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Journal of Consumer Health On the Internet Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wchi20
Online Technologies for Health Information and Education: A Literature Review a
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Harkiran K. Gill , Navkiranjit Gill & Sean D. Young a
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Columbia University , New York , New York , USA
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University of California , Los Angeles , California , USA Published online: 24 May 2013.
To cite this article: Harkiran K. Gill , Navkiranjit Gill & Sean D. Young (2013) Online Technologies for Health Information and Education: A Literature Review, Journal of Consumer Health On the Internet, 17:2, 139-150, DOI: 10.1080/15398285.2013.780542 To link to this article: http://dx.doi.org/10.1080/15398285.2013.780542
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Journal of Consumer Health on the Internet, 17(2):139–150, 2013 Published with license by Taylor & Francis ISSN: 1539-8285 print/1539-8293 online DOI: 10.1080/15398285.2013.780542
Online Technologies for Health Information and Education: A Literature Review HARKIRAN K. GILL
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Columbia University, New York, New York, USA
NAVKIRANJIT GILL, and SEAN D. YOUNG University of California, Los Angeles, California, USA
There is a growing body of research focused on the use of social media and Internet technologies for health education and information sharing. The authors reviewed literature on this topic, with a specific focus on the benefits and concerns associated with using online social technologies as health education and communication tools. Studies suggest that social media technologies have the potential to safely and effectively deliver health education if privacy concerns are addressed. Utility of social media-based health education and communication will improve as technology developers and public health officials determine ways to improve information accuracy and address privacy concerns. KEYWORDS Internet, health education, health communication, privacy, social media technologies
INTRODUCTION The Internet has revolutionized the way society shares and receives information (Larreamendy-Joerns and Leinhardt 2006; Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord
© Harkiran K. Gill, Navkiranjit Gill, and Sean D. Young Received August 30, 2012; revised January 8, 2013; accepted January 18, 2013. The authors gratefully acknowledge the support of the National Institute of Mental Health (NIMH). Address correspondence to Sean D. Young, Department of Family Medicine, University of California, Los Angeles, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, CA 90024. E-mail: [email protected] 139
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2000). Social media technologies, such as mobile texting, blogging, social networking web sites, and instant messaging, have been an instrumental contributing factor because of their ability to facilitate rapid social and educational communication (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord 2000). While people use online social networking technologies to talk about diverse topics such as entertainment, current events, and personal opinions, health information is one of the most actively discussed topics on these virtual communication networks (Fox 2011; Holme, Edling, and Liljeros 2004; Kontos et al. 2010; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010; Young, Dutta, and Dommety 2009; Young and Rice 2011; Young and Jaganath in press). Social networking technologies can provide rapid and scalable access to health information. However, the platforms may also bring potential concerns, such as the ability for public access to disseminate inaccurate and/or confidential health information (Impicciatore et al. 1997; Pequegnat et al. 2007; Scullard, Peacock, and Davies 2010; Williams 2010). This article will investigate whether social networking can function as an effective online health education and communication tool by reviewing 1) the general effectiveness of online health education and communication, 2) the effectiveness of social networking as a means for online health education and communication, and 3) the health privacy concerns associated with online social technologies.
ONLINE HEALTH EDUCATION AND COMMUNICATION Over the past two decades, the Internet has become a top source of educational information, both inside and outside of school settings (Allen and Seaman 2008; Eynon and Malmberg 2011; Harasim 2000; Kassop 2003; Bell 2002; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). While traditional education has been successful because it is interactive ( Johnson, Aragon, and Shaik 2000; McDonald 2002) and can be tailored to fit the needs of individual students ( Johnson, Aragon, and Shaik 2000), researchers argue that online education is able to improve upon traditional education because it is more convenient, has the capacity to reach a wider population, and allows students to learn at their own pace (Kassop 2003; Larreamendy-Joerns and Leinhardt 2006; Morahan-Martin 2004). Part of examining the rapidly growing field of online education is realizing that it is ever changing and constantly adapting to meet the needs and demands of society (Allen and Seaman 2008; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). Online education has been able to constantly adapt to changing educational needs by going from hosting a class syllabus online to offering lectures and multimedia instruction (Harasim 2000; Kontos et al. 2010; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000).
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The use of the Internet as an educational tool has been extended to many disciplines, with a strong focus on health education and health communication (Fox 2011; Jones and Biddlecom 2011; Webb et al. 2010; White and Dorman 2001). In 2011, the Pew Internet Project estimated that out of all of the adults in the United States who use the Internet, 80% have utilized it to search for health information (Fox 2011). The use of the Internet as a health education tool has also entered the realm of patient–physician interaction. Physicians have reported that many patients are requesting procedures, medications, or screening tests based on information they have found on the Internet (Dilliway and Maudsley 2008; Ferguson 2000; Hesse et al. 2005). Taken together, research supports that the Internet has become a primary source of information for patients and general health consumers (Dilliway and Maudsley 2008; Fox 2011; White and Dorman 2001). Health information seekers use the Internet for various purposes. Morahan-Martin (2004) reported that Internet searches regarding health information are typically conducted to fill information gaps, thus enhancing patients’ coping abilities and self-efficacy (White and Dorman 2001; Morahan-Martin 2004). In a study examining health-related uses of the Internet, Hesse and colleagues (2005) found that patients often look for information online before seeking advice from their physicians. The authors gathered data from the Health Information National Trends Survey that was completed by 6,369 adult participants in 2003 (Hesse et al. 2005). Results indicated that 48.6% of adults first resorted to the Internet when looking for specific health information whereas only 10.9% reported going to their physicians (Hesse et al. 2005). They also examined trust in health information sources regarding cancer and found that 25% reported having a lot of trust in information on the Internet whereas another 25% of participants reported having no trust in information found on the Internet. The team also found that people with higher education had more trust in online sources of health information compared with people with less education (Hesse et al. 2005). While these studies demonstrate the Internet’s use as a source for health information, its effectiveness depends on the quality of information provided (Dilliway and Maudsley 2008; Maloney, Ilic, and Green 2005; Young 2011). Many physicians and health care professionals worry that health information on the Internet can often be misleading or false because content on web pages is not subject to editorial review (Hesse et al. 2005; Rice and Katz 2000; White and Dorman 2001). Additionally, many health information web sites are created by companies promoting their product and therefore provide biased information (Rice and Katz 2000). Internet award rating systems have been used to distinguish credible from noncredible web sites; however, these systems are often flawed (Eastin 2001). The inaccuracy of Internet health information therefore remains a problem to both patients and health providers.
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The use of the Internet as a source of health information has led to numerous investigations regarding the quality and accuracy of information available on the web. For example, Scullard and colleagues (2010) assessed the reliability and accuracy of health information found through searches on Google. They examined five common pediatric questions and evaluated the accuracy of the first 100 results generated by the Google search engine. Of the 500 sites they evaluated, only 39% of the sites provided accurate information (Scullard, Peacock, and Davies 2010). They found that the web sites created by the government were accurate whereas web sites created by news organizations only provided correct advice 55% of the time (Scullard, Peacock, and Davies 2010). This demonstrates that the source of information is very important in determining the accuracy of health information. Being able to discern the accuracy of sites offering health information can be quite challenging. It is important that people understand that health information found on the web is not necessarily authored, reviewed, nor regulated by health care professionals (Eastin 2001). There are many different ways of assessing the quality of a web page and thus determining whether to trust the information. One way to determine whether a web page provides accurate information is to examine the references, citations, or sources from which the information was gathered (Eastin 2001; Gagliardi and Jadad 2002; Purcell, Wilson, and Delamothe 2002). However, debate continues over whether examining citations is the best method to assess the quality of health information on a web site. Purcell and colleagues (2002) argue that the criteria for determining whether a web page contains quality health information should be based on its ability to meet the needs of the user (Purcell, Wilson, and Delamothe 2002). For example, the assessment of the quality of health information for a web site used by physicians should be different than the assessment of the quality of health information for a web site used by high school students. Purcell and colleagues recommend that educating the producers of health content is the best method for improving the quality of health information found on the Internet (Purcell, Wilson, and Delamothe 2002).
SOCIAL MEDIA TECHNOLOGIES AND THE COMMUNICATION OF HEALTH INFORMATION Social media technologies are growing especially quickly, allowing them to be used for the rapid spread of educational information. A social networking site is a web-based service that allows people to connect and communicate based on a common interest, lifestyle, and/or activity (Boyd and Ellison 2007; Valkenburg, Peter, and Schouten 2006). These technologies allow users to connect to networks of family members, school friends, and professional contacts, (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Volery
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and Lord 2000) and to strengthen different aspects of their offline connections (Subrahmanyam et al. 2008). Populations ranging from high school students to retired senior citizens use social networking technologies as a means to further absorb information and form learning communities (Baird and Fisher 2005; Subrahmanyam et al. 2008). The benefits of social networking range from being able to connect people from all around the world, raise awareness of grassroots social justice movements, and informally educate people about current events (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Volery and Lord 2000). With social media technologies’ instant accessibility, it offers a large realm of information to a large population for a relatively low cost (Lim et al. 2008; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010). Taken together, research suggests that social media technologies are prevalent in daily life and therefore have the ability to be incorporated into the delivery of education (Holme, Edling, and Liljeros 2004; Lim et al. 2008; Scanfeld, Scanfeld, and Larson 2010). Social media technologies are slowly being recognized as an effective educational tool inside the classroom (Harasim 2000; Volery and Lord 2000; Allen and Seaman 2008). For example, students have begun adopting social networking to connect with other students to discuss topics, ask questions, and receive instant feedback at any time of the day (Gross and Acquisti 2005; Subrahmanyam et al. 2008). Facebook, Twitter, and YouTube are used as health information sources, and (Kontos et al. 2010) due to their large number of users, social networking sites such as these allow education to be more accessible to diverse populations (Mason and Rennie 2008; Chou et al. 2009). Chou and colleagues (2009) reported that participation in social networking sites quadrupled between 2005 and 2009 (Chou et al. 2009). Using data from the Health Information National Trends Survey, Chou et al. (2009) found that 27% of all Internet users utilized at least one form of social media. Furthermore, 65% of Internet users between the ages of 18 and 24 used at least one social media site, demonstrating that social media usage varies across age groups (Chou et al. 2009). Social media technologies have been a particularly powerful tool for health education among younger populations (White and Dorman 2001; Guan and Subrahmanyam 2009). In their report titled “Social Networking Websites and Teens,” Lenhart and Madden (2007) reported that 48% of teens visit social networks at least once a day, and 28% of teens’ online activities involve looking for health and physical fitness information. Furthermore, 79% of young adults aged 18–29 reportedly use the Internet to look for health information (Lenhart and Madden 2007). As a result of this increase in the use of social media technologies for health information, the authors advocated for health educators to use online tools to educate the general population (Lenhart and Madden 2007; White and Dorman 2001).
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With an estimated 140 million active users, Twitter is a social media technology being used to disseminate real-time educational information (Scanfeld, Scanfeld, and Larson 2010; Guyn 2012). Twitter updates, or “tweets,” are normally one-sentence statements that are no longer than 140 characters on any topic (Scanfeld, Scanfeld, and Larson 2010). Borau and colleagues (2009) conducted a study in Shanghai determining the usefulness of micro-blogging in second language learning programs through the use of the social network Twitter (Borau et al. 2009). The study used Twitter to help students practice their English communication skills. At the end of the course, students filled out a bilingual questionnaire that addressed their opinion of the usage of Twitter in class (Borau et al. 2009). The main outcome in this study was that Twitter enhanced the learning experience of students by encouraging a sense of community, by building cultural competence in English, and introducing students to more informal dialogue. Furthermore, 70% of students found it easier to communicate in English after using Twitter and 62% of students reported that that they felt less shy about communicating in English after using Twitter (Borau et al. 2009). People are also using Twitter to share health-related information. Scanfeld and colleagues (2010) investigated the dissemination of health information on social networks through examining the mentioning of antibiotics on Twitter (Scanfeld, Scanfeld, and Larson 2010). Their team examined 1,000 Twitter status updates mentioning antibiotics that were randomly chosen. These status updates could be either public, allowing accessibility to anyone on the web, or protected, allowing accessibility to approved users predetermined by the account holder (Scanfeld, Scanfeld, and Larson 2010). Of the 1,000 tweets, 289 commented on generally taking antibiotics; 157 offered or desired to seek information or advice; 113 claimed or mentioned side effects; 102 mentioned the reason for taking antibiotics; and 92 discussed information on resistance (Scanfeld, Scanfeld, and Larson 2010). They found that social media sites such as Twitter are indeed a space for the informal sharing of health information. Additionally, they concluded that Twitter and similar social media sites provide a location to promote positive behavior change, to disseminate valid information, and to identify potential misuse or misunderstanding of antibiotics (Scanfeld, Scanfeld, and Larson 2010). They further suggested that Twitter could be used to remind people to take their medications and refill their prescriptions, both of which would enhance the efficacy of drug therapies (Scanfeld, Scanfeld, and Larson 2010). While social media is typically associated with social networking technologies, text messaging is another form of social media that is being used for health education and information delivery (Oksman and Turtiainen 2004). Rodgers et al. (2005) conducted a study examining whether mobile phone text messaging would be an effective tool to help smokers in a smoking cessation program successfully quit (Rodgers et al. 2005; Webb et al. 2010). In a randomized controlled study, 1,705 smokers from New Zealand who owned
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cellphones were split into an intervention group and a control group (Rodgers et al. 2005). In an effort to help them quit smoking, the intervention group received regular, personalized text messages, which provided them with advice, support, and something to divert their attention away from smoking (Rodgers et al. 2005). They found that after six weeks 28% of the intervention group had quit smoking versus 13% of the control group. They concluded that text messaging could be a potential new way to help young smokers quit because it is affordable, personalized, age appropriate and not dependent on location.
SOCIAL NETWORKING AS SOURCES FOR HEALTH DELIVERY AND SUPPORT GROUPS Researchers are currently examining whether social media technologies can be an effective method for scaling health information delivery. Chou et al. (2009) found that younger populations might be a reasonable target population for social media health communication because they use social media at greater rates than older populations and most do not have access to a regular health care provider (Chou et al. 2009). Chou et al. (2009) suggest that using social media to communicate health information could help narrow the digital divide and health disparities because of their ability to reach a wider, demographically diverse audience. Public health efforts, such as the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), have also begun to use social media outreach methods (Currie 2009). Currie (2009) reports that Twitter and Facebook are being used to deliver health information because they have a larger and more diverse reach than traditional news sources, such as radio and television (Currie 2009). Moreover, research suggests that social networking technologies are not only useful for providing health information but also that health information communicated via these technologies can affect actual health decisions and behaviors (Redmond et al. 2010). Social networking technologies may also provide social forums where people facing health challenges can share knowledge and experiences (Young and Jaganath 2012, in press; Jaganath et al. 2011; Young et al. published online before print). Benefits of online health support groups include 1) the ability to appeal and cater to people who do not wish to attend face-toface sessions; 2) the ability to have immediate access to a group, regardless of geographic differences between users; and 3) the ability for anonymity, which may be preferable to people who face stigma or are reluctant to disclose sensitive information face-to-face (White and Dorman 2001; Barak, Boniel-Nissim, and Suler 2008). Researchers suggest that online support groups may encourage more honesty and self-disclosure when discussing
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topics that may be potentially embarrassing or considered taboo (Barak, Boniel-Nissim, and Suler 2008; White and Dorman 2001).
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PRIVACY, SOCIAL NETWORKING, AND HEALTH INFORMATION While the examples provided primarily focus on the benefits of using online and social media technologies for health information education and sharing, use of these technologies is accompanied by potential privacy and health information security issues (Williams 2010; Young 2012). Social media technologies pose a risk to users as strangers can access the information that they provide (Williams 2010). The lack of basic security measures surrounding social media sites, such as secure sockets layer (SSL) login, can allow thirdparty hackers to access “private” social media data (Gross and Acquisti 2005). Possible risks may include identity theft (Gross and Acquisti 2005; Milne, Rohm, and Bahl 2004; Belanger, Hiller, and Smith 2002; Solove 2003), online and physical stalking (Gross and Acquisti 2005; Pittaro 2007), embarrassment, price discrimination, and blackmailing (Gross and Acquisti 2005). In a study focused on general privacy risks associated with social networking, Gross and Acquiti (2005) analyzed 4,000 Facebook profiles in the Carnegie Mellon network and found they were able to access students’ social security numbers using only basic profile information, such as their hometown and date of birth (Gross and Acquisti 2005). While this study did not attempt to uncover health information, it suggests a potential to also use social networking to gain access to personal health information. This is particularly important to note as research suggests that the majority of people on social media sites reveal accurate personal information, making them susceptible to harassment, identity theft, and other dangerous situations (Gross and Acquisti 2005). Researchers and engineers are gradually providing guidelines on how to reduce privacy-related risks online (Young 2012). Recommended steps include increasing personal security settings, avoiding use of public computers, using multiple email addresses, and only accessing health information within private and knowingly protected locations (Pequegnat et al. 2007). Therefore, it becomes the responsibility of the user to maintain a private and safe online environment. However, as researchers and engineers become increasingly aware of potential privacy issues, more effective and safer solutions will become available.
CONCLUSION Research suggests that social media technologies can be used to effectively disseminate general health information. However, privacy issues need to be
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taken into account. Based on this review of relevant research, it can be theorized that once information quality has been verified and privacy problems have been addressed, social networks can be used as a tool to provide online general health education. While online social networks have created a uniquely accessible platform for the dissemination of information, they have also blurred the line between public and private information. Expansion of online health platforms will depend upon engineers’ and policy makers’ abilities to balance information accessibility with public and personal safety.
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Webb, T. L., J. Joseph, L. Yardley, and S. Michie. 2010. Using the Internet to promote health behavior change: A systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Journal of Medical Internet Research 12, no. 1: e4. White, M., and S. M. Dorman. 2001. Receiving social support online: implications for health education. Health Education Research 16, no. 6: 693–707. Williams, James. 2010. Social networking applications in health care: Threats to the privacy and security of health information. In Proceedings of the 2010 ICSE Workshop on Software Engineering in Health Care. Cape Town, South Africa: ACM. Young, S. D. 2011. Recommendations for using online social networking technologies to reduce inaccurate online health information. Online Journal of Health and Allied Sciences 10, no. 2. Young, S. D., and E. Rice. 2011. Online social networking technologies, HIV knowledge, and sexual risk and testing behaviors among homeless youth. AIDS Behavior 15, no. 2: 253–60. Young, S., D. Dutta, and G. Dommety. 2009. Extrapolating psychological insights from Facebook profiles: A study of religion and relationship status. CyberPsychology and Behavior 12, no. 3: 347–50. Young, S.D., and D. Jaganath. 2012. Using social networking technologies for mixed methods HIV prevention research. Journal of Mobile Technology in Medicine 1 (abstract), 4s: 40. Young, S.D., and D. Jaganath. In press. Feasibility of using social networking technologies for health research among men who have sex with men: A mixed methods study. American Journal of Men’s Health. _____. In press. Online social networking for HIV education and prevention: A mixed methods analysis. Sexually Transmitted Diseases. Young, Sean D., Lauren Harrell, Devan Jaganath, Adam Carl Cohen, and Steve Shoptaw. Published online before print. Feasibility of recruiting peer educators for an online social networking-based health intervention. Health Education Journal. Young, Sean D. 2012. Recommended guidelines on using social networking technologies for HIV prevention research. AIDS and Behavior 16, no. 7: 1743–45.
ABOUT THE AUTHORS Harkiran K. Gill, MPH, BS ([email protected]) is at Columbia University Mailman School of Public Health, New York, NY; Navkiranjit Gill, BS ([email protected]) is at University of California, Los Angeles; Sean D. Young, PhD, MS ([email protected]) is at Department of Family Medicine, University of California, Los Angeles, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, CA 90024.
Journal of Consumer Health On the Internet Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wchi20
Online Technologies for Health Information and Education: A Literature Review a
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Harkiran K. Gill , Navkiranjit Gill & Sean D. Young a
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Columbia University , New York , New York , USA
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University of California , Los Angeles , California , USA Published online: 24 May 2013.
To cite this article: Harkiran K. Gill , Navkiranjit Gill & Sean D. Young (2013) Online Technologies for Health Information and Education: A Literature Review, Journal of Consumer Health On the Internet, 17:2, 139-150, DOI: 10.1080/15398285.2013.780542 To link to this article: http://dx.doi.org/10.1080/15398285.2013.780542
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Journal of Consumer Health on the Internet, 17(2):139–150, 2013 Published with license by Taylor & Francis ISSN: 1539-8285 print/1539-8293 online DOI: 10.1080/15398285.2013.780542
Online Technologies for Health Information and Education: A Literature Review HARKIRAN K. GILL
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Columbia University, New York, New York, USA
NAVKIRANJIT GILL, and SEAN D. YOUNG University of California, Los Angeles, California, USA
There is a growing body of research focused on the use of social media and Internet technologies for health education and information sharing. The authors reviewed literature on this topic, with a specific focus on the benefits and concerns associated with using online social technologies as health education and communication tools. Studies suggest that social media technologies have the potential to safely and effectively deliver health education if privacy concerns are addressed. Utility of social media-based health education and communication will improve as technology developers and public health officials determine ways to improve information accuracy and address privacy concerns. KEYWORDS Internet, health education, health communication, privacy, social media technologies
INTRODUCTION The Internet has revolutionized the way society shares and receives information (Larreamendy-Joerns and Leinhardt 2006; Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord
© Harkiran K. Gill, Navkiranjit Gill, and Sean D. Young Received August 30, 2012; revised January 8, 2013; accepted January 18, 2013. The authors gratefully acknowledge the support of the National Institute of Mental Health (NIMH). Address correspondence to Sean D. Young, Department of Family Medicine, University of California, Los Angeles, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, CA 90024. E-mail: [email protected] 139
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2000). Social media technologies, such as mobile texting, blogging, social networking web sites, and instant messaging, have been an instrumental contributing factor because of their ability to facilitate rapid social and educational communication (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Harasim 2000; Volery and Lord 2000). While people use online social networking technologies to talk about diverse topics such as entertainment, current events, and personal opinions, health information is one of the most actively discussed topics on these virtual communication networks (Fox 2011; Holme, Edling, and Liljeros 2004; Kontos et al. 2010; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010; Young, Dutta, and Dommety 2009; Young and Rice 2011; Young and Jaganath in press). Social networking technologies can provide rapid and scalable access to health information. However, the platforms may also bring potential concerns, such as the ability for public access to disseminate inaccurate and/or confidential health information (Impicciatore et al. 1997; Pequegnat et al. 2007; Scullard, Peacock, and Davies 2010; Williams 2010). This article will investigate whether social networking can function as an effective online health education and communication tool by reviewing 1) the general effectiveness of online health education and communication, 2) the effectiveness of social networking as a means for online health education and communication, and 3) the health privacy concerns associated with online social technologies.
ONLINE HEALTH EDUCATION AND COMMUNICATION Over the past two decades, the Internet has become a top source of educational information, both inside and outside of school settings (Allen and Seaman 2008; Eynon and Malmberg 2011; Harasim 2000; Kassop 2003; Bell 2002; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). While traditional education has been successful because it is interactive ( Johnson, Aragon, and Shaik 2000; McDonald 2002) and can be tailored to fit the needs of individual students ( Johnson, Aragon, and Shaik 2000), researchers argue that online education is able to improve upon traditional education because it is more convenient, has the capacity to reach a wider population, and allows students to learn at their own pace (Kassop 2003; Larreamendy-Joerns and Leinhardt 2006; Morahan-Martin 2004). Part of examining the rapidly growing field of online education is realizing that it is ever changing and constantly adapting to meet the needs and demands of society (Allen and Seaman 2008; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000). Online education has been able to constantly adapt to changing educational needs by going from hosting a class syllabus online to offering lectures and multimedia instruction (Harasim 2000; Kontos et al. 2010; Larreamendy-Joerns and Leinhardt 2006; Volery and Lord 2000).
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The use of the Internet as an educational tool has been extended to many disciplines, with a strong focus on health education and health communication (Fox 2011; Jones and Biddlecom 2011; Webb et al. 2010; White and Dorman 2001). In 2011, the Pew Internet Project estimated that out of all of the adults in the United States who use the Internet, 80% have utilized it to search for health information (Fox 2011). The use of the Internet as a health education tool has also entered the realm of patient–physician interaction. Physicians have reported that many patients are requesting procedures, medications, or screening tests based on information they have found on the Internet (Dilliway and Maudsley 2008; Ferguson 2000; Hesse et al. 2005). Taken together, research supports that the Internet has become a primary source of information for patients and general health consumers (Dilliway and Maudsley 2008; Fox 2011; White and Dorman 2001). Health information seekers use the Internet for various purposes. Morahan-Martin (2004) reported that Internet searches regarding health information are typically conducted to fill information gaps, thus enhancing patients’ coping abilities and self-efficacy (White and Dorman 2001; Morahan-Martin 2004). In a study examining health-related uses of the Internet, Hesse and colleagues (2005) found that patients often look for information online before seeking advice from their physicians. The authors gathered data from the Health Information National Trends Survey that was completed by 6,369 adult participants in 2003 (Hesse et al. 2005). Results indicated that 48.6% of adults first resorted to the Internet when looking for specific health information whereas only 10.9% reported going to their physicians (Hesse et al. 2005). They also examined trust in health information sources regarding cancer and found that 25% reported having a lot of trust in information on the Internet whereas another 25% of participants reported having no trust in information found on the Internet. The team also found that people with higher education had more trust in online sources of health information compared with people with less education (Hesse et al. 2005). While these studies demonstrate the Internet’s use as a source for health information, its effectiveness depends on the quality of information provided (Dilliway and Maudsley 2008; Maloney, Ilic, and Green 2005; Young 2011). Many physicians and health care professionals worry that health information on the Internet can often be misleading or false because content on web pages is not subject to editorial review (Hesse et al. 2005; Rice and Katz 2000; White and Dorman 2001). Additionally, many health information web sites are created by companies promoting their product and therefore provide biased information (Rice and Katz 2000). Internet award rating systems have been used to distinguish credible from noncredible web sites; however, these systems are often flawed (Eastin 2001). The inaccuracy of Internet health information therefore remains a problem to both patients and health providers.
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The use of the Internet as a source of health information has led to numerous investigations regarding the quality and accuracy of information available on the web. For example, Scullard and colleagues (2010) assessed the reliability and accuracy of health information found through searches on Google. They examined five common pediatric questions and evaluated the accuracy of the first 100 results generated by the Google search engine. Of the 500 sites they evaluated, only 39% of the sites provided accurate information (Scullard, Peacock, and Davies 2010). They found that the web sites created by the government were accurate whereas web sites created by news organizations only provided correct advice 55% of the time (Scullard, Peacock, and Davies 2010). This demonstrates that the source of information is very important in determining the accuracy of health information. Being able to discern the accuracy of sites offering health information can be quite challenging. It is important that people understand that health information found on the web is not necessarily authored, reviewed, nor regulated by health care professionals (Eastin 2001). There are many different ways of assessing the quality of a web page and thus determining whether to trust the information. One way to determine whether a web page provides accurate information is to examine the references, citations, or sources from which the information was gathered (Eastin 2001; Gagliardi and Jadad 2002; Purcell, Wilson, and Delamothe 2002). However, debate continues over whether examining citations is the best method to assess the quality of health information on a web site. Purcell and colleagues (2002) argue that the criteria for determining whether a web page contains quality health information should be based on its ability to meet the needs of the user (Purcell, Wilson, and Delamothe 2002). For example, the assessment of the quality of health information for a web site used by physicians should be different than the assessment of the quality of health information for a web site used by high school students. Purcell and colleagues recommend that educating the producers of health content is the best method for improving the quality of health information found on the Internet (Purcell, Wilson, and Delamothe 2002).
SOCIAL MEDIA TECHNOLOGIES AND THE COMMUNICATION OF HEALTH INFORMATION Social media technologies are growing especially quickly, allowing them to be used for the rapid spread of educational information. A social networking site is a web-based service that allows people to connect and communicate based on a common interest, lifestyle, and/or activity (Boyd and Ellison 2007; Valkenburg, Peter, and Schouten 2006). These technologies allow users to connect to networks of family members, school friends, and professional contacts, (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Volery
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and Lord 2000) and to strengthen different aspects of their offline connections (Subrahmanyam et al. 2008). Populations ranging from high school students to retired senior citizens use social networking technologies as a means to further absorb information and form learning communities (Baird and Fisher 2005; Subrahmanyam et al. 2008). The benefits of social networking range from being able to connect people from all around the world, raise awareness of grassroots social justice movements, and informally educate people about current events (Boyd and Ellison 2007; Scanfeld, Scanfeld, and Larson 2010; Volery and Lord 2000). With social media technologies’ instant accessibility, it offers a large realm of information to a large population for a relatively low cost (Lim et al. 2008; Mason and Rennie 2008; Scanfeld, Scanfeld, and Larson 2010). Taken together, research suggests that social media technologies are prevalent in daily life and therefore have the ability to be incorporated into the delivery of education (Holme, Edling, and Liljeros 2004; Lim et al. 2008; Scanfeld, Scanfeld, and Larson 2010). Social media technologies are slowly being recognized as an effective educational tool inside the classroom (Harasim 2000; Volery and Lord 2000; Allen and Seaman 2008). For example, students have begun adopting social networking to connect with other students to discuss topics, ask questions, and receive instant feedback at any time of the day (Gross and Acquisti 2005; Subrahmanyam et al. 2008). Facebook, Twitter, and YouTube are used as health information sources, and (Kontos et al. 2010) due to their large number of users, social networking sites such as these allow education to be more accessible to diverse populations (Mason and Rennie 2008; Chou et al. 2009). Chou and colleagues (2009) reported that participation in social networking sites quadrupled between 2005 and 2009 (Chou et al. 2009). Using data from the Health Information National Trends Survey, Chou et al. (2009) found that 27% of all Internet users utilized at least one form of social media. Furthermore, 65% of Internet users between the ages of 18 and 24 used at least one social media site, demonstrating that social media usage varies across age groups (Chou et al. 2009). Social media technologies have been a particularly powerful tool for health education among younger populations (White and Dorman 2001; Guan and Subrahmanyam 2009). In their report titled “Social Networking Websites and Teens,” Lenhart and Madden (2007) reported that 48% of teens visit social networks at least once a day, and 28% of teens’ online activities involve looking for health and physical fitness information. Furthermore, 79% of young adults aged 18–29 reportedly use the Internet to look for health information (Lenhart and Madden 2007). As a result of this increase in the use of social media technologies for health information, the authors advocated for health educators to use online tools to educate the general population (Lenhart and Madden 2007; White and Dorman 2001).
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With an estimated 140 million active users, Twitter is a social media technology being used to disseminate real-time educational information (Scanfeld, Scanfeld, and Larson 2010; Guyn 2012). Twitter updates, or “tweets,” are normally one-sentence statements that are no longer than 140 characters on any topic (Scanfeld, Scanfeld, and Larson 2010). Borau and colleagues (2009) conducted a study in Shanghai determining the usefulness of micro-blogging in second language learning programs through the use of the social network Twitter (Borau et al. 2009). The study used Twitter to help students practice their English communication skills. At the end of the course, students filled out a bilingual questionnaire that addressed their opinion of the usage of Twitter in class (Borau et al. 2009). The main outcome in this study was that Twitter enhanced the learning experience of students by encouraging a sense of community, by building cultural competence in English, and introducing students to more informal dialogue. Furthermore, 70% of students found it easier to communicate in English after using Twitter and 62% of students reported that that they felt less shy about communicating in English after using Twitter (Borau et al. 2009). People are also using Twitter to share health-related information. Scanfeld and colleagues (2010) investigated the dissemination of health information on social networks through examining the mentioning of antibiotics on Twitter (Scanfeld, Scanfeld, and Larson 2010). Their team examined 1,000 Twitter status updates mentioning antibiotics that were randomly chosen. These status updates could be either public, allowing accessibility to anyone on the web, or protected, allowing accessibility to approved users predetermined by the account holder (Scanfeld, Scanfeld, and Larson 2010). Of the 1,000 tweets, 289 commented on generally taking antibiotics; 157 offered or desired to seek information or advice; 113 claimed or mentioned side effects; 102 mentioned the reason for taking antibiotics; and 92 discussed information on resistance (Scanfeld, Scanfeld, and Larson 2010). They found that social media sites such as Twitter are indeed a space for the informal sharing of health information. Additionally, they concluded that Twitter and similar social media sites provide a location to promote positive behavior change, to disseminate valid information, and to identify potential misuse or misunderstanding of antibiotics (Scanfeld, Scanfeld, and Larson 2010). They further suggested that Twitter could be used to remind people to take their medications and refill their prescriptions, both of which would enhance the efficacy of drug therapies (Scanfeld, Scanfeld, and Larson 2010). While social media is typically associated with social networking technologies, text messaging is another form of social media that is being used for health education and information delivery (Oksman and Turtiainen 2004). Rodgers et al. (2005) conducted a study examining whether mobile phone text messaging would be an effective tool to help smokers in a smoking cessation program successfully quit (Rodgers et al. 2005; Webb et al. 2010). In a randomized controlled study, 1,705 smokers from New Zealand who owned
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cellphones were split into an intervention group and a control group (Rodgers et al. 2005). In an effort to help them quit smoking, the intervention group received regular, personalized text messages, which provided them with advice, support, and something to divert their attention away from smoking (Rodgers et al. 2005). They found that after six weeks 28% of the intervention group had quit smoking versus 13% of the control group. They concluded that text messaging could be a potential new way to help young smokers quit because it is affordable, personalized, age appropriate and not dependent on location.
SOCIAL NETWORKING AS SOURCES FOR HEALTH DELIVERY AND SUPPORT GROUPS Researchers are currently examining whether social media technologies can be an effective method for scaling health information delivery. Chou et al. (2009) found that younger populations might be a reasonable target population for social media health communication because they use social media at greater rates than older populations and most do not have access to a regular health care provider (Chou et al. 2009). Chou et al. (2009) suggest that using social media to communicate health information could help narrow the digital divide and health disparities because of their ability to reach a wider, demographically diverse audience. Public health efforts, such as the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA), have also begun to use social media outreach methods (Currie 2009). Currie (2009) reports that Twitter and Facebook are being used to deliver health information because they have a larger and more diverse reach than traditional news sources, such as radio and television (Currie 2009). Moreover, research suggests that social networking technologies are not only useful for providing health information but also that health information communicated via these technologies can affect actual health decisions and behaviors (Redmond et al. 2010). Social networking technologies may also provide social forums where people facing health challenges can share knowledge and experiences (Young and Jaganath 2012, in press; Jaganath et al. 2011; Young et al. published online before print). Benefits of online health support groups include 1) the ability to appeal and cater to people who do not wish to attend face-toface sessions; 2) the ability to have immediate access to a group, regardless of geographic differences between users; and 3) the ability for anonymity, which may be preferable to people who face stigma or are reluctant to disclose sensitive information face-to-face (White and Dorman 2001; Barak, Boniel-Nissim, and Suler 2008). Researchers suggest that online support groups may encourage more honesty and self-disclosure when discussing
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topics that may be potentially embarrassing or considered taboo (Barak, Boniel-Nissim, and Suler 2008; White and Dorman 2001).
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PRIVACY, SOCIAL NETWORKING, AND HEALTH INFORMATION While the examples provided primarily focus on the benefits of using online and social media technologies for health information education and sharing, use of these technologies is accompanied by potential privacy and health information security issues (Williams 2010; Young 2012). Social media technologies pose a risk to users as strangers can access the information that they provide (Williams 2010). The lack of basic security measures surrounding social media sites, such as secure sockets layer (SSL) login, can allow thirdparty hackers to access “private” social media data (Gross and Acquisti 2005). Possible risks may include identity theft (Gross and Acquisti 2005; Milne, Rohm, and Bahl 2004; Belanger, Hiller, and Smith 2002; Solove 2003), online and physical stalking (Gross and Acquisti 2005; Pittaro 2007), embarrassment, price discrimination, and blackmailing (Gross and Acquisti 2005). In a study focused on general privacy risks associated with social networking, Gross and Acquiti (2005) analyzed 4,000 Facebook profiles in the Carnegie Mellon network and found they were able to access students’ social security numbers using only basic profile information, such as their hometown and date of birth (Gross and Acquisti 2005). While this study did not attempt to uncover health information, it suggests a potential to also use social networking to gain access to personal health information. This is particularly important to note as research suggests that the majority of people on social media sites reveal accurate personal information, making them susceptible to harassment, identity theft, and other dangerous situations (Gross and Acquisti 2005). Researchers and engineers are gradually providing guidelines on how to reduce privacy-related risks online (Young 2012). Recommended steps include increasing personal security settings, avoiding use of public computers, using multiple email addresses, and only accessing health information within private and knowingly protected locations (Pequegnat et al. 2007). Therefore, it becomes the responsibility of the user to maintain a private and safe online environment. However, as researchers and engineers become increasingly aware of potential privacy issues, more effective and safer solutions will become available.
CONCLUSION Research suggests that social media technologies can be used to effectively disseminate general health information. However, privacy issues need to be
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taken into account. Based on this review of relevant research, it can be theorized that once information quality has been verified and privacy problems have been addressed, social networks can be used as a tool to provide online general health education. While online social networks have created a uniquely accessible platform for the dissemination of information, they have also blurred the line between public and private information. Expansion of online health platforms will depend upon engineers’ and policy makers’ abilities to balance information accessibility with public and personal safety.
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ABOUT THE AUTHORS Harkiran K. Gill, MPH, BS ([email protected]) is at Columbia University Mailman School of Public Health, New York, NY; Navkiranjit Gill, BS ([email protected]) is at University of California, Los Angeles; Sean D. Young, PhD, MS ([email protected]) is at Department of Family Medicine, University of California, Los Angeles, 10880 Wilshire Boulevard, Suite 1800, Los Angeles, CA 90024.
