communication were reported for the general public, patients, and health professionals. A major benefit of social media for health communication is the accessibility and widening access of health information to various population groups, regardless of age, education, race or ethnicity, and locality, compared to traditional communication methods [ 35, 64, 95, 72]. While these changing patterns may lessen health disparities, traditional inequalities in overall Internet access remain. Furthermore, variation in social media engagement according to personality traits, age, and gender [ 15] suggests the need for ongoing scrutiny regarding equality of access and effectiveness for different users. Social media can be used to provide a valuable and useful source of peer, social, and emotional support to individuals, including those with various conditions/illnesses [ 48, 62, 71]. Hwang and colleagues [ 62] reported that encouragement, motivation, and shared experience were important social support features of social media sites.

Social media allows users to generate peer-to-peer discussion in a way not enabled by traditional websites [ 48, 50, 62, 71]. However, this may challenge expectations, relationships, quality, and consistent health care practice. As Moen et al [ 44] explain, current patterns of collaboration tend to produce an asymmetric patient-health care provider relationship. This highlights a strong need for health providers to maintain a role within social media health communication that is not simply the same as that of patient and general public users. Keitzmann et al [ 17] have suggested that organizations need to recognize and understand the social media landscape, and where the conversations about them are already being held (cognize), develop strategies that are suitable, work out how often and when they should enter into conversations, and be aware of what others are doing and act accordingly. This review highlights clearly that social media has benefits for health communication but the long-term effects are not known. As the use of social media is expected to increase in the future [ 1], there may be further benefits of using social media in health care. It is not yet known how effective social media applications are in health communications, which warrants further research.

Gaps in the Research Literature and Recommendations of Research Into Social Media for Health Communication

This literature review has shown that the general public, patients, and health professionals use social media in health care for various purposes with numerous benefits and limitations. The current research's methodological scoring was low; this was mainly due to the fact that the vast majority of the studies in this review were exploratory and descriptive. To date, there is very limited evidence from RCTs and longitudinal studies. To more fully determine the role of social media for health communication, further research with larger sample sizes and more robust methodologies are required. Based on this review [ 24- 121], several gaps in the literature have been identified that need to be addressed:

the impact of social media for health communication in specific population groups, such as minority groups, patients groups, culture differences;

the relative effectiveness of different applications of social media for health communication;

the longer-term impact on the effectiveness of social media for health communication;

the most suitable mechanisms to monitor and enhance the quality and reliability of health communication using social media;

the risks arising from sharing information online, the consequences for confidentiality and privacy, and the most suitable mechanisms for effectively educating users in the maintenance of their confidentiality and privacy;

the full potential of social media in effectively supporting the patient-health professional relationship;

the impact of peer-to-peer support for the general public, patients, and health professionals to enhance their interpersonal communication;

the impact of social media on behavior change for healthy lifestyles.

To address these gaps in the literature, the key recommendations for future health communication research focus on robust and comprehensive evaluation and review, using a range of methodologies. The research priorities are highlighted below:

To determine the impact of social media for health communication in specific population groups with large sample sizes (representation of population groups).

To determine the relative effectiveness of different social media applications for health communication using RCTs.

To determine the longer-term impact on the effectiveness of social media for health communication using longitudinal studies.

To explore potential mechanisms for monitoring and enhancing the quality and reliability of health communication using social media.

To investigate the risks arising from sharing information online and the consequences for confidentiality and privacy, coupled with developing the most suitable mechanisms to effectively educate users in the maintenance of their confidentiality and privacy.

To determine how social media can be effectively used to support the patient-health professional relationship.

To determine the impact of peer-to-peer support for the general public, patients, and health professionals to enhance their interpersonal communication.

To explore the potential for social media to lead to behavior change for healthy lifestyles to inform health communication practice.

Conclusions

Social media brings a new dimension to health care, offering a platform used by the public, patients, and health professionals to communicate about health issues with the possibility of potentially improving health outcomes. Although there are benefits to using social media for health communication, the information needs to be monitored for quality and reliability, and the users' confidentiality and privacy need to be maintained. Social media is a powerful tool that offers collaboration between users and a social interaction mechanism for a range of individuals. With increasing use of social media, there will be further opportunities in health care. Research into the application of social media for health communication purposes is an expanding area because increasing general use of social media necessitates that health communication researchers match the pace of development. Further robust research is required to establish whether social media improves health communication practices in both the short and long terms.

Abbreviations

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

RCT

randomized controlled trial

Multimedia Appendix 1

Excluded studies.

Multimedia Appendix 2

Summary of the selected studies (n=98).

Multimedia Appendix 3

Study quality scores using Downs and Black scale: checklist for measuring study quality (n=50).

Footnotes

Contributed by

Authors' Contributions: Dr. Anne Moorhead developed the concept of this paper and selected and evaluated papers and led this manuscript. Laura Harrison conducted the searches for studies, and Dr. Anne Moorhead and Laura Harrison evaluated the papers. All authors evaluated the studies and contributed to this manuscript.

Conflicts of Interest:

Conflicts of Interest: None declared.

References

11. Short J, Williams E, Christie B. The social psychology of telecommunications. Hoboken, NJ: John Wiley & Sons, Ltd; 1976.

12. Goffman E. The presentation of self in everyday life. New York: Doubleday Anchor Books; 1959.

115. Veinot TC, Campbell TR, Kruger D, Grodzinski A, Franzen S. Drama and danger: The opportunities and challenges of promoting youth sexual health through online social networks. Proceedings of the AMIA Annual Symposium. Improving Health: Informatics and IT Changing the World; AMIA Annual Symposium. Improving Health: Informatics and IT Changing the World; Oct. 22-26, 2011; Washington, DC. 2011. [ PMC free article]

128. Gilbert E, Karahalios K. Predicting tie strength with social media. Proceedings of the SIGHI Conference on Human Factors in Computing Systems; SIGHI Conference on Human Factors in Computing Systems; April 4-9, 2009; Boston, MA. 2009. pp. 211-220.

# data[].attributes.attachment_link.title
A New Dimension of Health Care: Systematic Review of the Uses, Benefits, and Limitations of Social Media for Health Communication

# data[].attributes.attachment_link.description
Monitoring Editor: Gunther Eysenbach Reviewed by Peter Schulz, Ari-Matti Auvinen, and Bradley Crotty S Anne Moorhead, PhD, MSc, 1 Diane E Hazlett, PhD, MSc, 1 Laura Harrison, MSc, 1 Jennifer K Carroll, MD, MPH, 2 Anthea Irwin, PhD, 1 and Ciska Hoving, PhD 3 There is currently a lack of information about the uses, benefits, and limitations of social media for health communication among the general public, patients, and health professionals from primary research.

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Blogs and Tweets, Texting and Friending: Social Media and Online Professionalism in Health Care summarizes the most common mistakes - and their legal and ethical ramifications -made in social media by busy health care professionals. It gives best practices for using social media while maintaining online professionalism.