Media and Social Media in Public Health Messages: A Systematic Review

Media and Social Media in Public Health Messages: A Systematic Review

K. Bruce Newbold Director, McMaster Institute of Environment & Health (MIEH) Sarah Campos McMaster Institute of Environment & Health (MIEH)

McMaster Institute of Environment & Health 1280 Main St. West Hamilton, ON www.mcmaster.ca/mieh

December 2011

Media and Social Media in Public Health Messages: A Systematic Review EXECUTIVE SUMMARY ........................................................................................................... 4 1. Background and Introduction............................................................................................. 5 a. Summary of Evidence on Traditional Media ........................................................................... 5 b. Emerging Trends: Social Media in Healthcare ........................................................................ 6 2. Objectives ......................................................................................................................... 7 3. Methods ............................................................................................................................ 8 a. Traditional Media Review ....................................................................................................... 8 Inclusion Criteria ..................................................................................................................... 8 Search Strategy ....................................................................................................................... 8 b. Social Media Review ............................................................................................................... 9 Search Strategy ....................................................................................................................... 9 Inclusion Criteria ..................................................................................................................... 9 4. Results............................................................................................................................. 10 a. Traditional Media Review ..................................................................................................... 10 Sources of Information .......................................................................................................... 11 Reach of Media Campaigns .................................................................................................. 12 Recall of Health Messages .................................................................................................... 12 Effect on Health Behaviours .................................................................................................. 12 Effect on Attitudes ................................................................................................................ 12 Correlational and Observational Studies .............................................................................. 13 Most Effective Media ............................................................................................................ 13 Internet Campaigns ............................................................................................................... 13 b. Social Media Review ............................................................................................................. 14 Adoption and Usage Patterns of Social Media by Health Consumers .................................. 14 Adoption and Usage of Social Media by Public Health Authorities ...................................... 14 Efficacy of Social Media Campaigns ..................................................................................... 15 Intervention-based Studies ................................................................................................... 15 Observational and Correlational Studies .............................................................................. 16 5. Discussion ....................................................................................................................... 18 6. Conclusion ....................................................................................................................... 20 7. Recommendations ........................................................................................................... 20 8. References....................................................................................................................... 24

Appendices Appendix 1: Overview of Social Media ................................................................................. 33 Facebook............................................................................................................................. 33 YouTube .................................................................................................................................... 34 Twitter ....................................................................................................................................... 34 Blogger ...................................................................................................................................... 35 Appendix 2: Social Media Use for Health Information in North America ............................... 37 2

Appendix 3: Summary of Reviewed Public Health Interventions ........................................... 39 1. Evaluation of the Centre for Disease Control’s H1N1 Social Media Campaign .................... 39 2. Experience of social media campaigns promoting blood donation in the United States .... 39 3. Development of a text messaging campaign promoting poison prevention ....................... 40 4. Social media campaigns promoting sexual health................................................................ 40 5. The VERB campaign .............................................................................................................. 40 Appendix 4: Environmental Scan of Social Media in Ontario Public Health Practice .............. 42 Introduction .............................................................................................................................. 42 Best Practice Guidelines............................................................................................................ 43 Methods .................................................................................................................................... 44 Results ....................................................................................................................................... 45 National and Provincial Organizations.................................................................................. 45 Local Integrated Health Networks ........................................................................................ 45 Public Health Units................................................................................................................ 46 Discussion and Recommendations ........................................................................................... 48 References ................................................................................................................................ 50 Appendix 5: Survey for Health Care Professionals (Public Health Unit Reps) Using Social Media ........................................................................................................................................... 74

List of Figures Figure 1: General Media Review Search Strategy ...................................................................... 222 Figure 2: Social Media Review Search Strategy .......................................................................... 233 Figure 3: Types of Social Media Used by Ontario Public Health Units ......................................... 72 Figure 4: Staff Managing Social Media, by Role ........................................................................... 72 Figure 5: Social Media Strategies and Policies in Ontario Public Health Units............................. 73 Figure 6: Social Media Evaluation Status...................................................................................... 73

List of Tables Table 1: Prominent Types of Social Media ................................................................................... 36 Table 2: Outcomes of Public Health Unit Social Media Survey .................................................... 51 Table 3: Patterns of Social Media Use in Local Integrated Health Networks (LIHNs) .................. 52 Table 4: Social Media Use by Public Health Unit .......................................................................... 54 Table 5: Staff and Workflow Characteristics of Social Media Applications in Public Health Units: Summary Table ............................................................................................................................. 63 Table 6: Strategies, Policies, Procedures and Evaluation Processes among Public Health Units 68

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Media and Social Media in Public Health Messages: A Systematic Review EXECUTIVE SUMMARY While efficacy and efficiency of traditional media campaigns are well documented in the literature, social media use such as Twitter or Facebook use in health messaging remains an enigmatic topic with a small evidence base. Traditional media campaigns are used widely in public health for a wide variety of objectives and have shown positive outcomes in terms of reach, public awareness, and to a certain extent, behaviour change. Online campaigns utilizing websites or “Web 1.0� applications are also effective, but have not been adequately compared to traditional media in the literature.

As more consumers turn to the internet for health related information, health organizations have begun to turn to social media as a tool for connecting with the public. An emerging topic, very few studies have analyzed the efficacy of social media in this context. Preliminary reports have demonstrated considerable reach associated with social media applications and have potential for engaging specific target audiences, however controlled studies are needed before social media’s role in public health can be adequately defined. Difficulties in evaluating social media applications, as well as a lag in publishing such reports remain major barriers for gathering evidence of its utility.

Despite this lack of evidence base, larger public health organizations are already using social media applications, and smaller units are beginning to launch them. Published evaluations of these initiatives are crude, but very positive. Reports suggest that social media is a very feasible option that is relatively easy to adopt, but requires adequate and appropriate human resources to maintain. Success of social media applications may also be related to the development of a strategic business plan for its use in a particular public health context. Given the rapid and exponential growth of social media use, development of best practices guidelines for public health organizations based on current research are crucial for adapting social media to every day public health practice.

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Media and Social Media in Public Health Messages: A Systematic Review 1. Background and Introduction In our society that relies on effective and efficient communication, the media plays a major role in informing multiple aspects of individuals’ lives, including their access to health information.

Traditionally, public health organizations have used print and radio media and social marketing frameworks to disseminate important health messages to the public. In the past few decades, electronic media have stepped to the forefront of communication, and public health communication has evolved to reflect this. In the wake of the “Web 2.0” phenomenon, public health communication strategies are also changing to match the increasingly influential and rapidly evolving social media revolution. a. Summary of Evidence on Traditional Media There is an abundance of literature summarizing the effectiveness of using traditional media for public health interventions and communications. In general, reviews have found that mass media campaigns in public health can be effective (1-5) with some exceptions noting inconsistent findings (6, 7).

Only one recent review found that mass media campaigns, in contrast to printed pamphlets, could not cause significant behaviour change in subjects (7). The same review found that campaigns were able to increase awareness and recall of public health messages, and that campaigns delivered over webpages, e-mail and other Web 1.0 applications can change behaviour in motivated volunteers (7). Many studies claim that media campaigns are more effective when supplemented by some form of environmental or community support (5, 7).

The majority of recent evidence emphasizes common challenges in the use of mass media campaigns. Given the diversity of the campaigns, settings, media outlets, and health topics, evaluation of communication campaigns can be extremely difficult (2-4). Furthermore, the reach and frequency of media exposure are predictive factors of campaigns’ success, and as such, getting the message out can be a challenge (3, 4). Hornik and colleagues (2007) fault many media campaigns for a lack of focus on the broader social system rather than the individual outcomes (3). Individual-based campaigns do not reach enough people for improvements in population health, albeit changing individual behaviour (3).

It is this emphasis placed on reach that has caused enthusiasm in the public health community in discussing the potential of internet based campaigns, which have proved promising (1, 7). It is clear that North Americans are gravitating to the internet for health information, given that the majority of Canadian and American internet users report searching for health information online (109,112). The challenge remains in recruiting and retaining enough participant engagement in website based interventions to realize the potential impact s of the internet for behaviour change (7).

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b. Emerging Trends: Social Media in Healthcare The birth and development of social media has fundamentally changed how individuals interact in our society, engaging record numbers of people both online and otherwise. Social Networking Sites like Facebook, MySpace, LinkedIn, Twitter and others allow individuals to instantly communicate with large networks of friends, acquaintances and colleagues, while supporting multimedia content linked to other social media applications such as YouTube and Flickr (Appendix 1).

Health information gathering is no exception to this phenomenon: social media provides an outlet for the publication of health information to consumers, while allowing consumers to respond and contribute to advice that was traditionally only issued by providers (8). Social media attends to the needs of modern health consumers, who are highly engaged and desire to be more involved in their health than ever before, while providing the means for reach that was previously unimaginable (9). Organizations are attracted to using social media partially because of the huge potential it provides in reaching members of their target audience (10).

Furthermore, messages counter to public health objectives are rapidly being disseminated to the public through social media. For example, large pharmaceutical companies are turning to social media to promote their drug brands, sometimes violating national laws regulating direct to consumer marketing of drugs (11).

With these advantages, it is no surprise that a variety of Canadian healthcare organizations, including the Public Health Agency of Canada, and many regional health units, such as Toronto Public Health and Peel Public Health are adopting social media in their practices in a variety of ways (See Appendix 4). Organizations establish pages for community outreach, patient education, marketing and crisis communications, taking advantage of the rapid speed and engaging nature of these sites (12). The Mayo clinic, a pioneer among health care providers in the use of social media, has recently taken the trend one step further: developing a patientcentered social networking site, allowing patients to interact with one another and healthcare professionals in the manner of Facebook, but on the Mayo’s unique and private global interface (13). Mayo reports that over 1000 users joined within the first week, further cementing evidence that consumers wish to amalgamate their health care needs using these tools (13).

Although the combined literature on social media use in public health communication is scarce, one report commissioned by the Region of Peel Public Health department, aims to assist in closing this gap with by reviewing the current and potential uses of social media on the Public Health stage (see Appendix 4)(9).

The review emphasizes the shift towards participatory methods for health consumers from the “traditional gatekeepers” of health information (9). Although some public health bodies are currently using social media, there is a deficit of peer-reviewed research on its utility, especially in the form of experimental or quasi-experimental evidence. Most studies are observational, and analyze the current health related “conversations” taking place over social media (9).

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Given the variable quality of health information available through social media, public health organizations cite the ability to provide credible information to consumers how and when they want it as their main motivation for reaching out via these channels (9). The potential to reach target audiences is also a factor (9), given that Facebook boasts the potential to reach over 500 million members of the exact audience you are targeting (14).

Public health is also taking advantage of the reach of social media by enlisting it for “Infoveillance� (9). Organizations can use social media for syndrome surveillance, by monitoring the frequency of searches related to a particular illness, enlisting the public to report infections or symptoms, and mapping outbreaks with new tools and data mined from existing social networking sites (9). Furthermore, surveying the public’s beliefs regarding a public health topic can provide critical information informing the types of messages that will be most effective (9).

Major challenges lie in adapting social media technologies, include logistical issues, such as perceived resistance of government organizations to change, as well as the procedures, policies and manpower needed to launch and effectively maintain a social media presence(9). The lack of evidence guiding public health enterprises is also a major challenge, but in part results from the difficulty that exists in evaluating such complex campaigns that often use different and multiple aspects of social media for a number of objectives. To exacerbate this, the current delay in publishing evidence in credible health journals lags behind the constantly and rapidly changing social media landscape, making it uncertain that literature will even be relevant for public health units by the time it is published (9). Additionally, although literature supports the feasibility of public health campaigns being delivered online and through social media, more data is needed to determine the real costs of implementing such a program (15).

2. Objectives It is clear from the conclusions drawn by Schein and colleagues (2010) and the recommendations made in their report, that the body of evidence regarding the utility of social media in public health needs to be constantly updated. The current popularity of social media, coupled with its capacity for continuous and rapid evolution, makes it critical that health care organizations stay as informed as possible when developing social media campaigns of their own. For this reason, the current systematic review aims to determine the efficacy of traditional and social media in delivering public health messages, as reported by the current body of public health literature. As part of this analysis, the review will address the following research questions: 1) What sources are most accessed and preferred by contemporary consumers for health information?

2) Are traditional and social media outlets able to reach consumers and improve their health knowledge in an effective way?

3) What types of media outlets are most effective in delivering health messages to consumers?

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These questions were addressed using an appropriate search strategy and inclusion criteria, as outlined below.

3. Methods The current review was compiled by conducting two separate systematic reviews of the literature: the first on the use of traditional media, the second on the use of social media, both in the context of public health communications. Each review utilized different methodologies.

Additionally, an environmental scan was conducted of regional public health units and other key players in Canadian public health, in order to identify the current state of social media practice in public health in Canada. a. Traditional Media Review Inclusion Criteria Articles were included in the present review that included some evaluation of a public health or health education intervention that used media presentation. Included studies measured efficacy via some direct measure, or through correlation measures, such as the correlation of disease testing rates and the frequency of public health advertisements promoting screening.

Articles were included if they addressed at least one intervention presented via mass media, such as television and radio programming, or newspaper advertisements. Articles evaluating interventions presented in print media form, such as flyers or letters were also included, as were those delivered via the internet and movie trailers. Finally, studies that compared the effects of public health messages delivered via different types of media were included, as were studies that assessed the sources of information accessed by health consumers.

Articles were excluded if they did not contain an intervention aimed at improving health, or if the intervention was not delivered via the types of media outlined above. Articles were also excluded if they did not evaluate the efficacy of the intervention. Articles that analyzed the content of health related messages in the mass media, such as the portrayal of a health issue in the news were excluded. Studies that examined the effects of unhealthy advertising, such as tobacco advertising, were also excluded. Commentaries, editorials as well as articles that were not peer-reviewed or authored by reputable organizations were also excluded.

Search Strategy A comprehensive search of Medline databases was conducted for the purposes of this review.

Aligned with our objective of reviewing the literature on the use of traditional media in public health communication and health promotion, two main concepts were addressed in our search strategy: media and health. The initial search was conducted by mapping these concepts using MESH terms, including: “communications media”, covering all types of telecommunications and mass media, as well as printed materials and publications; and “information dissemination”. The results from this search were overlapped with the results of the search for the health concept, which used terms: “health care”, covering health services, public health and environmental health; “health education” (MESH), which included consumer health information as well, and “marketing of health services” (MESH). Combining these concepts 8

produced a total of 469 articles, which were reduced to 391 articles after limiting the results to publications in the past 10 years (2000-current record). A keyword search was also conducted to make the search more comprehensive, producing an additional 808 results. Based on a review of abstracts and then the full texts, a total of 62 articles were considered to fit our inclusion criteria, 41 from the concept mapped search and 30 from the keyword search (See Figure 1). b. Social Media Review The review of the literature on social media efficacy in public health was an update of a similar review commissioned by the Region of Peel Public Health Department in July, 2010 (9). The current review used the same methodology and search strategy, including articles published from July 2010 up to the current record (See Figure 2).

Search Strategy Mirroring the search strategy of Schein et al., we conducted a comprehensive review of several relevant health, social science, psychology and marketing databases, using the keywords “social media” AND “health”(9). Since “social media” is not a MESH term, we did not use mapped terms for this search as in the traditional media search strategy. We searched six of the seven databases used by Schein et al. : Medline, Embase, PsycInfo, Social Sciences Citation Index, ABIInform, and CPI.Q (9). The remaining database, JSTOR, was not searched as it did not cover publications in the past three years. We used keyword “social media” in searching the health related databases (Medline, Embase and PsycInfo) and “social media” AND health was search terms used for the remaining databases. All searches were limited to the previous year (2010current record). The literature search yielded a total of 860 combined citations. After reviewing these abstracts, a total of 94 articles were retained for full text review. From this, we selected a total of 23 articles for the final set relevant to our research questions.

The literature review in Schein et al. did not incorporate grey literature (9). We decided to search grey literature of the past 5 years in order to get a more comprehensive view of the use of social media, especially considering the rapid evolution of social media compared to the publication of traditional journal articles. Grey literature was retrieved using Google, Google Scholar, the Canadian Research Index, Conference Board of Canada, ProQuest Dissertations and Theses and Dissertations and Theses from our own institution, McMaster University. Some grey literature pieces were also retrieved using the references of previously found materials, and through a Google News Alert that was set up to notify the reviewer of social media related news articles for a total of four weeks. We classified a total of 3 citations as grey literature, and results are presented in the present report.

Inclusion Criteria Articles were included in the social media review that included some evaluation of a public health or health education intervention that used social media, as defined in Appendix 1. We included articles that examined adoption and usage patterns of social media among health consumers, as well as reports of the types of information sought on social media platforms.

Campaigns and proposed campaigns related to public health that had used social media 9

platforms for delivery were included as long as they included an evaluative component. Studies assessing the benefits and/or potential pitfalls of social media, either through direct or correlation measures were included. Non peer-reviewed articles were included as grey literature if they were authored by an organization considered reputable in the health or marketing field (for example, Peel Public Health).

Articles that strictly analyzed the content of health related messages on social media platforms were also excluded as were articles examining the efficacy of social media in health care professional education, or health care marketing, including pharmaceutical marketing. Studies that used social media platforms for different objectives (i.e. as part of delivering non public health interventions) were excluded. Studies that examined the effects of unhealthy advertising via social media, such as tobacco advertising, were also excluded. As this report focuses on the efficacy of social media in public health communication to consumers, studies that used data mining of social media platforms to extract epidemiological trends were also excluded. Studies that examined the effects of social media on patient privacy were excluded as they were not considered relevant to public health objectives. As this report aimed to assess the practicality of using social media in a public health context in developed nations, studies of interventions in developing countries were excluded. Finally, as in the traditional media review, we excluded editorial articles or commentaries.

4. Results a. Traditional Media Review Of the 62 articles included, 33 studied programs or interventions using multiple types of media (16-48). Five studies focused primarily on television media (49-53), while another 12 focused exclusively on media delivered through the internet (18, 54-64), and about 7 more investigated print media, such as newspapers, magazines, pamphlets and billboards with health messages (65-71). Additionally, one study was based on a radio campaign (72), one study analyzed an intervention delivered through a movie trailer focused on mental health related topics (73), and another delivered health information via text messages (16). Two studies focusing exclusively on social media were identified in the general media review, and thus are also discussed here (74, 75).

The 62 studies analyzed were diverse in design and outcomes. We identified several themes among them. Twenty-two reported the distribution and patterns of information seeking among health consumers (18, 19, 27-29, 39-41, 43, 45-47, 54, 56, 58, 61-64, 66, 74, 76). These included studies on preferred sources of information as well as most utilized media for health information. Some of these also studied the patterns of use of some types of media, namely the internet (54). Twenty-one of the 62 studies analyzed the reach of different media outlets, including measures of recall of health media messages as well as recall of campaigns themselves (16-18, 20, 22-25, 28, 31-34, 37, 46, 52, 55, 66, 68, 72, 73). All of 16 reports measured behaviour change as a result of a health media campaign (21-25, 30, 35, 36, 44, 48, 50, 52, 53, 65, 67, 72).

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Four of the studies were experimental (16, 36, 42, 67), with others using clearly outlined qualitative (focus groups) and correlational designs (17, 21, 24, 26, 32, 37, 49, 51, 53, 61, 69).

Only a few studies specifically analyzed or commented on the delivery of public health messages via social media. Vance et al. (2009) and Rietmeijer et al. (2009) reviewed a number of types of social media and commented on how each is generally used in today’s public health environment (74, 77). Two other studies focused on the effects of YouTube: one analyzed the effectiveness of test videos made by epidemiology students for health promotion purposes (78), while another evaluated the negative effects of YouTube videos on adolescent health through the promotion of self-asphyxiation games (60). One study appraised an earlier form of social media: the List Server(62). A last study proposed potential upcoming application of social media combined with technology, involving the use of cell phones and GPS linked to a main social media site (75).

Sources of Information The retrieved articles assessed a number of diverse outcomes to determine the efficacy and feasibility of delivering health messages via traditional media outlets. One of the main themes identified was analysis of the distribution of information sources used by health consumers. A number of studies assessed the type of traditional media outlets preferred and most utilized by consumers in seeking health information. Preferred sources of information varied widely among the studies. Most studies reported television (27, 28, 40), often ahead of radio, posters, newspapers, the internet, and other types of media. Murphy and colleagues (2010) cited the internet as the second most preferred source after television (28), with other studies citing it as third or fourth most preferred (27, 29). The internet’s popularity is supported by the increased computer usage of adolescents in recent years (79), however the internet is still only used by a minority of people seeking health information, with use depending on age as well as the type of health decision being made (56). Even among those classified as internet users, the internet was only the second most popular source of health information, after health care professionals (56). In Latino populations, Spanish-language media are generally preferred, along with physicians (41) and family (47).

Of the studies that measured the utilization of different media outlets, television, internet (46), and radio (45) were the most frequently cited sources, as studied in an emergency flood situation and West Nile Virus epidemic, respectively. One study found the internet to be particularly effective in rural areas (46), however there were prominent demographic differences in information sources: older individuals tended to acquire less information from the internet, health care professionals and word of mouth, and more information from newspaper sources (46). This study also found educational differences, though the extent of this effect was unclear from the report (46). Health care professionals were a significant source of information in individual emergencies, with the majority of parents bringing poisoned children to an emergency department citing poison control as their primary source of information, over books and the internet (43).

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Reach of Media Campaigns Health campaigns were evaluated using a variety of different outcomes. Studies that evaluated the reach of health media campaigns generally found that campaigns were able to reach a significant proportion of target populations. This was true for campaigns regarding domestic violence, (32, 68), alcohol (72), smoking(26, 80), vaccinations (66), drinking water information (29), disaster information (28), heat warnings (25), and nutrition campaigns (24, 31).

Campaigns targeted to vulnerable populations were also shown to be effective in their objectives (70). Only one study reported a campaign with a poor ability to reach the public (34).

Recall of Health Messages To complement reach outcomes, some studies measured the ability of targeted consumers to recall the health campaign or its key messages. The majority of these reported good recall of the campaign (16, 18, 25, 52, 66, 72), though two studies reported no effect or negative effect on recall (34, 66). Additionally, one study reported positive results, but measured recall of any campaign related to smoking, not just the campaign being evaluated, and thus may not accurately reflect true recall (52). Improved awareness regarding the health topic addressed by media campaigns was also reported by most studies using this as an outcome (22, 23, 31, 33, 37, 46, 53, 69, 71, 73), with only one study reporting no effect on awareness (34).

Effect on Health Behaviours Many of the articles reviewed referred to the Transtheoretical Model, (81) or stages of change model for health behaviour, in their objectives and included outcomes measuring change of attitudes, behaviour and intentions in their analysis. Of the studies that examined behaviour change, about half showed some form of improved behaviour, including healthier eating habits (24), increased rates of infectious disease testing (38), increased preventative behaviours towards abuse (23), heat (25), increased rates of organ donation (35), improved parenting behaviours toward good childhood development (21), and improved smoking quit rates (80). A campaign aimed at improving drinking behaviours in college students was unsuccessful (67), as was one targeting increased physical activity in older adults (65). Some types of behaviours showed mixed response to campaigns. In attempting to improve stroke outcomes by encouraging victims to seek emergency care at the first signs of stroke, two campaigns had conflicting results: Hodgson and colleagues reported improved stroke outcomes with the a campaign (53), where Fogle and colleagues observed no change (33). Similarly, one campaign aimed at reducing antibiotic prescription by healthcare professionals was proven effective (22), while another was much less promising (44).

Effect on Attitudes In terms of ability to change attitudes and intentions related to health issues and health behaviours, the results of the reviewed studies were overwhelmingly positive. Three studies assessing quit intentions of smokers reported a positive effect of media campaigns (30, 50, 55).

Only one reported no effect, but had a positive impact on provoking discussions about the health effects of smoking in a vulnerable population, particularly among smokers (52). Of those studies measuring efficacy in changing attitudes among the target audience, most were successful (21, 22, 73), improving the accuracy of public perceptions and beliefs surrounding 12

antibiotics (22), domestic violence (32) and child development (21). Campaigns were also able to shift social norms (73). There were only two negative results: one campaign reported unchanged attitudes towards domestic abuse as a result of a public health campaign on the topic (23), and another reported no improvement of self efficacy ratings in relation to a periodontal health campaign, but was able to improve knowledge of periodontal health (31).

Correlational and Observational Studies In the absence of measuring behaviour change in individuals, studies drew conclusions about media campaign effectiveness based on correlational data. For example, two studies found a positive relationship between health advertisement frequency and health outcomes, including improved knowledge of warning signs of stroke (49) and utilization of a smoking cessation hotline (51). One study found that a public education campaign related to stroke was related to improved public awareness of stroke as well as increased presentations of strokes to the emergency department early in the course of treatment (53). Other studies uncovered relationships between public health campaigns related to sexually transmitted diseases, improved testing rates (38) and reduced incidence (17) of those infections. Reports on internet campaigns showed that hits to the Centre for Disease Control’s chronic fatigue syndrome website corresponded to the airing of a separate media campaign on the topic (58). Likewise, increased visitors to one hospital’s orthopedics website corresponded with increased health service usage in that department (61).

Most Effective Media Studies reviewed provided mixed conclusions on the most effective media vehicle for the delivery of health information. Most studies claimed the superiority of one type of media based on that outlet’s ability to better reach consumers. For example, one intervention promoting glaucoma awareness among patients named radio as the most effective medium given that most subjects claimed to have gained glaucoma information from the radio in a postintervention evaluation (37). Previously, the majority sought information from health care providers (37). In another study, media were evaluated in the context of improved recall by consumers. In this manner, Johnston and colleagues concluded that although television and internet sources were more likely to reach youth, secondary school students were better able to recall television and radio messages (18).

Only three studies incorporated measures to directly compare media outlets into their design.

Two of these found that the efficacy of media campaigns was improved by augmentation with other materials (outreach worker visits (82) or brochures (23)). Conversely, Johnson and colleagues’ media campaign improved the effect of mailed reminders for voluntary immunizations only slightly, and not significantly enough to warrant its use from a costeffectiveness standpoint (42).

Internet Campaigns Another notable trend in the literature is the emergence of studies on internet applications of public health media with an overwhelmingly positive response. Altogether 17 studies reviewed here included some form of internet-based intervention, varying from Listservs, to more 13

technologically advanced applications, such as SMS messaging (54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64). Studies analyzing the usage of health related information on the internet found that in the majority of cases it was usable, feasible and effective in reaching target audiences (18, 54, 58). This was especially true for youth and adolescents (18, 54). Campaigns with internet-based components have successfully altered health behaviors in target populations, including organ donation (35) and preventative mental health hospitalization (48). Listservs aimed to provide support and health information are documented as being highly accessed (57, 62). Only one internet based intervention reviewed had no effect on physical activity behaviours, citing lack of participant retention and engagement (7). b. Social Media Review The 23 articles and reports retrieved were divided into themes based on their outcomes, which included rates of usage of social media by health consumers and public health units, factors affecting adoption of social media by consumers and public health authorities, as well as the efficacy of social media based on a number of outcomes.

Adoption and Usage Patterns of Social Media by Health Consumers Recent surveys have provided substantial evidence that increasing numbers of North Americans are going online to search for health information, and are using social media for health information management. An overview of the current use of social among health consumers in North America is provided in Appendix 2. The articles identified in the current review provide further insight on this topic.

A total of 35% of US adults reported using social networking sites (such as Facebook, Myspace or Twitter) in the past year (83). The same survey reported no significant differences between users and non-users by either race or socioeconomic status, though younger adults were significantly more likely to be users. Those who were married, or had survived cancer were significantly less likely to have used social networking sites in the past year (83). In contrast, an online survey conducted through a pregnancy-related social networking site showed that 75% of women surveyed self-reported as Caucasian, and had a mean age of 31 years (84). Most of these women were college educated, though over half had an annual household income of less than $50,000 US dollars (84).

Adoption and Usage of Social Media by Public Health Authorities Public health lags in the implementation of social media to support their goals. In the US, 17% of a representative sample of public relations practitioners at health departments used social media as part of their public health practice (8). These units were significantly more likely to be located in urban communities, and adoption rates could be predicted in a stepwise fashion based on community size, with rural areas with the smallest populations having the lowest adoption rates (8). Practitioners in rural areas tended to estimate that fewer members of the public used the internet for obtaining health information than did their urban counterparts.

Of those who estimated low rates of internet use, the most commonly perceived barrier by practitioners was lack of internet access at home (8). Public health practitioners mostly used 14

social networking sites, followed by new media broadcasts, then blogs and discussion boards, podcasts, and finally Twitter. Very few practitioners reported using text messaging applications or wikis to distribute health information (8). Rural practitioners, however, were significantly more likely to incorporate podcasts into their practice than their urban and suburban counterparts.

Disparities in adoption also exist between countries. A study comparing the US and European Union found that both health care consumers and physicians in Europe were more receptive to the use of social media in health than their American counterparts (85). Almost 7 in 10 European consumers surveyed said they trusted social media for health information, compared to only 4 in 10 Americans (85). Interestingly, more European than American physicians had a positive attitude towards health care professional participation in social media health forums, which could be indicative of attitudes among other allied health providers, including public health practitioners (85).

Efficacy of Social Media Campaigns Low adoption rates may in part be due to the lack of existing evidence on the efficacy of social media-based interventions and communications in a public health setting. No meta-analyses of social media applications were identified, however one meta-analysis of 29 online behaviour change interventions was found, which included 2 involving social media platforms, specifically online videos and blogs (86). A small but significant effect of online interventions was evident in changing health related behaviours, including nutrition, physical activity, smoking and drug related activities (86). Online interventions were compared to several controls, and were considered to have a high impact compared to placebos or treatment waitlists, but only a small advantage over lower-tech interventions (86). Online campaigns had no greater impact than print pamphlets, however they had a wider reach and were more cost effective in comparison (86).

Intervention-based Studies Evaluations of individual public health campaigns involving social media as a major component have provided mixed evidence. The present review identified 8 completed interventions that had been evaluated in the literature. Of these, 1 focused on the CDC vaccination campaign during the H1N1 pandemic (87), 2 focused on promoting blood donation in the community (10, 88); 1 transmitted poison control messages through text messaging (89); 2 promoted safe sexual health practices, through condom promotion and HIV awareness, respectively (90, 91); 1 promoted physical activity among young teens (92); and lastly, Villigran et al. discussed evolving tools for public health practice in vulnerable populations (93).

Detailed descriptions of each of these 8 interventions are provided in Appendix 3. All of the studies reported excellent reach in terms of the number of users listed as accessing their social media applications (87, 89, 90, 90-93). The advantage of being able to directly manage reach through the tally of those accessing the social media applications was echoed by many of the different organizations (10, 87-89). Despite positive outcomes in terms of reach in general, educational aspects of the media websites were not accessed as frequently as anticipated (90).

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Encouragingly, organizations found utility in inviting consumers to become further engaged by contacting them through social media or other means, if they required more than the services the application provided (10, 88, 91). Furthermore, social media applications were praised for their ability to promote engagement in populations that are traditionally difficult to serve (93).

Beyond reach and engagement, only a few interventions measured the ability of social media applications in changing health behaviours, including those related to condom use, blood donation, and usage of an HIV information line, respectively (10, 90, 91). All of these studies reported positive results, though none provided an accurate control to measure improvements against (10, 90, 91).

Of the studies that described the process of implementing social media in their organization, all reported positive experiences (10, 88, 89). One author cited the hiring of a recent college graduate who was already familiar with social media as integral to the project’s success (88).

All three studies emphasized the need for the employment of a carefully designed strategic plan in the implementation of these programs, as well as the necessity of building and following comprehensive procedures and policies reflecting the nature of the ongoing processes involved in maintaining a social media presence (10, 88, 89).

Observational and Correlational Studies The remaining studies identified in the current review were classified as observational or correlational. These generally described emerging trends related to the use of social media in public health, and uncovered relationships useful in guiding future practice.

Evidence supports social media as a tool for disease surveillance, as posts using H1N1 related keywords were found to have a positive relationship with the CDC’s surveillance data for the pandemic (94). The H1N1 pandemic was one of the first major public health events that heavily involved the use of social media, and in light of it and other recent pandemics, the WHO is calling for improved research on the topic of effective communication and the development of new communication tools in such pandemic settings (95). Social media tools have also been proposed in overcoming language and health literacy barriers in disease surveillance and public health research (93). Through the use of pictures, individuals who may not have otherwise been able to participate in such initiatives could communicate effectively with public health authorities (93).

Other proposed interventions have cited the ease of use, ability to engage and feasibility as key reasons for turning to social media to communicate important public health messages to target groups (96, 97).

In capturing audiences that are traditionally harder to reach, social media presents a unique opportunity. For example, Robinson and colleagues call for further research into using social media to engage young men, who traditionally are not receptive to public health messages. The 16

report argues that social media can “legitimize young men’s participation in health and support their engagement� (97).

Others have called for more social media efforts targeted at disadvantaged populations, such as the African American and Latino populations of the United States, to reduce health disparities in these groups (98). Given that African-American wireless internet users outnumber their Caucasian counterparts, social media provides a novel tool in connecting with these individuals (98). Villigran and colleagues (2011) also describe an emerging tool aimed at these groups: Photovoice allows members of low income communities to take pictures and post them online in order to convey health related issues relevant to their communities (93). These photos can be used to initiate a community dialogue regarding the health issues that most require interventions, and can engage local individuals and health care professionals in developing interventions to meet the described needs (93). Older adults have also been cited as important target populations, with recommendations for communications through social media for the prevention and reduction of severe strokes (96).

Although the mounting enthusiasm for social media use in the health care industry is evident, only two observational studies assessed the potential impacts of such media on health status.

In a dissertation, Hether (2010) provided mixed evidence on the effects of length of membership and frequency of use of a social networking site for pregnant women on a number of dimensions. Use of the site was related to increased knowledge about the health issues related to pregnancy, but was also positively correlated to the number of visits to a physician during pregnancy (84). Women who used the site most often were also more likely to inquire with their physician about an issue discussed online (84).

The second study reviewed evidence on the effects of social media use on children and adolescents, and found that there were marked benefits in social media website use related to improved socialization, communication, access to health information and enhanced learning opportunities. These did not come without concerning risks, which included cyber bullying and harassment, leading to major mental health and privacy issues (99).

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5. Discussion The current state of the literature documenting the use of traditional media for public health messages generally mirrors the recent reviews that have been conducted on this topic (1-5).

Overall, traditional campaigns show positive outcomes in terms of reach, message recall, and public awareness of health issues. There is mixed evidence regarding the efficacy of media campaigns in changing health behaviours, where media supplemented by other types of initiatives, such as community support, are generally most effective. Where types of media were compared, radio and television advertisements were cited as the most effective in terms of reach and message recall. Of the research conducted on internet-based initiatives, evidence is generally supportive, suggesting that more research is needed in comparing the utility of internet campaigns to other types of media.

In contrast to the literature on traditional media, the role of social media in public health initiatives is not well documented, in large part because it is so new. The current review identified only 23 articles, making it difficult to draw conclusions in the current study.

The articles that were identified suggest that the use of social media is growing exponentially, and extending into the health field. More and more users are turning to social media for health information, advice and support. Users of social media tend to be younger and more educated than the general population. However, the role of socioeconomic status in predicting social media use remains unclear. The adoption of social media based campaigns by public health authorities remains low, however this was assessed by only a single American study. Adoption of social media in Europe appears higher than in North America, both by health consumers and health care providers.

Very few studies reported measures of the efficacy of social media and none were able to compare it directly to the efficacy of other types of interventions. Online interventions however, were found to be at least as effective as those using other media outlets, and more cost effective. All studies identified reported public health campaigns using social media were able to effectively reach and engage high numbers of participants. In terms of changing health behaviours, studies also reported that social media campaigns were effective, but measures and methods varied between studies, and no studies were able to compare the interventions to relative controls.

Observational studies also lent support for social media initiatives, highlighting new innovations for public health surveillance and targeting elusive populations, including young men, older adults, and those of low socioeconomic status.

The implementation of social media applications by public health groups was generally reported to be feasible, and produce positive results. Emphasis was placed on developing an appropriate social media strategy to meet the goals of the organization, prior to implementing any interventions. The expertise of project managers was also reported crucial to the success of these projects.

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Regrettably, no studies directly compared social media initiatives to other types of media, making it difficult to draw conclusions on the relative efficacy of both types of media. In terms of utility, social media certainly shows promise in its ability to reach and engage health consumers, especially given its rapidly growing popularity.

It is also difficult to compare the cost effectiveness of traditional and social media campaigns, as very few studies measured this dimension and none compared between media types except Cugelman and colleagues (2011) who concluded that internet based interventions were generally more cost-effective than other types of media. Research by Schein and colleagues (2010) also suggests that social media initiatives are reasonably feasible in public health settings and are not costly to implement. As in the current review, evidence cited here suggests that human resources are an important determinant of success, and that social media based campaigns benefit from a project manager who is “native” to using such applications (9).

Both reviews presented results suggesting that internet and social media campaigns attracted younger, more educated users. Mixed evidence exists on the relationship of socioeconomic status and social media use, with some studies suggesting that the previously documented “digital divide” between high and low socioeconomic status health consumers, is being eliminated by more frequent use of social media and mobile internet by low income, minority, and older groups (100). One expert even suggests that by not making information available “on a small screen” risks leaving major target groups such as recent immigrants and low income individuals out of the conversation (101). Even more astounding is the upward trend of the adoption of social media by older adults (102). These emerging trends represent a huge opportunity for public health to effectively target and engage the most vulnerable and riskadverse groups in the Canadian population.

In agreement with Schein and colleagues (2010), this review provides further evidence for the need for more controlled studies measuring the efficacy of public health campaigns. Comparing results across studies is an extremely crude measure given the great variation in methodologies that they present. Notably, many campaigns had a variety of features, often combining a number of media and social media outlets, making evaluation of each campaign challenging on its own. Given the complexity of public health interventions, it may be unrealistic to demand tightly controlled research methods in evaluating them. Alternatively, more qualitative methods might be appropriate, however summarizing and comparing results between qualitative studies presents a novel challenge for public health researchers and policy advisors.

The difficulty in evaluating public health interventions makes the current study extremely vulnerable to publication bias. The overwhelmingly positive results of the studies retrieved in the current review may reflect the tendency of public health journals to publish positive results, and discard any negative studies. In addition, public health authorities may not even submit negative results to journals for consideration, given their low publication rate.

Similarly, the reports of social media implementation processes in public health were also positive, citing resources necessary for successful programs. This may reflect the fact that the 19

organizations with adequate resources to fund and maintain social media programs were the ones able to launch successful programs. Other organizations may not have even attempted due to a deficit of resources, or have not succeeded in launching initiatives due to such deficits.

The lack of accounts of unsuccessful social media programs should be interpreted with caution, as this certainly does not reflect the true state of all such programs.

Another limitation of the current study is its inability to retrieve a substantial amount of grey literature. In the public health field, where academic journal turnover rates are extremely slow, grey literature is relied upon for an accurate and up to date source of information. This is exacerbated given the constantly evolving nature of the current topic. Public health reports are authored by a variety of different organizations, and can often be difficult to locate. Thus, regrettably, the current study likely did not include some recent evidence present in the grey literature, though best efforts were made to avoid this.

6. Conclusion Although an abundance of evidence exists on the topic of traditional media use in public health campaigns, the utility of social media is not well documented in the literature. Traditional media has been a staple of public health campaigns for decades, and has been found largely effective in transmitting messages to health consumers. Although similar reports on social media are sparing, the results of these show promise for the induction of social media into regular public health practice.

7. Recommendations More primary research studies are needed on the efficacy of social media in public health. In particular, evaluations from public health organizations using social media applications should be conducted and published. In addition, studies that incorporate direct comparisons between social media and other media campaigns are necessary to determine the extent of the advantage of social media if one exists.

Given the growth of social media in the past year, relatively few studies on its use in public health have been published in that time. This indicates a need for a higher turnover rate for public health journals in publishing results of these types of studies. Further, more grey literature should be published, circulated and advertised by the public health community, to facilitate the rapid dissemination of knowledge and advise future social media campaigns.

Public health units undergoing social media strategies should develop a communications strategy or business plan for social media that includes the goals of social media projects, identifies target audiences, estimates time and resources necessary to sustain the initiative, and references best practice documents or guidelines steering how messages can be effectively communicated through social media in an ethical manner. Evaluation should be conducted concurrent to social media development, and evaluation design should be incorporated into the organization’s social media strategy prior to its implementation. Results of evaluations as well 20

as best practice guidelines should be shared with the public health community, including other local public health units in order to facilitate knowledge transfer and interprofessional collaboration on this topic.

The development of universal best practices documents is necessary to guide the evaluation of social media campaigns, and to provide standardized criteria that can be compared uniformly across studies. Outcomes of interest include: the reach of social media campaigns; efficacy in facilitating behaviour change; extent of social media message recall; measures of engagement, feasibility and cost effectiveness. Future research should also focus on the use of social media in targeting vulnerable populations.

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Figure 1: General Media Review Search Strategy

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Figure 2: Social Media Review Search Strategy

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98. Christopher Gibbons M. Use of health information technology among racial and ethnic underserved communities. Perspect Health Inf Manag. 2011 Jan 1;8:1f.

99. O'Keeffe GS, Clarke-Pearson K. The impact of social media on children, adolescents, and families. Pediatrics. 2011;127(4):800.

100. Fox S, Jones S. The social life of health information. Pew Internet & American Life Project; 2009.

101. Fox S. The power of mobile. . 2010.

102. Madden M. Older adults and social media. Pew Internet & the American Life Project; 2010.

103. Eckler P, Worsowicz G, Rayburn JW. Social media and health care: An overview. PM R. 2010 Nov;2(11):1046-50.

104. Statistics Canada. Canadian internet use survey. The Daily. 2010 Wednesday, May 25, 2011.

105. Statistics Canada. Internet use of individuals, by selected characteristics. Statistics Canada; 2010. Report No.: CANSIM tables 358-0123, 358-0124, 358-0125 and 358-0126.

106. Fox S, Purcell K. Chronic disease and the internet. Pew Internet & The American Life Project; 2010.

107. Ipsos Reid. Who isn't using a mobile app? Press Release. 2011 Wednesday, June 29, 2011.

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Appendix 1: Overview of Social Media The American Academy of pediatrics defines a social media website as “any website that allows social interaction” (99). While this is a very loose description, social media is inherently defined by its ability to provide an interactive environment for users, where communication and discussion flows in multiple directions, and users are encouraged to contribute content (9).

Further, social media generally taps into networks made up of peers, creating collaborative communities where multimedia content is generated and shared (10). Social media applications are often referred to as “Web 2.0”, implying a new generation of social technologies spawned from the previous generation of “Web 1.0” less interactive web pages, e-mail and list servers, where content did not rely on the input of users (77). Table 1 depicts the most common forms of social media and cites examples.

Although social media can refer to a variety of different applications, including media sharing and blogging servers, social networking sites such as Facebook allow users to create online networks of friends and acquaintances (74). These networks provide immense market potential, since a user’s social network can view the pages within the website that the user subscribes to (74). Despite this obvious advantage, social networking sites remain underused in the public health sphere (74).

Different types of applications are adapted by health organizations based on their target audiences, resources and specific goals (103). Social media can be used for spreading health messages, providing support related to chronic illness and connect healthcare consumers with providers (74). Each type of social media application can cater to a different demographic, and each have a unique and ever evolving role in the modern social media landscape.

Facebook Public Health bodies can sign up for an organizational or institutional page through Facebook.

Organizations such as the Public Health Agency of Canada, Health Canada’s Healthy Canadians campaign, the US Centre for Disease Control and the World Health Organization all subscribe to Facebook in this way. These pages allow for most of the features of Facebook (i.e. a wall for posts, photo and video uploads, discussion boards, etc.), but settings can be modified according to the needs of the organization. For example, most institution pages allow users to “like” the page instead of “friending” between private users. When users click to “like” the Facebook page, they automatically receive updates and posts that the institution releases through their page. Organizations often ask users of their website to “like” them on Facebook by posting a link to their official website. Additionally, awareness of social media can be spread to consumers by networking with existing social media applications of other organizations.

Institutions can access information on the users that have “liked” them, and receive updates from other organizations by “liking” their pages. Users can also see which institutions have “liked” each other, thus networking with other community partners in this way is also an effective method of advertising on Facebook.

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Organizations and institutions can create Facebook pages for free. Organizations can also use Facebook advertising to promote themselves, or their Facebook page. Advertisements can target specific audiences, coming up on their Facebook home pages or in banners while they are using the site. Facebook uses a “Cost Per Click” model which bases fees based on the current price similar advertisers are paying to get a certain number of clicks by users, per thousand times the advertisement is shown. The costs can thus vary greatly, but Facebook allows a “daily budget” scheme where organizations can set a maximum daily budget for advertising that can begin anywhere as low as $20.00 US dollars per day. More information on creating organizational pages and advertisements on Facebook can be found at http://www.facebook.com/help/.

YouTube Creating a YouTube channel, or collection of uploaded videos, comes at no cost to users, including corporate and public organizations. A link to the channel can be embedded on an organizational website or other social media the organization is using. Users only have to sign up through the website, and then can immediately begin to upload videos on a user-friendly interface. YouTube can be linked to Google accounts such as g-mail, and users can create playlists of favourite videos that are saved to their accounts. Organizations using YouTube also have access to analytic information on who is accessing their YouTube channel.

Twitter Creating a Twitter account with all available features comes at no cost to users, including corporate and public organizations. Twitter feeds can also be embedded on external websites, including the official websites of public health departments, such as Hamilton Public Health Services at no extra cost. Users can “follow” the health department by clicking on the link provided and logging into their own Twitter account to confirm their interest in following the organization. Then they will automatically receive updates (either through their Twitter account, text messaging, or smartphone applications) broadcast by that organization.

Alternatively, non-Twitter users can click the link provided and be taken to that organization’s Twitter feed to view recent posts, though non-Twitter subscribers are not able to “follow” the feed to get updates sent to them. Besides being an interactive outreach medium that broadcasts in real time, Twitter is an excellent networking tool. Organizations can follow community partners for their updates and “re-tweet” (or re-broadcast) messages broadcast by them. Similar to Facebook, this type of direct networking doubles as extra promotion for an organization’s Twitter page. More information on Twitter’s features can be found at www.twitter.com.

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Blogger Blogger, as well as other blogging sites such as Blogspot, LiveJournal and WordPress are free applications that allow users to create and design their own blog. With unique features like allowing lists of “followers” and “favourite blogs”, Blogger is versatile enough to fit almost any need at no cost to the user. It can also be linked to Google accounts and other social media applications. Like Twitter, Blogger allows other Blogger users to follow an organization’s blog and receive instant updates notifying them of new posts, simply by clicking a button on the blog. Non-Blogger users can also easily access agency authored blogs as long as the blog’s privacy settings are set to be available to the public. Blogger does allow for minimal website design through a template application, though more elaborate designs may require the cost of hiring a web developer. For more information on Blogger’s features, visit www.blogger.com.

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Table 1: Prominent Types of Social Media Type of Social Description Media Blogs Online journals that are presented in reverse chronological order with most recent posts generally coming first. These can consist of accounts of bloggers’ personal lives or can be themed. Entries vary in length and frequency, which are at the discretion of the author. Entries often contain multimedia content.

Microblogging

Social Networking Sites

Multimedia Sharing Sites

Similar to blogs, but posts are much shorter. Posts can link to external content or contain messages about the author’s current “status”.

Twitter prompts bloggers by asking “What’s happening?”, limits posts to 140 characters and facilitates posting and reading via text messaging and mobile internet.

Allow users to build profiles and extensive networks with other users. Often users share updates about themselves, links to external content, photos and videos. Users are usually able to interact via public message postings and commenting on content.

Websites that allow for posting, sharing, and commenting on photos and videos. Often these are linked to other forms of social media. Videos that are spread in this manner are often referred to as “viral”.

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Examples Blogger; http://www.blogger.com LiveJournal; http://www.livejournal.com WordPress; http://www.wordpress.org

Twitter; http://www.twitter.com Tumblr; http://www.tumblr.com FourSquare; www.foursquare.com Facebook; http://www.facebook.com/ MySpace; http://www.myspace.com/ LinkedIn; http://www.linkedin.com/ YouTube; http://www.youtube.com/ Flickr; http://www.flickr.com/ SlideShare; http://www.slideshare.net/

Appendix 2: Social Media Use for Health Information in North America There is substantial evidence that increasing numbers of North Americans are going online for health information. Just under 80% of Canadians are classified as internet users by Statistics Canada (104). Although usage rates in Canada favour the young, most educated and those with highest incomes, in recent years the distribution of internet usage has showed signs of equalizing (105). About 80% of internet users in the US look for health information online (100), whereas in Canada, the figure nears 70% (105). Fifteen percent of American internet users have used internet websites or applications to track their weight, diet, exercise or health information (100). Furthermore, 62% report using social networking websites such as Facebook, Myspace and Twitter (100). Of these, 23% follow friends’ health experiences, 15% have sought out and received health information, and 11% have participated in posted discussions about health (100). Within this group, the elderly are more and more inclined to join social networking websites, representing an excellent target for public health (102).

Persons living with disability or chronic conditions often face barriers to accessing the internet (106). Surrogates, however, can often help these individuals gain access to health information through their own internet searches, as most often, health searches on the internet are conducted on behalf of others (100) .

Mobile internet is also becoming increasingly popular, and of the 85% of Americans who have cell phones, 17% have looked up health information and 9% have downloaded health applications. Young people, African Americans, and those with higher education are more likely to use these (100). In Canada, 31% of online adult Canadians now own a smartphone or tablet and 48% use their phone for social networking (Facebook or Twitter)(107). This represents over a 50% increase in smartphone usage than reported in 2010 (107). In 2010, 17% of smartphone users downloaded a health or wellness related application and this number has likely also increased in the past year (107).

Those with smartphones are also more likely to be active in health discussions online, which is especially important when considering the demographics of mobile internet users mirror those most targeted by public health efforts (101). Mobile internet allows users to access information no matter what their location, and can make location extremely relevant, as in allowing them to access risk information relevant to their area, or find clinic close by (101). This represents a major advantage over internet on its own, and, as Fox argues, makes mobile health an untapped “frontier� of potential for health promotion and peer-to-peer healthcare (101).

Social media has made users more involved and health information consumers are evolving into health information contributors. This trend reflects the sources of information individuals want and trust. For technical medical issues, such as diagnosis and treatment information, individuals still trust their healthcare providers (100). On the other hand, they prefer hearing from their peers for advice on day-to-day remedies and emotional support from those who can relate, 37

namely, other laypeople. For coping strategies that are practical and recommended, they trust both health care professionals and peers (100).

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Appendix 3: Summary of Reviewed Public Health Interventions 1. Evaluation of the Centre for Disease Control’s H1N1 Social Media Campaign The CDC H1N1 campaign took place during and after the height of the H1N1 flu pandemic, beginning in April 2009 (87). The CDC used Twitter, Myspace and YouTube to broadcast messages informing the population on a mass scale about the current state of the outbreak, important infection prevention information, vaccination progress, and eventually, information on vaccination clinics (87). In using different social media outlets and providing different messages, individuals could tailor the information they wished to receive, by subscribing to one or more of the CDC’s campaigns (87). As a result, there was extremely high traffic recorded on the CDC’s H1N1 website, and corresponding buttons, widgets and links to related social media between April and June 2009 (87). By communicating information in an interactive, two-way manner, the CDC built trust with the public in allowing individuals to publicly comment and respond to the broadcast information (87). As a result, public satisfaction ratings of the CDC went up significantly during this time period, and individuals who subscribed to the CDC’s social media initiative were more likely to report high satisfaction with the organization (87).

2. Experience of social media campaigns promoting blood donation in the United States The two articles depicting blood donation promotion describe two separate experiences of American blood centers in initiating a social media presence using Facebook (10, 88). The organizations each conducted informal evaluations of their respective campaigns, achieving moderate success in both cases as measured by increased numbers of online supporters and page visits (10, 88). The United Blood Services Central Coast Facebook experience began with asking Facebook users to “like” a photo in a campaign aimed at increasing the number of Rh negative donors (10). Their viewership increase during the first 4 weeks of the campaign then declined until the seventh week (10). The percentage of Rh negative donors significantly increased in the 4 weeks after the campaign was initiated, compared to the 4 weeks prior, however there was no other control in the study (10). As a result, the organization reports a positive experience and estimates they can reach up to 195,000 donors with their Facebook Profile alone(10).

The second report on blood donations is more focused on the process involved in developing a Facebook profile (88). The Blood Centers of the Pacific followed several steps in establishing themselves on Facebook, including hiring an intern solely for this purpose, researching other social media related to blood donation, prepared content for uploading on the page in advance, designed and customized the page, and developing a social media policy for staff (88). After the page was active, the center promoted it by placing links on other promotional materials and on other web pages within the organization, as well as purchasing ads to be displayed on Facebook itself, targeted specifically at their audience (88). Besides describing the steps involved and the potential in creating a social media presence, the centre reports increased numbers of Facebook “fans”, and have described some other positive outcomes of the page, including providing an excellent portal in which to interact with donors, advertising promotions, and strengthening their relationships with other community health organizations as well as their reputation in the public eye (88).

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3. Development of a text messaging campaign promoting poison prevention In a similar manner, Simenov and colleagues depict their experience with developing a text messaging service for the public, sending facts about poison control and prevention. In order to develop this free, opt-in service, the team first researched the logistics of providers and the technology that would be necessary (89). They then developed content for the daily messages, related to the dates and seasons the messages were programmed to be sent. The campaign was promoted through advertising on other forms of media, including social media platforms in existence, press releases, health reporters and e-mails (89). The campaign received 70 opt-ins per day on average through its duration, and the rates of opt-ins were found to be related to outside advertising (89). With this result, text messaging was concluded to be a valuable tool, especially since reach was easily measured, and professionals were able to further engage clients through telephone or text if they so requested (89).

4. Social media campaigns promoting sexual health Other campaigns focused on improving sexual health practices through social media, and offered less detailed accounts of their development. In a comprehensive online campaign, a Turkish study used a Facebook fan page and advertisements, photo and video hosting sites (such as YouTube), prominent bloggers, and viral (shared) videos in order to promote the online sale of condoms and improve condom use in Turkey (90). Although less than 8% of sales were online, this was considered high compared to online sales of condoms in comparable countries and considerably higher than other documented social marketing campaigns (90). Although the effect on sales was positive, the educational portions of the website were not visited frequently, confirming that users were not using the site for entertainment or education, and limiting the potential for education from a public health standpoint (90). Further, although sales were compared to a national competitor, the authors do not report a control in the sales of the specific brand of condom marketed, which is a severe limitation to the study (90).

A second sexual health related campaign targeted youth to increase awareness about HIV infection (91). The campaign organizers, in partnership with MTV, produced an MTV special featuring videos submitted by American youth affected by HIV (91). In combination with a separate video contest and public service announcements, this was thought to substantially increase calls to an HIV hotline promoted throughout the program (91). Like Purdy and colleagues (2011), this evaluation reported no control with which to compare the telephone hotline outcome (91).

5. The VERB campaign In a unique US national campaign called VERB, a program for promoting physical activity was targeted at pre-adolescents and adolescents through a number of media platforms (92). The campaign included TV commercials, but emphasized new media including an interactive website, viral videos, a text messaging campaign and a unique combination of new media and human interaction, called the Yellowball campaign (92). Through the opt-in text messaging program alone, 25,000 teens were reached with messages about where and how to participate in physical activity, relevant to the time frame they were received (92). The wildly successful 40

Yellowball campaign involved dropping off yellow sports balls at schools and community centers across the country. The balls were labeled with instructions to register them on the campaign website, and once registered, teens were instructed to play with the ball and then describe what type of physical activity they did with it through a blog on the website. Then they were to pass the ball on to a friend to do the same. This campaign successfully used teens’ social networks to reach over 56% of American teens, according to a nationwide survey. In addition, 17,000 blogs and 170,000 videos were created by participants, representing 105 of the teens reached by the program: a proportion much higher than the typical 1-3% seen by similar social marketing campaigns (92). Although successful in reaching the population, the authors did not report outcome measures for the effects of this campaign on improving physical activity in their target audience (92).

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Appendix 4: Environmental Scan of Social Media in Ontario Public Health Practice Introduction In recent years social media has transformed from being a form of entertainment restricted to post-secondary students, to a standard form of communication among social networks that span all age, gender and class groups in nearly all corners of the globe. Changing the fundamental ways that the population communicates, social media has surpassed geographical and demographic boundaries and led to a demand from consumers for instantaneous delivery of more detailed and more relevant information.

Health information is no exception to this, and countless public health organizations have climbed aboard and harnessed the obvious communication power that social media can provide. The US Centre for Disease Control and Prevention (CDC) highlights the unique characteristics of social media that make them highly effective health promotion tools, listing the “Three P’s”: personalization, presentation and participation. Social media allows for tailored message that are personalized to target audiences in unique ways, it allows for presentation of messages in multiple formats appealing to a wide variety of users, and most importantly, it allows for participatory contributions from health consumers themselves, facilitating two-way communication that is a novel and exciting concept in public health, where information has traditionally been disseminated in a one-way manner from gatekeeper to consumer (CDC toolkit). The CDC emphasizes that social media not only allows public health organizations to leverage social networks to expand the reach of target messages, but engages users in invaluable ways (CDC toolkit). By facilitating participation by health consumers in the spread of health information and knowledge sharing, social media can deeply empower them to make good health decisions for themselves and influence their peers to do the same.

Arguably, this makes social media one of the most valuable devices in the public health toolbox (CDC toolkit).

Social media can thereby be integrated into existing public health campaigns to improve and expand reach and encourage participation. Like any health promotion tool, however, implementing social media in public health practice requires a finite number of resources.

Social media can be tailored to virtually any campaign, and can be adapted to fit nearly any resource budget. The CDC recommends that before public health organizations “get their feet wet” in the social media sphere, they develop clear objectives and identify target audiences and key messages as with any campaign. Further, public health organizations should carefully determine the resources available to allocate to social media, and choose tools carefully based on this, as social media tools vary greatly in the amount of expertise, time, and energy required to launch and maintain them (CDC toolkit).

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Best Practice Guidelines The CDC has developed a set of best practices documents and a toolkit that is often consulted by public health organizations to aid them in developing their own unique social media strategies. These documents not only provide a good overview of the utility of social media for different health objectives, they also contain checklists, recommendations and other valuable tools to help public health agencies create their own communication strategies and policies surroundings social media. In the age of information sharing, taking advantage of these tools can immensely guide organizations in developing effective tools in an efficient manner. All best practice documents can be found at http://www.cdc.gov/SocialMedia/Tools/guidelines/ , however a summary of the CDC’s reported “Top Lessons Learned from Using Social Media” is outlined below: CDC’s Top Lessons Learned from Using Social Media*: 1. Be strategic when deciding on their objectives, audience and key messages for a social media campaign. This includes taking into account the time and effort necessary for such a campaign.

2. Social media is “where the people are”, so it makes sense to take the messages you want to provide to them. As one public health unit representative put it, “social media has reached a critical mass” (Personal interview, Jamie Lamott, Sudbury and District Health), and it is only logical to follow the public there to better communicate with them.

3. Adopting low-risk solutions such as videos, podcasts and widgets, first is a good way to experiment with social media and avoid investing too many resources too fast.

4. Like all other health communications, social media messages should be accurate, credible and accountable.

5. Take advantage of portable content, such as videos and widgets , which make it easy for users to spread your message.

6. Using social networking sites to facilitate viral information sharing among users can expand reach and allow users to become health advocates.

7. Encouraging participation by interacting with users over social media and accepting their contributions can help create valuable partnerships, facilitating future communication.

8. Reach can be greatly expanded by taking advantage of the existing social networks of your audience on social networking sites.

9. Multiple formats expand reach by giving users different ways to engage in health information and interact with public health.

10. Mobile phones can expand reach even more, given their current popularity.

11. Develop clear goals for social media and adhere to them.

12. Take advantage of metrics provided by social media for evaluation purposes. *Adapted from CDC Toolkit 43

The current environmental scan aimed to identify which Canadian health organizations are currently using social media applications, and how they are using them to meet their goals. In particular, we wanted to identify the patterns of social media use among large national health organizations, as well as smaller public health organizations including public health units within Ontario.

Methods The current scan was conducted between July 8th and July 28th, 2011. Information on the social media applications used by large, national and provincial public health organizations, such as Health Canada and the Public Health Agency of Canada was gathered from their respective internet sites. Given the depth of these larger initiatives, data was collected on the types of social media being used only.

This was also the method used to obtain data regarding the social media use of Local Integrated Health Units (LIHNs). Outcomes for the LIHN scan included the types of social media applications used, the types of health messages being transmitted, the audience to which they were targeted, the type of content posted, the frequency of posts as well consumer engagement. Consumer engagement was measured by the number of users following that page (i.e. “likes” for Facebook pages and “followers” for Twitter).

The scan of Ontario public health units was conducted by contacting each of the 35 public health units serving Ontario (not including Hamilton Public Health Services). Contacts were identified through either the unit’s website or by speaking with the receptionist for the unit over the phone. Once a contact who managed social media or communications for the department was identified, a telephone survey was conducted with them over the telephone with their consent. A copy of the survey used can be found in Appendix 5. A number of outcomes were addressed by this survey relating to the current status, strategies surrounding, and feasibility and workflow of social media initiatives (as outlined in Table 2). Additionally, an internet scan of social media applications used by the health units was conducted. These were identified through internet searches, as well as links provided by public health unit websites or health unit representatives that had been surveyed.

Quantitative outcomes assessed by the internet scan consisted of: frequency of posts and public engagement. The frequency of posts was determined by counting the number of days per week the organization posted on the social media application. For example, if an organization posted new content on their Facebook page twice on Monday, four times on Wednesday and once on Friday, the raw frequency would be qualified as 3 times per week. The frequencies were then categorized into either ≤1 post per week, 2-4 posts per week or daily, for more frequent posting. Consumer engagement was measured by the number of users following that page (i.e. “likes” for Facebook pages and “followers” for Twitter), however it should be noted that this included outside organizations or stakeholders that may have been following the page, and was not limited to the unit’s public clientele. Two-way engagement was 44

measured by determining whether the page included two-way communication between the public health unit officials and their clients, for example, allowing and responding to client comments on Facebook or re-tweeting posts by clients or other organizations on Twitter.

Engagement was not an outcome for YouTube, Blogging or Facebook Advertisements, as views of these were either not an accurate measure of engagement, given that users generally do not subscribe to new content as they would on Facebook or Twitter. Examples of content were the only qualitative outcome assessed. These consisted of the topics of the last 5 new content posts on a given application. If content was repeated in those 5 most recent posts, only the original content was reported. For example if a public health unit posted 3 links to a heat alert warning on their Facebook in their 5 most recent posts, then one heat alert along with the other 2 unique posts was reported.

Results National and Provincial Organizations Both the Public Health Agency of Canada (PHAC) and Health Canada are leading in their use of multiple social media channels to relay information to Canadians. Health Canada broadcasts messages to Canadians using Facebook, mobile applications, RSS feeds, Twitter, a YouTube channel and a video gallery. Widgets are also available, allowing users to connect their personal blogs with Health Canada messages. These provide up to date and relevant health information on a variety of health topics. Similarly PHAC engages in using RSS feeds, Twitter, Facebook, a mobile website and widgets. These can be accessed at: www.phac-aspc.gc.ca/sm-ms/indexeng.php and http://hc-sc.gc.ca/home-accueil/sm-ms/index-eng.php .

On a provincial level, the Ontario Public Health Association does not currently list any social media applications on their website, however the Ontario Agency for Health Protection and Promotion, and the Ministry of Health and Long Term Care both have Twitter feeds.

Additionally, the Ministry of Health and Long Term Care connects with the public and the media though RSS Feeds, a Flickr photo gallery as well as a YouTube channel. These can be accessed at: http://www.health.gov.on.ca/en/ and http://www.oahpp.ca/.

Local Integrated Health Networks A total of 6 out of 13 LIHNs were found to use social media applications (Table 3). The majority of these used Facebook, while only the South West LIHN appeared to engage in other forms of social media. Most of the LHINs pages appeared to be aimed at both public health partners and people in the community (Table 2). The majority posted external content, or content linked to their website on a variety of health topics. Generally posts were made frequently, ranging from a few times a week to every day (Table 2). The average number of users following the social media pages (measured by number of “likes� on Facebook since that was the most popular application) was 112, with likes ranging from 22-183.

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Public Health Units Following in the footsteps of Ontario LIHNs and larger health authorities in Canada, the vast majority of Ontario Public Health Units are adopting some type of social media, and only 3 PHUs did not use any form of social media. Twitter feeds are the most popular form of social media subscribed to, followed closely by Facebook pages (Figure 3). Many units also have official YouTube channel’s and use Facebook advertising. Specific health units using social media can be found in Table 4. The majority of these units are using social media applications as an additional form of broadcast media, where applications complement established channels of communication to their catchment area, often driving traffic to their website, telephone lines or clinics. Most units are targeting the same clients they would through traditional marketing means, such as television, radio and web ads, with target audiences depending on the type of campaign being marketed rather than the channel being used. However, some units, such as Toronto Public Health, have found from preliminary evaluations that the majority of users accessing these applications are aged 25-44.

Time-sensitive messages are those most broadcast by public health units’ social media applications. For example, Huron County and many other units use Twitter feeds to broadcast updates on beach postings to interested clients in their areas. This type of real-time delivery allows public health units to take advantage of social media for transmitting seasonal messages (such as heat alerts or humidex warnings), promoting current events (such as open houses or free clinics) and communicating with the public in times of crisis (such as the H1N1 pandemic).

In fact, many public health units cited the H1N1 pandemic as a catalyst for initiating social media strategies in their organizations, due to Twitter’s particular utility to transmit important updates, vaccine clinic locations, and vaccine wait times (Table 5).

Public Health units are also using social media to network with other organizations in the community. On Twitter, the majority of units establish connections with similarly-minded organizations by “following” them, and allow other organizations to “follow” them in turn.

“Following” allows an organization to receive the messages public health units broadcast, which can be re-broadcast or “re-tweeted” to that organization’s set of “followers”, essentially creating a ripple effect and expanding a message’s reach exponentially. Likewise, when public health units follow each other, the advantages are threefold: they receive instant updates on the other unit’s activities, they can re-broadcast relevant messages to their clientele, and they can have their message re-broadcast for an exponential reach. Similar advantages exist for messages on other social media applications, including Facebook and blogs. For this reason, many public health units were linked to each other, LIHNs and other Canadian Health Authorities.

Resources are a major discussion point in public health in general, and social media is no exception. Public health staff time being scarce, it is important to address social media strategies from a feasibility and sustainability standpoint. In the current scan, public health units were able to update their social media applications very frequently (i.e., updated 2-4 times per week). However, in many cases, units were unable to determine the actual number of times social media was updated over the course of the week, and weekends typically meant 46

that updates did not occur (with a few exceptions including notification of beach closures in season). None of the public health units surveyed reported having a dedicated social media specialist on staff for the purposes of managing public health social media. The majority of units reported that communications, marketing and health promotions staff had most of the social media related responsibilities at the department. Front line program staff, including public health nurses; health promotion staff; and graphic or web designers also took on roles in social media management (Table 5, Figure 4).

Staff time was an important resource and barrier to frequent social media use, as cited by many public health units (Table 5). Interestingly, public health units were divided in the time they reported spending on social media, with most either reporting under 2 hours per week or over 5 hours. This discrepancy likely reflects the diversity of social media programs present among public health units, and is further displayed in public health’s adoption of social media strategies and policies.

Content of social media was often posted by one individual but created by a team. Generally, communications staff who managed the pages would collaborate with program staff regarding content that would be approved for posting. Often these messages were pre-parceled for other campaigns, and thus were already approved. In other cases, news releases and other emergent messages would be the sole content of the messages, and these would be released on the spot, reflecting the real-time emphasis of social media applications (Table 6).

The implementation of social media initiatives often had some catalyst reported by public health units. In some cases, the urgency of the H1N1 pandemic led public health units to adopt Twitter feeds first, using them to disseminate vaccine and clinic information. After the pandemic had ceased, they continued to use the Twitter feed for emergent information and often expanded campaigns to other social media applications based on the success of the H1N1 campaigns. In other cases, initiation was not so rapid, with public health managers and directors getting pressure from program staff, communications staff and even public stakeholders to embrace social media as part of their everyday communications practice. Still other sites report that their social media initiatives are currently in the form of pilot projects or are largely experimental. These departments cite evidence from these projects as the factor deciding whether their social media efforts will continue (Table 6).

Given the rapid growth of social media in Public Health, and the increasing number of resources necessary to manage it, social media policies and strategies are becoming more common in public health units. As depicted in Figure 3, health units are in multiple stages of developing communications strategies specific or encompassing social media. Almost equal numbers report having, developing, and not having forms of social media policies and procedures in place, regulating both official and unofficial staff use of social media, including but not limited to: personal workplace use, client communications, privacy, and message content approval process (Figure 5, Table 6). Public Health Units also vary in how they regulate social media use at the work place, with some sites having such websites blocked, and others allowing discretionary use.

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Evaluation on the other hand, seems to be much more universal, with just under two thirds of units reporting ongoing evaluation, and another fifth planning on evaluating in the near future (Figure 6, Table 6). This suggests that the evidence-base on public health use of social media can be expected to continue to grow, and emphasizes the need for information sharing among public health units to maximize benefit from new media.

Discussion and Recommendations Based on this scan it is clear that public health units and authorities in Canada are adopting social media applications both nationally, provincially and locally. Many are paving the way by developing strategies and policies to regulate the use of social media, and nearly all organizations are evaluating their initiatives in some way. This is promising in terms of a future evidence base that can be expected for these initiatives. In the meantime, given the preliminary nature of current evaluations as well as the lack of literature on the topic, public health units need to proceed with caution by working together in this emerging field.

Based on the contents of this report, two major recommendations are made. The first involves the use of available data to produce evidence to guide future discussions on social media use as well as future public health initiatives. Data from this report, for example, could be used to elucidate relationships between characteristics of public health units and their social media use, or characteristics of social media initiatives and their success.

The second major recommendation is to encourage discussion between public health units. In conducting the scan, we came across many representatives from different health units who were in the process of conducting similar scans. Nearly all public health representatives showed interest in the results of this report, hoping to guide their own social media initiatives and strategy development.

Thus, overall best practice documents are a necessary part of creating successful social media campaigns across the province. The development of a universal document would be ideal, presenting current evidence from across the province and providing general guidelines. More specific guidelines could be developed for each LIHN, based on their unique needs, but leaving room for individual public health units to modify guidelines based on their unit’s and their population’s needs and characteristics.

Guidelines should include: a) Goals for social media applications in a variety of different contexts b) Evidence of the use of social media applications in a variety of different contexts a. From the literature and b. From other health units c. Examples of strategies, policies and procedures regulating official and unofficial use of social media, including instructions on their development.

48

c) A list of recommended resources regarding social media, including best practice documents, other public health unit reports, government reports, etc. d) Recommendations for policies on IT practices, including the question of blocking social media websites from staff computers In order to facilitate the development of such guidelines, information sharing among public health units is crucial. In creating partnerships, lessons about social media development can be learned and transferred, and the determinants of successful social media strategies and campaigns will be illuminated for better communication practices of public health units in the future.

49

References 1. Centre for Disease Control and Prevention. The Health Communicator’s Social Media Toolkit.

Atlanta: August, 2010. Available at: http://www.cdc.gov/SocialMedia/Tools/guidelines/

50

Table 2: Outcomes of Public Health Unit Social Media Survey Description of Social Media Which applications used Health topic – health unit wide vs. for a particular program Target audience of applications Target for frequency of updates – i.e. target for how often there is a new post Logistics of Initiative Characteristics of social media strategy – i.e. does one exist, specific to social media or overall communications?

Procedures/policies regulating official use Procedures/policies regulating unofficial/personal use at the workplace Evaluation timeline – undergoing evaluation or planning?

Implementation of initiative – decription of how initiated Feasibility Staff characteristics – team vs. individual; qualifications of staff; other roles and responsibilities of staff managing social media Staff time – in hours per week Content determination – Who creates content and is it pre-planned?

51

Table 3: Patterns of Social Media Use in Local Integrated Health Networks (LIHNs) Social Media used Facebook YouTube Twitter LinkedIn

Health Topics

Audience

Type of Info

Content Type

Frequency

organization info and events

public health authorities and laypeople

Mostly videos

dailyweekly

WaterlooWellington

Facebook

organization info and events

public health authorities and laypeople

Hospital News, videos of what local health units are doing, updates re: how to get care, etc. local events, political issues, policy, staffing, public interest

daily, few times a week

Erie St. Clair

Facebook

organization info and events

public health authorities and laypeople

local events, political issues, policy, staffing

South East

Facebook

organization info and events

public health authorities and laypeople

local events, political issues, policy, staffing

North East

Facebook

organization info and events

public health authorities and laypeople

local events, political issues, policy, staffing,

some videos, but mostly links to outside content, i.e. reports, news articles some videos, but mostly links to outside content, i.e. reports, news articles some videos, but mostly links to outside content, i.e. reports, news articles some videos, but mostly links to outside

South West

52

Followers/Likes/views

140

22

every few days, but inconsistent in past few months

138

started daily, since December 2010: monthly

157

few times a week

34

public reports

Central East Central Hamilton Niagara Haldimand Brant Mississauga Halton Toronto Central Champlain

none none none

N/a N/a N/a

N/a N/a N/a

N/a N/a N/a

content, i.e. reports, news articles N/a N/a N/a

none

N/a

N/a

N/a

N/a

N/a

N/a

none

N/a

N/a

N/a

N/a

N/a

N/a

Facebook

organization info and events

public health authorities and laypeople

Links to outside content, news,etc.

few times a week

North Simcoe Muskoka North West

None

N/a

N/a

local events, political issues, staffing, outreach, public interest N/a

N/a

N/a

N/a

None

N/a

N/a

N/a

N/a

N/a

N/a

53

N/a N/a N/a

N/a N/a N/a

183

Table 4: Social Media Use by Public Health Unit Public Health Unit

Social Media Used

Health Topic

Target Audience(s)

Algoma Public Health Unit

Facebook

All

Youth

Brant County

None

N/A

N/A

N/A

Chatham-Kent

Facebook

Sun safety; child safety; beach warnings

Catchment

3x/week

Twitter

Durham Region

YouTube Facebook

Frequency with which updated (target)

Frequency with which updated (actual)

Followers, Friends, Views, or Likes

Engage with users and/or stakeholders and/or partners

Algoma public health youth engagement theatre group - part of youth engagement initiative N/A

N/A

N/A

308

Varies by feed Catchment area

N/A National drowning prevention week; Fee dental clinic; Child booster seat safe; Tips to stay cool Heat alert

Catchment

Seasonal information (beaches, sun), infectious disease; parenting / child health; prenatal

Examples of Content

<3/week

54

1/week

41

No

National drowning prevention week; Free dental clinic

health Eastern Ontario

Elgin-St. Thomas Grey Bruce

HaldimandNorfolk

Facebook

Health alerts (food safety, heat, recalls, etc); nutrition; food safety; staffing; local events

Catchment

Daily

99

No

Extreme heat alert; Burger recall; Active elderly women

Twitter

All

Catchment

Daily

96

No

Swim safety; Cancer screening link; Swim advisories; Link to article about heat wave; Tip about heat stroke

Blog None

All N/A

Youth N/A

N/A

N/A

N/A

N/A

N/A

Facebook

All - Page link to official â&#x20AC;&#x153;Grey-Bruce gets healthyâ&#x20AC;?

FB page

Catchment

Daily except weekends

< 3x/week

70

No

Facebook

Tanning; Tobacco; Environment; Heat alerts

Catchment

Daily, except weekends

Few times a week, except weekends

72

No

Water safety testing; Link to Ontario 211; Hearth and Stroke recipe; Running guide Local news; Water safety testing information; Link to Ontario 211; Running guide

55

Twitter Haliburton, Kawartha, Pine Ridge District

Facebook

Youth Seasonal information(su n safety, water quality, beach closures); Nutrition; Food safety; Child safety; Tobacco

Catchment

Facebook Ads

Halton Region

Hastings and Prince Edward Counties Huron

3-4/week

<1x/week

3-4x/week

3-4x/week

3-4x/week

14

No

Precaution against sun; Link to Guide to Eating Fish; Beach closure information

96

No

Beach postings; Heat tips; Promotion of pregnancy classes;

1235

Yes

Bed bug tips; ReTweet of water safety tips;

Twitter

All

Catchment

< 3-4x / week

YouTube

All

Catchment

Unknown

Twitter

Parenting; Child health

Parents

Daily, except weekends (1012 tweets / day)

Blog

Parents

1-2 x / week

Twitter

Parenting; Child Health All

Catchment

1x/month

Facebook

Breastfeeding

New parents

2-3x/week

>4x/week

308

No

Twitter

Beach water quality

Catchment

Daily (in season)

Daily, except weekends

161

No

56

Communicable diseases

Beach conditions; Sun & water

safety

Kingston, Frontenac and Lennox & Addington Lambton

YouTube

All

Blog (Dietician blog) Facebook â&#x20AC;&#x201C; inactive

Diet

Twitter inactive Facebook

Blog

Nutrition coalition Tobacco prevention

YouTube Leeds, Grenville and Lanark District

MiddlesexLondon

Facebook (pilot)

Sexual health clinic

Facebook Ads

All

Twitter

All

YouTube Facebook Ads (working on Facebook page)

Catchment

No target 3x/week

Community

Weekly, monitored daily

Youth

No target

All video hosting Youth

Variable

Based on campaign All

Unknown / no target

Daily

3-4x/week

All Various campaigns

1301

12

All

57

Yes

Heat alert; Promotion of smoking cessation study; Promotion of Dinesafe event

Niagara

Northwestern

North Bay Parry Sound

Ottawa

Oxford County

Facebook (connected to Niagara Regionâ&#x20AC;&#x2122;s FB page, allowing sharing)

Health

Catchment area, especially 2544 year olds

1x/week

Twitter Twitter

Health Youth

Catchment Youth (all media)

1x/week 3-5x/week (all media)

Facebook

All

All

Catchment

3-4x/week

Yahoo/flickr Facebook

Parents Exercise safety; Nutrition; Seasonal information; Environmental health; Mental health

Catchment Consumers

Twitter

All

Catchment area

Facebook

Seasonal info (water

Consumers

YouTube Twitter (Establishing Facebook)

Few times a week

58

<4x/week

115

Daily or more

265

Making balanced meals; Boil water advisory; Extreme heat alert; Beach closure.

Daily, including some weekends

5484

E-coli tips; Beach postings; Hep. B vaccine promotion; Promotion of prenatal classes Heat alert advisory;

130

No

Yes

ReTweeted Eatright Ontario; Job postings;

Peel

Facebook

Perth District

Twitter

Peterborough (effective December 2011)

safety/quality) ; Local events; Emergency info; Infectious disease; Smoking cessation; Food safety; Child health Parenting in Peel

Beach closure advisory; Water safety link

Parents

Daily except weekends

All

All

1x/week

Facebook

Sexual health; Tobacco and drug prevention

Young adults

No target

Facebook Ads

Prenatal health fair: Well water testing

Facebook

Twitter

315

Yes

1x/week

3

No

More than 1x/month, but less than weekly

18

No

Baby and car safety; Open question Heat safety; Food safety tips; Cancer cluster report release Sexual health video game link; Link to cervical cancer org; Antihomophobia link; Link to CMHA

As needed

Youth, 13-25

Speak up!

Speak out! FB page updated 5-7x /week

Parents 30+

59

Distracted driving; Injury prevention; Sun safety;

Safe homes; Sexual health

Porcupine Health Unit

Renfrew County and District Simcoe Muskoka

Sudbury and District

Facebook Ads

Immunization

Specific campaign

2x/month

YouTube None

N/A

N/A

N/A

Twitter (Pilot)

Alcohol awareness

Facebook (pilot)

Alcohol awareness

Facebook

All - Allows sharing content posted on website

YouTube Blog

N/A

N/A

N/A

N/A

All â&#x20AC;&#x201C; alcohol users

Daily, including some weekends

546

Yes

Strategies for managing low risk drinking; Promoting farmers market; ReTweet re. diabetes care

All â&#x20AC;&#x201C; alcohol users

3-4x / week

74

No

Link to strategies for low risk drinking; Post about weather; Water safety tips

Daily while conference happening

School coalition

60

Thunder Bay District Timiskaming

Facebook (new â&#x20AC;&#x201C; none PHS wide) Facebook

Toronto

Facebook

Waterloo Region

forum for conference Tobacco

Youth

Job postings; Local events; Environmental health; Oral health; Seasonal info; Nutrition; Courses Seasonal info (heat, air/water quality); Local events; Sexual health; Environmental health; Infectious disease

All

1/week

Less than weekly

85

Opiate use; Swimmers itch; Injury prevention

No

Consumers

Daily

Daily except weekends

675

No

Link to heat alert article; Link to map of AC places; Link to HPV article;

Twitter

All

Catchment area

Daily

Daily including some weekends

1208

Yes

ReTweet exercise tips; Sun tips; Video ReTweet on low risk drinking; ReTweet of CCO screening information

YouTube

Health and other topics Link to Region of Waterloo

Catchment area

Unknown/no target

Facebook

61

general FB page

WellingtonDufferinGuelph

Windsor-Essex

Twitter

ROW PH

Catchment

2x/month

1/week â&#x20AC;&#x201C; 1/ month

212

No

Twitter

All

Catchment

<3-4x/week

> 4x/week

592

Yes

Facebook Ads

All

N/A

N/A

N/A

N/A

Facebook Ads

Variable

Varies by message Variable

infrequent

YouTube All All <1/month York Region None of their Catchment 1x/week own â&#x20AC;&#x201C; connected to York Region social media, with PHS contributing content Notes: Data collected during summer 2011. Blank cells indicate non-response.

62

Tips for WNV protection; Humidex / smog warning; Urban cycling promotion; Child health fare promotion Beach postings; hours notification; Humidex advisory N/A

Table 5: Staff and Workflow Characteristics of Social Media Applications in Public Health Units: Summary Table

Public Health Unit

Social Media Staff title/qualifications

Social Media Staff roles/responsibilities

Content development

Public relations/PHN

Media coordinator

Current events

n/a n/a

n/a n/a

n/a n/a

n/a n/a

Team

6

health promotion, communications staff

health promotion and web development

Eastern Ontario

Team

3

Communications, various

Elgin-St. Thomas Grey Bruce

n/a

n/a

Communications staff, frontline staff (monitor related blogs) n/a

News releases and current events as they come up. Program specific news as well.

Based on current events

n/a

n/a

Individual

unknown

Graphic designer

All other design work

HaldimandNorfolk

Individual

<0.5/week

Graphic designer

All other design work

Haliburton, Kawartha, Pine Ridge District

Team

1.5

media web design/ marketing

Media relations, communications and design for whole department

Collaboration between program leads and graphic designer to come up with content.

Health teams submit two key messages per month each, then rotate through them.

Post news releases and seasonal messages as they come up. If none, retweet. Not

Algoma Public Health Unit Brant County ChathamKent Durham Region

Staff Responsible for Social Media (individual vs. team) Team

Estimated Staff Time Spent on social media (hrs/week)

n/a n/a

63

Public Health Nurses and replacement staff who have been trained Media relations

Halton Region

Team

1

Hastings and Prince Edward Counties Huron

Individual

<1

Team

Public Health Nurses

Kingston, Frontenac and Lennox & Addington Lambton

Individual

Twitter – minimal Facebook – unknown Blog – 45 min/week unknown

Communications Officer

media relations, communications strategies for all programs

Team

10

health promotion staff, communications staff

prepared weekly

Leeds, Grenville and Lanark District MiddlesexLondon

Team

now unknown

various

web development, communications for whole department, dietetics for department various

Team (Twitter), individual (YouTube)

1

YouTube: Public Health Nurse, Twitter: communications staff

Consulting, health promotion duties, client interaction; all other communications for department

Niagara

Team

6

2 communications specialists, 2 health promoters, will soon have 5 Public health

communications for the whole department, monitoring, health promotion, etc.

Media releases as they come up. Programs can submit key messages if wish to have Twitter exposure.

Post seasonal messages and news releases as they come up

64

Consulting, health promotion duties, client interaction, etc.

contributed by other teams or prepared in advance.

Some prepared in advance, others spontaneous Programs collaboration on content. News releases as they come.

Some prepared in advance, others depending on what is happing

All media relations and communications for department.

Confidential messages to public health nurses.

Northwestern

Team

2-4

Nurses PH staff.

North Bay Parry Sound

Team

3-4

Communications Staff

Communications and marketing for whole department.

Ottawa

Individual with team consultation

20

Communications

Media relations

Oxford County

Team

4

Communications

Media relations

Social media is only a piece of assigned moderator’s role.

Depending on the program, they are nurses, youth advisors, or health

Peel

65

Program content is program driven rather than by communications, and mixes posts prepared in advance with onthe-spot updates Program staff collaborate with communications staff to develop content or pull pre-approved messages.

Communications staff post content.

Posts prepared in advanced – usually by the social media person with support from a specific program area. The information that is posted on any of these platforms are approved through management.

Content is considered as part of the communications planning process for programs, initiatives and announcements— this includes “stock” messages that are rotated over a season

Perth District

team

5-6

Program staff, health promoters and public health nurses

program development, maintenance, evaluation, health promotion for department, client interaction, etc.

Spontaneous depending on what is happening in community, news releases, etc.

Individual, but trying to decentralize

5

Communications Specialist

Other communications for department

Renfrew County and District Simcoe Muskoka

N/a

N/a

N/a

N/a

program driven, programs approach communication for outreach, based on hot topics or evergreen topics. Prep in advance N/a

Team

15

All media relations, health promotion, programs, client interaction, etc.

Prepare in advance a few weeks at a time.

Sudbury and District

Team

sporadic

Team of 6 editors: mostly public health nurses and media coordinator Communications Team

Communications and marketing for whole department.

Thunder Bay District Timiskaming

Team

<1

No one assigned yet

n/a

Approval based. Other teams collaborate and communications.

Videos prepared in advance n/a

Individual

>1/week

Graphic designer

All other design work

Toronto

Team

>4h - includes weekends

Health promotion, communications and media relations staff

Each manage communications for a specific group of clients at the health department

Peterborough Porcupine Health Unit

66

All job postings as they come up Seasonal, popular topics, underused topics on website to get more exposure, current campaigns.

Prepare in advance so something goes out every day, then add

Waterloo Region

team

1

Marketing Staff

All other marketing

WellingtonDufferinGuelph

team

5

Communications specialists

All communications for the department

WindsorEssex

Teams

<1

communications team and IT support

York Region

team

too early to tell

Appointed social media monitors

Communications and IT support for whole department do all types of marketing for all programs, programs do campaign marketing through them

67

extra on top of that Post as things come up and contributed by other teams Programs collaborate to contribute content, then approved by communications.

Some preapproved/prepared messages No process

Developed calendar of events based on previous years and health promotion calendars (preplanned). Add unplanned messages and news releases

Table 6: Strategies, Policies, Procedures and Evaluation Processes among Public Health Units Public Health Unit

Status of Social Media Strategy

Algoma Public Health Unit Brant County Chatham-Kent Durham Region

Under development Not currently NA None currently

Eastern Ontario

Social Media Strategy Part of Larger Communications Strategy?

Yes

Social Media Policies/Procedures for Official Use

Staff Access to Social Media Sites Blocked?

Status of social media evaluation

Description of Implementation of Social Media

Yes

Social Media Policies/ Procedures for personal/unofficial use?

Yes

No

N/a

No

No

No

Yes

Under development N/a

Will be

No

No

Yes

Under development

In place

Yes

Under development

Under development

No

Planning

Elgin-St. Thomas Grey Bruce

None currently

N/a

No

No

N/a

Strategy to drive traffic to website

yes

Under development Overarching policies apply

Department was charged to develop ads using new media, decided to use Facebook page instead due to cost.

Youth website moved to Facebook, sparked unit wide Facebook N/a

Yes

Yes

Ongoing

HaldimandNorfolk

In place

Yes

Under development

Under development

Haliburton, Kawartha, Pine Ridge District Halton Region

Under development

No

Under development

Under development

Under development

Yes

Yes

Ongoing

No

Ongoing, planning more

Ongoing

68

N/a

Initiated through Health Communities Concept (campaign) Created one monthâ&#x20AC;&#x2122;s worth of posts and continued Started as experiment based on what others were doing Pilot project for Halton Parents

Hastings and Prince Edward Counties Huron

None currently

N/a

No

No

Yes

Business and Sustainability Plans in place initiative

No, unique to each initiative

No

Outlined in business and sustainability plans

Outlined in business and sustainability plans

Kingston, Frontenac and Lennox & Addington Lambton

Under development

Yes

Yes, IT policies apply

Yes, IT policies apply

Under development

Yes

Yes

Leeds, Grenville and Lanark District MiddlesexLondon Niagara

Under development

No

No

Northwestern North Bay Parry Sound

Ottawa

Some previously, planning more Ongoing

Experimentation

No, recently lifted

None Yet

Driven by program requests

Yes

No

Ongoing and planning more

No

No

No

Ongoing

Pressure from other units/best practices; early adoption of tobacco group Pilot

No

No

No

No

None yet

In place

Yes

Yes

Yes

No

Ongoing, Planning more

Under development Part of outreach strategy: goals to reach more, especially during emergency situations In place

Yes

Yes

Yes

No

Yes

Under Development

Under Development

Some â&#x20AC;&#x201C; varies by area

Under development Ongoing, planning more

Yes

Yes

Partial

No

69

Ongoing â&#x20AC;&#x201C; monitor use and Facebook

Initiated by development of business and sustainability plans

Initiated during H1N1 and evolved Initiated by communications staff working group

For emergency situations, then evolved

Initiated during H1N1

Oxford County

No

No response

No response

No response

No response

advertising effectiveness No response

Peel

Under Development Under development

Yes

Under development Under development

Under development

*

Ongoing

Under development

Yes

Ongoing

Under development with communications department Undergoing development; internally trying to lower resistance to use of social media No

Uncertain

Under development

Under development

*

Individual campaigns tracked and evaluated

Yes

Undergoing Development

Undergoing Development

*

ongoing

Media relationsâ&#x20AC;&#x2122; pet project

N/a

No

No

No

N/a

N/a

In place

Yes

Under development

No

No

Ongoing

Sudbury and District

Under Development

No

Under Development

Existing IT and privacy policies apply to social media

No

Ongoing

Thunder Bay

Undergoing

Yes

Undergoing

Yes, corporate IT

Yes

Ongoing

Hired outside firm to consult on social media specific to the pilot campaign Due to critical mass of people moving to social media.

Convinced key managers by demonstrating its utility.

Want to get on

Perth District

Peterborough County

Porcupine Health Unit

Renfrew County and District Simcoe Muskoka

N/a

70

Piloted for health unit Initiated by program team Pressure from public, stakeholders and staff.

Initiated by health promotion staff

District Timiskaming

Development Part of recruitment strategy

Toronto

Not official

N/a

Waterloo Region WellingtonDufferinGuelph Windsor-Essex

None currently

No

In place for some programs Under development In place

York Region

Development Under Development

policies apply No

Yes, for specific programs

Yes, web policies apply Yes, corporate policies Yes, for specific programs

No Yes

No

board From Human Resources conference recommendations Initiated during H1N1 and evolved Started as med

Yes

None yet

Yes , web policies apply Yes, corporate policies None

No

Ongoing

No

Yes

Initiated during H1N1 and evolved

No

Under development

*

Planning

Yes

Yes

No

Planning

Recommendation from Workshop Pressure from programs and communications staff

71

Planning

Figure 3: Types of Social Media Used by Ontario Public Health Units

Figure 4: Staff Managing Social Media, by Role

72

Figure 5: Social Media Strategies and Policies in Ontario Public Health Units

Figure 6: Social Media Evaluation Status

73

Appendix 5: Survey for Health Care Professionals (Public Health Unit Reps) Using Social Media Name: Title: Public Health Unit: 1. Description of social media a. What social media applications does your department use? b. Are they specific to health topics? Y N i. If Y, describe: c. What target audience? d. How often is the social media updated?

2. Logistics of the initiative a. What are goals of the social media initiative, or is there specific strategy it is aligned with? b. What type of procedures/best practices/policies do you have in place to regulate social media, either as part of the initiative or to regulate staff use? c. Is your initiative currently undergoing evaluation or do you have plans for evaluation? d. How did the initiative come about? (Please describe implementation process): 3. Feasibility a. What team/individual is in charge of updating the social media and what is their role in it? b. How much staff time is dedicated to it? (estimate in hours/week if possible) c. What are their qualifications? d. Is social media their only role? What else do they do? e. How is content determined? (i.e. in advance, on the spot updates, contributed by other teams?)

74