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Do you believe in the use of health education on the internet? Why or Why not?

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What are the advantages and disadvantages of increased patient engagement in healthcare?

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As consumers experience more information transparency across various industries, many expect more accessible, user-friendly data around healthcare. The result has left some entities struggling to keep up with rising expectations, while others have adjusted by lowering prices, improving quality of services, and focusing on patient experiences.

Still, despite these consumer preferences and push, in our 2019 Consumer Health Insights Survey, only a fraction of respondents said they have been able to retrieve the information they sought when making healthcare decisions, contributing to low satisfaction. Our analysis shows that when respondents can access relevant information when making a healthcare decision, they will choose an option that best meets their needs. They often look for lower costs, even if it means making other trade-offs (for example, a more convenient location).

More than 60 percent of patients report they want more information when deciding where to get care. In a world of limited information, some patients chose to look for more information, while nearly 49 percent of respondents stated that they instead chose to follow the recommendation for care from their doctor, clinician, or health insurer.

In our analysis, about 90 percent of respondents chose the lower-cost, in-network options that were of average quality over the higher-quality, higher-cost options. Our research suggests that providing consumers with better and more accessible information could have a profound impact on how decisions are made (Exhibit 1).

What does care look like in a world where consumers have more transparency of information?

Consumers have driven certain healthcare businesses to adapt and meet their expectations. These adaptations include:

Lowered price: The cost of elective surgeries, such as LASIK surgery, breast augmentation, and eyelid lifts, has decreased 10 to 15 percent cumulatively over the last decade, enabled by technology advances that now allow these entire procedures to take around 10 minutes. By comparison, the price of nonelective surgeries, like childbirth delivery, has increased by up to four times over the same time period.

Improved quality of services: As the price of some elective consumer services declined, the quality of those same services has improved. For example, when LASIK first debuted in the 1990s, 60 percent of patients had 20/20 range of vision after surgery. Today, those numbers have improved dramatically, with more than 90 percent achieving perfect vision.

Improved experience: From contact lenses on-demand to at-home kits for retainers to customized healthcare entities, healthcare leaders and start-ups are investing rapidly in improving experiences for consumers. Customers are able to receive more personalized, seamless, and digitally enabled healthcare experiences, such personalized live video doctor visits.

What increasing information transparency and new business models mean for traditional healthcare services

While rising customer expectations are driving new business models, increased choice pressure is also affecting existing healthcare systems. Increased price transparency is driving more pricing information, and therefore more "shoppable" healthcare services. Certain services with relatively straightforward pricing structures, such as imaging, can now be viewed in easy-to-use, Kayak-like search engines in certain areas. For example, Colorado's Center for Improving Value in Health Care's online tool allows patients to locate facilities with the lowest cost, nearest location, and best patient experience; this information empowers patients to potentially significantly lower the cost of their healthcare services. Previous research has indicated the use of price transparency information was associated with lower total claims for routine medical services, with the largest difference for advanced imaging services.

Start-ups are offering consumers more options, such as healthcare financial wellness platforms that provide the information they need to make high-value healthcare decisions or tools that make shopping for government-funded healthcare more transparent. Other companies have focused on digital marketplaces for patients to purchase prescriptions with full-price transparency. While many providers have been either hesitant or challenged in offering price transparency estimates, some have worked to provide greater transparency.

For example, UCHealth in Colorado, Mayo Clinic in Minnesota, and University of Utah Health have been commended for their efforts in price transparency, enabling consumers to receive an estimate for services. While the consumer is warned that it is impossible to know the exact cost, this high-level estimate gives patients the ability to make more informed decisions around their care. Additionally, many providers (such as retail clinics and urgent care centers) of basic health services (for example, lab tests, primary care, ancillary) offer standard pricing, which removes any need for consumer uncertainty.

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How is the lack of information transparency today driving consumer behavior?

Respondents said they desire personalized, tailored information to make the right decisions about their healthcare-particularly in relationship to cost. Some gaps currently exist between the healthcare information that they want, what is available, and where it can be found. Moreover, respondents said they find the tools meant to help often do not give them the information they need.

Information for deciding where to get care

Most respondents don't have the information they want when deciding where to get care. That lack of information also is reflected in low consumer satisfaction scores. Among 15 journeys respondents rated, commercially insured respondents reported the lowest satisfaction scores for "ability to find out if there are lower-cost options for treatment" and "ability to figure out what their cost for a service would be" (scoring 7.2 out of 10.0). In contrast, "how easy it was to fill a prescription" had the highest satisfaction score (8.5) (Exhibit 2).

"I would like to clearly understand what is covered and what isn't. It's so hard to find that information. Even when you call, the people on the line, they can't give a clear answer."
-Female, 33, group

While most insured respondents say that they understand their deductibles, opportunity remains to further expand information about this category. Many insured respondents didn't know what their deductibles were. Thirty-four percent didn't know their deductible for out-of-network medical coverage, 24 percent didn't know their deductible for prescription drugs, and 16 percent didn't know their deductible for in-network medical coverage. Furthermore, as an example for choosing the most cost-efficient site of care, only 45 percent of respondents said they understood "cost differences for inpatient (hospital) vs outpatient (non-hospital) settings for a procedure" such as a colonoscopy.

"I asked for the information, but providers refuse to disclose ... the cost."
-Female, 42, uninsured

Helping US healthcare stakeholders understand the human side of the COVID-19 crisis: McKinsey Consumer Healthcare Insights

Information for quality of care

How could decisions (and cost) be supported by greater information transparency?

When consumers have access to information that is personalized to their situation, they are likely to make different decisions, often prioritizing factors important to them, such as cost. The survey attempted to understand how consumers might use transparent information to make decisions through a simulated experience. We identified several trends through this simulation:

Across different scenarios, respondents often chose lower-cost options that are of average quality rather than higher-cost, higher-quality options. As we increased out-of-pocket costs, even fewer chose higher-cost, higher-quality options.

Most respondents were willing to change their preferred site of care when they learned that someone they knew experienced a poor administrative experience at that site.

Proximity appears to be more of a "nice-to-have" option. Most respondents chose lower-cost or high-quality options over options that were higher-cost and more convenient.

Past consumer experiences matter in decision making. We found respondents who have experienced an inpatient stay in the past or face chronic conditions are more willing to choose higher-quality options that are more expensive.

To ascertain consumer choices in a real-world situation, we created three different health scenarios.

We asked respondents to imagine that they recently moved and were looking to find a new PCP for their annual physicals. Respondents had to pick a PCP that best fit their needs. We provided them with eight options that had varying location information, wait times, and out-of-pocket costs.

Respondents preferred going farther away if they could get an appointment more quickly (43 percent chose the farthest option where they could be seen within 24 hours; 14 percent chose the closet location but where their wait would have been between four and six days).

Few respondents (17 percent) were willing to pay a higher cost for a more conveniently located facility.

Respondents were equally split between preferring to book their appointment online or call. More than half of Gen Z and millennial respondents preferred booking online, while more than two-thirds of baby boomers and those older preferred booking over the phone. Gen X respondents were equally split.

We next asked respondents to imagine that they had been visiting a specialist and were referred for an outpatient procedure. We informed them that their health insurance plan has a $5,000 deductible. We showed them five options with varying locations, quality, appointment wait times, and costs.

Thirty-two percent of respondents were willing to drive 30 minutes farther if it meant a cost savings of $750. This result skewed more heavily with younger generations.

More than a third were more motivated by quality, with a fourth choosing a higher-quality option that had a week-longer wait than others. More than a third of respondents over age 65 chose this high-quality, less convenient option.

Few respondents (13 percent) chose the most convenient, lowest-quality option. Gen X had the highest share, at 16 percent, of those choosing the convenient option.

In the simulation, we told respondents that the original cost was wrong: it would now cost $100 to $750 more for the option they chose. Fewer respondents said they would look for an alternative option (22 percent) when their original choice was $100 more, but nearly half (48 percent) would do so if the cost was $750 more. Respondents who said they would stick with their original choice tended to be younger, wealthier, and individually insured.

In the third scenario, respondents were asked to imagine that their specialist and physical therapist recommended spinal surgery to improve their lower back pain. Respondents were asked to pick a facility they would want to attend to receive surgery.

We informed the respondents of a poor administrative experience in which the specialist did not communicate well with the respondents' PCP. We found a similar number of respondents were driven to switch locations based on learning about a poor experience. Of the 45 percent of respondents who originally picked Hospital 1, 52 percent of respondents switched hospitals (Exhibit 7).

Conclusion

The healthcare industry is becoming more transparent as stakeholders in the healthcare ecosystem are not only expecting but also often demanding access to information. Providing consumers greater access to transparent information that they can understand has the potential to significantly improve their ability to engage in choosing where to receive care, including making trade-offs that are important to them, while improving their experience.

On the flip side, healthcare companies that lead the way in transparency may have the opportunity to build relationships with consumers to help them make their health decisions more effectively and to shape what and how information is shared at the industry level. These companies that can provide greater value to consumers will benefit from increased customer satisfaction. For those healthcare companies seeking to lower the total cost of healthcare, engaging consumers has been an underutilized means of improving medical cost trend. As technology, data, and consumer engagement increase, so too will the importance of information transparency in improving the healthcare ecosystem.

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Consumer decision making in healthcare: The role of information transparency

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As consumers experience more information transparency across various industries, many expect more accessible, user-friendly data around healthcare. The result has left some entities struggling to keep up with rising expectations, while others have adjusted by lowering prices, improving quality of services, and focusing on patient experiences.

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Abstract

Introduction

Interest in the Internet as a tool for health-related information and communication has grown immensely in recent years. Today, not only is there an extensive amount of medical information and interactive services available through the Internet, but also an increasing number of health sites focusing on 'healthy lifestyle' issues. Such general health sites appeal to the public in general, providing a wide range of information on different health topics, 'Ask an Expert' services, tests, discussion boards, etc.

Only recently has the debate started on the implications of the expanding universe of 'health on the Internet' (or e-health) for health care and health promotion. Most commentators seem to adopt a positive, or even Utopian, perspective, focusing on the future possibilities that information technology can offer in the fields of health care and health promotion [e.g. ( Bernhardt and Hubley, 2001; Eysenbach and Jadad, 2001)]. Some have called the impact of information technology a paradigm shift [e.g. ( Kahn, 1997; Chin, 2000)], others refer to a revolution ( Fox and Rainie, 2000; Bernhardt and Hubley, 2001). However, warnings have also been raised, concerning primarily the quality of the information available on the Internet. These concerns have led to concerted efforts to assess the quality of e-health information and to create quality standards for Internet health sites [e.g. ( Ambre et al., 1997; Eysenbach et al., 2000; Risk and Dzenowagis, 2001; Eysenbach, 2002)].

Still, the main argument is that the Internet is a valuable tool for health care and health promotion, and that the initial problems that have been encountered will, in due course, be both properly addressed and resolved. From such a perspective, health on the Internet is fundamentally a good thing. However, this is a contestable assumption; health on the Internet is a fact but, rather than simply and unproblematically taking its value in a health promotion context for granted, its implications need to be thoroughly analyzed.

The purpose of this article is to discuss the implications of the phenomenon 'health on the Internet' for health promotion. This discussion is based on a review of research in the area of health on the Internet (e-health). A number of recurring themes in the debate on health on the Internet will be presented and analyzed in relation to the concept of empowerment.

In an earlier review of the accessing of health information on the Internet, Cline and Haynes ( Cline and Haynes, 2001) found both benefits and pitfalls associated with health advice on the Internet. They found that widespread access to health information, interactivity, information tailoring and anonymity where all obvious benefits. Conversely, inequity in access, navigational challenges, poor quality of online health information and poorly developed navigational skills among consumers were found to detract from the value of the Internet as a health promotional tool. The authors also stress the lack of empirical research on health information and the Internet. Several of Cline and Haynes' findings will be replicated here; however, while their review has, primarily, a communication perspective, the analysis presented here has its focus on health promotion and empowerment.

Concepts and definitions

Empowerment

Empowerment is often said to be a 'key principle' of health promotion [e.g. ( Tones, 1996; Rootman et al., 2001) and it is also a frequently used concept in the debate on health on the Internet [e.g. ( Chin, 2000; Eysenbach, 2001; Metcalf et al., 2001)]. The basis of the common definition of empowerment within health promotion is derived from the Ottawa Charter [( WHO 1986), p. 1] and replicates the idea of a process that enables people to 'increase control over, and to improve, their health'.

It could, therefore, be argued that one important common denominator is the ambition to strengthen the knowledge and skills of the lay actor. This could, in turn, be said to entail an increase in power for the lay actor. This argument rests on the idea that the fundamental concern for health promotion is to change the power structures in society that impose limits on the ability of individuals and groups to control and manage their lives in accordance with the needs and interests that they themselves have defined. This, in turn, entails an analysis of the concept of power.

On a general level, power can be viewed from both zero-sum and non-zero-sum perspectives [( Laverack, 2004), p. 34]. In the former case, an increase of one actor's power entails a decrease in the power of another actor. In the later case, an increase in the power of one actor does not necessarily result in the decrease of another actor's power. The former understanding of power, as a matter of conflict, produces questions concerning domination and emancipation, while a non-zero-sum understanding of power foregrounds questions about how people can gain a degree of control over their lives. As Laverack ( Laverack, 2004) argues, both a zero-sum and a non-zero-sum understanding of power may be relevant for the practice of health promotion. The task of health promotion may thus be both to 'increase feelings of value and sense of mastery' [( Laverack, 2004), p. 37] among individuals and groups, and to challenge hegemonic power relationships that shut down 'critical thinking, public debate and the possibility of change' [( Laverack, 2004), p. 38].

In this article, the main question is whether or not the Internet can function as an empowering resource for knowledge acquisition, communication and support. The focus is therefore on empowerment both as a means of strengthening the individual's sense of mastery and control, and as a means for community building and a possible challenge to hegemonic power structures.

Internet

The focus of this article is directed at the Internet as an interactive medium for information and communication. The main feature of the Internet is said to be its accessibility and interactivity (Jensen, 1997). The Internet makes a universe of information and knowledge easily accessible for anyone with a computer and an Internet connection. It also makes possible interactivity in the shape of direct feedback and real-time communication, and, not the least, contact between people independent of time and space.

An important aspect of the Internet is its potential to empower by putting more control in the hands of the user, as compared with other media [e.g. ( Walch, 1999)]. It is argued that the Internet could challenge traditional one-way information delivery by the development of interactive environments 'with the potential for independent action and discovery' [( Manning, 1997), p. 73]. It is, however, important to remember that the Internet is in itself not a neutral technology to be used on equal terms by everybody; it is highly commercialized and tends, as other media do, to mediate prevailing ideas and values in society ( Pitts, 2004).

Accessibility, anonymity and support

Perhaps the most important aspect of health on the Internet is the advanced information and knowledge seeking it enables [( Street and Rimal, 1997), p. 3]. Most people do in fact find the health information they are looking for when they search the Internet; according to a study by the Pew Internet and American Life Project, roughly 80% of the health seekers find the information they need [(Fox and Rainie, 2002), p. 23].

Frequent users of health sites on the Internet are patients (especially those who have long-term illnesses) who are searching for reliable information about their specific diseases [( Poensgen and Larsson, 2001), p. 11]. The likelihood of patients seeking information and advice on the Internet increases with the specificity and severity of their diagnosis ( Houston and Allison, 2002). It seems that patients and/or their care-givers tend to seek specific answers to specific questions-they want to know as much as possible about the disease and the diagnosis.

The information and knowledge that is accessed can have a significant impact on the way that a patient comes to terms with a disease, possibly increasing control over the illness and in coping with everyday life following the onset of the disease. This can be a matter of finding better ways of handling concrete problems and/or a way towards the patient becoming more involved in engaging with his/her illness. In a study conducted by the Boston Consulting Group ( von Knoop et al., 2003), the influence of the Internet, on a general level, is regarded as increasing steadily for both patients and doctors alike. In particular, the advent of the Internet as a source of health care advice has enhanced the opportunities for patients to be more actively engaged in their own treatment and care. It also seems that patients using the Internet for health information are more engaged and active in coping with their problems and in communication with their doctor, compared to those who do not seek advice from the Internet ( Lovich et al., 2001).

If patients become better informed and knowledgeable as a result of accessing information from health sites and health communities, they may be better prepared and likely to ask more relevant and critical questions when they meet their doctors. This also implies that they will not always take their doctor's opinion for granted. Health on the Internet might, in the long term, affect the doctor-patient relationship, moving power and initiative from the former to the latter. This is a Utopian idea often presented and discussed in the debate on health on the Internet [e.g. ( Chin, 2000); ( Kahn, 1997), p. 191; ( Rice, 2001), p. 19]. Whether this will be borne out by practice or not remains to be seen. However, there is a possibility that the use of the Internet as a source of health information will challenge the traditional doctor-patient relationships and, as a possible extension of this, the expert-lay actor relationships on a more general level. The other side of this is a strengthening of the position of the patient, and the public in general, in relation to experts and public institutions.

Another aspect of the Internet as a source of health information is the possibility of looking for information and answers to questions in an individual way and at each individual's own pace [( Fox and Rainie, 2000), p. 10; ( Metcalf et al., 2001)]. Each individual can take the time needed to figure out what questions to ask and how to ask them. In a face-to-face situation with a doctor or health consultant, many people feel uneasy and experience stress, often forgetting to ask all the questions they had planned to ask. Another important factor is the anonymity of the Internet-you can ask questions to an online doctor or health consultant without him/her ever getting to see you or know who you are [( Fox and Rainie, 2000), p. 10]. An additional aspect of health on the Internet is related to convenience-people can search, find and review information independent of time and space (Rimal and Flora, 1997).

The Internet can also make it easier for people to make contacts with others. This could, again, be especially valuable for people with a specific diagnosis and/or disease, but also for people in need of support in relation to other health issues. There is no doubt that there is great potential for health communities on the Internet to work as online support or self-help groups ( Brennan and Fink, 1997; Preece and Ghozati, 2001; Nettleton et al., 2002). The Internet might thus give a new dimension to people's lives in that it 'gives an opportunity to meet other people and to establish social networks' [( Nettleton et al., 2002), p. 182]. This, of course, also implies opportunities for knowledge sharing and community building ( Walch, 1999).

Another aspect of online communities is that they have the possibility to function as arenas for mobilization and collective action for disempowered groups in society ( Mele, 2000). The need for a computer and Internet access in order to take part in an online community might, however, restrict the possibilities for certain disempowered groups to take part in online communication. As Mele [( Mele, 2000), p. 304] points out, such a political project also requires vast investments in time, dedication and will in order to overcome the type of obstacles that are likely to be encountered.

Quality, credibility and trust

The debate on health on the Internet has, so far, been strongly focused on the question of the quality and credibility of the information given on different health sites [e.g. ( Ambre et al., 1997; Risk and Dzenowagis, 2001; Eysenbach, 2002; Eysenbach et al., 2000). In this debate, quality assessment and quality grading is seen as an empowering endeavor, strengthening the online health consumer's ability to find authoritative and reliable information. When it comes to questions within the domain of clinical medicine, it is no doubt important for an information seeker to be confident in the knowledge that the respondent is a qualified medical doctor, and that the advice given is reliable and correct.

However, given the focus on empowerment in this article, the introduction of quality controls and the setting of quality standards for general health sites are problematic issues; the implication is clearly that the power of judgment is solely in the hands of the expert. Medical science has a tendency to colonize the whole health domain, leaving little room for alternatives or for the lay actor to explore different ways to achieve health and well-being other than those recommended from a medical point of view ( Ernst, 2002).

Using scientifically based quality criteria, many health sites prove to have significant shortcomings; as Katz and Rice [( Katz and Rice, 2001), p. 426] have pointed out, there is 'a lot of everything' on the Internet when it comes to health. Any quality assessment of health information on the Internet is likely to be fraught with difficulty. For instance, a recent study of experts' ratings of health information on the Internet displayed a low level of consensus between the different experts ( Craigie et al., 2002).

An important factor influencing people's willingness to look for health information on the Internet is the trust, or lack of it, that they experience in relation to different information providers ( Kemper, 2001). This is, in turn, conditioned, to a not inconsiderable extent, by concerns about privacy and confidentiality, and the credibility of the information found. The quality of Internet health information is, of course, closely linked to the trust that people place in it. However, quality (according to scientific standards) and trust are by no means identical issues. More often than not the discussion focuses on quality assessment and quality grading rather than the difficult question of how to define 'good-quality' health information. The distinction between good and bad health information, and between serious health actors and the advice of quacks, is often taken for granted, but this is not necessarily the case from a lay perspective. The legitimacy of knowledge claims in the field of health is a complex issue, and it is important to realize that any distinction between 'healthy' and 'unhealthy' therapies and programmes is intrinsically problematic ( Vankevich, 2002).

In health promotion, lay knowledge and lay perspectives have, or should have, an important value. Health is said not only to be a matter of the absence of disease, but also a matter of well-being-thus implying a subjective dimension and a reference to the 'everyday experience of people' [( Raeburn and Rootman, 1998), p. 16]. It is therefore desirable that the individual's views and experiences can find a means of expression in matters concerning personal health. A truly health promotive strategy ought, according to Lupton [( Lupton, 1995), p. 155], to 'recognize that health-maintaining practices do not stand alone or above other practices of everyday life'.

The digital divide

A general problem with the Internet as a resource for social development is the so-called digital divide. The well-educated and well-off have access to and use the Internet to a much greater extent than those who are less well educated and who are less well off. This can be accounted for by the fact that better-educated groups in society have online access to a far greater extent than those who are less well educated ( Loader, 1998). However, it also applies to health on the Internet-education levels are a determining factor for the use of the Internet for health purposes ( Andreassen et al., 2002). Another factor is income; higher-income groups tend to use the Internet for health purposes more often than lower-income groups ( Kalichman et al., 2003).

Most likely this also applies to patients looking for specific types of information, as discussed above. The fact is that the likelihood is much greater that information-rich users looking for yet more information in a qualified and systematic way will be the predominant users of health sites, as opposed to those who have only limited information and who struggle to cope with cyberspace [(Fox and Rainie, 2002), p. 11].

For professionals involved in general health interventions, the recurring problem of reaching those most in need of support seems to be the same when it comes to Internet-supported health information and communication [( Schneider et al., 2001), pp. 174-175]. The digital divide and the general user characteristics of people visiting health sites on the Internet suggest that there is little reason to believe that Internet health initiatives would have any significant impact on this problem. Moreover, apart from the problem of access, there is also reason to believe that different groups in society have different interests and needs when it comes to health issues, as well as different capacities for searching for, accessing and evaluating information, i.e. different levels of health literacy [( Baur et al., 2001), p. 375].

Medicalization and healthism

While the Internet is a valuable source of health information and communication, it is also a possible source of medicalization and healthism. The concepts of medicalization and healthism highlight the process whereby areas of everyday life are, ever increasingly, defined as problematic in relation to health and therefore fall under the jurisdiction of professional health expertise [( O'Brien, 1995), p. 196]. The concept of healthism is today frequently used in the criticism of health promotion strategies which have a narrow focus on the individual's responsibility for his/her own health [( Lupton, 1995), p. 70]. Medicalization and healthism are, in this context, understood as processes whereby experts, whether they be doctors, health promoters or some other 'lifestyle expert', define different areas of the lay person's everyday life as problematic and suggest remedial solutions that involve individual behavioral change in order to promote health.

Recent developments towards a holistic approach to health run the risk of strengthening the healthism in society ( Fitzpatrick, 2001). An ever-increasing number of aspects of our everyday reality have become health topics, and, as such, possible areas of control and improvement. This has been debated at some length [e.g. ( Armstrong, 1993; Lupton, 1995; Fitzpatrick, 2001).

There is good reason to believe that health on the Internet, at least to some extent, promotes healthism. Health sites on the Internet have an abundance of general health information, including, amongst other things, information on specific health topics, 'read more' functions, advice for staying healthy, information about health risks and dangers, interactive tests, and online doctors.

In Sweden the marketing of online 'weight-watching' programs by the most popular tabloid papers is a conspicuous development in this area (e.g. the 'weight club' at www.aftonbladet.se and the 'weight coach' at www.expressen.se). The tabloids carry extensive advertising of their own specific programs as well as regularly featuring articles on the 'success stories' of people who have managed to loose weight using the program that the paper has initiated. In a survey of 35 Swedish health websites, the National Board of Health and Welfare ( National Board of Health and Welfare, 2002) found that some kind of 'Ask the Doctor' service featured on 24 of the sites. Other prevalent forms of interactivity were discussion forums, chat rooms, notice boards, quizzes and self-testing instruments. Advertising in terms of positive descriptions of specific products appeared on 23 sites, while 11 sites featured sales of health products. A brief review of eight prominent Swedish health sites ( www.apoteket.se, www.halsolinjen.nu, www.halsomalet.se, www.hjart-lungfonden.se, www.infomedica.se, www.netdoktor.se, www.primavi.se and www.suntliv.nu) reveals that the most common topics featured on these sites are the promotion of physical activity, good eating habits and weight control, smoking, and drug and alcohol use. However, there are also other topics, such as stress, sex, sleeping habits, mental health, natural/alternative medicine, parenting, humor and beauty. Taken together, the contents of these sites form a finely meshed net encompassing the vast majority of health concerns that individuals might have.

Common to all of the sites reviewed is a primary focus on health risks and healthy habits, as well as on actions, therapies and available products that can enhance the individual's health. All health sites try to be authoritative and attempt to legitimize their advice by means of references made to experts and expert knowledge. However, a recent study of the information presented on Internet health sites has revealed that this type of referencing tends to be rather superficial ( Lamminen et al., 2002). It seems justified to ask whether this excessive focus on health promotes health or whether it is in fact more likely to promote anxiety.

Discussion

In some respects, the Internet, as an unlimited and uncontrollable source of information, is a good thing. It provides opportunities for people to search for and to access valuable-as well as useless-information in a convenient and individually tailored way. It also provides opportunities for people to make contacts and communicate with others in matters of importance for their health and well-being. In this respect, health on the Internet is empowering-it puts more control and power in the hands of lay people. It may also function as a medium for shared experiences and knowledge between users, as well as for recognition and emotional support for people in need of support and guidance.

Health on the Internet also has the potential to challenge institutionalized and professional interests. On the other hand, efforts are being made to put the power back in the hands of the experts; this is done by attempts to control the sources of health information on the Internet by means of evaluation and quality grading. This whole issue raises questions of paramount importance for health promotion, such as what kind of knowledge and knowledge interests should health promotion give prominence to? Another is: how does expert versus lay knowledge relate to each other from a health promotional point of view?

Health on the Internet also opens up avenues for the exploitation of people's health anxieties and risk consciousness. However, it is important to realize that such forms of exploitation may be derived from different sources and it makes little difference whether it is a 'lose weight without effort' site or a certified doctor-online site that makes the individual start to think or worry about his/her health. It is, rather, the total sum of all health topics, questions, tests and sources of advice readily available at each and every health site that is entered that is the problem. There is a multitude of powerful vested interests in people's health worries and it might be persuasively argued that a relevant task for health promotion would be to emancipate people from the power of such interests.

The Internet, as such, also tends to widen the gap between the well off and the less well off in society, thus limiting the value of health on the Internet for health promotion strategies that focus on equity in health. Health on the Internet might function as an additional resource for people already in possession of knowledge and information skills, but less so for people with few such resources. The disempowering aspects of health on the Internet, from a health promotion perspective, are thus problematic and challenging.

In order to capitalize on the positive aspects of health on the Internet, a health promotive and empowering strategy should be directed towards strengthening the ability of individuals to evaluate different information sources in relation to their own interests and needs, and not in relation to scientific and/or professional standards. This requires a strategy aimed at developing in the individual, a critical consciousness in relation to different sources of information and an ability to select from competing sources of knowledge, rather than a strategy aimed at safeguarding specific forms of expert knowledge. The primary focus of such a strategy would be to develop knowledge and skills in media criticism. What is needed are educational initiatives aimed at providing skills in navigating, evaluating and applying information and knowledge in the information overflow of late-modern society [( Kickbush, 2001), p. 294].

The article was written as part of the Information Technology and Health Promotion research project at University of Trollhättan/Uddevalla, Sweden, financed by the Knowledge Foundation in Sweden, through the Learning and IT (LearnIT) research programme.

References

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Health on the Internet: implications for health promotion

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Interest in the Internet as a tool for health-related information and communication has grown immensely in recent years. Today, not only is there an extensive amount of medical information and interactive services available through the Internet, but also an increasing number of health sites focusing on 'healthy lifestyle' issues.

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Consumer Demand for Health Information on the Internet

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Use of Internet for Health Education

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Review

Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Corresponding Author:

Deema Farsi, BDS, MSci

Department of Pediatric Dentistry

Faculty of Dentistry

King Abdulaziz University

PO Box 80200

Jeddah, 21589

Saudi Arabia

Phone: 966 16402000 ext 20388

Email: dfarsi@kau.edu.sa

Background: As the world continues to advance technologically, social media (SM) is becoming an essential part of billions of people's lives worldwide and is affecting almost every industry imaginable. As the world is becoming more digitally oriented, the health care industry is increasingly visualizing SM as an important channel for health care promotion, employment, recruiting new patients, marketing for health care providers (HCPs), building a better brand name, etc. HCPs are bound to ethical principles toward their colleagues, patients, and the public in the digital world as much as in the real world.

Objective: This review aims to shed light on SM use worldwide and to discuss how it has been used as an essential tool in the health care industry from the perspective of HCPs.

Methods: A literature review was conducted between March and April 2020 using MEDLINE, PubMed, Google Scholar, and Web of Science for all English-language medical studies that were published since 2007 and discussed SM use in any form for health care. Studies that were not in English, whose full text was not accessible, or that investigated patients' perspectives were excluded from this part, as were reviews pertaining to ethical and legal considerations in SM use.

Results: The initial search yielded 83 studies. More studies were included from article references, and a total of 158 studies were reviewed. SM uses were best categorized as health promotion, career development or practice promotion, recruitment, professional networking or destressing, medical education, telemedicine, scientific research, influencing health behavior, and public health care issues.

Conclusions: Multidimensional health care, including the pairing of health care with SM and other forms of communication, has been shown to be very successful. Striking the right balance between digital and traditional health care is important.

J Med Internet Res 2021;23(4):e23205

doi:10.2196/23205

Keywords

Background

Specifically, SM is increasingly becoming an augmenting tool in health care by enabling its users to acquire and share information; connect with others in the field; and communicate with colleagues, patients, or the public regarding health topics. Furthermore, SM supports patient empowerment by expanding the knowledge of the patients and placing them in a position where they can take control of their own health care needs []. This review is based on numerous studies and reviews that have investigated the different uses of SM in health care and its limitations and shortcomings. Consequently, this narrative is comprehensive and up to date, including the recent use of SM during the COVID-19 pandemic. The topic is relevant in today's scenario because the use of SM and social networking sites (SNSs) is increasing worldwide, especially in the health care industry. The findings presented in this review have strong implications for health care professionals, educators, and researchers.

Objectives

This review aims to shed light on SM use worldwide and discuss how SM has been an essential tool in the health care industry from the perspective of health care providers (HCPs). The review will be continued in Part II, where the use of SM from the perspective of patients will be discussed.

Search Strategy and Information Sources

Between March and April 2020, a comprehensive search on 4 databases (MEDLINE, PubMed, Google Scholar, and Web of Science) was conducted for all English-language medical studies that were published since 2007 and discussed SM use in any form for health care. A combination of the following keywords was used to search for titles and abstracts: "social media" (MeSH term) OR "social networking" OR "internet" (MeSH term) OR "WhatsApp" OR "Instagram" OR "Facebook" OR "YouTube" OR "Twitter" OR "LinkedIn" AND "healthcare" OR "health" (MeSH term) OR "medicine" (MeSH term) OR "physician" (MeSH term) OR "nursing" (subheading) OR "dentistry" (MeSH term) OR "telemedicine" (MeSH term), "recruitment" OR "education" (subheading) OR "career" OR "behavior" (MeSH term) OR "research" (MeSH term). Each of the 9 words in the first set was separately searched with each of the 12 words in the second set using "AND."

Screening Process

The articles were entered into an EndNote library, and duplicate publications were removed. Articles published before 2007 were excluded, as the words social and media at that time did not represent the current definition of SM. Titles and abstracts were assessed for eligibility. Studies that were not in English were excluded, along with those with inaccessible full text after unsuccessful attempts to access them. Irrelevant studies, such as studies that were not related to health care, studies whose primary outcome was not the use of SM in health care, or studies that discussed the negative impact of SM on health, were also excluded. Dissertations were also excluded from the study. The full texts of the studies were then appraised. Several relevant studies investigating SM use from patients' perspectives were found. Reviews on legal and ethical issues pertaining to the use of SM in health care were also obtained, following which, the publications were divided into 4 groups: HCP, patient or the public, ethics and legal considerations, and shortcomings. A decision was made to defer reviewing the last 3 groups and focus on this review on SM use by HCPs.

Categorization

After accessing the complete texts of the articles of interest, their reference lists were searched for additional studies, and the cited studies were also located. Thereafter, the articles were comprehensively reviewed. On the basis of the key findings, articles were initially grouped as follows: sharing information, recruitment, education, and marketing. As the review proceeded and more information was obtained, the groups were modified. Sharing information was divided into 2 groups: health promotion, focusing on HCPs sharing scientific information with the public, and critical public health care issues, which focuses on health announcements in crisis, especially COVID-19-related publications that warrant special attention. Recruitment was also divided into 2 groups: recruitment, which included job employment and residency program enrollment, and scientific research, in which studies discussed recruiting research participants and analyzing SM data. Education was renamed professional medical education, as this name specifies medical education. Studies related to continuous education were added to marketing, and the group was renamed career development and practice promotion. Another group was created- professional networking and destressing-which included findings from sharing information that discussed peer-to-peer communication and those from education that did not reflect professional education or career development. Finally, an additional group was created, telemedicine, as studies on this subject were abundant.

Summary and Characteristics of Included Studies

The search yielded 5683 titles that were scanned with their abstracts. After exclusion of duplicates and noneligible studies, the initial sample comprised 73 publications. The full-text papers were retrieved. Additional studies from the article references or those emerged from the review but were not identified earlier were also added. This was because of variation in the keywords with respect to spellings (eg, behavior and behaviour), terminology (social networking and social network), and synonyms (eg, recruitment and employment) that were not accounted for in the initial search. A total of 142 articles (63 original studies) and 3 textbook chapters were reviewed ().

The studies were conducted in the United States (61), Canada (12), Brazil (2), the United Kingdom (12), Europe (22), the Middle East (9), India (9), Asia (8), and Australia (7). The earliest study was published in 2008, and the latest studies were published in 2020, with most of them being published after 2014 ().

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Figure 1. Flowchart of the selection procedure.
View this figure

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Figure 2. Number of included publications per year.
View this figure

SM Platforms

Most reviews discussed SM in general and did not specify a particular platform; however, some original studies investigated specific platforms. The platforms investigated were WhatsApp/WeChat (15), Facebook (8), Twitter/Weibo (9), YouTube (4), Instagram (1), LinkedIn (1), Podcast (1), and Wikipedia (1).

Medical Specialties

Some reviews discussed SM use in a particular medical specialty, whereas others reviewed studies from diverse or unspecified specialties. Researchers from a variety of medical specialties investigated SM use in their original studies. These specialties were surgery (1), plastic surgery (4), neurosurgery (1), maxillofacial surgery (2), medicine (2), emergency medicine (2), psychiatry (3), orthopedics (3), otolaryngology (1), immunology (2), dermatology (1), radiology (1), urology (2), anesthesia (1), cardiology (1), pediatrics (1), oncology (3), nursing (5), dentistry (11), and pharmacy (1).

Principal Findings

This literature review aimed to examine SM use in the modern world and how it has been recently incorporated into health care. Most of the reviewed articles were published in the past decade, suggesting that this review is both relevant and contemporary. It is evident from the published studies that SM has broad applications in modern health care. As discussed in the subsequent sections, HCPs (the term is used in this review as including physicians, dentists, nurses, medical and dental allied personnel, and health care organizations) not only use SM to provide care to their patients but also for personal development and destressing.

SM Use

Many SM tools have been introduced, and they continue to evolve. They may be categorized as tools for social networking (eg, Facebook and Instagram), professional networking (eg, Doximity and Sermo), media sharing (eg, YouTube and WhatsApp), content production (eg, Twitter), and blogs [].

Although most SM platforms share common features such as free registration, public and private communication, and fast content upload and retrieval, each platform is unique and has distinctive uses. It is common for users to have different accounts across multiple platforms, using each platform for different purposes. Facebook is an SNS that can be accessed from any internet-enabled device, such as personal computers and smartphones. Registration on Facebook is free, and users can create a profile that reveals selective information about themselves []. Users can post text, photos, and multimedia that become available to any user in their friend list. Users generally begin by adding family members and friends to their friend list, which can be expanded to include colleagues, acquaintances, and strangers with or without common interests. Apart from being able to share public comments and likes, a few years after Facebook was founded, a messaging feature was added that allows users to send private messages to individuals and groups. Users can use a variety of embedded apps; join and create groups and pages; play games; and receive updates regarding the activities of their friends, pages, and groups. Although the platform was initially limited to students in certain American universities, Facebook now has users worldwide. Instagram is a newer SM platform owned by Facebook and is designed primarily for free photo and video sharing []. By modifying their privacy preferences, Instagram users can opt to have either public accounts or limit their content to users that they accepted as followers. The platform also allows viewing, commenting on, and liking posts shared by users that they follow as well as private messaging between users. WhatsApp, which was acquired by Facebook in 2014, is a text and voice messaging app that has become incredibly popular owing to its features, flexibility, and compatibility with various phone and computer operating systems []. Although a free service, WhatsApp allows exchange of messages and calls on both desktop and mobile devices, in addition to media sharing and group features. WhatsApp's objective was to provide an alternative to SMS. Using WhatsApp, billions of users across the globe can simultaneously and instantly connect with others.

"Twitter is what's happening in the world and what people are talking about right now"-this is how Twitter describes itself []. It is a microblogging platform that allows users to post and access short text, image, or video posts called tweets. Although tweets were originally limited to 140 characters, the limit was increased to 280 characters in 2018, along with permitting the sharing of website links and multimedia. Twitter's mission is to provide users with the ability to create and share ideas and information instantly and without barriers. Users follow other personal, official, or organizational accounts. They can either create their own tweets or retweet those by others to their followers. YouTube is a web-based video-sharing platform that allows users to upload, view, share, rate, report, comment on videos, and subscribe to other users []. Its mission is to provide users with a voice through video sharing, stemming from the belief that the world would be a better place when people listen, share, and build a community through their stories. The name of this platform is straightforward: You represents content that is user-generated and not created by the site itself, and Tube is an older term for television. Most YouTube content is uploaded by individuals, but some media corporations have established partnerships with YouTube to offer some of their materials on this platform. LinkedIn, acquired by Microsoft in 2016, is a business and employment-oriented SM service that operates as both a website and mobile app. LinkedIn is mainly used for professional networking, allowing employers to post about job openings and seekers to share their curricula vitae []. Using the platform, users can build strategic professional relationships rather than expand their friend circle. LinkedIn's vision is to provide professional opportunities to its users, and its mission is to connect professionals worldwide. It originated in the living room of one of its cofounders a year before its launch in 2003. LinkedIn today has a diversified business model that has generated successful recruitments.

SM Use in Health Care

The more digitally oriented the world becomes, the more the health care industry visualizes SM as an important channel for health care promotion, employment, recruitment of new clients or patients, marketing for HCPs, and building a captivating brand name. HCPs have realized that SM is not just a platform to post vacation photos and interact with followers. Perhaps the 4 most common areas where SM plays a major role in the health care industry are health promotion, research, marketing and branding for individuals and practices, and recruitment. It has been evident that web-based content can be spread to offline environments, such as classrooms and meeting rooms. Furthermore, SM has undeniably changed patient-practitioner relationships because of patients' better understanding of health information and their more active role in health maintenance [].

Technology is evolving very rapidly []. Competition produces better services, and the diversity of options enables users to choose a tool that best matches their individual needs. Although different platforms often have different target demographics, audience overlapping may occur and should be considered by health organizations when devising their SM health promotion strategies. In health care, SM tools can be used for different purposes (health promotion; dissemination of health information; education; professional development; recruitment; communication with the public, colleagues, and patients; and research) and in diverse medical specialties (cardiology, nursing, radiology, dentistry, surgery, pathology, pediatrics, pharmacy, emergency, and critical and palliative care) []. As of August 4, 2020, 27,546 results appeared when searching for social media on PubMed, demonstrating the growing interest in SM within the health care industry.

Health care systems, especially in times of crisis and outbreaks, require the dissemination of information to practitioners, patients, and the general public rapidly and effectively []. Health organizations and officials, by taking upon a more active SM presence, gain access to vast global networks capable of quickly spreading information and promptly mobilizing large numbers of people toward public health goals [,]. Never before has the entire world united as it has in recent months in its fight against the disease caused by SARS-CoV-2, more commonly known as COVID-19. Searching COVID-19 on PubMed on August 4, 2020, yielded 37,576 results, which exposes the abundance of information and data that has become available in 7 months since the beginning on the pandemic []. However, the World Health Organization (WHO) has expressed concerns about fighting 2 battles at once: the pandemic and the infodemic -the latter refers to a rapid and far-reaching spread of both accurate and inaccurate information about the disease [].

SM Use From the Perspective of HCPs

The literature review yielded an abundance of information. The studies were categorized as follows to best present the findings: health promotion, career development or practice promotion, recruitment, professional networking and destressing, professional medical education, telemedicine, scientific research, and critical public health care issues.

Health Promotion

Career Development or Practice Promotion

One of the measures of the success of HCPs is their ability to attract and retain patients. This will not only maximize income but will also boost reputation. SM has played an important role in enhancing practice or practitioner ranking on search engines, even more than academic pedigree and experience []. As search engines generally direct patients' traffic, a strong presence on the web can be crucial to attract patients to a practice.

In summary, there is no one-size-fits-all SM platform, and there is no single way to share content that is superior to all others. It is essential for an HCP to emphasize the importance of their specialty; present the strengths in their particular practice; understand the features and user demographics for SM platforms; and, most importantly, know their target audience. For example, a plastic surgeon or orthodontist may find it beneficial to share pre- and posttreatment or procedure photos of anonymized patients, for which Instagram may be the ideal platform. A practice that is community friendly may invest in a Facebook page to keep the audience updated on offers and services. A family medicine office may share announcements regarding the arrival of a flu-vaccine and post photos of staff members vaccinating themselves to motivate people. Twitter may be useful for posting specialty-related educational messages or sharing information on health-related matters to make HCPs more visible. A pediatric dentist may use YouTube to share videos of tricks used in the office to make the experience less threatening for children. More training courses and talks on how to leverage SM to establish a presence and build a name may be beneficial for HCPs who are not SM savvy.

Recruitment

SM is making great strides not only in the modern world of technology but also in the workplace: it is transforming the way people find and engage in work. It seems that the conventional channels for recruiting employees are not as effective as they once were. Instead, we are shifting toward SM not only as a platform for social interaction, photograph exhibition, and creative expression but also as a space for far-reaching, low-cost job searches. Regarding employment, the interest in SM is bidirectional. On the one hand, employers are often keen to know more about a candidate applying for a position than what is stated in their resumé. On the other hand, employees, especially millennials, will first want to know more about the dynamics of a firm and the personalities of their future boss and coworkers before they commit to the job. Recruitment in the medical field requires more than an application. In this section, the recruitment of HCPs for employment or students for residency programs is discussed.

Regarding residency programs, SM is a mechanism to accentuate the programs' visibility on the web and to screen residency applicants []. It is important to note that it is not only credentials and high scores that secure a spot in a specialty program; personality traits and characters are becoming more significant than ever. Program directors (PDs) now want to know applicants on a personal level. As much of this information would be illegal to obtain in a traditional interview, they may search for it on SM []. Admission officers and PDs are now capitalizing on the abundance of information and the popularity of SM []. They may encounter content that seems unprofessional or exposes negative character traits that are useful in making decisions about applicants. Many residency programs now search Facebook and other personal SM platforms to screen applicants []. Even residents are now using SM platforms to obtain information on possible postgraduate opportunities [].

Professional Networking and Destressing

In recent months, SM platforms have become helpful in maintaining communication with friends and family and reducing isolation and sense of loneliness, which could have a negative psychological impact []. Amid the COVID-19 pandemic, many practices have been affected and many jobs have been lost worldwide []. The sense of unity and comradery introduced by SM among users has helped countless individuals overcome hardships, including HCPs. In the first half of 2020, HCPs were deployed into unfamiliar environments because of the COVID-19 pandemic, worked beyond their areas of expertise and over long hours, and had to involuntarily isolate themselves from their families. This crisis has been anxiety inducing and stressful for HCPs, who often resorted to SM to voice their frustrations, experiences, and opinions not only with family and friends but also with the global network of frontline staff enduring similar challenges. The unique virtual siblinghood united the global health care community like never before. A Facebook page was created to facilitate the renting of recreational vehicles for HCPs to self-isolate outside their homes []. The public played an important role in paying due respect to HCPs, who were often referred to as heroes, both literally and figuratively. Illustrations portraying their pivotal role were shared on every known SM platform. Videos showing countless people applauding for HCPs at certain hours of the day went viral. Many HCPs engaged in what was labeled as COVID-19-free zones to escape, even if momentarily, from the pandemic stress. Clinicians from all specialties in diverse locations joined forces against a single enemy. Their voices echoed louder when they addressed lawmakers demanding improved access to personal protective equipment (PPE), increased testing for COVID-19, reduced reimbursement barriers to telemedicine, and improved mental health care.

To conclude, SM plays an important role in the lives of HCPs at a personal level. Whether SM is used for amusement, zoning out, or commiserating, it provides a safe haven for HCPs to put off their metaphoric heroes' capes and find comfort in their humanhood again. Future research should investigate the role of SM in helping HCPs individually and collectively tackle the challenges resulting from the COVID-19 pandemic.

Professional Medical Education

Millennial students of health professions are increasing in numbers each year. They possess qualities consistent with being lifelong learners []. As Prensky [] discussed, traditional education systems are no longer suitable for contemporary students. Millennials and younger generations process information in a fundamentally different manner from their predecessors. SM offers formal and informal educational opportunities and has the ability to remove physical barriers that could otherwise impede access to educational resources []. Not only is SM rich in educational resources but coupling the information with the interactive exchange of ideas and the live discussions has also made it a valuable educational tool. When SM was integrated into teaching, students were motivated by content obtained from SM, and positive behavioral changes were promoted []. Moreover, when SM was incorporated into clinical education, students perceived better collaboration with their peers, improved professional and career development, and larger supportive learning communities [].

In a study by Alsuraihi et al [], YouTube, Facebook, and Twitter were among the most commonly used resources for learning. Although 95.8% of the students believed that SM was beneficial for learning, 40% thought it might be distracting []. In a review by Chan et al [], it was found that multiple residencies used SM to broaden the horizons of trainees and facilitate engagement in journal clubs using virtual classrooms; a wide range of SM platforms were featured, including Facebook, blogs, Wikipedia, and podcasts. Specifically, dermatologists in a study agreed that WhatsApp discussions enriched their scientific knowledge of clinical cases and promoted learning about relevant references and upcoming meetings []. Participants of a 2015 study on surgical teams expressed that WhatsApp helped to flatten the hierarchy among students, residents, and experienced consultants, enabling them all to actively contribute to discussions without inhibition. This comfortable environment is especially helpful for shy and marginalized students [].

To summarize, today's students are unique in how they learn and acquire skills. Current educational systems must adapt to the needs and qualities of modern students and augment, if not replace, the traditional teaching methods with more digital means. It is essential for educators to put every effort in determining the best means of presenting information to their students and guiding them in their information search and appraisal. Retrospective research can be planned to compare the performances, learning outcomes, and teaching strategies between 2 student cohorts: those that were taught in a traditional manner and those that relied on SM.

Telemedicine

In conclusion, it is noteworthy that telemedicine is not a practice in and of itself []. It is not the most suitable model of care for every patient and is not the preferred approach when physicians cannot meet clinical standards of care. Patients using telemedicine must also have access to traditional emergency care, if needed. Although these innovations have significant potential benefits, the electronic exchange of health information and care may pose risks to patients' privacy, confidentiality, and safety and to quality and continuity of care. Furthermore, the limitations of electronically mediated physical examination may weaken the relationship between patients and HCPs, thereby jeopardizing care []. High-quality research is needed to improve the utilization of telemedicine, and more well-designed studies comparing telemedicine with traditional patient care are essential.

Scientific Research

There are conveniences in taking scientific research to the digital world. Publishing study findings on SM provides enhanced dissemination of research and increases the access to valid evidence-based information for patients. Furthermore, because not all studies end in a publication in a traditional journal, their findings can thus be shared via SM to a wider audience and be of substantial value to a broader research community []. Another advantage of SM for scientific research became evident during the COVID-19 pandemic, which made it possible to break geographical barriers and arrange collaborative research projects, surveys, and multicenter studies []. Sites such as Google Scholar and ResearchGate create communities for researchers to network, collaborate with each other, and promote publications [,]. The anonymity of posts, not having to answer questions in the presence of others and acquiring large samples that attenuate the effect of false information or extreme views were viewed as advantages unique to SM surveys and possible factors that improve research accuracy []. Content posted on the web may be used as data for research without interacting with the authors of the content, and perhaps without even considering them to be human subjects []. Moreover, compared with traditional recruitment methods, web-based surveys have the ability to store large numbers of responses, which can be easily accessed for analysis [].

A review by Topolovec-Vranic and Natarajan [] showed that 40% of the studies found SM to be the most effective recruitment method, whereas 50% of them stated that their target population was hard to reach. Approximately 43% of the studies reported cost-effectiveness []. In addition, SM helped in recruiting a large number of individuals and reached challenging populations such as adolescents and young adults. Another review found that traditional recruitment methods tend to underrepresent users of marijuana, ecstasy, cocaine, or alcohol or people with at-risk sexual behavior; in comparison, Facebook recruitment yielded more representative results [].

To summarize, there is growing evidence to suggest that SM is a useful research tool that enables researchers to connect with each other, recruit participants, and share their findings with the public. Moreover, the data obtained from SM can be investigated. Nevertheless, researchers must not overlook the shortcomings of SM that may ultimately debilitate the integrity of the study. Privacy concerns and ethical considerations must also be considered. The development of guidelines for ethical conduct in web-based research should be based on the best available practices and should be comprehensive and standardized to minimize a study's error margin. Future studies that compare different recruitment methods and varying participant demographics recruited using various methods should be encouraged. Research investigating the cost-effectiveness of SM research and those with large sample sizes that enable the generalizability of findings is also recommended.

Critical Public Health Care Issues

Perhaps there is no more powerful example of SM use during a health crisis than what has happened during the COVID-19 pandemic. The dissemination of information during a pandemic has never been this quick and effective in the past. Information on the virus spread as quickly as the virus itself and dominated conversations on SM. On March 11, 2020, there were more than 20 million mentions of coronavirus-related terms on SM []. Since the beginning of the outbreak, SM has been one of the most commonly used communication channels by international health organizations such as the WHO and the CDC to possibly disseminate information to every person on earth with access to SM. Thousands of smaller health authorities may have also used SM to communicate with local communities. Although traditional access to medical guidelines and policies often requires some form of affiliation or membership, it is available to internet users today with a tap on a keyboard or a finger slide on a smartphone. The distribution of PPE, sharing treatment protocols, clinical trial results, and allocation of medical resources have been efficient with the aid of SM []. A recent study evaluated the 100 most viewed coronavirus videos on YouTube; as of March 5, 2020 (very early in the pandemic), these videos had 165 million views []. Another study in China collected data from 250 million Weibo users, a Twitter-like SM platform. Posts mentioning symptoms or diagnoses significantly predicted daily case counts ahead of the statistics announced by officials in Hubei Province, the epicenter of the initial outbreak, and the rest of China [].

Despite its catastrophic impact and the substantial loss of lives, humans will overcome the existential threat brought by COVID-19 and will also likely overcome future pandemics. Over time, humans have survived environmental, biological, and man-made calamities because of their innate adaptability, resilience, innovativeness, and persistence. Today, humans use SM to disseminate information quickly and to a large number of people, thus eliciting an almost immediate response. More research is already taking place and will continue to investigate the key role of SM in the fight against pandemics, not only from a medical perspective but also from social and economic viewpoints.

Conclusions

This review provided an overview of the different uses of SM in health care. It is evident that SM use indicates not a trend but a fundamental shift in how people communicate today. Multidimensional health care, which includes SM and other forms of communication, has been shown to be highly successful. Not only can SM be used to improve direct patient care but it can also be used to increase the public's knowledge, facilitate research, connect HCPs, improve medical education, and combat public health crises. However, striking the right balance between digital and traditional health care is imperative. As SM is a relatively recent phenomenon, further research is needed to determine its long-term effectiveness and to identify the best strategies for maximizing its advantages and limiting risks. This review will be continued in the second part, in which the use of SM from patients' perspectives will be discussed. This discussion will be supplemented with specific barriers, ethical considerations, and disadvantages reported in the extant literature.

Acknowledgments

The author acknowledges the steadfast support and telementoring of Professor Paul Casamassimo.

Conflicts of Interest

None declared.

‎

CDC: Centers for Disease Control and Prevention

HCP: health care provider

PD: program director

PPE: personal protective equipment

ROI: return on investment

SM: social media

SNS: social networking site

WHO: World Health Organization

Edited by R Kukafka; submitted 04.08.20; peer-reviewed by C Escobar-Viera, E Said-Hung, O Anikeeva; comments to author 23.09.20; revised version received 05.11.20; accepted 04.03.21; published 05.04.21

©Deema Farsi. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 05.04.2021.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

Background: As the world continues to advance technologically, social media (SM) is becoming an essential part of billions of people's lives worldwide and is affecting almost every industry imaginable. As the world is becoming more digitally oriented, the health care industry is increasingly visualizing SM as an important channel for health care promotion, employment, recruiting new patients, marketing for health care providers (HCPs), building a better brand name, etc. HCPs are bound to ethical principles toward their colleagues, patients, and the public in the digital world as much as in the real world.

Objective: This review aims to shed light on SM use worldwide and to discuss how it has been used as an essential tool in the health care industry from the perspective of HCPs.

Methods: A literature review was conducted between March and April 2020 using MEDLINE, PubMed, Google Scholar, and Web of Science for all English-language medical studies that were published since 2007 and discussed SM use in any form for health care. Studies that were not in English, whose full text was not accessible, or that investigated patients' perspectives were excluded from this part, as were reviews pertaining to ethical and legal considerations in SM use.

Results: The initial search yielded 83 studies. More studies were included from article references, and a total of 158 studies were reviewed. SM uses were best categorized as health promotion, career development or practice promotion, recruitment, professional networking or destressing, medical education, telemedicine, scientific research, influencing health behavior, and public health care issues.

Conclusions: Multidimensional health care, including the pairing of health care with SM and other forms of communication, has been shown to be very successful. Striking the right balance between digital and traditional health care is important.

J Med Internet Res 2021;23(4):e23205

doi:10.2196/23205

Keywords

Background

Specifically, SM is increasingly becoming an augmenting tool in health care by enabling its users to acquire and share information; connect with others in the field; and communicate with colleagues, patients, or the public regarding health topics. Furthermore, SM supports patient empowerment by expanding the knowledge of the patients and placing them in a position where they can take control of their own health care needs []. This review is based on numerous studies and reviews that have investigated the different uses of SM in health care and its limitations and shortcomings. Consequently, this narrative is comprehensive and up to date, including the recent use of SM during the COVID-19 pandemic. The topic is relevant in today's scenario because the use of SM and social networking sites (SNSs) is increasing worldwide, especially in the health care industry. The findings presented in this review have strong implications for health care professionals, educators, and researchers.

Objectives

This review aims to shed light on SM use worldwide and discuss how SM has been an essential tool in the health care industry from the perspective of health care providers (HCPs). The review will be continued in Part II, where the use of SM from the perspective of patients will be discussed.

Search Strategy and Information Sources

Between March and April 2020, a comprehensive search on 4 databases (MEDLINE, PubMed, Google Scholar, and Web of Science) was conducted for all English-language medical studies that were published since 2007 and discussed SM use in any form for health care. A combination of the following keywords was used to search for titles and abstracts: "social media" (MeSH term) OR "social networking" OR "internet" (MeSH term) OR "WhatsApp" OR "Instagram" OR "Facebook" OR "YouTube" OR "Twitter" OR "LinkedIn" AND "healthcare" OR "health" (MeSH term) OR "medicine" (MeSH term) OR "physician" (MeSH term) OR "nursing" (subheading) OR "dentistry" (MeSH term) OR "telemedicine" (MeSH term), "recruitment" OR "education" (subheading) OR "career" OR "behavior" (MeSH term) OR "research" (MeSH term). Each of the 9 words in the first set was separately searched with each of the 12 words in the second set using "AND."

Screening Process

The articles were entered into an EndNote library, and duplicate publications were removed. Articles published before 2007 were excluded, as the words social and media at that time did not represent the current definition of SM. Titles and abstracts were assessed for eligibility. Studies that were not in English were excluded, along with those with inaccessible full text after unsuccessful attempts to access them. Irrelevant studies, such as studies that were not related to health care, studies whose primary outcome was not the use of SM in health care, or studies that discussed the negative impact of SM on health, were also excluded. Dissertations were also excluded from the study. The full texts of the studies were then appraised. Several relevant studies investigating SM use from patients' perspectives were found. Reviews on legal and ethical issues pertaining to the use of SM in health care were also obtained, following which, the publications were divided into 4 groups: HCP, patient or the public, ethics and legal considerations, and shortcomings. A decision was made to defer reviewing the last 3 groups and focus on this review on SM use by HCPs.

Categorization

After accessing the complete texts of the articles of interest, their reference lists were searched for additional studies, and the cited studies were also located. Thereafter, the articles were comprehensively reviewed. On the basis of the key findings, articles were initially grouped as follows: sharing information, recruitment, education, and marketing. As the review proceeded and more information was obtained, the groups were modified. Sharing information was divided into 2 groups: health promotion, focusing on HCPs sharing scientific information with the public, and critical public health care issues, which focuses on health announcements in crisis, especially COVID-19-related publications that warrant special attention. Recruitment was also divided into 2 groups: recruitment, which included job employment and residency program enrollment, and scientific research, in which studies discussed recruiting research participants and analyzing SM data. Education was renamed professional medical education, as this name specifies medical education. Studies related to continuous education were added to marketing, and the group was renamed career development and practice promotion. Another group was created- professional networking and destressing-which included findings from sharing information that discussed peer-to-peer communication and those from education that did not reflect professional education or career development. Finally, an additional group was created, telemedicine, as studies on this subject were abundant.

Summary and Characteristics of Included Studies

The search yielded 5683 titles that were scanned with their abstracts. After exclusion of duplicates and noneligible studies, the initial sample comprised 73 publications. The full-text papers were retrieved. Additional studies from the article references or those emerged from the review but were not identified earlier were also added. This was because of variation in the keywords with respect to spellings (eg, behavior and behaviour), terminology (social networking and social network), and synonyms (eg, recruitment and employment) that were not accounted for in the initial search. A total of 142 articles (63 original studies) and 3 textbook chapters were reviewed ().

The studies were conducted in the United States (61), Canada (12), Brazil (2), the United Kingdom (12), Europe (22), the Middle East (9), India (9), Asia (8), and Australia (7). The earliest study was published in 2008, and the latest studies were published in 2020, with most of them being published after 2014 ().

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Figure 1. Flowchart of the selection procedure.
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Figure 2. Number of included publications per year.
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SM Platforms

Most reviews discussed SM in general and did not specify a particular platform; however, some original studies investigated specific platforms. The platforms investigated were WhatsApp/WeChat (15), Facebook (8), Twitter/Weibo (9), YouTube (4), Instagram (1), LinkedIn (1), Podcast (1), and Wikipedia (1).

Medical Specialties

Some reviews discussed SM use in a particular medical specialty, whereas others reviewed studies from diverse or unspecified specialties. Researchers from a variety of medical specialties investigated SM use in their original studies. These specialties were surgery (1), plastic surgery (4), neurosurgery (1), maxillofacial surgery (2), medicine (2), emergency medicine (2), psychiatry (3), orthopedics (3), otolaryngology (1), immunology (2), dermatology (1), radiology (1), urology (2), anesthesia (1), cardiology (1), pediatrics (1), oncology (3), nursing (5), dentistry (11), and pharmacy (1).

Principal Findings

This literature review aimed to examine SM use in the modern world and how it has been recently incorporated into health care. Most of the reviewed articles were published in the past decade, suggesting that this review is both relevant and contemporary. It is evident from the published studies that SM has broad applications in modern health care. As discussed in the subsequent sections, HCPs (the term is used in this review as including physicians, dentists, nurses, medical and dental allied personnel, and health care organizations) not only use SM to provide care to their patients but also for personal development and destressing.

SM Use

Many SM tools have been introduced, and they continue to evolve. They may be categorized as tools for social networking (eg, Facebook and Instagram), professional networking (eg, Doximity and Sermo), media sharing (eg, YouTube and WhatsApp), content production (eg, Twitter), and blogs [].

Although most SM platforms share common features such as free registration, public and private communication, and fast content upload and retrieval, each platform is unique and has distinctive uses. It is common for users to have different accounts across multiple platforms, using each platform for different purposes. Facebook is an SNS that can be accessed from any internet-enabled device, such as personal computers and smartphones. Registration on Facebook is free, and users can create a profile that reveals selective information about themselves []. Users can post text, photos, and multimedia that become available to any user in their friend list. Users generally begin by adding family members and friends to their friend list, which can be expanded to include colleagues, acquaintances, and strangers with or without common interests. Apart from being able to share public comments and likes, a few years after Facebook was founded, a messaging feature was added that allows users to send private messages to individuals and groups. Users can use a variety of embedded apps; join and create groups and pages; play games; and receive updates regarding the activities of their friends, pages, and groups. Although the platform was initially limited to students in certain American universities, Facebook now has users worldwide. Instagram is a newer SM platform owned by Facebook and is designed primarily for free photo and video sharing []. By modifying their privacy preferences, Instagram users can opt to have either public accounts or limit their content to users that they accepted as followers. The platform also allows viewing, commenting on, and liking posts shared by users that they follow as well as private messaging between users. WhatsApp, which was acquired by Facebook in 2014, is a text and voice messaging app that has become incredibly popular owing to its features, flexibility, and compatibility with various phone and computer operating systems []. Although a free service, WhatsApp allows exchange of messages and calls on both desktop and mobile devices, in addition to media sharing and group features. WhatsApp's objective was to provide an alternative to SMS. Using WhatsApp, billions of users across the globe can simultaneously and instantly connect with others.

"Twitter is what's happening in the world and what people are talking about right now"-this is how Twitter describes itself []. It is a microblogging platform that allows users to post and access short text, image, or video posts called tweets. Although tweets were originally limited to 140 characters, the limit was increased to 280 characters in 2018, along with permitting the sharing of website links and multimedia. Twitter's mission is to provide users with the ability to create and share ideas and information instantly and without barriers. Users follow other personal, official, or organizational accounts. They can either create their own tweets or retweet those by others to their followers. YouTube is a web-based video-sharing platform that allows users to upload, view, share, rate, report, comment on videos, and subscribe to other users []. Its mission is to provide users with a voice through video sharing, stemming from the belief that the world would be a better place when people listen, share, and build a community through their stories. The name of this platform is straightforward: You represents content that is user-generated and not created by the site itself, and Tube is an older term for television. Most YouTube content is uploaded by individuals, but some media corporations have established partnerships with YouTube to offer some of their materials on this platform. LinkedIn, acquired by Microsoft in 2016, is a business and employment-oriented SM service that operates as both a website and mobile app. LinkedIn is mainly used for professional networking, allowing employers to post about job openings and seekers to share their curricula vitae []. Using the platform, users can build strategic professional relationships rather than expand their friend circle. LinkedIn's vision is to provide professional opportunities to its users, and its mission is to connect professionals worldwide. It originated in the living room of one of its cofounders a year before its launch in 2003. LinkedIn today has a diversified business model that has generated successful recruitments.

SM Use in Health Care

The more digitally oriented the world becomes, the more the health care industry visualizes SM as an important channel for health care promotion, employment, recruitment of new clients or patients, marketing for HCPs, and building a captivating brand name. HCPs have realized that SM is not just a platform to post vacation photos and interact with followers. Perhaps the 4 most common areas where SM plays a major role in the health care industry are health promotion, research, marketing and branding for individuals and practices, and recruitment. It has been evident that web-based content can be spread to offline environments, such as classrooms and meeting rooms. Furthermore, SM has undeniably changed patient-practitioner relationships because of patients' better understanding of health information and their more active role in health maintenance [].

Technology is evolving very rapidly []. Competition produces better services, and the diversity of options enables users to choose a tool that best matches their individual needs. Although different platforms often have different target demographics, audience overlapping may occur and should be considered by health organizations when devising their SM health promotion strategies. In health care, SM tools can be used for different purposes (health promotion; dissemination of health information; education; professional development; recruitment; communication with the public, colleagues, and patients; and research) and in diverse medical specialties (cardiology, nursing, radiology, dentistry, surgery, pathology, pediatrics, pharmacy, emergency, and critical and palliative care) []. As of August 4, 2020, 27,546 results appeared when searching for social media on PubMed, demonstrating the growing interest in SM within the health care industry.

Health care systems, especially in times of crisis and outbreaks, require the dissemination of information to practitioners, patients, and the general public rapidly and effectively []. Health organizations and officials, by taking upon a more active SM presence, gain access to vast global networks capable of quickly spreading information and promptly mobilizing large numbers of people toward public health goals [,]. Never before has the entire world united as it has in recent months in its fight against the disease caused by SARS-CoV-2, more commonly known as COVID-19. Searching COVID-19 on PubMed on August 4, 2020, yielded 37,576 results, which exposes the abundance of information and data that has become available in 7 months since the beginning on the pandemic []. However, the World Health Organization (WHO) has expressed concerns about fighting 2 battles at once: the pandemic and the infodemic -the latter refers to a rapid and far-reaching spread of both accurate and inaccurate information about the disease [].

SM Use From the Perspective of HCPs

The literature review yielded an abundance of information. The studies were categorized as follows to best present the findings: health promotion, career development or practice promotion, recruitment, professional networking and destressing, professional medical education, telemedicine, scientific research, and critical public health care issues.

Health Promotion

Career Development or Practice Promotion

One of the measures of the success of HCPs is their ability to attract and retain patients. This will not only maximize income but will also boost reputation. SM has played an important role in enhancing practice or practitioner ranking on search engines, even more than academic pedigree and experience []. As search engines generally direct patients' traffic, a strong presence on the web can be crucial to attract patients to a practice.

In summary, there is no one-size-fits-all SM platform, and there is no single way to share content that is superior to all others. It is essential for an HCP to emphasize the importance of their specialty; present the strengths in their particular practice; understand the features and user demographics for SM platforms; and, most importantly, know their target audience. For example, a plastic surgeon or orthodontist may find it beneficial to share pre- and posttreatment or procedure photos of anonymized patients, for which Instagram may be the ideal platform. A practice that is community friendly may invest in a Facebook page to keep the audience updated on offers and services. A family medicine office may share announcements regarding the arrival of a flu-vaccine and post photos of staff members vaccinating themselves to motivate people. Twitter may be useful for posting specialty-related educational messages or sharing information on health-related matters to make HCPs more visible. A pediatric dentist may use YouTube to share videos of tricks used in the office to make the experience less threatening for children. More training courses and talks on how to leverage SM to establish a presence and build a name may be beneficial for HCPs who are not SM savvy.

Recruitment

SM is making great strides not only in the modern world of technology but also in the workplace: it is transforming the way people find and engage in work. It seems that the conventional channels for recruiting employees are not as effective as they once were. Instead, we are shifting toward SM not only as a platform for social interaction, photograph exhibition, and creative expression but also as a space for far-reaching, low-cost job searches. Regarding employment, the interest in SM is bidirectional. On the one hand, employers are often keen to know more about a candidate applying for a position than what is stated in their resumé. On the other hand, employees, especially millennials, will first want to know more about the dynamics of a firm and the personalities of their future boss and coworkers before they commit to the job. Recruitment in the medical field requires more than an application. In this section, the recruitment of HCPs for employment or students for residency programs is discussed.

Regarding residency programs, SM is a mechanism to accentuate the programs' visibility on the web and to screen residency applicants []. It is important to note that it is not only credentials and high scores that secure a spot in a specialty program; personality traits and characters are becoming more significant than ever. Program directors (PDs) now want to know applicants on a personal level. As much of this information would be illegal to obtain in a traditional interview, they may search for it on SM []. Admission officers and PDs are now capitalizing on the abundance of information and the popularity of SM []. They may encounter content that seems unprofessional or exposes negative character traits that are useful in making decisions about applicants. Many residency programs now search Facebook and other personal SM platforms to screen applicants []. Even residents are now using SM platforms to obtain information on possible postgraduate opportunities [].

Professional Networking and Destressing

In recent months, SM platforms have become helpful in maintaining communication with friends and family and reducing isolation and sense of loneliness, which could have a negative psychological impact []. Amid the COVID-19 pandemic, many practices have been affected and many jobs have been lost worldwide []. The sense of unity and comradery introduced by SM among users has helped countless individuals overcome hardships, including HCPs. In the first half of 2020, HCPs were deployed into unfamiliar environments because of the COVID-19 pandemic, worked beyond their areas of expertise and over long hours, and had to involuntarily isolate themselves from their families. This crisis has been anxiety inducing and stressful for HCPs, who often resorted to SM to voice their frustrations, experiences, and opinions not only with family and friends but also with the global network of frontline staff enduring similar challenges. The unique virtual siblinghood united the global health care community like never before. A Facebook page was created to facilitate the renting of recreational vehicles for HCPs to self-isolate outside their homes []. The public played an important role in paying due respect to HCPs, who were often referred to as heroes, both literally and figuratively. Illustrations portraying their pivotal role were shared on every known SM platform. Videos showing countless people applauding for HCPs at certain hours of the day went viral. Many HCPs engaged in what was labeled as COVID-19-free zones to escape, even if momentarily, from the pandemic stress. Clinicians from all specialties in diverse locations joined forces against a single enemy. Their voices echoed louder when they addressed lawmakers demanding improved access to personal protective equipment (PPE), increased testing for COVID-19, reduced reimbursement barriers to telemedicine, and improved mental health care.

To conclude, SM plays an important role in the lives of HCPs at a personal level. Whether SM is used for amusement, zoning out, or commiserating, it provides a safe haven for HCPs to put off their metaphoric heroes' capes and find comfort in their humanhood again. Future research should investigate the role of SM in helping HCPs individually and collectively tackle the challenges resulting from the COVID-19 pandemic.

Professional Medical Education

Millennial students of health professions are increasing in numbers each year. They possess qualities consistent with being lifelong learners []. As Prensky [] discussed, traditional education systems are no longer suitable for contemporary students. Millennials and younger generations process information in a fundamentally different manner from their predecessors. SM offers formal and informal educational opportunities and has the ability to remove physical barriers that could otherwise impede access to educational resources []. Not only is SM rich in educational resources but coupling the information with the interactive exchange of ideas and the live discussions has also made it a valuable educational tool. When SM was integrated into teaching, students were motivated by content obtained from SM, and positive behavioral changes were promoted []. Moreover, when SM was incorporated into clinical education, students perceived better collaboration with their peers, improved professional and career development, and larger supportive learning communities [].

In a study by Alsuraihi et al [], YouTube, Facebook, and Twitter were among the most commonly used resources for learning. Although 95.8% of the students believed that SM was beneficial for learning, 40% thought it might be distracting []. In a review by Chan et al [], it was found that multiple residencies used SM to broaden the horizons of trainees and facilitate engagement in journal clubs using virtual classrooms; a wide range of SM platforms were featured, including Facebook, blogs, Wikipedia, and podcasts. Specifically, dermatologists in a study agreed that WhatsApp discussions enriched their scientific knowledge of clinical cases and promoted learning about relevant references and upcoming meetings []. Participants of a 2015 study on surgical teams expressed that WhatsApp helped to flatten the hierarchy among students, residents, and experienced consultants, enabling them all to actively contribute to discussions without inhibition. This comfortable environment is especially helpful for shy and marginalized students [].

To summarize, today's students are unique in how they learn and acquire skills. Current educational systems must adapt to the needs and qualities of modern students and augment, if not replace, the traditional teaching methods with more digital means. It is essential for educators to put every effort in determining the best means of presenting information to their students and guiding them in their information search and appraisal. Retrospective research can be planned to compare the performances, learning outcomes, and teaching strategies between 2 student cohorts: those that were taught in a traditional manner and those that relied on SM.

Telemedicine

In conclusion, it is noteworthy that telemedicine is not a practice in and of itself []. It is not the most suitable model of care for every patient and is not the preferred approach when physicians cannot meet clinical standards of care. Patients using telemedicine must also have access to traditional emergency care, if needed. Although these innovations have significant potential benefits, the electronic exchange of health information and care may pose risks to patients' privacy, confidentiality, and safety and to quality and continuity of care. Furthermore, the limitations of electronically mediated physical examination may weaken the relationship between patients and HCPs, thereby jeopardizing care []. High-quality research is needed to improve the utilization of telemedicine, and more well-designed studies comparing telemedicine with traditional patient care are essential.

Scientific Research

There are conveniences in taking scientific research to the digital world. Publishing study findings on SM provides enhanced dissemination of research and increases the access to valid evidence-based information for patients. Furthermore, because not all studies end in a publication in a traditional journal, their findings can thus be shared via SM to a wider audience and be of substantial value to a broader research community []. Another advantage of SM for scientific research became evident during the COVID-19 pandemic, which made it possible to break geographical barriers and arrange collaborative research projects, surveys, and multicenter studies []. Sites such as Google Scholar and ResearchGate create communities for researchers to network, collaborate with each other, and promote publications [,]. The anonymity of posts, not having to answer questions in the presence of others and acquiring large samples that attenuate the effect of false information or extreme views were viewed as advantages unique to SM surveys and possible factors that improve research accuracy []. Content posted on the web may be used as data for research without interacting with the authors of the content, and perhaps without even considering them to be human subjects []. Moreover, compared with traditional recruitment methods, web-based surveys have the ability to store large numbers of responses, which can be easily accessed for analysis [].

A review by Topolovec-Vranic and Natarajan [] showed that 40% of the studies found SM to be the most effective recruitment method, whereas 50% of them stated that their target population was hard to reach. Approximately 43% of the studies reported cost-effectiveness []. In addition, SM helped in recruiting a large number of individuals and reached challenging populations such as adolescents and young adults. Another review found that traditional recruitment methods tend to underrepresent users of marijuana, ecstasy, cocaine, or alcohol or people with at-risk sexual behavior; in comparison, Facebook recruitment yielded more representative results [].

To summarize, there is growing evidence to suggest that SM is a useful research tool that enables researchers to connect with each other, recruit participants, and share their findings with the public. Moreover, the data obtained from SM can be investigated. Nevertheless, researchers must not overlook the shortcomings of SM that may ultimately debilitate the integrity of the study. Privacy concerns and ethical considerations must also be considered. The development of guidelines for ethical conduct in web-based research should be based on the best available practices and should be comprehensive and standardized to minimize a study's error margin. Future studies that compare different recruitment methods and varying participant demographics recruited using various methods should be encouraged. Research investigating the cost-effectiveness of SM research and those with large sample sizes that enable the generalizability of findings is also recommended.

Critical Public Health Care Issues

Perhaps there is no more powerful example of SM use during a health crisis than what has happened during the COVID-19 pandemic. The dissemination of information during a pandemic has never been this quick and effective in the past. Information on the virus spread as quickly as the virus itself and dominated conversations on SM. On March 11, 2020, there were more than 20 million mentions of coronavirus-related terms on SM []. Since the beginning of the outbreak, SM has been one of the most commonly used communication channels by international health organizations such as the WHO and the CDC to possibly disseminate information to every person on earth with access to SM. Thousands of smaller health authorities may have also used SM to communicate with local communities. Although traditional access to medical guidelines and policies often requires some form of affiliation or membership, it is available to internet users today with a tap on a keyboard or a finger slide on a smartphone. The distribution of PPE, sharing treatment protocols, clinical trial results, and allocation of medical resources have been efficient with the aid of SM []. A recent study evaluated the 100 most viewed coronavirus videos on YouTube; as of March 5, 2020 (very early in the pandemic), these videos had 165 million views []. Another study in China collected data from 250 million Weibo users, a Twitter-like SM platform. Posts mentioning symptoms or diagnoses significantly predicted daily case counts ahead of the statistics announced by officials in Hubei Province, the epicenter of the initial outbreak, and the rest of China [].

Despite its catastrophic impact and the substantial loss of lives, humans will overcome the existential threat brought by COVID-19 and will also likely overcome future pandemics. Over time, humans have survived environmental, biological, and man-made calamities because of their innate adaptability, resilience, innovativeness, and persistence. Today, humans use SM to disseminate information quickly and to a large number of people, thus eliciting an almost immediate response. More research is already taking place and will continue to investigate the key role of SM in the fight against pandemics, not only from a medical perspective but also from social and economic viewpoints.

Conclusions

This review provided an overview of the different uses of SM in health care. It is evident that SM use indicates not a trend but a fundamental shift in how people communicate today. Multidimensional health care, which includes SM and other forms of communication, has been shown to be highly successful. Not only can SM be used to improve direct patient care but it can also be used to increase the public's knowledge, facilitate research, connect HCPs, improve medical education, and combat public health crises. However, striking the right balance between digital and traditional health care is imperative. As SM is a relatively recent phenomenon, further research is needed to determine its long-term effectiveness and to identify the best strategies for maximizing its advantages and limiting risks. This review will be continued in the second part, in which the use of SM from patients' perspectives will be discussed. This discussion will be supplemented with specific barriers, ethical considerations, and disadvantages reported in the extant literature.

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social media; social networking; internet; health care; covid-19; research activity; medical education; telemedicine; mobile phone

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Social Media and Health Care, Part I: Literature Review of Social Media Use by Health Care Providers

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Background: As the world continues to advance technologically, social media (SM) is becoming an essential part of billions of people's lives worldwide and is affecting almost every industry imaginable. As the world is becoming more digitally oriented, the health care industry is increasingly visualizing SM as an important channel for health care promotion, employment, recruiting new patients, marketing for health care providers (HCPs), building a better brand name, etc.

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Consumer Demand for Information

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In the year 2020, the COVID-19 pandemic left many businesses in an unprecedented state of uncertainty. Healthcare companies across the care continuum had to face new challenges, pushing them to rapidly learn, adapt and transform the way they deliver healthcare. As a result, the concept of "anytime anywhere care" has become mainstream, changing the rate at which we access healthcare forever. Vendors will consequently need to redefine their strategies to ensure they are ready for 2021 and this new breed of consumer demand.

Opportunities to innovate

While the pandemic has presented many adversities, it has also introduced growth opportunities to enhance companies' performance, leading to the acceleration of new customer engagement models and innovative methods to serve customer needs.

Reenita Das, transformational health partner and senior vice president at Frost & Sullivan said: "The health system of the future will be consumer-centric, wellness-oriented, care everywhere, and digitally connected.

"Healthcare stakeholders will need to upgrade and adopt patient engagement and more virtual, innovative health management tools and techniques to support patients at home."

Artificial intelligence has also been praised for being a key facilitating technology during the pandemic. Experts predict that we will see increased adoption and implementation across the healthcare spectrum, from drug discovery to precise preventive care, to workflow management.

"Healthcare will witness virtualisation to a large extent. Novel business models will emerge to support this paradigm shift and the emergence of this new care delivery ecosystem. Interoperability and data security will be table stakes," added Chandni Mathur, senior industry analyst at Frost & Sullivan.

Telehealth on the rise

Online doctor visits will top 400 million globally next year, according to Deloitte's new 2021 predictions. This is in stark contrast to pre-pandemic levels, where 0.1% of all US Medicare primary care visits were via telehealth services.

According to Linda Comp-Noto, divisional president of healthcare at Teleperformance, virtual healthcare services are set to shift from a pandemic-induced necessity to a new normal of patient care.

Comp-Noto said: "Long after the pandemic has ended, telehealth will continue to rise as the foundation of a robust healthcare strategy, fit for the new normal. Future trends in the healthcare space will revolve around continued patient centricity and consumer-driven health plans.

"Technology is set to play an even bigger role in patient engagement, through the development of healthcare portals, telehealth applications, and wearable devices."

Digital empowering primary care

The impending global vaccine roll-out will also influence many changes in primary care. According to Wais Shaifta, CEO of video-consultation platform, Push Doctor, in the long-term, it will significantly decrease the rates of coronavirus, enabling primary care providers to begin working through the backlog of patients in need of care. Although this is positive, in the short-term, it will place additional pressure on the already stretched NHS.

Shaifta told Healthcare IT News: "To meet the target set by NHS England of administering 975 vaccines a week, GPs in practices will need to focus almost exclusively on this task, causing further disruption to patients with health concerns unrelated to the pandemic.

"We believe that digital health solutions will play a central role in supporting primary care during this critical time by providing thousands of remote GP appointments to such patients who would otherwise go unseen.

"At this time more than ever we expect to see the power of digital and face-to-face care when deployed in tandem."

Security breaches become a greater issue

Security breaches will become a greater issue as working from home continues and healthcare becomes the most targeted sector globally for phishing and malware attacks, says Brian Bogie, director healthcare vertical at financial computer software company, Sage Intacct.

Bogie told Healthcare IT News: "While employees and their information were once safely behind the office firewall, and out of view of their family members, patients' confidential health information is at a greater risk because attackers now have access to makeshift at-home workstations.

"As we enter the new year, we will see more companies implement new processes and procedures to help keep patient's health information secure, including audit trails that show who accessed what information and when."

Mental health technology

The pandemic has had many implications for our mental health this year. According to the Samaritans, in a survey of over 70,000 adults in the UK, over 1 in 10 reported experiencing suicidal thoughts or thoughts of hurting themselves during the first week of lockdown. This year's World Mental Health Day marked a different kind of year for mental health therapy, where new technology started to take precedence over face-to-face therapy.

Experts have predicted that this trend will remain strong next year. Medical device company Flow recently reported a 247% increase in sales of its at-home, brain stimulation headset treatment for depression since the pandemic, indicating a promising level of acceptance towards mental health technology.

Health inequities here to stay

Although large strides in health innovation are being made, in order to benefit globally, health inequalities will remain an extremely important topic for health care providers over the next few years.

Shaifta explains: "Regrettably, inequality still exists across our health system and the pandemic has unfortunately exacerbated many of the long-standing disparities between different groups.

"We now see that some of those with the greatest need for care have the least amount available to them, bringing the need to tackle health inequalities into sharp focus."

Push Doctor is currently trialling bookable, sound-proofed video pods with computers in community spaces and deprived areas. These allow the patient to have a private digital consultation, with staff on hand to give practical advice on using the technology.

"Moving forward, we expect to see our industry continue to work together to prevent people in the UK experiencing differences in healthcare based on factors often outside their control and enable everyone to share in the benefits of digital," concludes Shaifta.

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'The health system of the future will be consumer-centric, wellness-oriented and digitally connected'

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In the year 2020, the COVID-19 pandemic left many businesses in an unprecedented state of uncertainty. Healthcare companies across the care continuum had to face new challenges, pushing them to rapidly learn, adapt and transform the way they deliver healthcare.

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Health Literacy in School-Aged Children

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By M. Elaine Auld, Marin P. Allen, Cicily Hampton, J. Henry Montes, Cherylee Sherry, Angela D. Mickalide, Robert A. Logan, Wilma Alvarado-Little, and Kim Parson

This NAM Perspectives paper provides an overview of health education in schools and challenges encountered in enacting evidence-based health education; timely policy-related opportunities for strengthening school health education curricula, including incorporation of essential health literacy concepts and skills; and case studies demonstrating the successful integration of school health education and health literacy in chronic disease management. The authors of this manuscript conclude with a call to action to identify upstream, systems-level changes that will strengthen the integration of both health literacy and school health education to improve the health of future generations. The COVID-19 epidemic [10] dramatically demonstrates the need for children, as well as adults, to develop new and specific health knowledge and behaviors and calls for increased integration of health education with schools and communities.

Enhancing the education and health of school-age children is a critical issue for the continued well-being of our nation. The 2004 Institute of Medicine (IOM, now the National Academies of Sciences, Engineering, and Medicine [NASEM]) report, Health Literacy: A Prescription to End Confusion [27] noted the education system as one major pathway for improving health literacy by integrating health knowledge and skills into the existing curricula of kindergarten through 12th-grade classes. The NASEM Roundtable on Health Literacy has held multiple workshops and forums to "inform, inspire, and activate a wide variety of stakeholders to support the development, implementation, and sharing of evidence-based health literacy practices and policies" [37]. This paper strives to present current evidence and examples of how the collaboration between health education and health literacy disciplines can strengthen K-12 education, promote improved health, and foster dialogue among school officials, public health officials, teachers, parents, students, and other stakeholders.

This discussion also expands on a previous NAM Perspectives paper, which identified commonalities and differences in the fields of health education, health literacy, and health communication and called for collaboration across the disciplines to "engage learners in both formal and informal health educational settings across the life span" [1]. To improve overall health literacy, i.e., "the capacity of individuals to obtain, process, and understand basic health information and services needed to make appropriate health decisions" [42], it is important to start with youth, when life-long health habits are first being formed.

Another recent NAM Perspectives paper proposed the expansion of the definition of health literacy to include broader contextual factors, including issues that impact K-12 health education efforts like state rather than federal control of education priorities and administration, and subsequent state- or local-level laws that impact specific school policies and practices [39]. In addition to addressing individual needs and abilities, socio-ecological factors can impact a student's health. For example, the Centers for Disease Control and Prevention (CDC) uses a four-level social-ecological model to describe "the complex interplay" of (1) individuals (biological and personal history factors), (2) relationships (close peers, family members), (3) community (settings such as neighborhoods, schools, after-school locations), and (4) societal factors (cultural norms, policies related to health and education, or inequalities between groups in societies) that put one at risk or prevent him/her from experiencing negative health outcomes [11]. Also worth examining are protective factors that help children and adolescents avoid behaviors that place them at risk for adverse health and educational outcomes (e.g., self-efficacy, self-esteem, parental support, adult mentors, and youth programs) [21,59].

Recognizing the influence of this larger social context on learning and health can help catalyze both individual and community-based solutions. For example, students with chronic illnesses such as asthma, which can affect their school attendance, can be educated about the impact of air quality or housing (e.g., mold, mites) in exacerbating their condition. Students in varied locations and at a range of ages continue, often with the guidance of adults, to take health-related social action. Various local, national, and international examples illustrate high schoolers taking social action related to health issues such as tobacco, gun safety, and climate change [18,21,57].

By employing a broad approach to K-12 education (i.e., using combined principles of health education and health literacy), the authors of this manuscript foresee a template for the integration of skills and abilities needed by both school health professionals and children and parents to increase health knowledge for a lifetime of improved health [1,29,31].

The right measurements to evaluate success and areas that need improvement must be clearly identifed because in all matters related to health education and health literacy, it is vital to document the linkages between informed decisions and actions. Often, individuals are presumed to be making informed decisions when actually broader socio-ecological factors are predominant behavioral influences (e.g., an individual who is overweight but has never learned about food labeling and lives in a community where there are no safe places to be physically active).

Health Education in Schools

Standardized and broadly adopted strategies for how health education is implemented in schools-and by whom and on what schedule-is a continuing challenge. Although the principles of health literacy are inherently important to any instruction in schools and in community settings, the most effective way to incorporate those principles in existing and differing systems becomes a key to successful health education for children and young people.

The concept of incorporating health education into the formal education system dates to the Renaissance. However, it did not emerge in the United States until several centuries later [26]. In the early 19th century, Horace Mann advocated for school-based health instruction, while William Alcott also underscored the contributions of health services and the school environment to children's health and well-being [17]. Public health pioneer Lemuel Shattuck wrote in 1850 that "every child should be taught early in life, that to preserve his own life and his own health and the lives of others, is one of the most important and abiding duties" [43]. During this same time, Harvard University and other higher education institutions with teacher preparation programs began including hygiene (health) education in their curricula.

Despite such early historical recognition, in the mid-1960s, the School Health Education Study documented serious disarray in the organization and administration of school health education programs [45]. A renewed call to action, several decades later, introduced the concepts of comprehensive school health programs and school health education [26].

From 1998 through 2014, the CDC and other organizations began using the term "coordinated school health programs" to encompass eight components affecting children's health in schools, including nutrition, health services, and health instruction. Unfortunately, the term was not broadly embraced by the educational sector, and in 2014, CDC and ASCD (formerly the Association for Supervision and Curriculum Development) unveiled the Whole School, Whole Community, Whole Child (WSCC) framework [36]. This framework has ten components, including health education, which aims to ensure that each student is healthy, safe, engaged, supported, and challenged. Among the foundational tenets of the framework is ensuring that every student enters school healthy and, while there, learns about and practices a healthy lifestyle.

At its core, health education is defined as "any combination of planned learning experiences using evidence-based practices and/or sound theories that provide the opportunity to acquire knowledge, attitudes, and skills needed to adopt and maintain healthy behaviors" [3]. Included are a variety of physical, social, emotional, and other components focused on reducing health-risk behaviors and promoting healthy decision making. Health education curricula emphasize a skills-based approach to help students practice and advocate for their health needs, as well as the needs of their families and their communities. These skills help children and adolescents find and evaluate health information needed for making informed health decisions and ultimately provide the foundation of how to advocate for their own well-being throughout their lives.

In the last 40 years, many studies have documented the relationship between student health and academic outcomes [29,40,41]. Health-related problems can diminish a student's motivation and ability to learn [4]. Complications with vision, hearing, asthma, occurrences of teen pregnancy, aggression and violence, lack of physical activity, and low cognitive and emotional ability can reduce academic success [4].

To date, there have been no long-term sequential studies of the impact of K-12 health education curricula on health literacy or health outcomes. However, research shows that students who participate in health education curricula in combination with other interventions as part of the coordinated school health model (i.e., physical activity, improved nutrition, and/or family engagement) have reduced rates of obesity and/ or improved health-promoting behaviors [25,30,34]. In addition, school health education has been shown to prevent tobacco and alcohol use and prevent dating aggression and violence. Teaching social and emotional skills improves the academic behaviors of students, increases motivation to do well in school, enhances performance on achievement tests and grades, and improves high school graduation rates.

As with other content areas, it is up to the state and/or local government to determine what should be taught, under the 10th Amendment to the US Constitution [48]. However, both public and private organizations have produced seminal documents to help guide states and local governments in selecting health education curricula. First published in 1995 and updated in 2004, the National Health Education Standards (NHES) framework comprises eight health education foundations for what students in kindergarten through 12th grade should know and be able to do to promote personal, family, and community health (see Table 1) [12]. The NHES framework serves as a reference for school administrators, teachers, and others addressing health literacy in developing or selecting curricula, allotting instructional resources, and assessing student achievement and progress. The NHES framework contains written expectations for what students should know and be able to do by grades 2, 5, 8, and 12 to promote personal, family, and community health.

The Coordinated Approach to Child Health (CATCH) model, which was first developed in the late 1980s with funds by the National Heart, Lung, and Blood Institute, serves to implement the NHES framework and was the largest school-based health promotion study ever conducted in the United States. CATCH has 25 years of continuous research and development of its programs [24] and aligns with the WSCC framework. Individualized programs like the CATCH model develop programming based on the NHES framework at the local level, so that local control still exists, but the mix and depth of topics can vary based on need and composition of the community.

Based on reviews of effective programs and curricula and experts in the field of health education, CDC recommends that today's state-of-the-art health education curricula emphasize four core elements: "Teaching functional health information (essential knowledge); shaping personal values and beliefs that support healthy behaviors; shaping group norms that value a healthy lifestyle; and developing the essential health skills necessary to adopt, practice, and maintain health enhancing behavior" [13]. In addition to the 15 characteristics presented in Box 1, the CDC website has more detailed explanations and examples of how the statements could be put into practice in the classroom. For example, a curriculum that "builds personal competence, social competence, and self-efficacy by addressing skills" would be expected to guide students through a series of developmental steps that discuss the importance of the skill, its relevance, and relationship to other learned skills; present steps for developing the skill; model the skill; practice and rehearse the skill using real-life scenarios; and provide feedback and reinforcement.

In addition, CDC has developed a Health Education Curriculum Analysis Tool [14] to help schools conduct an analysis of health education curricula based on the NHES framework and the Characteristics of an Effective Health Education Curriculum.

Despite CDC's extensive efforts during the past 40 years to help schools implement effective school health education and other components of the broader school health program, the integration of health education into schools has continued to fall short in most US states and cities. According to the CDC's 2016 School Health Profiles report, the percentage of schools that required any health education instruction for students in any of grades 6 through 12 declined. For example, 8 in 10 US school districts only required teaching about violence prevention in elementary schools and violence prevention plus tobacco use prevention in middle schools, while instruction in only seven health topics was required in most high schools [6].

Although 8 of every 10 districts required schools to follow either national, state, or district health education standards, just over a third assessed attainment of health standards at the elementary level while only half did so at the middle and high school levels [6]. No Child Left Behind legislation, enacted in 2002, emphasized testing of core subjects, such as reading, science, and math, which resulted in marginalization of other subjects, including health education [22,31]. Academic subjects that are not considered "core" are at risk of being eliminated as public school principals and administrators struggle to meet adequate yearly progress for core subjects, now required to maintain federal funding.

In addition to the quality and quantity of health education taught in schools, there are numerous problems related to those considered qualified to provide instruction [5,7]. Many school and university administrators lack an understanding of the distinction between health education and physical education (PE) [9,16,19] and consider PE teachers to be qualified to teach health education. Yet the two disciplines differ regarding national standards, student learning outcomes, instructional content and methods, and student assessment [5]. Kolbe notes that making gains in school health education will require more interdisciplinary collaboration in higher education (e.g., those training the public health workforce, the education workforce, school nurses, pediatricians) [29]. Yet faculty who train various school health professionals usually work within one university college, focus on one school health component, and affiliate with one national professional organization. In addition, Kolbe notes that health education teachers in today's workforce often lack support and resources for in-service professional development.

Promising Opportunities for Strengthening School Health Education

Comprehensive health education can increase health literacy, which has been estimated to cost the nation $1.6 to $3.6 trillion dollars annually [54]. The National Action Plan to Improve Health Literacy by the US Department of Health and Human Services (HHS) includes the goal to "Incorporate accurate, standards-based, and developmentally appropriate health and science information and curricula in childcare and education through the university level" [49].

HHS's Healthy People Framework presents another significant opportunity for tracking health in education as well as health literacy. The Healthy People initiative launched officially in 1979 with the publication of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention [50]. This national effort establishes 10-year goals and objectives to improve the health and well-being of people in the United States. Since its inception, Healthy People has undertaken extensive efforts to collect data, assess progress, and engage multi-stakeholder feedback to set objectives for the next ten years. The Healthy People 2020 objectives were self-described as having input from public health and prevention experts, a wide range of federal, state, and local government officials, a consortium of more than 2,000 organizations, and perhaps most importantly, the public" [51]. In addition to other
childhood and adolescent objectives (e.g., nutrition, physical activity, vaccinations), Healthy People 2020 specified social determinants as a major topic for the first time. A leading health indicator for social determinants was "students graduating from high school within 4 years of starting 9th grade (AH-5.1)" [52]. The Secretary's Advisory Committee report on the Healthy People 2030 objectives includes the goal to "eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all" [53]. The national objectives are expected to be released in summer 2020 and will help catalyze "leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well-being of all" [53].

In terms of supports in federal legislation, the Every Student Succeeds Act (ESSA) of 2015 recognized health education as a distinct discipline for the first time and designated it as a "well-rounded" education subject [2,22]. According to Department of Education guidelines, each state must submit a plan that includes four academic indicators that include proficiency in math, English, and English-language proficiency. High schools also must use their graduation rates as their fourth indicator, while elementary and middle schools may use another academic indicator. In addition, states must specify at least one nonacademic indicator to measure school quality or school success, such as health education. Under the law, federal funding also is available for in-service instruction for teachers in well-rounded education subjects such as health education. These two items open additional pathways for both identifying existing or added programs and having the capacity to collect data.

While several states have chosen access to physical education, physical fitness, or school climate as their nonacademic indicators of school success, the majority (36 states and the District of Columbia) have elected to use chronic absenteeism [2]. Given the underlying causal connection between student health and chronic absenteeism, absenteeism as an indicator represents a significant opportunity to raise awareness of chronic health conditions or other issues (e.g., student social/emotional concerns around bullying, school safety) that contribute to absenteeism. It also represents a significant opportunity for schools to work with stakeholders to prevent and manage such health conditions through school health education and other WSCC strategies to improve school health. Educators are more likely to support comprehensive health education if they are made aware of its immediate benefits related to student learning (e.g., less disruptive behavior, improved attention) and maintaining safe social and emotional school climates [31].

In an assessment of how states are addressing WSCC, Child Trends reported that health education is either encouraged or required for all grades in all states' laws, with nutrition (40 states) and personal health (44 states) as the most prominent topics [15]. However, the depth and breadth of such instruction in schools is not known, nor if health education is being taught by qualified teachers. In 25 states, laws address or otherwise incorporate the NHES as part of the state health education curriculum.

The authors' review of state 2017-2018 ESSA plans, analyzed by the organization Cairn, showed nine states that have specifically identified health education as one of its required well-rounded subjects (Florida, Georgia, Indiana, Louisiana, Maine, Maryland, Nevada, North Dakota, and Tennessee) [8]. Cairn recommends that most states include health education and physical education in state accountability systems, school report card indicators, school improvement plans, professional development plans, needs assessment tools, and/or prioritized funding under Title IV, Part A.

In 2019, representatives of the National Committee on the Future of School Health Education, sponsored by the Society for Public Health Education (SOPHE) and the American School Health Association (ASHA), published a dozen recommendations for strengthening school health education [5,31,55]. The recommendations addressed issues such as developing and adopting standardized measures of health literacy in children and including them in state accountability systems; changing policies, practices, and systems for quality school health education (e.g., establishing Director of School Health Education positions in all state and territory education agencies tasked with championing health education best practices, and holding schools accountable for improving student health and wellbeing); and strengthening certification, professional preparation, and ongoing professional development in health education for teachers at both the elementary and secondary levels. Recommendations also call for stronger alignment and coordination between the public health and education sectors. The committee is now moving ahead on prioritizing the recommendations and developing action steps to address them.

Integrating Youth Health Education and Health Literacy: Success Stories

Minnesota Statewide Model: Integrating School Health Education and Health Literacy Through Broad Partnership

The Roundtable on Health Literacy held a workshop on health literacy and public health in 2014, with examples of how state health departments are addressing health literacy in their states [28]. One recent example of a strong collaboration between K-12 education and public health agencies is the Statewide Health Improvement Partnership (SHIP) within the Minnesota Department of Health's Office of Statewide Health Initiative [35].

SHIP was created by a landmark 2008 Minnesota health reform law. The law was intended to improve the health of Minnesotans by reducing the risk factors that lead to chronic disease. The program funds grantees in all of the state's 87 counties and 10 tribal nations to support the creation of locally driven policies, systems, and environmental changes to increase health equity, improve access to healthy foods, provide opportunities for physical activity, and ensure a tobacco-free environment [35]. Local public health agencies collaborate with partners including schools, childcare settings, workplaces, multiunit housing facilities, and health care centers through SHIP.

SHIP models the integration of (1) law, (2) policy, (3) goal-setting, and (4) resource building and forging some 2,000 collaborative partnerships and measuring outcomes. SHIP sets a helpful example for others attempting to create synergies across the intersections of state government, health education, local communities, and private organizations. The principles of health literacy are within these collaborations.

Grantees throughout the state have received technical assistance and training to improve school nutrition and physical activity strategies (see Figure 1). SHIP grantees and their local school partner sites set goals and adopt best practices for physical education and physical activity inside and outside the classroom. They improve access to healthy food environments through locally sourced produce, lunchrooms with healthier food options, and school-based agriculture. In 2017, SHIP grantees partnered with 995 local schools and accounted for 622 policy, systems, and environmental changes.

Minnesota has also undertaken a broad approach to health literacy by educating stakeholders and decision-makers (i.e., administrators, food service and other staff, students, community partners, and parents) about various health-related social and environmental issues to reduce students' chronic disease risks.

SHIP grantees assist in either convening or organizing an established school health/wellness council that is required by USDA for each local education agency participating in the National School Lunch Program and/or School Breakfast Program [46,47]. A local school wellness policy is required to address the problem of childhood obesity by focusing on nutrition and physical activity. SHIP also requires schools to complete an assessment that aligns with the WSCC model and provides annual updates. Once the assessment is completed by a broad representation of stakeholders, SHIP grantees assist schools in prioritizing and working toward annual goals. The goal-setting and assessment and goal-setting cycle is continuous.

The Bigger Picture: A Case Study of Community Integration of Health Education and Health Literacy

Improving the health literacy of young people not only influences their personal health behaviors but also can influence the health actions of their peers, their families, and their communities. According to the SEARCH for Diabetes in Youth study funded by the CDC and the National Institutes of Health's National Institute of Diabetes, Digestive, and Kidney Diseases, from 2002 to 2012, the national rate of new diagnosed cases of Type 2 diabetes increased 4.8% [32]. Among youth ages 10-19, the rate of new diagnosed cases of Type 2 diabetes rose most sharply in Native Americans (8.9%) (although not generalizable to all Native American youth because of small sample size), compared to Asian Americans/Pacific Islanders (8.5%), non-Hispanic blacks (6.3%), Hispanics (3.1%), and non-Hispanic whites (0.6%).

Since 2011, Dean Schillinger, Professor of Medicine in Residence at the University of California San Francisco and Chief of the Diabetes Prevention and Control Program for the California Department of Public Health, has led a capacity-building effort to address Type 2 diabetes [23,28,44].

This initiative called The Bigger Picture (TBP) has mobilized collaborators to create resources by and for young adults focused on forestalling and, hopefully, reversing the distressing increase in pediatric Type 2 diabetes by exposing the environmental and social conditions that lead to its spread. Type 2 diabetes is increasingly affecting young people of color, and TBP is specifically developed by and directed to them.

TBP seeks to increase the number of well-informed young people who can participate in determining their own lifelong health behaviors and influencing those of their friends, families, communities, and their own children. The project aims to create a movement that changes the conversation about diabetes from blame-and-shame to the social drivers of the epidemic [23].

TPB is described by the team that created it as a "counter-marketing campaign using youth-created, spoken-word public services announcements to reframe the epidemic as a socio-environmental phenomenon requiring communal action, civic engagement, and norm change" [44]. The research team provides a description of questionnaire responses to nine of the public service announcements in the context of campaign messages, film genre and accompanying youth value, participant understanding of fi lm's public health message, and the participant's expression of the public health message. The investigators also correlate the responses with dimensions of health literacy such as conceptual foundations, functional health literacy, interactive health literacy, critical skills, and civic orientation.

One of the campaign partners, Youth Speaks, has created a toolkit to equip and empower students and communities to become change agents in their respective environments, raising their voices and joining the conversation about combating the spread of Type 2 diabetes [56].

In a discussion of qualitative evaluations of TBP and what low-income youth "see," Schillinger et al. note that "TBP model is unique in how it nurtures and supports the talent, authenticity, and creativity of new health messengers: youth whose lived experience can be expressed in powerful ways" [44].

COVID-19: Health Crisis Affecting Children and their Families and a Need for Health Education and Health Literacy in K-12

In a recent op-ed, Rebecca Winthrop, co-director of the Center for Universal Education and Senior Fellow of Global and Economic Development of the Brookings Institution asked, "COVID-19 is a health crisis. So why is health education missing from school work?" [58] She notes that "helping sustain education amid crises in over 20 countries, I've learned that one of the first things you do, after finding creative ways to continue educational activities, is to incorporate life-saving health and safety messages." Her call is impassioned for age-appropriate, immediately available resources on COVID-19 that can be easily incorporated into distance lesson plans for both children and families. Many organizations, such as Child Trends, are curating collections of such resources. Framing these materials using principles of health literacy and incorporating them into health education messages and resources may
be an ideal model for incorporating new pathways for public health K-12 learning.

Call to Action for Collaboration

Strategic and dedicated efforts are needed to bridge health education and health literacy. These efforts would foster the expertise to provide students with the information needed to access and assess useful health information, and to develop the necessary skills for an emerging understanding of health.

Starting with students in school settings, learning to be health literate helps overcome the increased incidence of chronic diseases such as Type 2 diabetes, and imbues a sense of self-efficacy and empowerment through health education. It also sets the course for lifelong habits, skills, and decision making, which can also influence community health.

Pursuing institutional changes to reduce disparities and improve the health of future generations will require significant collaboration and quality improvement among leaders within health education and health literacy. Recommendations provided in previous reports such as IOM's 1997 report, Schools and Health: Our Nation's Investment [26]; the 2004 IOM report on Health Literacy [27]; and the 2010 National Action Plan to Improve Health Literacy [49] should be revisited. More recently, a November 2019 Health Literacy Roundtable Workshop (1) explored the necessity of developing health literacy skills in youth, (2) examined the research on developmentally appropriate health literacy milestones and transitions and measuring health literacy in youth, (3) described programs and policies that represent best practices for developing health literacy skills in youth, and (4) explored potential collaborations across disciplines for developing health literacy skills in youth [38]. With its resulting report, the information provided in the workshop should provide additional insights into collaborations needed to reduce institutional barriers to youth health literacy and empowerment.

At the national level, representatives from public sector health and education levels (e.g., HHS's Office of Disease Prevention and Health Promotion, CDC, Department of Education) can collaborate with school-based nongovernmental organizations (e.g., SOPHE, ASCD, ASHA, National Association of State Boards of Education, School Superintendents Association, Council of Chief State School Officers, Society of State Leaders of Health and Physical Education) to provide data and lead reform efforts. Leaders of higher education (e.g., Association of American Colleges and Universities, Association of Schools and Programs of Public Health) can join with philanthropies and educational scholars to pursue curricular reforms and needed research to further health education and health literacy as an integral component of higher education.

Among the approaches needed are (1) careful incorporation of key principles of leadership within systems; (2) the training and evaluation of professionals; (3) finding and sharing replicable, effective examples of constructive efforts; and (4) including young people in the development of information and materials to ensure their accessibility, appeal, and utility. Uniting the wisdom, passion, commitment, and vision of the leaders in health literacy and health education, we can forge a path to a healthier generation.

Tweet this! A lifetime of improved health starts with educating children about their health and introducing health literacy early. A new #NAMPerspectives provides upstream and systems-level interventions to integrate health education into every classroom: https://doi.org/10.31478/202007b

Tweet this!Standardized strategies for how health education is implemented in schools is a challenge. Authors of our newest #NAMPerspectives propose integrated strategies that can improve the health and health literacy of all students: https://doi.org/10.31478/202007b

Tweet this! A new #NAMPerspectives discussion paper examines case studies from across the nation that successfully coupled education in health literacy to robust general health education. Read more: https://doi.org/10.31478/202007b

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Health Literacy and Health Education in Schools: Collaboration for Action - National Academy of Medicine

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Introduction This NAM Perspectives paper provides an overview of health education in schools and challenges encountered in enacting evidence-based health education; timely policy-related opportunities for strengthening school health education curricula, including incorporation of essential health literacy concepts and skills; and case studies demonstrating the successful integration of school health education and health literacy in [...]

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HANDS UP | 1 - Introduction to Physical & Health Literacy

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60 Seconds for Safety: Patient Engagement

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Healthcare Organizations Approaches to Engagement

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Introduction and background

Person-centered care is the cornerstone of high-quality healthcare service as outlined by the Institute of Medicine (now National Academy of Medicine) in its 2001 seminal report, Crossing the Quality Chasm [ 1]. Delivering person-centered care requires "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that (these) values guide all clinical decisions" [ 1]. Globally the patient-centered care measurement indicators demonstrate huge variations, as mentioned in the following tri-institutional reports published during late 2018. In its report "Crossing the Global Quality Chasm: Improving the Healthcare Worldwide," the National Academies of Sciences, Engineering, and Medicine describes patient-centered care as the levels of dissatisfaction for overall care (2.2% to 54.3% globally) [ 2]. The "Lancet Global Health Commission High-Quality Health Systems in the Sustainable Development Goals Era: Time for a Revolution" reports the patient-centered care measurement as poor user experience upon contact with the healthcare systems (34% of people in low-income and middle-income countries) [ 3]. The "World Health Organization, Organization for Economic Co-operation and Development, and The World Bank Delivering Quality Health Services: A Global Imperative" report mentions the patient-centered care measured as doctors providing easy-to-understand explanations (age-standardized rate of 81.3 per 100 patients for high-income countries in the Organization for Economic Co-operation and Development) [ 4]. These reports called upon the healthcare stakeholders across the globe to work collaboratively on reducing the ambiguity on what it actually means or how to measure patient-centeredness through a standardized method best.

In the midst of this ongoing global healthcare paradigm shift towards patient and family-centered care, the emergence of the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in December 2019 led to a novel coronavirus disease 2019 (Covid-19) pandemic, catalyzing a chain of rapid worldwide transformations in the practices of delivering healthcare services [ 5, 6]. The contagion spread through the communities globally, overwhelming healthcare system capacity [ 6]. Governments and healthcare stakeholders locally, regionally, and internationally rushed to implement multiple measures to prevent disease transmission [ 7, 8]. As a result, patients faced significant care disruptions of healthcare services. Globally, healthcare systems faced a dual challenge to work on innovative approaches to deliver healthcare during the Covid-19 pandemic and at the same time provide continued care to the non-Covid-19 patients [ 9- 11]. We aim to present various lessons learned globally on patient and family engagement, focusing on the approaches that can continue to prove effective in the post-Covid-19 pandemic era.

Review

Key lessons learned globally for strategic implementation and continued use in healthcare to improve patient-centered care:

1. Co-production of Healthcare Services as Core Strategy for Patient and Family Engagement

Healthcare service outcomes (good and bad) are co-produced or co-created by healthcare professionals in relation to one another and people seeking help to restore or maintain health for themselves and their families [ 12, 13]. In its functional essence, 'co-production' means that we have patients onboard the design team co-creating from the beginning of a healthcare service improvement effort to achieve high quality, value-based, low cost, and sustainable outcomes with a shared vision [ 14]. It is the equal partnership between healthcare providers bringing the wealth of 'learned experience' and the patients having the relevant 'lived experience' in a healthcare setting that provides a whole story demonstrating what matters most to the patients [ 15]. Only then the healthcare organizations can co-design and co-produce healthcare improvement through robust, innovative, and practical experience-based change ideas [ 15]. The Covid-19 pandemic underscores the importance of patient-and-family-centeredness contributing to a loved one's quality of care [ 8]. An international multi-stakeholder effort led by US-based Planetree International developed "Person-Centered Guidelines for Preserving Family Presence in Challenging Times" to globally encourage the frontline healthcare staff and organizations in delivering patient-and-family-centered care during the Covid-19 pandemic [ 8]. Such multi-stakeholder global-level initiatives are of high importance and should continue in the post-Covid-19 era to minimize the variation in the patient-and-family-centeredness measures across the healthcare systems around the world.

Moreover, reducing patient and family engagement barriers to effectively co-produce in a rapid turnaround time is also of utmost importance [ 14]. An 'Always Event' (refers to aspects of the patient experience that are so important to patients and families that healthcare providers must perform them consistently for every patient, every time) approach has been used by more than 50% of healthcare providers in England with an aim to activate patients and providers to co-produce and commit to change [ 14, 15]. Recently, National Steering Committee for Patient Safety released the "Safer Together: A National Action Plan to Advance Patient Safety," highlighting the total system approach to advance patient safety through healthcare organizations committed to the goal of fully engaging patients, families, and care partners in all aspects of care across all levels using key tactics like 'AHRQ Questions Are the Answers,' 'Ask Me 3,' 'Choosing Wisely,' 'Prepare for Your Care,' 'The Conversation Project,' 'Cake,' 'What Matters to You,' 'Open Notes,' 'Patient and Family Advisory Councils for Quality and Safety,' and 'Patient and Family Advisor Program' [ 16- 18]. These co-production and co-design playbook techniques can be used worldwide in a standardized manner to improve patient safety and quality of care, ultimately advancing patient-and-family-centered care.

2. Leverage Technological Advancements to Enhance Patient and Family Engagement

The recent challenging times in the context of the Covid-19 pandemic have highlighted the continued importance of solid human relationships, leading to telehealth's rapid growth to minimize interruption of vital clinical services [ 11, 19]. A survey of US physicians in 2020 revealed that about half of the physicians are treating patients using virtual visits [ 20]. Telehealth solutions have also been used extensively during the Covid-19 pandemic in the inpatient settings to promote patient and family engagement [ 21]. Telehealth provides a real opportunity for the future of healthcare delivery. However, there are few hurdles in telehealth's path to a sustainable healthcare delivery model. Firstly, the lack of a global framework to license healthcare workers and protect patient data privacy allowing cross-state or cross-country telehealth consultations [ 19, 22]. Secondly, an area of increasing concern is to ensure that telehealth services are equitable and accessible by all the communities, patient groups, and ethnicities [ 22, 23]. Finally, the telehealth services' payment structure needs to be devised. This can be radically different across jurisdictions [ 7, 19, 22]. In order to increase the use of telehealth services in the post-pandemic era with the recovery of the normal daily processes or 'new normal,' the healthcare organizations, providers, and frontline staffs need to embrace telehealth technologies using data-driven guidelines of the patient-and-family-centered care for a sustainable and scalable implementation of telehealth into the routine clinical care [ 7, 22].

Artificial Intelligence (AI), Machine Learning (ML), and Natural Language Processing (NLP) in the healthcare industry have been gaining popularity recently to solve the healthcare delivery operational issues mainly due to its capacity to analyze complex big data sets for accurate risk prediction, needs forecasting, and improving population-based healthcare outcomes [ 24]. One such protocol for ML algorithms can utilize patient data to predict the risk of poor patient and family engagement [ 25]. Such methodological approaches will help alarm the healthcare providers about the patients at risk of poor patient experience and low patient and family engagement to utilize more enhanced and focused strategies when dealing with such patients and families [ 25]. AI, ML, and NLP provide an opportunity for healthcare teams to collaborate while designing the healthcare technological solutions or tools that are capable of offloading the provider tasks like patient record review, provider order entry, and clinical documentation to allow more time for provider and patient interaction, preserving the patient-healthcare provider relationship [ 26].

3. Equity and the Patient and Family Engagement

The data on various healthcare outcomes clearly demonstrates the effect of structural racism and bias (both implicit and explicit) driving an international call to action towards more equitable healthcare ecosystems [ 27- 29]. Health Opportunity and Equity (HOPE) initiative showed that the health status and outcomes, access to care, and socioeconomic status in the US vary by race and ethnic group [ 30]. The ongoing Covid-19 pandemic has highlighted gaps in accessibility and equity [ 29]. To close this gap of variation of the health outcomes, a global strategic framework with specific measures to focus on operationalizing equity and anti-racism as part of the healthcare providers' everyday practices is required [ 28]. Applying the patient and family-centered care perspective, an example of the risk factor contributing to the inequity in the patient and family engagement, health outcomes, and patient safety is the language used for communication with the patients and the families. Karthik et al. described a pragmatic four-tier approach with measurable elements to overcome this issue, focusing on level 1) access to language interpreter; level 2) transition of care with similar interpreter services; level 3) measuring the quality of care for patients requiring interpreters; finally targeting level 4) socioeconomic and environmental factors that led to such language barriers [ 28]. Multiple organizations, including the Institute for Healthcare Improvement, have created conversation-ready toolkits and scripts in various languages to help healthcare providers conduct conversations with patients from different backgrounds [ 31, 32]. To improve the overall quality of care and enhance patient and family engagement, it has become increasingly crucial for healthcare organizations and providers to morally invest in the strategies that help improve health equity [ 33]. The new models of care and payment for the healthcare services need to increasingly imbed the healthcare equity-based measures into their frameworks as the healthcare systems transform towards a better future.

4. Leverage Health Policy and Regulatory Frameworks for Rapid Adaptation of Patient and Family Engagement Strategies

The adoption of telehealth and removal of multiple medical licensures related hurdles through temporary declarations and waivers for out-of-state medical licenses of clinicians at the level of various US states and at the federal level by the Centers for Medicare and Medicaid Services early during the Covid-19 pandemic provides a prime example of the significant role that health policy and regulatory framework play to improve access to medical care and patient-centered care [ 19]. The whole concept of de-regulation and pan-national medical licensing has to be balanced with overarching safety for the protection of the citizens/public when credentialing. Health policy across the globe should continue its pivotal role in ensuring a framework to provide healthcare 'a fundamental human right' for all [ 33]. Continued support for telehealth incentives and a matching payment model by the health policymakers and regulators is vital to enhance shared-decision making, patient and family engagement, and genuine co-production to help patients live healthier lives [ 19, 34, 35]. Secondly, there is an urgent need to move the care out of the hospitals and closer to communities in home-based settings to avoid unnecessary emergency department visits and hospitalizations by providing acute care in the home or helping older adults safely "age in place" [ 34, 35]. Thus, a combination of incentivization, deregulation, and additional forms of support is required, including reimbursement for home-based hospital services and removing barriers to safe and effective alternatives to the hospital for managing chronic diseases. Thirdly, the problems related to the social determinants of health that lead to poor health outcomes can be addressed by conducting more intersectoral work through community-based organizations that understand best what their communities need the most. By moving the money to education, job creation, criminal justice reform, immigration support systems, climate change, and increasing coordination with healthcare systems, we can increase health among populations and lower health care costs [ 33, 34]. Finally, by integrating the health policy and regulatory frameworks with the patient-and-family-centered care frameworks, the legislators need to prioritize patient-and-family-centered outcome-based healthcare measurements and incentives. This type of approach will help ensure that value-based payment incentive systems will be paying for the real changes in health outcomes that patients and their families value the most [ 34, 35].

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Patient and Family Engagement During Challenging Times: What Works and What Does Not?

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Person-centered care is the cornerstone of high-quality healthcare service as outlined by the Institute of Medicine (now National Academy of Medicine) in its 2001 seminal report, Crossing the Quality Chasm [ 1]. Delivering person-centered care requires "providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that (these) values guide all clinical decisions" [ 1].

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Schools for Health in Europe Network Foundation

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Health literacy in schools - a video about factsheet no. 6 (SHE, 2020)

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Are you confused about health information? You're not alone | Lisa Fitzpatrick | TEDxMidAtlantic

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Consumer Demand for Information

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Organizations must rethink their approach to build customer engagement and loyalty

By Kaufman Hall & Associates, LLC
Editor's note: This article is a shortened version of Kaufman Hall's report "2019 State of Consumerism in Healthcare." Click here for access to the complete report.
Health care continues to play catch-up in an online, convenience-obsessed, and increasingly consumer-focused world.

Results of Kaufman Hall's 2019 Healthcare Consumerism Index highlight the challenges that legacy health care providers face in trying to grasp a firm handhold on the ever-rising bar of consumer needs and expectations. The Index provides a lens to industry performance related to consumerism, based on survey responses from hospitals and health systems nationwide.

Top performers kept pace with previous years, while many lower performing organizations fell further behind. Falling scores in the area of "access" contributed to much of the backsliding among lower performers. It is not that these organizations reversed course on consumer initiatives, but rather that they struggled to adjust to continually changing expectations for what defines "great access."

The Threat of Disintermediation

Health care leaders nationwide acknowledge the risks, as numerous competitors seek to disrupt traditional care delivery models. A majority of respondents to this year's survey - 88 percent - agree or strongly agree that hospitals and health systems are vulnerable to consumer-friendly offerings from non-hospital competitors, compared to just 8 percent who disagreed.

When asked to rank potential competitors, survey respondents cited UnitedHealth Group/ Optum, CVS Health/Aetna, and Amazon as posing strong or extreme threats (see Figure 1: Perceptions of Potential Competitors). Respondents view companies with less of a health care focus - such as Google and Apple - as less of a threat.

Priorities vs. Capabilities: A Growing Gap

Each year, the Kaufman Hall Consumerism Survey seeks to gauge the level of alignment between organizational priorities and capabilities relative to consumerism initiatives. This year's findings reveal a steep divide between those that rank key initiatives as "high" or "extreme" priorities and those with high capabilities in those areas ( see Figure 2: Consumer-centric Priorities vs. Capabilities).

A majority of respondents (81 percent) identified improving the customer experience as a high priority for their organizations, while only 11 percent reported having best-in-class customer experience capabilities. Surprisingly, 20 percent said improving customer experience was a moderate-to-low priority, and more than a quarter said an enhanced customer experience was either not available or had limited availability at their organizations.

In terms of access, legacy providers continue to focus more on developing brick-and-mortar facilities than expanding digital tools or virtual services. Sixty-one percent of survey respondents identified "offering a variety of facility-based access points" as a high or extreme priority for their organizations, while 10 percent said their organizations are "best-in-class" in this area. More than a quarter said having a variety of facilities was a moderate priority, while 62 percent said their organizations already offered such access points on a widespread basis.

In contrast, just 27 percent cited "offering a variety of virtual access points" as a high priority for their organizations, and only 3 percent said they were top performers in this area. Nearly 30 percent said offering a variety of virtual access points was a low priority, and 63 percent said such access points were either not available or offered on a limited basis at their organizations. Forty-two percent of respondents identified "using digital tools to engage consumers" as a high-to-extreme priority, while 35 percent said it was a moderate priority and 21 percent said it was a low priority. Thirty-two percent said such tools were widely available.

When asked what most differentiates their organizations from competitors, most respondents cited the quality of clinical outcomes, geographic coverage, and accessibility of care. At the other end of the spectrum, respondents indicated factors such as price and "innovative products and services" as the least differentiating factors.

Consumer Access: The Bar Gets Higher

Overall performance in consumer access fell this year, due in large part to a higher bar in terms of what defines good access for the Kaufman Hall Consumerism Index, based on the firm's extensive research into changing consumer needs and attitudes. Today's consumers increasingly demand quick and easy access to any and all services through a variety of access points - physical and virtual - with digital tools to add convenience. Rising expectations require health care providers to work that much harder to meet consumer needs.

Just 9 percent of organizations rated as top performers for access, down 3 percentage points from 2018, while the lowest performing organizations rose 20 percentage points over last year to 30 percent.

This swelling of organizations in the lowest performing group is due, in part, to a persistent focus on relatively traditional physical access points. Historically, legacy providers have emphasized building brick-and-mortar care sites, as opposed to first understanding consumers' health care needs and determining how best to address those needs through a variety of modalities.

As in previous years, the majority of survey respondents indicated that they offer widespread urgent care (61 percent), ambulatory surgery centers (51 percent), and freestanding diagnostics facilities (41 percent). By comparison, nearly half said their organizations had no retail clinics.

Looking at access initiatives aimed at increasing convenience for consumers ( see Figure 3: Consumer Convenience Initiatives):

Nearly 80 percent of organizations report having no subscription-based primary care services.

A third offer widespread online self-scheduling for existing patients, but few offer this service for new patients.

Same-day appointments and extended and walk-in hours are common access strategies.

Thirty-eight percent of respondents offer widespread "Save a Spot" urgent care, while nearly 60 percent offer it on a limited basis or not at all.

Legacy health care providers need to rethink their approach to access if they want to appeal to today's consumers, said a senior strategy officer with a major health system in the Northeast.

"The old, traditional ways of access are not what people want," he said. "Everything is online and on the app of a phone. It's not just about one interaction or one moment in time, it's about building customer engagement and loyalty."

Consumer Access: Best Practices

Kaufman Hall's research shows the following best practices for developing state-of-the-art consumer access:

Start with how best to serve consumer needs, rather than asking "how many facilities do we need?" or "which real estate should we purchase?"

Identify new growth-oriented metrics to determine access success, such as new, unique patients captured.

Provide multiple options across physical, virtual and convenience dimensions for consumers to access your system - consumers are not homogeneous in their preferences and needs.

Consumer Experience: Efforts Remain Limited

As noted earlier, 81 percent of survey respondents identified improving the consumer experience as a top priority for their organizations. While many organizations are making progress, significant room for improvement remains across the board.

Enhancing communication has been a clear focus area for many hospitals and health systems, with a majority of respondents reporting widely available automated appointment reminders (72 percent), and centralized call routing (53 percent). Fifty-five percent of organizations have widely available electronic messaging between patients and providers, while 34 percent have it with limited availability. Thirty-nine percent of respondents said their organizations offer same-day communication with a provider by phone on a widespread basis, while 53 percent provide limited availability to such services.

Real-time communication offerings are particularly lacking:

Sixty-six percent of organizations offer limited-to-no opportunities for real-time patient feedback.

Nearly three-quarters of respondents said their organizations have limited-to-no real-time referral scheduling.

Half of organizations offer no real-time updates on in-office wait times, while 38 percent offer such updates on a limited basis.

To deliver a great consumer experience, executives must make it a cultural priority throughout their organizations, supported by the necessary workflows and enabled by the right technology. Health care leaders should strive to offer an experience that's on par with leaders across industries, not just those within health care.

Consumer Experience: Best Practices

Kaufman Hall's research shows the following best practices for developing a contemporary consumer experience for health care organizations:

Adopt a hospitality mindset: "delight," not "satisfaction."

Fully address all aspects of creating an optimal consumer experience, including developing a service culture, patient-centered workflows, and enabling tools and technology.

Address the most important pain points across the entire care journey, not just during a specific touchpoint or episode of care. Focusing on specific touchpoints becomes meaningless if consumers encounter cascading issues at subsequent points in their journey.

Conclusion

While a majority of hospitals and health systems strive to become more consumer centric, Kaufman Hall's annual Healthcare Consumerism Survey continues to show significant opportunities for improvement across the core areas of access, experience, pricing, and infrastructure. Some health care leaders are looking to develop consumer-centric capabilities internally, while others are seeking help from outside organizations with expertise in specific areas.

Whether built internally or aided by external partners, consumer-centric strategies and capabilities are critical for hospitals and health systems seeking to compete with increasingly larger industry contenders and innovative new entrants. The industry's historically slow, measured pace of change is working against legacy organizations, causing them to fall further and further behind in a race where the competitors already have significant advantages of greater agility, flexibility, and resources.

Organizations need to rethink their overall delivery model, and look for opportunities to meet consumer needs and expectations head-on. They need to shift from a focus on providing access through traditional brick-and-mortar facilities, to expanding virtual access and digital tools to streamline care and better engage consumers. They need to build real-time consumer experience offerings to enable providers to address patient needs at the time of care, and develop true price transparency across all facilities and services. Lastly, health care leaders should reassess what they are measuring, why they are measuring it, and how they are using that information to best serve consumers.

About the Report
This report is based on the 2019 Kaufman Hall Healthcare Consumerism Survey and the Kaufman Hall Healthcare Consumerism Index. The annual survey is a detailed online questionnaire sent to executives at hospitals and health systems nationwide. Well over 200 executives responded to this year's survey, representing a broad range of organizations, including community hospitals, academic medical centers, children's hospitals, and regional and national health systems. Respondents answer questions designed to gauge strategic focus and intent toward being a consumer-centric organization, as well as the resources and capabilities that aid in achieving a consumer-centric organizational core.

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Catching up to Consumer Expectations for Access | AHA Trustee Services

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By Kaufman Hall & Associates, LLC Editor's note: This article is a shortened version of Kaufman Hall's report "2019 State of Consumerism in Healthcare." Click here for access to the complete report. Health care continues to play catch-up in an online, convenience-obsessed, and increasingly consumer-focused world.

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Use of Internet for Health Education

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Technology has redefined the way patients and providers communicate and obtain health information. The realm of digital health encompasses a diverse set of technologies, including mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies have begun to improve care delivery without the traditional constraints of distance, location, and time. A growing body of evidence supports the use of digital health technology for improving patient education and implementation of skills and behaviors integral to lifestyle medicine. Patient education can now be delivered in standard formats (eg, articles, written messages) as well a wide array of multimedia (video, audio, interactive games, etc), which may be more appropriate for certain topics and learning styles. In addition, patient engagement in their care plays an important role in improving health outcomes. Despite digital health technology development often outpacing its research, there is sufficient evidence to support the use of many current technologies in clinical practice. Digital health tools will continue to grow in their ability to cost-effectively monitor and encourage healthy behaviors at scale, and better methods of evaluation will likely increase clinician confidence in their use.

'[Digital] technologies have begun to improve care delivery without the traditional constraints of distance, location, and time.'

Technology has redefined the way patients and providers communicate and obtain health information. Globally, an estimated 6.75 million internet queries on health-related topics are conducted every day. In 2013, the Pew Research Center found that 72% of Internet users in the United States searched for health information the previous year, with 35% using the Internet to determine their own or someone else's medical condition.

Digital health encompasses a diverse set of technologies, including mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies have begun to improve care delivery without the traditional constraints of distance, location, and time. They also offer new opportunities to educate patients and facilitate the process of behavior change integral to lifestyle medicine. Patient education can now be delivered in standard formats (eg, articles, written messages) as well a wide array of multimedia (video, audio, interactive games, etc), which may be more appropriate for certain topics and learning styles. Furthermore, education is not only the consumption of information but also the implementation and mastery of skills, sometimes referred to as experiential learning. Patient engagement in their care plays an important role in health outcomes. Engaged patients cost health care systems 8% less than nonengaged patients in their base year, and 21% less in future years.

Text Messaging

Text messaging is the most widely used data application in the world-used by over 78% of all mobile phone subscribers as of 2012 and over 97% of all mobile phone subscribers in the United States as of 2015. It is effective for reaching its audience, with estimates that 99% of received mobile text messages are opened and 90% within three minutes of receipt. Messages can be timed precisely, ranging from infrequent reminders to bursts throughout the day to specific moments of decision making. Multiple reviews have shown benefit in diabetes, cardiovascular disease, weight loss, physical activity, smoking cessation, and medication adherence.

Extensive literature exists on user-centered design for provision of educational material. Considerations include the length of the message, sender of the message, style of writing, cultural and linguistic appropriateness, literacy level of the population (generally eighth-grade level is maximum used for adults), and the need for translations. Some studies provide more messages during key behavior change periods, some only send messages when requested by a user, and others vary frequency based on the text habits of their users or based on users' adherence (e.g. higher frequency when adherence is low). An example includes The Tobacco, Exercise and Diet Messages (TEXT ME) trial, a randomized clinical trial of 710 patients with coronary heart disease. The intervention group received 4 text messages per week for 6 months in addition to usual care. Text messages provided advice, motivational reminders, and support to change lifestyle behaviors. Compared with usual care, this intervention resulted in a modest improvement in LDL-C (low-density lipoprotein cholesterol) level and greater improvement in other cardiovascular disease risk factors.

Mobile (Smartphone and Tablet) Applications

A mobile application ("app") is a computer program designed to run on a mobile device such as a smartphone or tablet. An estimated 81% of US adults owned a smartphone as of 2018, and approximately 325 000 health-related applications existed in 2017 for Apple iOS or Android smartphones, with the most popular apps focused on healthy eating and physical activity. Apps educate patients by providing insight into their behaviors and opportunities to practice new skills. A systematic review demonstrated that women with diabetes receiving preconception care education delivered either digitally or via health care professionals had significantly improved levels of glycosylated hemoglobin with fewer preterm deliveries and adverse fetal outcomes. The digital interventions further showed significant improvements in knowledge and attitudes toward preconception care, along with reduced barriers. Other examples of apps that provide education include myIBDcoach, my AF and mySinusitisCoach.

Wearables Devices

Wearable devices and sensors most commonly provide heart rate tracking and physical activity monitoring. Additionally, they can monitor sleep, track mood or stress levels, or deliver workouts. One in 6 consumers in the United States now uses wearable technology, with over half being smartwatches. As of 2017, 17% of US adults used a wearable device such as a smartwatch or a wrist-worn fitness band. Nonwearable sensors are contributing to the rise of the Internet of Things-a network of sensor-equipped devices able to exchange data. For example, digital scales can now detect not only weight and body fat measurements but also streamline daily weigh-ins by automatically sending measurements to a smartphone application or an online database. Smart refrigerators can help track available groceries, create shopping lists, and even help order food. Mattress covers connected to the internet can monitor temperature, breathing, and heart rate to track sleep quality. Eventually, these smart devices may operate in concert to monitor patient lifestyle and provide personalized education and feedback to encourage healthier behaviors.

Social Media

Social media is defined as an online means of communication used to share information and develop social contacts. It includes online social networks, forums, and messaging boards. Though it does not replace the need for in-person networks and connections, social media creates a new space for education, emotional support, campaigning, fundraising, and network formation. Online social support is particularly valuable for individuals with limited mobility as it decreases barriers for physical transportation. There have been positive studies with weight loss and smoking cessation. Patient-shared data can also be collected online to create research databases. For example, a social network focused on ALS (amyotrophic lateral sclerosis) treatment compiled patient outcomes showing that lithium had no clinical effect within the first 12 months, highlighting the potential of patient shared data to accelerate clinical findings. Evidence about social media's impact on health knowledge, behavior, and outcomes shows these tools can be effective in meeting individual and population health needs.

Telehealth

Telemedicine is broadly defined as the use of technologies to remotely diagnose, monitor, and treat patients. Telemedicine fits under the larger umbrella of telehealth services, which entails the application of technologies to help patients manage their own illnesses through improved self-care and access to education and support systems. Examples of telehealth interventions that have shown benefit in mortality and cost-savings include home telemonitoring programs for congestive heart failure, remote intensive care unit monitoring, and home health monitoring for veterans. Additionally, telehealth programs have been shown to improve medication adherence and access to specialty providers. A telehealth educational platform and interactive care plan for people with diabetes uses a voice-enabled scale and diabetic foot scanner.

Digital Therapeutics

Digital therapeutics are evidence-based digital health tools, often Food and Drug Administration approved, which integrate the above technologies in order to treat or reverse disease conditions. They are comprehensive treatment programs that may be prescribed by a clinician to replace or augment traditional treatments. Some digital therapeutic programs for diabetes and weight loss are now covered by insurance plans. Digital therapeutics can collect a high volume of user data from a variety of sources, ranging from traditional clinical biomarkers to physiologic sensors and social patterns. These data sets allow for big data analytics during active treatment periods, easy access to longitudinal data patterns, insight into the effectiveness of specific lifestyle medicine program variations, and opportunities to provide education. Most digital therapeutics provide some form of patient education. For example, a randomized control trial demonstrated a 12-week remote digital care program improved low back pain by providing sensor-guided exercise therapy, education, cognitive behavioral therapy, behavioral coaching and tracking. Other programs providing patient education have shown benefit in improving sleep, diabetes and other chronic disease management.

Emerging Technologies

Virtual and Augmented Reality

Virtual reality (VR) is an artificial, computer-generated simulation of a real-life environment, usually requiring users to wear a headset for an immersive experience. Augmented reality (AR) is a technology that layers computer-generated enhancements atop an existing reality. AR is built into applications on mobile devices to add digital components into the real world. This technology allows patients to implement new behaviors and skills through experiential learning. A lifestyle medicine application is the augmented reality game called Pokemon Go (developed by Niantic, Inc) that was developed for iOS and Android devices. The application was adopted by 40 million users worldwide and had 500 million downloads. A study showed a 34.8% relative increase in step counts, while the number of participants achieving a goal of 10 000 steps per day increased from 15.3% to 27.5%. A recent randomized review presented another augmented reality example in which a tablet application helped participants more accurately measure standard serving sizes compared with those who received information only. Finally, a 2017 systematic review and meta-analysis of 28 studies showed that virtual reality games had positive effects on balance and fear of falling in community-dwelling older adults.

Big Data and Machine Learning

The technologies described in the preceding sections will generate massive amounts of data, requiring advanced analytics to make the data meaningful and actionable. Artificial intelligence-the ability for machines to mimic facets of human cognition-is already being applied to other fields of medicine, such as making diagnoses in radiology and pathology. The branch of artificial intelligence that likely holds the most short-term relevance for lifestyle medicine is that of machine learning (ML). ML is an analytical method that allows a computer to be trained on massive quantities of data to make decisions about other data. ML can identify certain patterns of physiological or behavioral data, sometimes referred to as digital biomarkers, which can be used to predict the likelihood of future clinical outcomes. Such "predictive analytics" have potential to augment digital lifestyle medicine, as they could be embedded in behavioral feedback loops and population medicine strategies. For example, a digital therapeutic could capture patient text messaging patterns to assess the need for mental health intervention or monitor arm movements to determine abnormal eating patterns.

Physician's Role

The 2003 Health Information National Trends Survey found that nearly half of 6369 surveyed adults searched online first for information on cancer compared to only 11% who sought a physician's counsel first. Information available on the internet has helped inform and empower patients, shifting the patient-physician dynamic in the process. Despite the ease of access to information, there remains a lack of standards and a broad spectrum of quality and rigor. Physicians can play a major role in directing patients toward appropriate and substantiated educational materials and facilitating the uptake of digital health technologies in their patient populations. For example, physicians can communicate electronically with patients through the electronic medical record, which has been shown to increase patient satisfaction, promote adherence to preventative and treatment recommendations, improve clinical outcomes, and lower medical costs. However, physicians themselves need better ability to assess the validity and utility of digital health products, and recent proposals such as a digital health scorecard utilizing an evaluation framework with technical, clinical, usability, and cost domains may increase clinician confidence.

Conclusion

A growing body of evidence supports the use of digital health technology for improving patient education and implementation of skills and behaviors integral to lifestyle medicine. Despite digital health technology development outpacing its research, there is sufficient evidence to support the use of many current technologies in clinical practice. Digital health tools will continue to grow in their ability to cost-effectively monitor and encourage healthy behaviors at scale, and better methods of evaluation will likely increase clinician confidence in their use.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval
Not applicable, because this article does not contain any studies with human or animal subjects.

Informed Consent
Not applicable, because this article does not contain any studies with human or animal subjects.

Trial Registration
Not applicable, because this article does not contain any clinical trials.

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Utilizing Digital Health Technologies for Patient Education in Lifestyle Medicine - Anne Kuwabara, Sharlene Su, Jeffrey Krauss, 2020

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Technology has redefined the way patients and providers communicate and obtain health information. The realm of digital health encompasses a diverse set of technologies, including mobile health, health information technology, wearable devices, telehealth and telemedicine, and personalized medicine. These technologies have begun to improve care delivery without the traditional constraints of distance, location, and time.

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Health Literacy and Health Initiatives

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Perspectives from The Economist Intelligence Unit (EIU)

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Health literacy around the world: policy approaches to wellbeing through knowledge and empowerment

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Health literacy improves lives and reduces health inequities.

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Healthcare Organizations Approaches to Engagement

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Involving Patients in Efforts to Improve Services
Healthcare and Patient Partnership Institute
In some cases, health care providers are forced to engage with patients when something goes wrong. Armando Nahum, an entrepreneur from Atlanta, began asking questions after three members of his family were diagnosed with life-threatening, health care-acquired infections in the space of 10 months. His father recovered, his wife is still living with complications, and his adult son died after developing sepsis from an infection, just as it seemed he would recover from a skydiving accident.

For Nahum, these incidents brought the deficits of the health system into sharp relief, including lack of transparency (the hospital where his son was treated did not disclose he'd twice contracted MRSA and listed the cause of death as complications of a skydiving accident rather than complications of a drug-resistant infection) and the burden placed on families to act as intermediaries and coordinate care, often without sufficient information. Wanting to do something in his son's honor, Nahum and his wife, Victoria, founded the Safe Care Campaign to educate other families about the risks of infections and empower them to ask their providers about their infection-control practices.

In 2011, Nahum was invited to take part in Partnership for Patients, an initiative led by the Center for Medicare and Medicaid Innovation that since 2010 has involved nearly all U.S. hospitals in efforts to reduce adverse drug events, infections, and other health care-acquired conditions. In 2014, Nahum and his wife together with two patient safety advocates, Marty Hatlie, J.D., and Tim McDonald, M.D., J.D., launched the Healthcare and Patient Partnership Institute to offer hospitals technical assistance and advice on how to effectively partner with patients, starting with the creation of robust patient and family advisory councils focused on quality and safety.

In one such partnership in 2014, Nahum worked with clinicians at MedStar Health, which runs 10 hospitals in Washington, D.C., and Maryland, to promote early identification and treatment of sepsis. Every year, some 1.7 million Americans develop sepsis, an overactive and toxic response to an infection, and 270,000 die; timely treatment is key to recovery.

Nahum attended monthly meetings with clinical leaders, reviewing data on health care processes and outcomes. In one, Nahum questioned why ED patients sometimes wait hours to be screened for sepsis. He recommended changing the triage process to include an initial sepsis screening question, which generated concern from some clinicians that it would make the triage process too long. "I looked at them and said, 'Really? Then tell me how much my son is worth,'" Nahum says. Today, every MedStar ED screens for sepsis during the triage process.

Nahum also helped break a logjam among MedStar clinicians who were debating how to use lab values and vital signs to make a sepsis diagnosis. "There's no gold standard for doing so," says Meena Seshamani, M.D., Ph.D., vice president for clinical care transformation at MedStar. "Armando's voice created a sense of urgency and encouraged the group to try making a change and evaluating its impact to make headway toward saving lives."

Today, MedStar has patient and family advisory councils focused on quality and safety at all 10 of its hospitals, modeled on the approach that Nahum recommends: including patients who represent the community the hospital serves in terms of race, ethnicity, gender identity, and socioeconomic status; including equal numbers of patients and staff, so patients won't be intimidated; and creating a mechanism for reporting patients' recommendations to hospital boards, for example by having a board member sit in on council meetings. To recruit patients, Nahum advises hospitals to go through their grievance databases. "I guarantee you that they will come and serve in your council," he says. "Families want to help if you give them a chance."

Nahum's organization encourages hospitals to partner with patients on two types of projects: their own quality improvement activities and ones suggested by community council members. Across the country, the more than 300 quality and safety-focused patient and family councils have been involved in a wide range of activities, including: holding simulation exercises to help clinicians understand patients' perspectives, participating in root cause analyses of adverse safety events, offering clinicians advice for broaching difficult conversations with patients, and designing programs to engage patients when there are clinical huddles or bedside shift changes.

An analysis of programs at 266 hospitals published by Vizient, a network that includes nonprofit hospitals and academic medical centers, found that those that had deeper levels of engagement with patients and families on issues related to quality and safety - assessed through qualitative interviews with patients and staff as well as quantitative measures of safety practices and ways in which patients were involved - had lower rates of unplanned hospital readmissions and fewer patient falls leading to injuries.

Engaging Patients in Their Health and Communities
Asian Health Services
As a condition of their funding, FQHCs must have patients comprise the majority (51%) of their governing boards; qualitative research has found most FQHC boards focus on finances and staffing and that patients tend to be recruited for their professional skills. Some FQHCs have also established patient advisory councils, which tend to get more involved in shaping services and may be more representative of their communities than governing boards.

Asian Health Services, an FQHC in the San Francisco Bay Area, serves 50,000 patients, many of whom immigrated from other countries. To understand their distinct needs and encourage engagement, leaders established seven Patient Leadership Councils, representing patients whose first language is Cantonese, Khmer, Korean, Mandarin, Tagalog, or Vietnamese. Council members receive training in health topics such as diabetes, mental health, and the importance of having health insurance, and are then encouraged to educate their broader communities as community ambassadors.

Asian Health Services staff have also partnered with patients to create healthier neighborhoods and workplaces. "Part of our work has been teaching our patients to assert their voices in their own languages. In this way, they can feel empowered to shape policies that affect them," says Julia Liou, M.P.H., chief deputy of administration and development.

In 2004, one of the health center's community health workers reported that nearly 100 Vietnamese nail salon workers were reporting health issues like dermatitis and respiratory problems. At the same time, many Vietnamese patients who were part of the salon workforce were asking their clinicians whether it was safe to work in nail salons. Asian Health Services staff found independent federal oversight over nail salon products lacking. After reaching out to other community-based groups in the region and bringing patients and other nail salon workers in other cities together, they realized the scope of the problem was far wider. "Everyone was experiencing the same health issues. We realized that this was an overlooked epidemic," Liou says.

In 2005, Asian Health Services helped cofound the California Healthy Nail Salon Collaborative. The group, which now includes 20 statewide organizations and professional staff, offers training to patients and other salon workers about workplace health and safety, and builds their capacity to advocate for policy changes, in part by testifying about the effects of toxic chemicals on their health. Initially, it was difficult to convince women to come forward because they worried about jeopardizing their livelihoods. "They said, 'If we tell our story, who will want to come to our salon to get their nails done?'" says Liou. "'This is my livelihood.'" Eventually, some patients and workforce members agreed to testify before the federal and state lawmakers, helping gain support for the 2016 passage of the state's Healthy Nail Salon Recognition Program Act, which incentivizes salons to reduce the use of toxic ingredients, install ventilation systems, and take other health and safety measures.

More recently, Asian Health Services staff have responded to increasing racist attacks on Asians throughout the nation and in the Bay Area amid political and public rhetoric blaming Asians for the pandemic. "Our patients and staff have experienced attacks and assaults, often within close vicinity of our clinic," Liou says. The health center established a victim's support fund and has been providing escorts for staff coming and going from clinic sites. Asian Health Services is also developing culturally tailored therapy and support for victims. "As a trusted community health provider, it has been in our DNA to respond to the needs of not only our patients, but our community as a whole," Liou says.
Stephen and Sandra Sheller 11th Street Family Health Services
Many FQHCs are rooted in communities that lacked primary care services. Asian Health Services grew out of a one-room clinic that opened in San Francisco's Chinatown in 1974; Stephen and Sandra Sheller 11th Street Family Health Service (11th Street) opened in 1998 in response to public housing residents' demands for more accessible care in their North Philadelphia neighborhood.

For this reason, and because the payment model for FHQCs supports larger staffs and more comprehensive services than most primary care practices, the health centers are often able to mount vigorous responses to community-identified needs. Before opening a clinic, 11thStreet's founders partnered with food banks to create an emergency food pantry. It and other health centers can then build on community members' trust to engage them in their health and care.

The health center, which operates in partnership with Family Practice and Counseling Network and now serves 6,000 patients, has had a Community Advisory Committee since its inception. Its members (there are now 15) have shaped services and built relationships with local churches, public housing councils, schools, and nonprofits.

After a 2009-10 survey revealed high rates of trauma among patients linked to exposure to gun violence, discrimination, and adverse childhood experiences including having been placed in foster care, Community Advisory Committee members helped launch a campaign to let people know healing from trauma is possible and encourage them to seek help. 11th Street had already added a wide array of services - from mindfulness classes to yoga and creative arts therapies - in response to feedback from the community that they wanted the health center to focus on wellness, not just treat sickness. Leaders say these classes have helped patients cope with mental health problems and build resiliency; many are more willing to try them than traditional therapy.

During the pandemic, 11th Street has been responding to patients' health and social needs while trying to keep them safe from COVID-19. Since April 2020, they've run a walk-up and drive-up coronavirus testing clinic for anyone, whether or not they have COVID symptoms or a prescription from a physician. Many testing sites only offer curbside testing, which leaves out people who don't own cars, and during the early months of the pandemic most were only testing those with COVID-19 symptoms. But the health center's leaders realized that many members of their community were at particular risk of contracting the coronavirus because they live in crowded homes and work where social distancing is not possible, and they wanted to make testing as easy as possible.

Starting this March, 11th Street began offering walk-up vaccination clinics to any Philadelphia resident who meets the city's eligibility criteria, in addition to proactively reaching out to schedule appointments for older patients and others at high risk. Beforehand, leaders held a Zoom meeting to offer information about the vaccines and answer staff and community members' questions. One staff member asked about the best way to convince patients who may be hesitant to get vaccinated. "I tell them that's not the focus," says Diana Hartley-Kim, M.S.W.,11th Street's operations director. "As one of our panelists noted, you need to let go of the desire to get somebody get vaccinated and instead hear their concerns and just share some education. We need to recognize it's their choice."

LESSONS

As these examples illustrate, involving patients in efforts to increase the safety, effectiveness, and experience of health care draws attention to problems that can deter people from seeking help and points the way toward potential solutions. Successful efforts have emphasized building trust by forging long-term relationships and educating patients on policies that affect them. Many also stressed the importance of two-way communication (e.g., responding to patients' feedback, not just asking for it) and attending to problems that patients themselves prioritize, even if the issues lie outside the four walls of their organization. One systematic review found that the benefits of patient engagement accrue not just to patients but to institutions in the form of greater staff satisfaction and improvements in safety.

It's not incidental that many of the clinics we feature serve marginalized patients, including those with low incomes, immigrants, and survivors of trauma. To engage patients, their leaders have had to create deliberate processes to make care as accessible as possible and acknowledge the root causes of fear and mistrust, including past instances of discrimination. While these clinics aren't typical, their experiences offer lessons for other providers who hope to build more effective partnerships with patients.

Spreading these practices to other institutions may require training for both patients and providers, as well as evidence of the types of leadership and culture that best support collaboration. Having frank conversations about what's not working isn't always comfortable. "Providers must make themselves vulnerable and transparent to patient and family representatives to truly engage them in improvement efforts," says Seshamani of MedStar. Patients may also need encouragement to challenge prevailing practices. "Having community representatives outflanked by staff doesn't work and can lead to them being marginalized," says Debra Ness, president of National Partnership for Women and Families, an advocacy group.

Providers may also need financial or other incentives to partner with patients. Some value-based payment models, including some Medicare and Medicaid accountable care organization contracts, require providers to demonstrate they have consulted with patients and are meeting their expectations. Although there isn't a one-size-fits-all model of patient engagement, best-practice standards could provide guidance about ensuring equitable recruitment, setting clear expectations, and providing accountability. "It matters who is at the table, how the conversations occur, and what expectations are set," says Anjana Sharma, M.D., assistant professor of family and community medicine at the University of California, San Francisco, School of Medicine.

Patients, too, may need to be compensated for their time. In 2020, PHF created the Lived Experience Advisory and Research Network, or LEARN, to pay survivors of gender-based violence for their expertise and time helping design health care services and engagement strategies for people who face a variety of financial, cultural, and logistical barriers in accessing care.

Ultimately, tracking engagement - from which patients are filling prescriptions and getting screenings to more complex patient-reported outcomes measures - will be essential for building the evidence base of what works. Technologies that enable patients to monitor their conditions day to day and easily share that information with providers also may help. "The very fact that there is no standard set of patient engagement measures is, I think, very revealing," says Vivian Lee, M.D., president of health platforms at Verily Life Sciences, a digital health company owned by Alphabet. "Oftentimes, we think about health as something that we as providers manufacture or produce. And that's sometimes true in a hospital operating room or in an emergency room or in an ICU," says Lee. "But we know that the vast majority of health is really determined by the behaviors of individuals and the degree to which health systems can support those individuals in enabling and producing their own health. And so engagement is absolutely essential to that."

Q&A: Lessons from YouTube's Leading Doctor About Engaging People in Their Health

In January, YouTube announced it would be collaborating with physicians and several health care organizations including the American Public Health Association, the Cleveland Clinic, and Mayo Clinic to create high-quality health content for the platform, which reaches 2 billion people monthly. Transforming Care spoke to Garth Graham, M.D., M.P.H., a cardiologist who previously served as U.S. Deputy Assistant Secretary of Health in the Bush and Obama administrations, about the effort. Graham now serves as director and global head of health care and public health partnerships at YouTube.

Transforming Care: When it comes to making medical information accessible, there seems to be a large divide between material that is either really simplified or very arcane and accessible only to experts. What's your vision for how health information should be communicated?

Graham: The way we communicate information to patients, to communities, and even among ourselves as clinicians has lagged behind technology. Long gone are the days of posters and fliers. People get things on their phone and have come to expect information that's relevant to be delivered instantaneously. COVID-19 has shown us we need to be transparent and communicate to the public in ways that people are going to understand and in the places they already are. YouTube is a platform that's very present in people's lives. People turn to it for information on all kinds of things, from yoga, meditation, and health to how to do things around the house.

Transforming Care: Is there something particular about video that makes it an advantageous way to communicate information?

Graham: Video allows you to take complicated information and make it digestible. For instance, it's very hard to explain messenger RNA in just a short brief. And again, a year ago, who would have thought people wanted to know what messenger RNA was? Video helps us break down complex information with visualization and makes it more engaging, digestible, and understandable. We can help people understand when it comes to social distancing, why six feet and not two feet? People want to know the evidence.

Transforming Care: YouTube has partnered with popular YouTube contributors to create health content. How do you go about picking which creators you partner with?

Graham:What we try to do is look for ways to make relevant, scientific information engaging with the help of creators who can engage people and encourage them to care about facts - for instance by bringing the rapper Fat Joe and Dr. Fauci together. Fat Joe has a large audience, with 1.37 million subscribers, and he was able to ask Dr. Fauci questions other people have not: When can I go back to my life and the kinds of activities I find important? He was able to articulate that.

Transforming Care: How much vetting do you do of people who are providing medical advice on YouTube?

Graham: We don't pre-vet any content that is posted to YouTube, but of course we look toward authoritative organizations when it comes to choosing partners to collaborate with. The core of this is science, so what we try to do is use credible scientific partners, whether it be the U.S. Centers for Disease Control and Prevention, the World Health Organization, or the National Institute of Allergy and Infectious Diseases. There are also a lot of clinicians like Kimberly Manning, M.D., a general internist in Atlanta, who are able to break down the science in real terms. So for us, when we select partners we want to make sure that the source is authoritative, scientific, and is able to articulate the evidence. Then, we work with the creators to help them make their content engaging.

Transforming Care: One of the challenges of the pandemic has been that information is evolving. How do you put out good information when it changes so quickly? How do you keep people's trust?

Graham: In medicine, we've never been good at explaining trials and studies, so people don't understand that as science evolves, a study may come out one day and a bigger study may come out another day, and they can be conflicting. One of the things I've learned about people is once they understand a process, they can understand the outcome. They don't just want to know whether the medicine is good: they want to know how many people you tested it on. They want to know what the side effect profiles are - all these things we are now making more transparent with the vaccine process. Early on in the pandemic, as we were getting information from smaller studies, we were passing it on without helping people understand these were initial pieces of information. Now that we want the public to participate in vaccination, their understanding the scientific process that is bringing this to their homes and into their bodies is important. It's a very valid process and one that the public should feel reassured and safe in.

Transforming Care: What might that look like in terms of explaining the process? Is it being more transparent about the limits?

Graham: We need to be transparent, engaging, and informative. We also need to put ourselves in the shoes of the person receiving the information. As a clinician, I'm explaining diagnoses, and I get caught up in the studies that gave me the information. But the person looking at it, listening to me, doesn't care about acronyms that only have meaning to clinicians and researchers or the impact factor of the journal. They want to know what does this mean for me? Put this in the context of my life. By getting this vaccination, it will allow you to visit your grandchildren more if you're a grandparent or it'll allow your community to become more economically vibrant. Fat Joe allows you to contextualize the science in that person's life without saying that's what he doing.

Transforming Care: Do you see a scenario where doctors would be prescribing videos or helping people navigate through and find information?

Graham: I think so. On average, patients may spend two hours or three hours a year with their doctor if they have a chronic condition. There are all those thousands of other hours. I can foresee a day where doctors figure out how to extend their impact. Video may help reinforce what they learned during visits and help them carry on with their lives and make the right decisions. I think we are in a phase where people expect more from our communication.

Publications of Note
Recommendations for Strengthening Medicaid Programs
In a commentary in the Journal of the American Medical Association, Rebekah E. Gee, M.D., M.P.H., former secretary of the Louisiana Department of Health; David Shulkin, M.D., former secretary of Veterans Affairs; and Iyah Romm, CEO of Cityblock Health, outline five principles for strengthening state Medicaid programs, which now cover more than 75 million Americans. Their recommendations take aim at high churn rates that create disruptions in care for patients and discourage providers from entering value-based payment contracts. They also call for new infrastructure to help states manage operations, compare performance, and engage in innovation, including putting greater emphasis on the nonmedical determinants of health. Rebekah E. Gee, David Shulkin, and Iyah Romm, " A Blueprint for Comprehensive Medicaid Reform," Journal of the American Medical Association 325, no. 7 (Feb. 2021):619-20.
Adults with Functional Limitations and American Indian/Alaska Natives Among Groups at Highest Risk for Deaths of Despair
Researchers who followed respondents to the 2008 American Community Survey through 2015 found the overall mortality rate for suicides, poisonings, and chronic liver disease was 41.3 deaths per 100,000 person-years. Groups at highest risk for such deaths included adults with functional disabilities (102.8 deaths per 100,000 person-years), American Indian/Alaska Native people (102.6), working-age adults who are not employed (77.3), separated or divorced people (76.5), people with net income losses (70.6), and people with military service (67.0). Mark Olfson et al., " Deaths of Despair: Adults at High Risk for Death by Suicide, Poisoning, or Chronic Liver Disease in the U.S.," Health Affairs 40, no. 3 (March 2021):505-12.
Racial Disparities in Excess Deaths Varied Substantially Among States
Researchers found racial and ethnic disparities in excess all-cause mortality rates varied substantially among states in the early part of the pandemic. Analyzing data from April 2020, they found nationwide adjusted excess all-cause mortality was 6.8 per 100,000 for Blacks, 4.3 for Hispanics, 2.7 for Asians, and 1.5 for whites. Michigan and Louisiana had markedly different rates of Black mortality as did Pennsylvania compared with Rhode Island. They found Wisconsin experienced no significant excess mortality among whites but had significant Black excess mortality. More research is needed to understand the drivers of geographic variation to develop policy responses, the authors say. Maria Polyakova et al., " Racial Disparities in Excess All-Cause Mortality During the Early COVID-19 Pandemic Varied Substantially Across States," Health Affairs 40, no. 2 (February 2021):307-16.
Racial Disparities in Heart Attack Outcomes Linked to Nurse Staffing Levels
Researchers studying disparities among patients who had a heart attack while hospitalized found the odds of survival were lower for Black patients than white patients (odds ratio of 0.70). They also found that each additional patient per nurse lowered the odds of survival for Black patients (odds ratio of 0.92) more than for white patients (odds ratio of 0.97). The authors say the benefits of being admitted to hospitals with better staffing may be more pronounced for Black patients. The study relied on data for 14,132 patients from 75 hospitals in four states. Carthon Brooks et al., " Better Nurse Staffing Is Associated with Survival for Black Patients and Diminishes Racial Disparities in Survival After In-Hospital Cardiac Arrests," Medical Care 59, no. 2 (February 2021):169-76.
An Alternate Approach to Defining Safety-Net Status
In a commentary in the New England Journal of Medicine, the authors suggest a new method of defining safety-net institutions. Rather than using a binary approach that depends heavily on metrics such as uncompensated care, they recommend creating a composite, sliding-scale measure. The scale could include the percentage of the patient population covered by Medicaid, a geographic measure of socioeconomic disadvantage, a measure of the proportion of services provided to racial and ethnic minorities, and a measure of the institution's community benefit spending and provision of essential but unprofitable services, among other variables. Creating such a scale would also allow for a more equitable distribution of funding and enable more accurate peer comparisons in pay-for-performance and alternative payments models, the authors say. Paul Chatterjee, Benjamin D. Sommers, and Karen E. Joynt Maddox, " Essential but Undefined - Reimagining How Policymakers Identify Safety-Net Hospitals," New England Journal of Medicine 383, no. 27 (Dec. 2020):2593-95.
Adjusting Lab Values for Kidney Disease Function May Reduce Outcomes Disparities for Black Patients
Researchers simulated the effect of eliminating a race-multiplier used to assess kidney function in patients with chronic kidney disease (CKD). They found eliminating the adjustment of estimated glomerular filtration rate equations, which assign higher values to Black patients, would reclassify a third of Black patients as having a later and more severe stage of CKD. With this change, roughly 3 percent of patients would newly qualify for kidney transplant prioritization. The study was based on an analysis of medical records at Partners HealthCare System. Salman Ahmed et al., " Examining the Potential Impact of Race Multiplier Utilization in Estimated Glomerular Filtration Rate Calculation on African-American Care Outcomes," Journal of General Internal Medicine 36, no. 2 (February 2021):464-71.
Capacity for Electronic Communications Plays a Key Role in PCMH Savings
Researchers assessing the relative contributions of different features of the patient-centered medical home (PCMH) model to savings found that, overall, the model was associated with a greater than 8 percent reduction in total health care expenditures. The savings came from significant reductions in emergency department (ED) use and outpatient care, as well as lab and imaging studies. The authors segmented practices into three groups: those with a relatively low level of PCMH implementation and two clusters with more extensive adoption of PCMH capabilities. They found that while all three groups achieved reductions in outpatient care, the reduction in ED utilization was driven by practices that had enhanced their electronic communications, potentially increasing access for patients. The authors say more research is needed to assess the impact of variation in PCMH capabilities on health outcomes. Philip Saynisch et al., " Evaluating Approaches to Patient-centered Medical Home Implementation," Medical Care 59, no. 3 (March 2021):195-201.
Analysis of Health System-Sponsored Housing Program Quantifies Societal Benefit
Researchers evaluating the benefits of Bon Secours Hospital's Housing for Health program, an affordable housing program in Baltimore, Md., found the program generated between $1.30 and $1.92 of social return in the community for every dollar in yearly operating costs. The analysis took a more expansive view of benefit, going beyond traditional return-on-investment or cost-effectiveness analyses by quantifying returns to residents and the city, as well as the health system. Bon Secours currently has 801 units of affordable housing across 12 properties in West Baltimore. Emmanuel Fulgence Drabo et al., " A Social-Return-on-Investment Analysis of Bon Secours Hospital's 'Housing for Health' Affordable Housing Program," Health Affairs 40, no. 3 (March 2021):513-20.
Recommendations for Improving Medicare's Value-Based Payment Programs
In a commentary in the Journal of the American Medical Association, the authors review the problems and successes of Medicare's value-based payment programs and offer suggestions for improving them to ensure they benefit patients and achieve savings while reducing administrative complexity for practices. They note successful programs use population-based models that assign beneficiaries, often prospectively, to clinician groups, using global spending targets and sharing the risk of savings and losses. Kenton J. Johnston, Jason M. Hockenberry, and Karen E. Joynt Maddox, " Building a Better Clinician Value-Based Payment Program in Medicare," Journal of the American Medical Association 325, no. 2 (Jan. 2021):129-30.
Geographic Disparities in Mortality Rates for Dual Eligibles
A study contrasting mortality rates among people who were dually eligible for Medicare and Medicaid, known as dual eligibles, in rural and urban communities found all-cause mortality rates for both groups declined between 2004 and 2017, but the declines were more pronounced among urban beneficiaries. In rural communities, the mortality rate among dual eligibles declined from 96.6 to 92.7 per 1,000, a 4 percent decline. Among urban beneficiaries the mortality rate dropped from 86.9 to 72.8 per 1,000, a decline of 16.2 percent. The researchers found rural mortality rates were highest in East North Central states and increased modestly in West North Central states during the study period. Emefah Loccoh et al., " Rural-Urban Disparities in All-Cause Mortality Among Low-Income Medicare Beneficiaries, 2004-17," Health Affairs 40, no. 2 (February 2021):289-96.
Joint Replacement Program Reduces Postacute Care Use, Readmissions But Not Disparities Between Medicare Beneficiaries and Dual Eligibles
Medicare's Comprehensive Care for Joint Replacement model is a mandatory bundled payment program for hospitals in randomly selected metropolitan statistical areas. Researchers studied its effects on three groups of patients who underwent hip or knee surgery - Medicare beneficiaries, those who were dually eligible for Medicare and Medicaid, and Medicare beneficiaries who had partial Medicaid benefits - to assess whether the program reduced persistent disparities between dual eligible and Medicare-only patients. They found that the program was associated with reduced stays at skilled nursing facilities and fewer unplanned hospital readmissions among all three groups, but it did not reduce disparities between them. Yue Li, Meiling Ying, Xueya Cai, and Caroline P. Thirukumaran, " Association of Mandatory Bundled Payments for Joint Replacement with Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients," Medical Care 59, no. 2 (February 2021): 101-10.
Telehealth Visits with CHWs Lead to Improved Diabetes Outcomes for Latinx Patients
A study of TIME, an intervention that relies on community health workers (CHWs) to improve glycemic control among Latinx patients with type 2 diabetes, found that compared with a control group, participants experienced significant decreases of hemoglobin A1c, saw improvements in blood pressure levels and had greater adherence to nutrition guidelines within six months. Weight changes were not significant between groups. As part of TIME, which stands for Telehealth-supported, Integrated care with CHWs, and MEdication-access program, CHWs communicated with patients via videoconferencing and helped them navigate the health care system. They also identified barriers to care, including accessing medication, that may have gone unrecognized otherwise. The authors recommend larger trials to determine the scalability and sustainability of the intervention. Elizabeth M. Vaughan et al., " A Telehealth supported, Integrated care with CHWs, and MEdication-access (TIME) Program for Diabetes Improves HbA1c: a Randomized Clinical Trial," Journal of General Internal Medicine 36, no. 2 (February 2021):455-63.

Editorial Advisory Board
Special thanks to Editorial Advisory Board member Clemens Hong for his help with this issue.
Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., director, Care Transitions Program

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., CEO of Massachusetts General Physician Organization and professor of medicine at Harvard Medical School

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., chair and professor, Department of Family and Community Medicine at The Ohio State University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

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Beyond the Survey: Engaging Patients and Communities as Partners

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Healthcare and Patient Partnership Institute In some cases, health care providers are forced to engage with patients when something goes wrong. Armando Nahum, an entrepreneur from Atlanta, began asking questions after three members of his family were diagnosed with life-threatening, health care-acquired infections in the space of 10 months.

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Health Literacy and Health Initiatives

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Centers for Disease Control and Prevention

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Why Does CDC Have a Health Literacy Action Plan?
Public health and safety rest in large part on people's access to information they can use to protect and promote their health. CDC created a health literacy plan to improve how we develop and share health information and provide public health services to different audiences.
We need this plan because limited health literacy is a national public health issue that affects almost 9 out of 10 adults. With the resources and staff at hand, we can take incremental, feasible steps to make our health information and services accessible and understandable by the different audiences we serve.

CDC Action Plan to Improve Health Literacy

The CDC Action Plan to Improve Health Literacy is adapted from the National Action Plan to Improve Health Literacy (National Action Plan) released by the U.S. Department of Health and Human Services. The National Action Plan provides a blueprint for efforts to improve health literacy across all sectors involved in health information and services. The CDC Office of Communications uses the action plan to identify and track the most important actions the agency can take to improve health literacy.

The plan provides a framework that guides our approach to using clear communication and health literacy methods. The plan is organized around three goals.
Goal 1: Develop and Share Health and Safety Information That Is Accurate, Accessible, and Actionable
In today's communication-rich environment, people look to many places for information about their health and safety. However, much of the publicly available health and safety information is too technical, too complex, and often too vague about recommended actions. CDC has a unique opportunity to serve as an accessible source of accurate and actionable public health and safety information to help the public as they try to:

Prevent harm or disease

Understand diagnoses

Decide on treatments

Evaluate risks to their health

CDC is implementing 7 strategies for this goal.
Goal 2: Integrate Clear Communication and Health Literacy into Public Health Planning, Funding, Policy Development, Research, and Evaluation
Clear communication is essential at CDC because we lead the public health system in the United States and are a key contributor to the global public health infrastructure. CDC influences many aspects of public health practice:

Planning

Data collection

Analysis and reporting

Disease outbreak investigations

Use and evaluation of interventions to determine effectiveness

Public health policy making

We also are a key source of much of the public health information distributed by other organizations. CDC's policies and procedures affect not only our own practices, but also the practices of other organizations such as public health departments, schools, and employers. Through our own actions in funding, policy development, research, and evaluation, we can use existing resources to set priorities for and address limited health literacy. Through our interactions with grantees, funded partners, and key decision makers, we can raise awareness of limited health literacy and create opportunities to address it.

CDC is implementing 5 strategies for this goal.
Goal 3: Incorporate Accurate, Standards-Based, and Developmentally Appropriate Health and Science Information and Curricula in Educational Settings from Preschool through University Levels
Public health has a special responsibility to make sure children and adolescents have the health literacy skills-including math and science literacy-they need to prevent early-onset chronic health problems and protect themselves from infectious diseases, violence, and injury. Children need health literacy skills early in life, and helping them build these skills is part of caring for and educating them. CDC can promote and encourage the use of its own evidence-based resources for health education and collaborate with other organizations to address gaps and develop new tools for health and education professionals.

CDC is implementing 2 strategies for this goal.

CDC's Progress

Using plain language is a health literacy strategy. Plain language can help address the needs of those with limited literacy skills, as well as those with limited health literacy skills. The Plain Writing Act (The Act) requires federal agencies to "[w]rite annual compliance reports and post these reports on its plain language web page." You can learn about CDC's progress in putting the Act into action by reading our annual Plain Writing Act Compliance Report [PDF - 1 MB] .​

How Can the National Action Plan and CDC's Action Plan Help My Organization?

You can use both plans as a framework for developing your own organizational plan or for providing a justification for your efforts to address health literacy. Additionally, you can use these plans to help guide your strategic actions by following the steps below.

Review: Examine your organization's priorities and programs and ask how attention to health literacy could improve the organization's services and outcomes.

Choose: Identify the goals and strategies in the plans that are most relevant to your programs.

Try: Plan and implement strategies.

Evaluate: Assess the effectiveness of chosen strategies.

In addition, the Institute of Medicine Roundtable on Health Literacy published the Ten Attributes of Health Literate Health Care Organizations. This report can help you launch your organization's journey to become aware of health literacy issues and address them for the people you serve.

Find out how to develop your own organizational plan.

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Use CDC's Action Plan to Improve Health Literacy and the National Action Plan as frameworks for your organization's plan or to justify why your organization needs a health literacy plan. These plans can help guide your goals and strategies to engage professionals, policymakers, communities, individuals, families, and other organizations and stakeholders in efforts to improve health literacy.

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Abstract

There is a growing body of research focused on the use of social media and Internet technologies for health education and information sharing. The authors reviewed literature on this topic, with a specific focus on the benefits and concerns associated with using online social technologies as health education and communication tools. Studies suggest that social media technologies have the potential to safely and effectively deliver health education, if privacy concerns are addressed. Utility of social media-based health education and communication will improve as technology developers and public health officials determine ways to improve information accuracy and address privacy concerns.

Keywords: Internet, health education, health communication, social media technologies, privacy

INTRODUCTION

The Internet has revolutionized the way society shares and receives information ( Larreamendy-Joerns and Leinhardt 2006; Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord 2000). Social media technologies, such as mobile texting, blogging, social networking web sites, and instant messaging, have been an instrumental contributing factor because of their ability to facilitate rapid social and educational communication ( Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord 2000). While people use online social networking technologies to talk about diverse topics such as entertainment, current events, and personal opinions, health information is one of the most actively discussed topics on these virtual communication networks ( Fox 2011; Holme, Edling, and Liljeros 2004; Kontos et al. 2010; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010; Young, Dutta, and Dommety 2009; Young and Rice 2011; Young and Jaganath In press, In Press). Social networking technologies can provide rapid and scalable access to health information. However, the platforms may also bring potential concerns, such as the ability for public access to inaccurate and/or confidential health information ( Impicciatore et al. 1997; Pequegnat et al. 2007; Scullard, Peacock, and Davies 2010; Williams 2010).

This paper will investigate whether social networking can function as an effective online health education and communication tool by reviewing: 1) the general effectiveness of online health education and communication; 2) the effectiveness of social networking as a means for online health education and communication; and 3) the health privacy concerns associated with online social technologies.

ONLINE HEALTH EDUCATION AND COMMUNICATION

Over the past two decades, the Internet has become a top source of educational information, both inside and outside of school settings ( Allen and Seaman 2008; Eynon and Malmberg 2011; Harasim 2000; Kassop 2003; Bell 2002; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). While traditional education has been successful because it is interactive, ( Johnson, Aragon, and Shaik 2000; McDonald 2002) and can be tailored to fit the needs of individual students, ( Johnson, Aragon, and Shaik 2000) researchers argue that online education is able to improve upon traditional education because it is more convenient, has the capacity to reach a wider population, and allows students to learn at their own pace ( Kassop 2003; Larreamendy-Joerns and Leinhardt 2006; Morahan-Martin 2004). Part of examining the rapidly growing field of online education is realizing that it is ever changing and constantly adapting to meet the needs and demands of society ( Allen and Seaman 2008; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). Online education has been able to constantly adapt to changing educational needs, by going from hosting a class syllabus online to offering lectures and multi-media instruction ( Harasim 2000; Kontos et al. 2010; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000).

The use of the Internet as an educational tool has extended to many disciplines, with a strong focus on health education and health communication ( Fox 2011; Jones and Biddlecom 2011; Webb et al. 2010; White and Dorman 2001). In 2011, the Pew Internet Project estimated that out of all of the adults in the United States who use the internet, 80% have utilized the Internet to search for health information ( Fox 2011). The use of the Internet as a health education tool has also entered the realm of patient physician interaction. Physicians have reported that many patients are requesting procedures, medications, or screening tests based on information they have found on the Internet ( Dilliway and Maudsley 2008; Ferguson 2000; Hesse et al. 2005). Taken together, research supports that the Internet has become a primary source of information for patients and general health consumers ( Dilliway and Maudsley 2008; Fox 2011; White and Dorman 2001).

While these studies demonstrate the Internet's use as a source for health information, its effectiveness depends on the quality of information provided ( Dilliway and Maudsley 2008; Maloney, Ilic, and Green 2005; Young 2011). Many physicians and health care professionals worry that health information on the internet can often be misleading or false because content on web pages is not subject to editorial review ( Hesse et al. 2005; Rice and Katz 2000; White and Dorman 2001). Additionally, many health information web sites are created by companies promoting their product and therefore provide biased information ( Rice and Katz 2000). Internet award rating systems have been used to distinguish credible from non-credible web sites; however, these systems are often flawed ( Eastin 2001). The inaccuracy of Internet health information therefore remains a problem to both patients and health providers.

The use of the Internet as a source of health information has led to numerous investigations regarding the quality and accuracy of information available on the web. For example, Scullard and colleagues (2010) assessed the reliability and accuracy of health information found through searches on Google. They examined five common pediatric questions and evaluated the accuracy of the first 100 results generated on the Google search engine. Out of the 500 sites they evaluated, only 39% of the sites provided accurate information ( Scullard, Peacock, and Davies 2010). They found that the web sites created by the government were accurate whereas web sites created by news organizations only provided correct advice 55% of the time ( Scullard, Peacock, and Davies 2010). This demonstrates that the source of information is very important in determining accuracy of health information.

SOCIAL MEDIA TECHNOLOGIES AND THE COMMUNICATION OF HEALTH INFORMATION

Populations ranging from high school students to retired senior citizens use social networking technologies as a means to further absorb information and form learning communities ( Baird and Fisher 2005; Subrahmanyam et al. 2008). The benefits of social networking range from being able to connect people from all around the world, raise awareness of grassroots social justice movements, and informally educate people about current events ( Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Volery and Lord 2000). With social media technologies' instant accessibility, it offers the largest realm of information to the largest population for a relatively low cost ( Lim et al. 2008; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010). Taken together, research suggests that social media technologies are prevalent in daily life and therefore have the ability to be incorporated into educational delivery ( Holme, Edling, and Liljeros 2004; Lim et al. 2008; Scanfeld, Scanfeld, and Larson 2010).

Social media technologies are slowly being recognized as an effective educational tool inside the classroom ( Harasim 2000; Volery and Lord 2000; Allen and Seaman 2008). For example, students have begun adopting social networking to connect to other students to discuss topics, ask questions, and receive instant feedback at any time of the day ( Gross and Acquisti 2005; Subrahmanyam et al. 2008).

SOCIAL NETWORKING AS SOURCES FOR HEALTH DELIVERY AND SUPPORT GROUPS

Researchers are currently examining whether social media technologies can be an effective method for scaling health information delivery. Chou et al., (2009) found that younger populations might be a reasonable target population for social media health communication because they use social media at greater rates than older populations and most do not have access to a regular health care provider ( Chou et al. 2009). Chou et al. (2009) suggest that using social media to communicate health education could help narrow the digital divide and health disparities because of their ability to reach a wider, demographically diverse audience.

Public health efforts, such as the Centers for Disease Control and Prevention (CDC), as well as the Food and Drug Administration (FDA), have also begun to use social media outreach methods ( Currie 2009). Currie (2009) reports that Twitter and Facebook are being used to deliver health information because they have a larger and more diverse reach than traditional news sources, such as radio and television ( Currie 2009). Moreover, research suggests that social networking technologies are not only useful for providing health information, but that health information communicated via these technologies can affect actual health decisions and behaviors ( Redmond et al. 2010).

PRIVACY, SOCIAL NETWORKING, AND HEALTH INFORMATION

While the examples provided primarily focus on the benefits of using online and social media technologies for health information education and sharing, use of these technologies is accompanied by potential privacy and health information security issues ( Williams 2010; Young 2012). Social media technologies pose a risk to users as strangers can access the information that they provide ( Williams 2010). The lack of basic security measures surrounding social media sites, such as secure sockets layer (SSL) login, can allow third-party hackers to access "private" social media data ( Gross and Acquisti 2005). Possible risks may include identity theft, ( Gross and Acquisti 2005; Milne, Rohm, and Bahl 2004; Belanger, Hiller, and Smith 2002; Solove 2003) online and physical stalking, ( Gross and Acquisti 2005; Pittaro 2007) embarrassment, price discrimination, and blackmailing ( Gross and Acquisti 2005).

In a study focused on general privacy risks associated with social networking, Gross and Acquiti (2005) analyzed 4,000 Facebook profiles in the Carnegie Mellon network and found they were able to access students' social security numbers using only basic profile information, such as their hometown and date of birth ( Gross and Acquisti 2005). While this study did not attempt to uncover health information, it suggests a potential to also use social networking to gain access to personal health information. This is particularly important to note as research suggests that the majority of people on social media sites reveal accurate personal information, making them susceptible to harassment, identity theft, and other dangerous situations ( Gross and Acquisti 2005).

Researchers and engineers are gradually providing guidelines on how to reduce privacy-related risks online ( Young 2012). Recommended steps include increasing personal security settings, avoiding use of public computers, using multiple email addresses, and only accessing health information within private and knowingly protected locations; ( Pequegnat et al. 2007) therefore it is the responsibility of the user to maintain a private and safe online environment. However, as researchers and engineers become increasingly aware of potential privacy issues, more effective and safer solutions will become available.

CONCLUSION

Research suggests that social media technologies can be used to effectively disseminate general health information. However, privacy issues need to be taken into account. Based on this review of relevant research, it can be theorized that once information quality has been verified and privacy problems have been addressed, social networks can be used as a tool to provide online general health education. While online social networks have created a uniquely accessible platform for the dissemination of information, they have also blurred the line between public and private information. Expansion of online health platforms will depend upon engineers' and policy makers' abilities to balance information accessibility with public and personal safety.

Acknowledgments

The authors gratefully acknowledge the support of the National Institute of Mental Health (NIMH) (Grant ID Nimh k01 MH090884), UCLA CHIPTS, and the UCLA AIDS Institute.

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Online Technologies for Health Information and Education: A literature review

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There is a growing body of research focused on the use of social media and Internet technologies for health education and information sharing. The authors reviewed literature on this topic, with a specific focus on the benefits and concerns associated ...