CIN: Computers, Informatics, Nursing
& Vol. 33, No. 4, 132–141 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
F E A T U R E A R T I C L E
Social Media The Key to Health Information Access for 18- to 30-Year-Old College Students GAYLE PRYBUTOK, PhD, MBA, BSN SHERRY RYAN, PhD
The provision of timely, accurate, and relevant health information that facilitates lifestyle changes in targeted populations is a public health imperative.1 Consumer Health Informatics (CHI) is defined as the development and implementation of Internet-based systems to deliver health risk management information and health intervention applications to the public.2 Over the last 40 years, CHI revolutionized both health education and healthcare delivery. As a result, the application of CHI to a wide range of public health educational and interventional efforts has recently garnered attention from both consumers and health communication researchers. While these communications reach a large audience, a gap in outreach to many younger users still exists, despite their engagement in the Internet. An important step in reaching this audience is to understand how they access health information and, more specifically, eHealth, or Internet-based health information. This work makes a research contribution that also has an implication for practice, because it builds on Bandura’s Social Learning Theory3 to identify how this younger population segment accesses eHealth information.
TARGETED HEALTH MESSAGES Kreuter and Wray4 reported that in health communication targeted messages are those designed to reach a population subgroup based on characteristics that members of the subgroup share. Health communication researchers recognize that a thorough understanding of the target audience and the way that they acquire health information online is a priority in designing relevant health information materials for an online venue.5 In 1966, Rosenstock6 proposed the Health Belief Model. The model, used in many successful health communication 132
This work examines where 18- to 30-year-old college students seek health information on the Internet and how they determine site and message credibility. Using a qualitative methodology, five focus groups were conducted with 18- to 30-year-old college students, and transcripts were analyzed with MaxQDA text analysis software. The study revealed that 18- to 30-year-old college students have Internet health information source preferences, reasons for seeking health information on the Internet, and message design factors that improve their perception of site and message credibility. We conclude that the Internet and social media show great promise as effective health communication channels for 18- to 30-year-old college students and confirm that preferred Internet/social media sites can be utilized by health educators to present important risk management/disease prevention information to 18- to 30-year-old college students. In addition, message design factors can lend credibility to both sites and the health information delivered there. KEY WORDS College students & Consumer health informatics & Health education & Social media
campaigns, posited that specific beliefs in a target population should be targeted to provoke positive health behavior changes in that population.
THE INTERNET AS A HEALTH INFORMATION CHANNEL The Internet is a health information channel that provides data in real time, cost-effectively, and allows a plurality of Author Affiliations: College of Information, Department of Library Information Science (Dr Prybutok); and College of Business, Department of Information Technology and Decision Sciences (Dr Ryan), University of North Texas, Denton, TX. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Gayle Prybutok, PhD, MBA, BSN, College of Information, University of North Texas, 1155 Union Circle #311068, Denton, TX 76203-5017 ([email protected]). DOI: 10.1097/CIN.0000000000000147
CIN: Computers, Informatics, Nursing & April 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
users to acquire new information or adopt new behaviors quickly.7,8 In fact, the Centers for Disease Control (CDC) published broad guidelines for health educators on the effective use of social media to communicate health information after the recent H1N1 crisis. Between June 2010 and August 2011, the CDC published guidelines and best practice documents for the use of Facebook, online videos, Twitter, text messages, e-cards, widgets, buttons, and badges, entitled The Health Communicator’s Social Media Toolkit.9 The term ‘‘social media marketing’’ is now used to describe a use of social media that incorporates ‘‘the principles and processes of commercial marketingI with a goal to design and implement programs to promote socially beneficial behavior change.’’10(pp183–184) Eng et al11 introduced the concept of interactive health communication (IHC), relevant because of the concurrent increase in the use of social media in eHealth communication. The authors defined IHC as the interaction between a person (patient, caregiver, professional, or consumer) and health information, mediated by a communication technology.11 This concept is relevant to the expanding use of social media in eHealth communication. Cline and Haynes12 proposed that IHC offers advantages to the healthy public, to those that are ill, and to caregivers, healthcare providers, and educators. It is clear that the use of social media as an eHealth marketing and eHealth education channel has arrived.
HEALTH MESSAGE DESIGN Many health communication researchers have explored parameters for health message design.13–16 Morris et al17 wisely noted that ‘‘to motivate behavior change, health messaging needs to be both persuasive and pervasive. It needs to be part of the rituals and environments—social as well as technological—that define daily life.’’16(p444) Internet use and engagement in social networking have become essential aspects of many users’ daily routines. As a result, users have gained experience and a degree of proficiency that have made online social engagement and interaction a familiar and trusted experience.18 Social media sites allow users to acquire the most current information available about health issues, to engage with other users facing the same issues, and to actively manage their own health.8 Colineau and Parisa19 said that patients have begun to use online social networks to form communities that discuss the physical and emotional aspects of illness with others who share the same experiences, as they do on sites such as Patients Like Me (www.patientslikeme.com). This has changed the customary relationships that patients have with their physicians. Online health communities offer members the benefit of others’ experiences with specific treatments or strategies for managing behaviors associated with specific health issues that often patients find more relevant than information from their medical professionals.20
THE EVOLUTION OF HEALTH LITERACY Another consequence of the digital age to both information science and consumer health informatics is the need to revise the concept of health literacy to include a wider cluster of skills that users must possess to benefit from digital information and to use it effectively. It is important to identify skills and access barriers in order to help underserved populations to use technology and to participate in their own healthcare.20 Chan and Kaufman21(pe94) defined eHealth literacy as ‘‘a set of skills and knowledge that are essential for productive interaction with technology based health tools.’’ In their more specific definition of eHealth literacy, Norman and Skinner22 detailed six types of literacy required of Internet-based health information consumers in the Internet age. These include computer literacy (skills related to using a computer); information literacy (the ability to express information needs and to find, assess, and use information to acquire knowledge and share it); media literacy (the ability to choose, understand, and use information represented in audio or visual forms); traditional literacy and numeracy (reading/writing/communicating, the ability to interpret scales and graphical representations of information); science literacy (familiarity with science concepts and scientific method and to apply scientific reasoning); and health literacy (ability to find, assess, and apply relevant health information when using health services and making health decisions). Traditional offline mechanisms are still successful in reaching large segments of the public. However, they remain ineffective in reaching a large segment of younger users who have moved to heavy engagement in Internetbased communication and socialization and who have developed a number of the skills necessary for eHealth literacy. In addition, there are users of all ages who are not intentionally looking for information on health issues but can benefit from finding it incidentally, while engaged in other activities on the Internet, and attending to it. This work makes a valuable contribution to the current body of knowledge in healthcare education and extends the reach of current educational efforts. While we now know a great deal about effective health message design, we have not yet determined which online message communication venues are most effective in reaching targeted populations. As technology continues to drive clinical practice, so must the information channels that deliver important health education messages evolve. Contemporary information channels such as the Internet and social media enable health educators to creatively bring essential health information to targeted user groups. In order to do that, there is a need to understand where targeted use groups seek health information and why. That is the aim of this work. Armed with a clearer view of specific groups of users who seek health information on the Internet and of their health information–seeking behaviors, educators can
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design and present health messages that will engage these user groups and positively affect health behaviors. This investigation, based on data gathered from focus groups, will clarify the health information–seeking behaviors and preferences of 18- to 30-year-old college students who report the use of Internet and social media sites to acquire important health information. As such, this study lays an important foundation for future quantitative research that empirically links specific user characteristics with health information–seeking behaviors identified in this study. In addition, user criteria for determining online health message credibility discovered in this study can be tested in future work.
BACKGROUND Historically, health educators disseminated health information verbally, via printed materials or via mass media communication channels such as radio and TV.23 However, health information delivery models changed with the emergence of the World Wide Web, and as a result, so have health information consumers. Consumers no longer passively accept the word of their healthcare providers. They want to be informed. They actively seek health information and want to collaborate with healthcare providers about the medical treatment that they receive. The Internet is a health information channel that provides data in real time, cost-effectively, and that facilitates the timely acquisition and exchange of health information and adoption of healthy behaviors.7
REASONS FOR HEALTH INFORMATION SEEKING ON THE INTERNET An important question that this work helps to address is: Why do 18- to 30-year-old college students seek health information on the Internet? In general, healthy people look for health information that confirms their sense of physical health. The sick seek information about their disease process, treatment options, and prognosis.24 A third type of health information seeker looks for ‘‘information on behalf or because of others, without necessarily being asked to do so or engaging in follow up.’’24(p310)
SOCIAL MEDIA AND HEALTH INFORMATION Social media exists in many forms. Social media includes familiar sites, such as MySpace, Twitter, Facebook, and YouTube, and professional sites, such as LinkedIn, blogs of all kinds, and online medical support groups. Social media sites are helping consumers to make important health decisions.8,19 Social media reaches users regardless of differences in race, educational level, ethnic background, or access to 134
healthcare.25 Haridakis and Hanson26 examined why and how people choose a particular social media venue and concluded that users choose social media sites that meet their needs at the time. They determined that user choices are also linked to their personalities and social styles. Consequently, healthcare marketers and health educators have begun to explore social media venues to better understand which venues are most appropriate for consumers in different age groups and most relevant for the topic area that initially provokes the consumer’s search.
SOCIAL LEARNING THEORY In 1986, Bandura3 introduced Social Learning Theory. Social Learning Theory is important in considering the educational potential of social media. Prominent in psychology and education, the theory proposed that people learn by observing others in the context of their experiences, social interactions, and media influences. The decision to adopt the behavior is dependent on whether the behavior results in reward or punishment and whether the behavior has a positive outcome. Bandura3 proposed that behavior is the result of a combination of behavior, cognition, environment, and physiology and that observational learning depends on four related cognitive processes: attention, motivation, production, and retention. Behaviors increase in frequency when positive outcomes are expected and valued and when an individual’s perceived ability to be successful, or his selfefficacy, positively influences his decision making. Bandura’s Social Learning Theory3 plays a significant role in eHealth learning and on the motivation to take protective action. It is useful to consider YouTube and other social media venues an online, social information use environments,27 where people can learn by observing and interacting with others, in the context of social media exchange.
COLLEGE STUDENT ENGAGEMENT WITH SOCIAL MEDIA College student Internet users in the 18- to 30-year age range are actively engaged in using social media for social interaction, relaxation, entertainment, and information exchange. This increases the likelihood that they will encounter important health information posted on these sites.28 The anonymity offered by social media venues can be appealing to young users seeking to preserve their privacy as they explore sensitive health topics.29 The target population of 18to 30-year-old college students has grown comfortable and is secure with exchanging personal information on social media venues with people whom they may not know well.30 However, this does not guarantee that they consider social media sites credible and reliable sources of health information. In order to effectively deliver important health information to 18- to 30-year-old college students, we must know
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why and how they seek or encounter health information, as well as where they prefer to look and what criteria they use to determine both site and message credibility.
COLLEGE STUDENTS AND HEALTH LITERACY Researchers have begun to investigate and assess the general level of health literacy among college students. In 2005, Ivanitskaya et al31 administered the Research Readiness Self-assessment to 400 college students. The Research Readiness Self-assessment included both multiple-choice questions and problem-solving questions designed to measure the participants’ ability to find and evaluate health information and to detect plagiarism. Results demonstrated that only half of the participants were able to identify the most trustworthy health information source. Most participants (84%) identified their research skills as ranging between good and excellent, but many were not able to carry out more complex searches successfully, evaluate the quality of health-related Web sites or articles, or distinguish between a variety of health information sources. In 2010, Ickes and Cottrell32 administered a different assessment instrument to approximately 400 junior and senior college students. The Test of Functional Health Literacy assessed numeracy and reading comprehension, based on the presentation and interpretation of real healthcare materials. They found that most participants (89.3%) thought that health literacy was important, and prior to testing, 86.2% thought that they were already health literate. After testing, the participants had a mean health literacy score of 93.83 out of 100, indicating strong health literacy skills, although many students had difficulty with individual test items. The researchers found that messages that followed the cultural and linguistic patterns of the target audience and that were presented using familiar modalities were more likely to be understood and utilized by members of the target audience. This is consistent with the research of Witte et al,16 who found that health messages that fit the culture, beliefs, and appearance of the target audience yield better responses and greater likelihood of following the protective health behavior.
ACTIVE INFORMATION SEEKING VERSUS INCIDENTAL INFORMATION ACQUISITION Much of the theory on information-seeking behavior addresses the user who actively looks for information. But what about the user who is unaware that he/she has a need or who is not purposefully looking for information? Healthy young people may not be looking for information associated with health risk management or disease prevention. Yet they are the users who stand to benefit the most from health behavior change that can be provoked by such
information. Fortunately, the engagement in social media typical of many young users offers health educators an opportunity to bring essential health education and healthy behavior training to them in a manner that is both enjoyable and memorable. The Internet is a browser-friendly environment that lends itself to the unexpected discovery of useful information.29 The user’s degree of attention depends on the match between the message and the receiver’s interest, familiarity with the topic, motivation, and emotional response.7 Wilson33 said that users often find information while engaging in activities that keep them informed about their environment. Williamson34(p23) extended Wilson’s work and labeled the finding of information by accident ‘‘incidental information acquisition.’’ She said that often the information that the user finds is useful, but it is not something that he/she was purposefully seeking. Erdelez35 identified the same random information collection process, and she called it ‘‘encountering’’ information in a way that the user can remember. More recently, Smith et al36 reported that memorable messages, when recalled later, have the ability to influence behavior. Kelly et al37 recognized that people can acquire a great deal of health information without actually looking for it, and they termed this type of informationseeking behavior ‘‘scanning.’’ They said that it is important to understand how people obtain and use information acquired by scanning during everyday activities in order to learn how to present information in a way that encourages them to make healthy behavioral decisions. Tewksbury et al38 suggested that many Internet users enjoy surfing the Web in order to explore unfamiliar sites. In fact, Tian and Robinson1 found that there is a positive association between incidental information seeking on the Internet and the acquisition of health knowledge. Therefore, it is essential to understand how people get and use health information acquired casually and unintentionally during everyday activities so that important health information is effectively communicated to specific groups. This article explores where and how 18- to 30-year-old college students seek health information on the Internet, what criteria they use to evaluate the credibility of the health information that they find, and what message qualities engage them when they encounter a health information message online, through either purposeful search or incidental acquisition, while engaged in another activity.
INFORMATION RELEVANCE AND CREDIBILITY Credible health information, and the Internet or social media venue that provides it, must be relevant to the health information seeker. This means that the information source must be deemed credible by the information seeker, and the information that it provides must hold
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meaning based on the user’s immediate situation. If the information is not considered credible or relevant, it will not be considered useful and will not be retained. Schamber and Eisenberg39 proposed such a user-centered view of information relevance. They said that relevant information satisfies the user because it relates to an information need that is specific to the user’s situation. Drawing upon their Theory of User-Centered Relevance, this work seeks to answer four research questions: 1. Where do 18- to 30-year-old college students search for health information? 2. What type of information do they seek and why? 3. What criteria do they use to determine if the site where health information is found is credible? 4. What criteria are used to determine if an online health information message is credible?
Health information must be presented on Internet sites that the user believes are credible, and the message itself must be deemed credible by the user before it can be attended to and before it can provoke a move to healthy behavior change.
within the texts. Then responses were iteratively classified, then grouped into higher-level hierarchical categories based on the research question being evaluated. The following sections describe the results of the text analysis.
RESULTS Where Do Users in the 18- to 30-Year Age Range Search for Health Information? At the beginning of each focus group, the purpose of the session and reason for recording it were explained. The first question to participants was ‘‘Where do you generally look for health information?’’ Participants specified Internet/social media sites 97 times (or 87% of the time), TV shows four times (4% of the time), and face-to-face (FTF) interactions 10 times (9% of the time). This clearly indicates that users of this generation obtain the majority of their health information online. Table 1 displays the
T a b l e 1 Sources of Health Information on the Internet by Type and Frequency Specified
RESEARCH METHOD Approval was received from the institutional review board at this southwestern university, ensuring compliance with ethical guidelines for the conduct of research. The convenience sample for this qualitative study was composed of 49 college students between the ages of 18 and 30 years, drawn from undergraduate business core classes at the university. The sample population had an almost even number of males (24) and females (25). Students participated in one of five recorded focus group sessions with the investigator in a location on campus that was private, familiar to the students, and highly accessible. Focus groups ranged in size from seven to 12 participants and lasted about 45 minutes each. Individually and collectively, focus group discussions continued until saturation in responses occurred, and no new information was introduced. At the conclusion of the recorded sessions, each session was transcribed and coded into categories using MaxQDA text analysis software (VERBI GmbH, Berlin, Germany; http://www.maxqda.com). By coding speech into categories, large amounts of text can be organized so that patterns undiscernible by listening become clear. Using the method recommended by Bogdan and Biklin,40 transcripts were first ordered by groups, and each line of each transcript was numbered, so that texts could be traced back to specific transcript locations. Initially, many categorical codes were created as transcripts were read twice, during undisturbed sessions. Codes were heuristic, as described by Seidel and Kelle,41 meaning that they were flexible and allow the researcher to group similar ideas and ‘‘discover’’ trends 136
Site Type and Name Internet search engine Google Yahoo Answers Sites from search engine using keywords Bing, AOL
No. of Times Specified 23 6 5 1 each (2) 3
Google Answers Social media Health blogs 14 Facebook 7 YouTube 6 Reddit or Twitter 2 each (4) Instagram, Tumblr 1 each (2) Popular Internet health sources WebMD 14 11 Professional medical site (including United HealthCare, Dr Oz, Mayo Clinic, BCBS, ZocDoc, Health.org) Television health information sources The Doctors TV show 2 ‘‘House’’ TV drama 1 Biggest Loser (weight loss 1 program) FTF health information sources FTF interactions See family doctor 8 Mom or clinical family member 2 Total 101 10
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number of times that participants mentioned a specific online source of health information. While the use of Internet search engines or directly accessing particular Internet Web sites was not surprising, the data show that social media is also a significant source of medical information for this age group. Participants stated that they used social media sources for health information specifically ‘‘because a lot of them [other users] are having the same problem I am’’ or another user on these sites ‘‘had asked the same question,’’ and as a result, ‘‘the best answer was already identified.’’ This is consistent with information provided by Fox,42 who pointed to the growth of ‘‘peer-to-peer healthcare’’ and the importance of technology and Internet platforms that make the exchange of health information useful for as many people as possible. Fox said that ‘‘one in five Internet users has gone online to find others who might have health concerns similar to his/hers.’’42 Focus group participants offered these confirmatory statements: I just think, like, this generation, I don’t know, I guess we go to other people, you know, for answers. You really have lots of help out there, from people who are suffering every day and who can tell you, ‘‘don’t waste your time on this place or zero in on this location,’’ so that is a good idea. My sister has a thyroid problem, and she wasn’t able to get really good treatment from doctors, so she did find a blog like that to find suggestions from people who had the exact same experience as she has had, and it kind of set her on the right track. Like random Tumblr sites. People will input information, just kind of talk about good foods to eat and good exercise routines and stuff and those are the sites I visit if I am looking for, like, wellness tips.
Of interest is the limited number of times that participants mentioned finding useful health information on television (four times). Two individuals independently reported acquiring useful health information while watching The Doctors TV show. One participant noted that ‘‘I’ve picked up a lot of information by watching stuff like ‘House’ (a medical drama on television).’’ In 2008, Arroyave43 explored Education Entertainment, the intentional inclusion of a health education message within an entertainment venue as a means to educate the public and promote healthy behaviors. According to Arroyave,43 Entertainment Education has been used successfully both here in the US and in more than 50 international locations. Participants confirmed that this is the case, and some use these programs as a springboard to further investigation: There is an actual show, with doctors, called ‘‘The Doctors.’’ They have kind of like question-and-answer-type sessions on the show. I mean, it gets pretty interesting, with the different topics in the show to talk about—and they even have their very own Web site.
Because I know like with Dr Oz, we watch his show, and then we go to his Web site because we want the full breakdown. Like he was talking about natural ways to take care of, like, antihistamines, and that’s like, that’s fine, but what does it interact with if I am taking other things and you know, can I take it for long periods of time, and all that. And he can’t cover that in the short time that he has, but if you go on to his Web site, then the information is really detailed.
What Type of Information Is Sought and Why? When asked what type of health information they sought in the last month, participants searched with nearly equal frequency for wellness information as for information about minor physical symptoms or a diagnosis of concern for a family member. This is not unexpected, given the age group of the respondents. Table 2 reflects the specific types of health information sought by participants in these two categories. In terms of wellness information, participants looked for information about maintaining health through exercise 25% of the time, dietary information 16% of the time, and information about weight loss 14% of the time. Alternatively, they searched for information when something was wrong with their bodies 37% of the time, information about a diagnosis they had been given 6% of the time, and information about a dental problem 2% of the time. One might anticipate that the ratio of wellness information sought versus information about illness might shift as individuals get older. Future research can examine the distribution of responses in other age groups. A few participants specifically mentioned that the reason that they were using technology-based health resources was that they were unhappy with the traditional medical establishment. Three people reported searching for information on the Internet because they were dissatisfied with the treatment provided by their family physician, whereas others said that they used the Internet to avoid a visit to the doctor because ‘‘all he will do is overprescribe prescription medication.’’ Several participants mentioned that T a b l e 2 Types of Health Information Sought Type of Health Information Sought Wellness information Maintaining health through exercise Dietary Information Information about weight loss Information about Illness ‘‘Something is wrong with my body’’ ‘‘I have been diagnosed with something’’ ‘‘I need information about a dental problem’’
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No. of Times Identified 12 8 7 18 3 1
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they could get information from others engaged in social media venues that their physicians would not offer them, such as nontraditional treatment options or information about herbal medicines.
What Criteria Are Used to Determine if the Health Information Is Credible? Most of the participants were searching for health information for themselves (19 participants or 39%). Others searched for information for family members (five participants or 10%), or friends/non–family members (nine participants or 18%). With the recognized willingness of users to take information from other users, users must create informal criteria for determining information credibility, and it is important to identify these criteria. Because any Web 2.0 user is able to post information, one of the greatest concerns among health professionals is information accuracy.19,44 Focus group participants were asked how they determine if the health information that they find on any of the identified sites is credible. The criteria that participants provided can be broken down into two categories: site credibility and message credibility, as shown in Table 3.
What Criteria Make a Health Information Message Relevant and Credible? Designing engaging health messages and posting them in locations where users are likely to discover them incidentally are critical to the successful use of social media venues in health education. Participants were asked, ‘‘What would make you pay attention to health information if you found it when you weren’t looking for it, and what would make it engaging?’’ Many of the criteria that they offered for either engaging or disengaging with incidental Ta b l e 3 Criteria for Assessment of Health Information Credibility Site Credibility Criteria Name recognition as professional medical site Prior positive experience with site Good site reviews from other users Professional site appearance Information is current and frequently updated
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Message Credibility Criteria Statistics provided References provided Specifics given Information provided is consistent with known facts Information provided is consistent with previous experience
health information were related to aesthetic appeal and site utility. Their responses appear in Table 4. Participants mentioned that the entertainment value of the message often caused them to engage in incidentally encountered health information, as shown in Table 4. Past research found that humor is an important factor in stimulating recall of information, which is especially important when information is acquired incidentally.45 However, Moyer-Guse et al46 reported that while ‘‘there is increasing evidence to suggest that humor provides a unique context within which persuasive effects can occur,’’(p766) they cautioned that the use of humor could trivialize the important health message conveyed. With this in mind, focus group participants were asked ‘‘which type of health education message do you think would be most persuasive to you—a humorous message, a message designed to invoke fear, or a message that was simply informative?’’ Most participants felt that a humorous message would be most effective and said a message that provoked fear would be most ineffective. One person did note, however, that humor would not be welcome if they had a serious health concern and stated that humor would negate the impact of the message. Finally, participants were asked what would provoke them to share a health information message with others. The most common provocation was ‘‘if the information was relevant.’’ Other motivations to share included ‘‘engaging message,’’ ‘‘made an impression on me,’’ ‘‘if I felt strongly about it,’’ and ‘‘if it helped me.’’
CONCLUSIONS This study contributes to the understanding of user preferences in the presentation of health information on the Internet. The information gained through focus groups with 18- to 30-year-old college students helps health educators to present health education messaging in venues and within parameters attractive to this user group. Focus group participants confirmed their substantial engagement with health information sources on the Internet. Whether actively seeking health information for themselves or others or acquiring information associated with wellness or illness, these users value the opportunity to interact with others. They want information that allows them to be more actively in charge of their own health. Some participants have preferred Internet health information sources, whereas others ‘‘Google it!’’ or conduct a keyword search using another Internet search engine. In reviewing search results, they evaluate information sources by assessing both the site and message credibility. The specifics gathered in this study, shown in Table 3, provide site developers insights in what they need to be attuned to when creating a health-oriented Web site. For example, in terms of site credibility, it is important that
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T a b l e 4 Message Design Factors that Matter Aesthetics
Functionality
Deterrents
Engaging title Site navigation Annoyances ‘‘Too many popups; streaming ‘‘Links that work’’; ‘‘a function within the ‘‘Cool title’’; ‘‘weird headline,’’ ‘‘a title such chat,’’ ‘‘more than 2 min long,’’ Web site that lets you get from one as The One Thing You Didn’t Know ‘‘music if the topic is serious, that place to another fast,’’ ‘‘easy to access,’’ About X,’’ ‘‘a title that gets the point is for entertainment’’; ‘‘too many ‘‘easy to navigate on the site’’ across quickly,’’ ‘‘title that intrigues me,’’ ads,’’ ‘‘site that forces you to view ‘‘catchy title’’ ads before viewing content,’’ ‘‘ads are a turnoff and I ignore them’’ Visual appeal Clear focus Emotional deterrents ‘‘If the message is frightening,’’ ‘‘Good description that tells me it is ‘‘Eye-catching picture,’’ ‘‘really creative or ‘‘fear doesn’t work,’’ ‘‘I don’t want relevant to me’’; ‘‘clear statement of weird and eye catching,’’ ‘‘something to see something that brings benefits or things that could hurt you’’; that grabs your eye,’’ ‘‘good preview my mood down’’; ‘‘site isn’t ‘‘proper links’’ picture,’’ ‘‘nice screenshot’’; ‘‘something secure so I don’t feel safe’’; red, like caution’’; ‘‘if I see a celebrity,’’ ‘‘clearly inaccurate’’ ‘‘professional appearance,’’ ‘‘proper colors,’’ ‘‘looks like it was put together by someone who knew what they were doing,’’ ‘‘videos are good if I am worried,’’ ‘‘good for visual learners’’; ‘‘videos are thorough’’ Auditory appeal Functional message format ‘‘Catchy music’’ ‘‘I like text because it is easy,’’ ‘‘text lets me refer to it later,’’ ‘‘easy to skim,’’ ‘‘I can quickly scan a document for what I want’, ‘‘faster to read it,’’ ‘‘I can come back to text later,’’ ‘‘easy to read and understand’’ Entertainment value ‘‘If it appeals to the senses’’; ‘‘something shocking,’’ ‘‘something comical,’’ ‘‘something humorous,’’ ‘‘humor would make me remember it more,’’ ‘‘how many views it has,’’ ‘‘if a lot of people watched, it is probably good,’’ ‘‘interesting,’’ ‘‘if it intrigues me’’; ‘‘videos are fun to watch’’
the site has a professional-looking design and that information on the site is current and frequently updated. Developers should also provide a mechanism to allow a clinical moderator to evaluate comments left on the site and to provide objective feedback that validates or refutes user comments and improves information accuracy. Reviews and comments are key ways in which individuals determine whether they should initially access and/or remain on a site. Procedures should be in place to leverage positive reviews and to take proactive steps correcting issues highlighted in negative reviews. In terms of message credibility, both references and statistics should be given on sites maintained by health professionals. Specific information should be provided that is consistent with known facts and experience. Future empirical research should examine the relative importance of these factors in terms
of creating site and message credibility in the health context and the degree to which each of these types of credibility is related to the draw of the Web site (in terms of both the users returning to the site, as well as the amount of time they spend on their visits). Table 4 shows that respondents used three major categories of criteria to evaluate whether a health information message is relevant and memorable, particularly if it is found incidentally: aesthetics, functionality, and deterrents. To make the message memorable, designers should ensure that titles are catchy and that they pay attention to both auditory as well as visual appeal and should potentially consider the entertainment value provided. College student users value easy navigation, brevity, and messages with a clear focus. They reported that these are the key factors that attract health information seekers to health
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information on the Internet. Difficult navigation, poor site design, too many ads or popups, and irrelevant information are most likely to detract from user engagement in this population. In general, college student users will share health information that they find relevant, engaging, and helpful to them. Future research should examine college student preferences for health message presentation style (ie, threat appeal vs factual or entertaining/humorous appeals). Additional empirical research is also needed to validate the strength of each of these factors in creating college student user perceptions of relevant/memorable messages.
PRACTICAL IMPLICATIONS This work makes an important contribution to research by establishing how social networks on the Internet are effective in communicating health education about risk prevention and disease management to targeted user groups, such as 18- to 30-year-old college students. An equally important outcome of this research it that it provides a foundation and direction for future work. In addition to the suggestions above, future work should explore whether health education presented by an individual that is well known or easily recognized (eg, a celebrity) is more effective in reaching 18- to 30-year-old college students. Or, would these users be more receptive to health information presented by an official source, such as the American Medical Association, the American Cancer Society, or the CDC? Future work should also be directed at correlating user characteristics with the perception of content relevance for health information presented via social media venues. This study shows that the Internet and social media messages can convey important health information and provides initial information about the message characteristics that will be effective. The value of this work extends to a variety of groups that provide health information to 18- to 30-year-olds so the findings have implications beyond nursing professionals to professionals such as health educators, public health workers, and physicians. However, more research is needed in this area.
REFERENCES 1. Tian Y, Robinson J. Accidental learning of health information among cancer victims and cancer free adults. In: National Communication Association Conference Paper. Washington, DC: National Communication Association; 2007;1. 2. Cleveland A, Cleveland D. Health Informatics for Medical Librarians. New York, NY: Neal-Schuman Publishers, Inc; 2009. 3. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Upper Saddle River, NJ: Prentice Hall; 1986. 4. Kreuter MW, Wray RJ. Tailored and targeted health communication: strategies for enhancing information relevance. Am J Health Behav. 2003;27(suppl 3):S227–S232.
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5. Lanning BA, Doyle EI. Health literacy: developing a practical framework for effective health communication. Am Med Writers Assoc J. 2010;25(4):155–161. 6. Rosenstock IM. Why people use health services. Milbank Med Fund Q. 1966;44:94–124. 7. Kahn J. The wisdom of patients: health care meets online social media. Med Benefits. 2008;25(13):12. 8. Suggs LS. A 10-year retrospective of research in new technologies for health communication. J Health Commun. 2006;11(1):61–74. 9. The health communicator’s social media toolkit. 2011. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/SocialMedia/ Tools/guidelines/. Accessed March 24, 2012. 10. Evans WD. Social marketing campaigns and children’s media use. Future Child. 2008;18(1):181–203. 11. Eng TR, Gustafson DH, Henderson J, Jimison H, Patrick K. Introduction to evaluation of interactive health communication applications: science panel on interactive communication and health. Am J Prev Med. 1999;16(1):10–15. 12. Cline RJ, Haynes KM. Consumer health information seeking on the Internet: the state of the art. Health Educ Res. 2001;16:671–692. 13. Levanthal H. Findings and theory in the study of fear communication. In: Berkowitz L, ed. Advances in Experimental Social Psychology. New York, NY: Academic Press; 1970:119–186. 14. Rogers RW. A protection motivation theory of fear appeals and attitude change. J Psychol. 1975;91(1):93–114. 15. Wilson TD. Information behavior: an interdisciplinary perspective. Inform Process Manag. 1997;33(4):551–572. 16. Witte K, Meyer G, Martell D. Effective Health Risk Messages: A Step-by-Step Guide. Thousand Oaks, CA: Sage; 2001. 17. Morris M, Consolvo S, Munson S, Kramer A, Patrick K, Tsai J. Facebook for Health: Opportunities and Challenges for Driving Behavior Change. Panel discussion at the ACM CHI Conference on Human Factors in Computing Systems, Vancouver, BC, Canada; May 7–12, 2011. 18. Choi SM, Kim Y, Sung Y, Sohn D. Bridging or bonding? A crosscultural study of social relationships in social networking sites. Inf Comm Soc. 2011;14:107–129. 19. Colineau N, Parisa C. Talking about your health to strangers: understanding the use of online social networks by patients. New Rev Hypermed Multimed. 2010;16(1–2):141–160. 20. Newman MW, Lauterbach D, Munson SA, Resnick P, Morris ME. It’s not that I don’t have problems, I’m just not putting them on Facebook: challenges and opportunities in using online social networks for health. In Proceedings of the ACM 2011 conference on Computer Supported Cooperative Work. New York, NY: Association for Computing Machinery; 2010:341–350. 21. Chan C, Kaufman D. A framework for characterizing eHealth literacy demands and barriers. J Med Internet Res. 2011;13(4):e94. 22. Norman CD, Skinner HA. eHEALS: the eHealth literacy scale. J Med Internet Res. 2006;8(4):e27. 23. Hanson C, West J, Neiger B, Thackeray R, Barnes M, McIntyre E. Use and acceptance of social media among health educators. Am J Health Ed. 2011;42:197–204. 24. Abrahamson JA, Fisher KE, Turner AG, Durrance JC, Turner TC. Lay information mediary behavior uncovered: exploring how nonprofessionals seek health information for themselves and others online. J Med Libr Assoc. 2008;96(4):310–323. 25. Chou WS, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res. 2009;11(4):e48–e48. 26. Haridakis P, Hanson G. Social interaction and co-viewing with YouTube: blending mass communication reception and social connection. J Broadcast Electron. 2009;53(2):317–335. 27. Taylor RS. Value added processes in the information life cycle. J Am Soc Inf Sci. 1982;33(5):341–346. 28. Liu Y. Social media tools as a learning resource. J Educ Tech Devel Exch. 2010;3(1):101–114. 29. Luo JS. Patient education in the Internet age. Prim Psychiatry. 2008;15(4):24–26. 30. Scale M. Facebook as a social search engine and the implications for libraries in the twenty-first century. Library Hi Tech. 2008;26: 540–556.
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31. Ivanitskaya L, O’Boyle I, Casey AM. Health information literacy and competencies of information age students: results from the interactive online Research Readiness Self-assessment (RRSA). J Med Internet Res. 2006;8(2):e6. doi: 10.2196/jmir.8.2.e6. 32. Ickes MJ, Cottrell R. Health literacy in college students. J Am Coll Health. 2010;58(5):491–498. 33. Wilson TD. Information behavior: an interdisciplinary perspective. Inf Proc Manag. 1997;33(4):551–572. 34. Williamson K. Discovered by chance: the role of incidental information acquisition in an ecological model of information use. Libr Inform Sci Res. 1998;20(1):23–40. 35. Erdelez S. Information encountering. In: Fisher K, Erdelez S, McKechnie L, eds. Theories of Information Behavior; Medford, NJ: Information Today, Inc; 1997;179–184. 36. Smith SW, Nazione S, LaPlante, et al. Topics and sources of memorable breast cancer messages and their impact on prevention and detection behaviors. J Health Commun. 2009;14(3):293–307. 37. Kelly BJ, Niederdeppe J, Hornik RC. Validating measures of scanned information exposure in the context of cancer prevention and screening behaviors. J Health Commun. 2009;14(8):721–740. 38. Tewksbury D, Weaver AJ, Maddex BD. Accidentally informed: incidental news exposure on the world wide web. J Mass Comm Q. 2001;78(3):533–554.
39. Schamber L, Eisenberg M. Relevance: The Search for a Definition. Paper presented at the Annual Meeting of the American Society for Information Science; Atlanta, GA; October 1988. 40. Bogdan RB, Biklin SK. Qualitative Research for Education: An Introduction to Theory and Methods. 3rd ed. Needham Heights, MA: Allyn and Bacon; 1998. 41. Seidel J, Kelle U. Different functions of coding in the analysis of textual data. In: Kelle U, ed. Computer-Aided Qualitative Data Analysis: Theory, Methods and Practice. London, UK: Sage; 1995. 42. Fox S. Peer to Peer Health. Keynote address. Medicine 2.0. ’11 Congress at Stanford University; Stanford, CA; September 2011. 43. Arroyave J. Testing the effectiveness of an entertainment-education health-focused soap opera: exposure and post-discussion in Colombian young adults. Investig Desarrollo. 2008;16(2):232–261. 44. Nasser S, Mullan J, Bajorek B. Assessing the quality, suitability and readability of Internet-based health information about warfarin for patients. Australas Med J. 2012;5(3):194–203. 45. Summerfelt H, Lippman L, Hyman IE. The effect of humor on memory: constrained by the pun. J Gen Psychol. 2010;137(4): 376–394. 46. Moyer-Guse E, Mahood C, Brookes S. Entertainment-education in the context of humor: effects on safer sex intentions and risk perceptions. Health Commun. 2011;26(8):765–774.
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& Vol. 33, No. 4, 132–141 & Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
F E A T U R E A R T I C L E
Social Media The Key to Health Information Access for 18- to 30-Year-Old College Students GAYLE PRYBUTOK, PhD, MBA, BSN SHERRY RYAN, PhD
The provision of timely, accurate, and relevant health information that facilitates lifestyle changes in targeted populations is a public health imperative.1 Consumer Health Informatics (CHI) is defined as the development and implementation of Internet-based systems to deliver health risk management information and health intervention applications to the public.2 Over the last 40 years, CHI revolutionized both health education and healthcare delivery. As a result, the application of CHI to a wide range of public health educational and interventional efforts has recently garnered attention from both consumers and health communication researchers. While these communications reach a large audience, a gap in outreach to many younger users still exists, despite their engagement in the Internet. An important step in reaching this audience is to understand how they access health information and, more specifically, eHealth, or Internet-based health information. This work makes a research contribution that also has an implication for practice, because it builds on Bandura’s Social Learning Theory3 to identify how this younger population segment accesses eHealth information.
TARGETED HEALTH MESSAGES Kreuter and Wray4 reported that in health communication targeted messages are those designed to reach a population subgroup based on characteristics that members of the subgroup share. Health communication researchers recognize that a thorough understanding of the target audience and the way that they acquire health information online is a priority in designing relevant health information materials for an online venue.5 In 1966, Rosenstock6 proposed the Health Belief Model. The model, used in many successful health communication 132
This work examines where 18- to 30-year-old college students seek health information on the Internet and how they determine site and message credibility. Using a qualitative methodology, five focus groups were conducted with 18- to 30-year-old college students, and transcripts were analyzed with MaxQDA text analysis software. The study revealed that 18- to 30-year-old college students have Internet health information source preferences, reasons for seeking health information on the Internet, and message design factors that improve their perception of site and message credibility. We conclude that the Internet and social media show great promise as effective health communication channels for 18- to 30-year-old college students and confirm that preferred Internet/social media sites can be utilized by health educators to present important risk management/disease prevention information to 18- to 30-year-old college students. In addition, message design factors can lend credibility to both sites and the health information delivered there. KEY WORDS College students & Consumer health informatics & Health education & Social media
campaigns, posited that specific beliefs in a target population should be targeted to provoke positive health behavior changes in that population.
THE INTERNET AS A HEALTH INFORMATION CHANNEL The Internet is a health information channel that provides data in real time, cost-effectively, and allows a plurality of Author Affiliations: College of Information, Department of Library Information Science (Dr Prybutok); and College of Business, Department of Information Technology and Decision Sciences (Dr Ryan), University of North Texas, Denton, TX. The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article. Corresponding author: Gayle Prybutok, PhD, MBA, BSN, College of Information, University of North Texas, 1155 Union Circle #311068, Denton, TX 76203-5017 ([email protected]). DOI: 10.1097/CIN.0000000000000147
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users to acquire new information or adopt new behaviors quickly.7,8 In fact, the Centers for Disease Control (CDC) published broad guidelines for health educators on the effective use of social media to communicate health information after the recent H1N1 crisis. Between June 2010 and August 2011, the CDC published guidelines and best practice documents for the use of Facebook, online videos, Twitter, text messages, e-cards, widgets, buttons, and badges, entitled The Health Communicator’s Social Media Toolkit.9 The term ‘‘social media marketing’’ is now used to describe a use of social media that incorporates ‘‘the principles and processes of commercial marketingI with a goal to design and implement programs to promote socially beneficial behavior change.’’10(pp183–184) Eng et al11 introduced the concept of interactive health communication (IHC), relevant because of the concurrent increase in the use of social media in eHealth communication. The authors defined IHC as the interaction between a person (patient, caregiver, professional, or consumer) and health information, mediated by a communication technology.11 This concept is relevant to the expanding use of social media in eHealth communication. Cline and Haynes12 proposed that IHC offers advantages to the healthy public, to those that are ill, and to caregivers, healthcare providers, and educators. It is clear that the use of social media as an eHealth marketing and eHealth education channel has arrived.
HEALTH MESSAGE DESIGN Many health communication researchers have explored parameters for health message design.13–16 Morris et al17 wisely noted that ‘‘to motivate behavior change, health messaging needs to be both persuasive and pervasive. It needs to be part of the rituals and environments—social as well as technological—that define daily life.’’16(p444) Internet use and engagement in social networking have become essential aspects of many users’ daily routines. As a result, users have gained experience and a degree of proficiency that have made online social engagement and interaction a familiar and trusted experience.18 Social media sites allow users to acquire the most current information available about health issues, to engage with other users facing the same issues, and to actively manage their own health.8 Colineau and Parisa19 said that patients have begun to use online social networks to form communities that discuss the physical and emotional aspects of illness with others who share the same experiences, as they do on sites such as Patients Like Me (www.patientslikeme.com). This has changed the customary relationships that patients have with their physicians. Online health communities offer members the benefit of others’ experiences with specific treatments or strategies for managing behaviors associated with specific health issues that often patients find more relevant than information from their medical professionals.20
THE EVOLUTION OF HEALTH LITERACY Another consequence of the digital age to both information science and consumer health informatics is the need to revise the concept of health literacy to include a wider cluster of skills that users must possess to benefit from digital information and to use it effectively. It is important to identify skills and access barriers in order to help underserved populations to use technology and to participate in their own healthcare.20 Chan and Kaufman21(pe94) defined eHealth literacy as ‘‘a set of skills and knowledge that are essential for productive interaction with technology based health tools.’’ In their more specific definition of eHealth literacy, Norman and Skinner22 detailed six types of literacy required of Internet-based health information consumers in the Internet age. These include computer literacy (skills related to using a computer); information literacy (the ability to express information needs and to find, assess, and use information to acquire knowledge and share it); media literacy (the ability to choose, understand, and use information represented in audio or visual forms); traditional literacy and numeracy (reading/writing/communicating, the ability to interpret scales and graphical representations of information); science literacy (familiarity with science concepts and scientific method and to apply scientific reasoning); and health literacy (ability to find, assess, and apply relevant health information when using health services and making health decisions). Traditional offline mechanisms are still successful in reaching large segments of the public. However, they remain ineffective in reaching a large segment of younger users who have moved to heavy engagement in Internetbased communication and socialization and who have developed a number of the skills necessary for eHealth literacy. In addition, there are users of all ages who are not intentionally looking for information on health issues but can benefit from finding it incidentally, while engaged in other activities on the Internet, and attending to it. This work makes a valuable contribution to the current body of knowledge in healthcare education and extends the reach of current educational efforts. While we now know a great deal about effective health message design, we have not yet determined which online message communication venues are most effective in reaching targeted populations. As technology continues to drive clinical practice, so must the information channels that deliver important health education messages evolve. Contemporary information channels such as the Internet and social media enable health educators to creatively bring essential health information to targeted user groups. In order to do that, there is a need to understand where targeted use groups seek health information and why. That is the aim of this work. Armed with a clearer view of specific groups of users who seek health information on the Internet and of their health information–seeking behaviors, educators can
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design and present health messages that will engage these user groups and positively affect health behaviors. This investigation, based on data gathered from focus groups, will clarify the health information–seeking behaviors and preferences of 18- to 30-year-old college students who report the use of Internet and social media sites to acquire important health information. As such, this study lays an important foundation for future quantitative research that empirically links specific user characteristics with health information–seeking behaviors identified in this study. In addition, user criteria for determining online health message credibility discovered in this study can be tested in future work.
BACKGROUND Historically, health educators disseminated health information verbally, via printed materials or via mass media communication channels such as radio and TV.23 However, health information delivery models changed with the emergence of the World Wide Web, and as a result, so have health information consumers. Consumers no longer passively accept the word of their healthcare providers. They want to be informed. They actively seek health information and want to collaborate with healthcare providers about the medical treatment that they receive. The Internet is a health information channel that provides data in real time, cost-effectively, and that facilitates the timely acquisition and exchange of health information and adoption of healthy behaviors.7
REASONS FOR HEALTH INFORMATION SEEKING ON THE INTERNET An important question that this work helps to address is: Why do 18- to 30-year-old college students seek health information on the Internet? In general, healthy people look for health information that confirms their sense of physical health. The sick seek information about their disease process, treatment options, and prognosis.24 A third type of health information seeker looks for ‘‘information on behalf or because of others, without necessarily being asked to do so or engaging in follow up.’’24(p310)
SOCIAL MEDIA AND HEALTH INFORMATION Social media exists in many forms. Social media includes familiar sites, such as MySpace, Twitter, Facebook, and YouTube, and professional sites, such as LinkedIn, blogs of all kinds, and online medical support groups. Social media sites are helping consumers to make important health decisions.8,19 Social media reaches users regardless of differences in race, educational level, ethnic background, or access to 134
healthcare.25 Haridakis and Hanson26 examined why and how people choose a particular social media venue and concluded that users choose social media sites that meet their needs at the time. They determined that user choices are also linked to their personalities and social styles. Consequently, healthcare marketers and health educators have begun to explore social media venues to better understand which venues are most appropriate for consumers in different age groups and most relevant for the topic area that initially provokes the consumer’s search.
SOCIAL LEARNING THEORY In 1986, Bandura3 introduced Social Learning Theory. Social Learning Theory is important in considering the educational potential of social media. Prominent in psychology and education, the theory proposed that people learn by observing others in the context of their experiences, social interactions, and media influences. The decision to adopt the behavior is dependent on whether the behavior results in reward or punishment and whether the behavior has a positive outcome. Bandura3 proposed that behavior is the result of a combination of behavior, cognition, environment, and physiology and that observational learning depends on four related cognitive processes: attention, motivation, production, and retention. Behaviors increase in frequency when positive outcomes are expected and valued and when an individual’s perceived ability to be successful, or his selfefficacy, positively influences his decision making. Bandura’s Social Learning Theory3 plays a significant role in eHealth learning and on the motivation to take protective action. It is useful to consider YouTube and other social media venues an online, social information use environments,27 where people can learn by observing and interacting with others, in the context of social media exchange.
COLLEGE STUDENT ENGAGEMENT WITH SOCIAL MEDIA College student Internet users in the 18- to 30-year age range are actively engaged in using social media for social interaction, relaxation, entertainment, and information exchange. This increases the likelihood that they will encounter important health information posted on these sites.28 The anonymity offered by social media venues can be appealing to young users seeking to preserve their privacy as they explore sensitive health topics.29 The target population of 18to 30-year-old college students has grown comfortable and is secure with exchanging personal information on social media venues with people whom they may not know well.30 However, this does not guarantee that they consider social media sites credible and reliable sources of health information. In order to effectively deliver important health information to 18- to 30-year-old college students, we must know
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why and how they seek or encounter health information, as well as where they prefer to look and what criteria they use to determine both site and message credibility.
COLLEGE STUDENTS AND HEALTH LITERACY Researchers have begun to investigate and assess the general level of health literacy among college students. In 2005, Ivanitskaya et al31 administered the Research Readiness Self-assessment to 400 college students. The Research Readiness Self-assessment included both multiple-choice questions and problem-solving questions designed to measure the participants’ ability to find and evaluate health information and to detect plagiarism. Results demonstrated that only half of the participants were able to identify the most trustworthy health information source. Most participants (84%) identified their research skills as ranging between good and excellent, but many were not able to carry out more complex searches successfully, evaluate the quality of health-related Web sites or articles, or distinguish between a variety of health information sources. In 2010, Ickes and Cottrell32 administered a different assessment instrument to approximately 400 junior and senior college students. The Test of Functional Health Literacy assessed numeracy and reading comprehension, based on the presentation and interpretation of real healthcare materials. They found that most participants (89.3%) thought that health literacy was important, and prior to testing, 86.2% thought that they were already health literate. After testing, the participants had a mean health literacy score of 93.83 out of 100, indicating strong health literacy skills, although many students had difficulty with individual test items. The researchers found that messages that followed the cultural and linguistic patterns of the target audience and that were presented using familiar modalities were more likely to be understood and utilized by members of the target audience. This is consistent with the research of Witte et al,16 who found that health messages that fit the culture, beliefs, and appearance of the target audience yield better responses and greater likelihood of following the protective health behavior.
ACTIVE INFORMATION SEEKING VERSUS INCIDENTAL INFORMATION ACQUISITION Much of the theory on information-seeking behavior addresses the user who actively looks for information. But what about the user who is unaware that he/she has a need or who is not purposefully looking for information? Healthy young people may not be looking for information associated with health risk management or disease prevention. Yet they are the users who stand to benefit the most from health behavior change that can be provoked by such
information. Fortunately, the engagement in social media typical of many young users offers health educators an opportunity to bring essential health education and healthy behavior training to them in a manner that is both enjoyable and memorable. The Internet is a browser-friendly environment that lends itself to the unexpected discovery of useful information.29 The user’s degree of attention depends on the match between the message and the receiver’s interest, familiarity with the topic, motivation, and emotional response.7 Wilson33 said that users often find information while engaging in activities that keep them informed about their environment. Williamson34(p23) extended Wilson’s work and labeled the finding of information by accident ‘‘incidental information acquisition.’’ She said that often the information that the user finds is useful, but it is not something that he/she was purposefully seeking. Erdelez35 identified the same random information collection process, and she called it ‘‘encountering’’ information in a way that the user can remember. More recently, Smith et al36 reported that memorable messages, when recalled later, have the ability to influence behavior. Kelly et al37 recognized that people can acquire a great deal of health information without actually looking for it, and they termed this type of informationseeking behavior ‘‘scanning.’’ They said that it is important to understand how people obtain and use information acquired by scanning during everyday activities in order to learn how to present information in a way that encourages them to make healthy behavioral decisions. Tewksbury et al38 suggested that many Internet users enjoy surfing the Web in order to explore unfamiliar sites. In fact, Tian and Robinson1 found that there is a positive association between incidental information seeking on the Internet and the acquisition of health knowledge. Therefore, it is essential to understand how people get and use health information acquired casually and unintentionally during everyday activities so that important health information is effectively communicated to specific groups. This article explores where and how 18- to 30-year-old college students seek health information on the Internet, what criteria they use to evaluate the credibility of the health information that they find, and what message qualities engage them when they encounter a health information message online, through either purposeful search or incidental acquisition, while engaged in another activity.
INFORMATION RELEVANCE AND CREDIBILITY Credible health information, and the Internet or social media venue that provides it, must be relevant to the health information seeker. This means that the information source must be deemed credible by the information seeker, and the information that it provides must hold
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meaning based on the user’s immediate situation. If the information is not considered credible or relevant, it will not be considered useful and will not be retained. Schamber and Eisenberg39 proposed such a user-centered view of information relevance. They said that relevant information satisfies the user because it relates to an information need that is specific to the user’s situation. Drawing upon their Theory of User-Centered Relevance, this work seeks to answer four research questions: 1. Where do 18- to 30-year-old college students search for health information? 2. What type of information do they seek and why? 3. What criteria do they use to determine if the site where health information is found is credible? 4. What criteria are used to determine if an online health information message is credible?
Health information must be presented on Internet sites that the user believes are credible, and the message itself must be deemed credible by the user before it can be attended to and before it can provoke a move to healthy behavior change.
within the texts. Then responses were iteratively classified, then grouped into higher-level hierarchical categories based on the research question being evaluated. The following sections describe the results of the text analysis.
RESULTS Where Do Users in the 18- to 30-Year Age Range Search for Health Information? At the beginning of each focus group, the purpose of the session and reason for recording it were explained. The first question to participants was ‘‘Where do you generally look for health information?’’ Participants specified Internet/social media sites 97 times (or 87% of the time), TV shows four times (4% of the time), and face-to-face (FTF) interactions 10 times (9% of the time). This clearly indicates that users of this generation obtain the majority of their health information online. Table 1 displays the
T a b l e 1 Sources of Health Information on the Internet by Type and Frequency Specified
RESEARCH METHOD Approval was received from the institutional review board at this southwestern university, ensuring compliance with ethical guidelines for the conduct of research. The convenience sample for this qualitative study was composed of 49 college students between the ages of 18 and 30 years, drawn from undergraduate business core classes at the university. The sample population had an almost even number of males (24) and females (25). Students participated in one of five recorded focus group sessions with the investigator in a location on campus that was private, familiar to the students, and highly accessible. Focus groups ranged in size from seven to 12 participants and lasted about 45 minutes each. Individually and collectively, focus group discussions continued until saturation in responses occurred, and no new information was introduced. At the conclusion of the recorded sessions, each session was transcribed and coded into categories using MaxQDA text analysis software (VERBI GmbH, Berlin, Germany; http://www.maxqda.com). By coding speech into categories, large amounts of text can be organized so that patterns undiscernible by listening become clear. Using the method recommended by Bogdan and Biklin,40 transcripts were first ordered by groups, and each line of each transcript was numbered, so that texts could be traced back to specific transcript locations. Initially, many categorical codes were created as transcripts were read twice, during undisturbed sessions. Codes were heuristic, as described by Seidel and Kelle,41 meaning that they were flexible and allow the researcher to group similar ideas and ‘‘discover’’ trends 136
Site Type and Name Internet search engine Google Yahoo Answers Sites from search engine using keywords Bing, AOL
No. of Times Specified 23 6 5 1 each (2) 3
Google Answers Social media Health blogs 14 Facebook 7 YouTube 6 Reddit or Twitter 2 each (4) Instagram, Tumblr 1 each (2) Popular Internet health sources WebMD 14 11 Professional medical site (including United HealthCare, Dr Oz, Mayo Clinic, BCBS, ZocDoc, Health.org) Television health information sources The Doctors TV show 2 ‘‘House’’ TV drama 1 Biggest Loser (weight loss 1 program) FTF health information sources FTF interactions See family doctor 8 Mom or clinical family member 2 Total 101 10
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number of times that participants mentioned a specific online source of health information. While the use of Internet search engines or directly accessing particular Internet Web sites was not surprising, the data show that social media is also a significant source of medical information for this age group. Participants stated that they used social media sources for health information specifically ‘‘because a lot of them [other users] are having the same problem I am’’ or another user on these sites ‘‘had asked the same question,’’ and as a result, ‘‘the best answer was already identified.’’ This is consistent with information provided by Fox,42 who pointed to the growth of ‘‘peer-to-peer healthcare’’ and the importance of technology and Internet platforms that make the exchange of health information useful for as many people as possible. Fox said that ‘‘one in five Internet users has gone online to find others who might have health concerns similar to his/hers.’’42 Focus group participants offered these confirmatory statements: I just think, like, this generation, I don’t know, I guess we go to other people, you know, for answers. You really have lots of help out there, from people who are suffering every day and who can tell you, ‘‘don’t waste your time on this place or zero in on this location,’’ so that is a good idea. My sister has a thyroid problem, and she wasn’t able to get really good treatment from doctors, so she did find a blog like that to find suggestions from people who had the exact same experience as she has had, and it kind of set her on the right track. Like random Tumblr sites. People will input information, just kind of talk about good foods to eat and good exercise routines and stuff and those are the sites I visit if I am looking for, like, wellness tips.
Of interest is the limited number of times that participants mentioned finding useful health information on television (four times). Two individuals independently reported acquiring useful health information while watching The Doctors TV show. One participant noted that ‘‘I’ve picked up a lot of information by watching stuff like ‘House’ (a medical drama on television).’’ In 2008, Arroyave43 explored Education Entertainment, the intentional inclusion of a health education message within an entertainment venue as a means to educate the public and promote healthy behaviors. According to Arroyave,43 Entertainment Education has been used successfully both here in the US and in more than 50 international locations. Participants confirmed that this is the case, and some use these programs as a springboard to further investigation: There is an actual show, with doctors, called ‘‘The Doctors.’’ They have kind of like question-and-answer-type sessions on the show. I mean, it gets pretty interesting, with the different topics in the show to talk about—and they even have their very own Web site.
Because I know like with Dr Oz, we watch his show, and then we go to his Web site because we want the full breakdown. Like he was talking about natural ways to take care of, like, antihistamines, and that’s like, that’s fine, but what does it interact with if I am taking other things and you know, can I take it for long periods of time, and all that. And he can’t cover that in the short time that he has, but if you go on to his Web site, then the information is really detailed.
What Type of Information Is Sought and Why? When asked what type of health information they sought in the last month, participants searched with nearly equal frequency for wellness information as for information about minor physical symptoms or a diagnosis of concern for a family member. This is not unexpected, given the age group of the respondents. Table 2 reflects the specific types of health information sought by participants in these two categories. In terms of wellness information, participants looked for information about maintaining health through exercise 25% of the time, dietary information 16% of the time, and information about weight loss 14% of the time. Alternatively, they searched for information when something was wrong with their bodies 37% of the time, information about a diagnosis they had been given 6% of the time, and information about a dental problem 2% of the time. One might anticipate that the ratio of wellness information sought versus information about illness might shift as individuals get older. Future research can examine the distribution of responses in other age groups. A few participants specifically mentioned that the reason that they were using technology-based health resources was that they were unhappy with the traditional medical establishment. Three people reported searching for information on the Internet because they were dissatisfied with the treatment provided by their family physician, whereas others said that they used the Internet to avoid a visit to the doctor because ‘‘all he will do is overprescribe prescription medication.’’ Several participants mentioned that T a b l e 2 Types of Health Information Sought Type of Health Information Sought Wellness information Maintaining health through exercise Dietary Information Information about weight loss Information about Illness ‘‘Something is wrong with my body’’ ‘‘I have been diagnosed with something’’ ‘‘I need information about a dental problem’’
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No. of Times Identified 12 8 7 18 3 1
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they could get information from others engaged in social media venues that their physicians would not offer them, such as nontraditional treatment options or information about herbal medicines.
What Criteria Are Used to Determine if the Health Information Is Credible? Most of the participants were searching for health information for themselves (19 participants or 39%). Others searched for information for family members (five participants or 10%), or friends/non–family members (nine participants or 18%). With the recognized willingness of users to take information from other users, users must create informal criteria for determining information credibility, and it is important to identify these criteria. Because any Web 2.0 user is able to post information, one of the greatest concerns among health professionals is information accuracy.19,44 Focus group participants were asked how they determine if the health information that they find on any of the identified sites is credible. The criteria that participants provided can be broken down into two categories: site credibility and message credibility, as shown in Table 3.
What Criteria Make a Health Information Message Relevant and Credible? Designing engaging health messages and posting them in locations where users are likely to discover them incidentally are critical to the successful use of social media venues in health education. Participants were asked, ‘‘What would make you pay attention to health information if you found it when you weren’t looking for it, and what would make it engaging?’’ Many of the criteria that they offered for either engaging or disengaging with incidental Ta b l e 3 Criteria for Assessment of Health Information Credibility Site Credibility Criteria Name recognition as professional medical site Prior positive experience with site Good site reviews from other users Professional site appearance Information is current and frequently updated
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Message Credibility Criteria Statistics provided References provided Specifics given Information provided is consistent with known facts Information provided is consistent with previous experience
health information were related to aesthetic appeal and site utility. Their responses appear in Table 4. Participants mentioned that the entertainment value of the message often caused them to engage in incidentally encountered health information, as shown in Table 4. Past research found that humor is an important factor in stimulating recall of information, which is especially important when information is acquired incidentally.45 However, Moyer-Guse et al46 reported that while ‘‘there is increasing evidence to suggest that humor provides a unique context within which persuasive effects can occur,’’(p766) they cautioned that the use of humor could trivialize the important health message conveyed. With this in mind, focus group participants were asked ‘‘which type of health education message do you think would be most persuasive to you—a humorous message, a message designed to invoke fear, or a message that was simply informative?’’ Most participants felt that a humorous message would be most effective and said a message that provoked fear would be most ineffective. One person did note, however, that humor would not be welcome if they had a serious health concern and stated that humor would negate the impact of the message. Finally, participants were asked what would provoke them to share a health information message with others. The most common provocation was ‘‘if the information was relevant.’’ Other motivations to share included ‘‘engaging message,’’ ‘‘made an impression on me,’’ ‘‘if I felt strongly about it,’’ and ‘‘if it helped me.’’
CONCLUSIONS This study contributes to the understanding of user preferences in the presentation of health information on the Internet. The information gained through focus groups with 18- to 30-year-old college students helps health educators to present health education messaging in venues and within parameters attractive to this user group. Focus group participants confirmed their substantial engagement with health information sources on the Internet. Whether actively seeking health information for themselves or others or acquiring information associated with wellness or illness, these users value the opportunity to interact with others. They want information that allows them to be more actively in charge of their own health. Some participants have preferred Internet health information sources, whereas others ‘‘Google it!’’ or conduct a keyword search using another Internet search engine. In reviewing search results, they evaluate information sources by assessing both the site and message credibility. The specifics gathered in this study, shown in Table 3, provide site developers insights in what they need to be attuned to when creating a health-oriented Web site. For example, in terms of site credibility, it is important that
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T a b l e 4 Message Design Factors that Matter Aesthetics
Functionality
Deterrents
Engaging title Site navigation Annoyances ‘‘Too many popups; streaming ‘‘Links that work’’; ‘‘a function within the ‘‘Cool title’’; ‘‘weird headline,’’ ‘‘a title such chat,’’ ‘‘more than 2 min long,’’ Web site that lets you get from one as The One Thing You Didn’t Know ‘‘music if the topic is serious, that place to another fast,’’ ‘‘easy to access,’’ About X,’’ ‘‘a title that gets the point is for entertainment’’; ‘‘too many ‘‘easy to navigate on the site’’ across quickly,’’ ‘‘title that intrigues me,’’ ads,’’ ‘‘site that forces you to view ‘‘catchy title’’ ads before viewing content,’’ ‘‘ads are a turnoff and I ignore them’’ Visual appeal Clear focus Emotional deterrents ‘‘If the message is frightening,’’ ‘‘Good description that tells me it is ‘‘Eye-catching picture,’’ ‘‘really creative or ‘‘fear doesn’t work,’’ ‘‘I don’t want relevant to me’’; ‘‘clear statement of weird and eye catching,’’ ‘‘something to see something that brings benefits or things that could hurt you’’; that grabs your eye,’’ ‘‘good preview my mood down’’; ‘‘site isn’t ‘‘proper links’’ picture,’’ ‘‘nice screenshot’’; ‘‘something secure so I don’t feel safe’’; red, like caution’’; ‘‘if I see a celebrity,’’ ‘‘clearly inaccurate’’ ‘‘professional appearance,’’ ‘‘proper colors,’’ ‘‘looks like it was put together by someone who knew what they were doing,’’ ‘‘videos are good if I am worried,’’ ‘‘good for visual learners’’; ‘‘videos are thorough’’ Auditory appeal Functional message format ‘‘Catchy music’’ ‘‘I like text because it is easy,’’ ‘‘text lets me refer to it later,’’ ‘‘easy to skim,’’ ‘‘I can quickly scan a document for what I want’, ‘‘faster to read it,’’ ‘‘I can come back to text later,’’ ‘‘easy to read and understand’’ Entertainment value ‘‘If it appeals to the senses’’; ‘‘something shocking,’’ ‘‘something comical,’’ ‘‘something humorous,’’ ‘‘humor would make me remember it more,’’ ‘‘how many views it has,’’ ‘‘if a lot of people watched, it is probably good,’’ ‘‘interesting,’’ ‘‘if it intrigues me’’; ‘‘videos are fun to watch’’
the site has a professional-looking design and that information on the site is current and frequently updated. Developers should also provide a mechanism to allow a clinical moderator to evaluate comments left on the site and to provide objective feedback that validates or refutes user comments and improves information accuracy. Reviews and comments are key ways in which individuals determine whether they should initially access and/or remain on a site. Procedures should be in place to leverage positive reviews and to take proactive steps correcting issues highlighted in negative reviews. In terms of message credibility, both references and statistics should be given on sites maintained by health professionals. Specific information should be provided that is consistent with known facts and experience. Future empirical research should examine the relative importance of these factors in terms
of creating site and message credibility in the health context and the degree to which each of these types of credibility is related to the draw of the Web site (in terms of both the users returning to the site, as well as the amount of time they spend on their visits). Table 4 shows that respondents used three major categories of criteria to evaluate whether a health information message is relevant and memorable, particularly if it is found incidentally: aesthetics, functionality, and deterrents. To make the message memorable, designers should ensure that titles are catchy and that they pay attention to both auditory as well as visual appeal and should potentially consider the entertainment value provided. College student users value easy navigation, brevity, and messages with a clear focus. They reported that these are the key factors that attract health information seekers to health
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information on the Internet. Difficult navigation, poor site design, too many ads or popups, and irrelevant information are most likely to detract from user engagement in this population. In general, college student users will share health information that they find relevant, engaging, and helpful to them. Future research should examine college student preferences for health message presentation style (ie, threat appeal vs factual or entertaining/humorous appeals). Additional empirical research is also needed to validate the strength of each of these factors in creating college student user perceptions of relevant/memorable messages.
PRACTICAL IMPLICATIONS This work makes an important contribution to research by establishing how social networks on the Internet are effective in communicating health education about risk prevention and disease management to targeted user groups, such as 18- to 30-year-old college students. An equally important outcome of this research it that it provides a foundation and direction for future work. In addition to the suggestions above, future work should explore whether health education presented by an individual that is well known or easily recognized (eg, a celebrity) is more effective in reaching 18- to 30-year-old college students. Or, would these users be more receptive to health information presented by an official source, such as the American Medical Association, the American Cancer Society, or the CDC? Future work should also be directed at correlating user characteristics with the perception of content relevance for health information presented via social media venues. This study shows that the Internet and social media messages can convey important health information and provides initial information about the message characteristics that will be effective. The value of this work extends to a variety of groups that provide health information to 18- to 30-year-olds so the findings have implications beyond nursing professionals to professionals such as health educators, public health workers, and physicians. However, more research is needed in this area.
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