Fluent Essays

Analysis on articles JuLY/AuGuST 2012 1541-1672/12/$31.00 © 2012 IEEE 81 Published by the IEEE Computer Society A I A N D H E A L T H Editor: Daniel B. Neill, H.J. Heinz III College, Carnegie Mellon University, [email protected] How Social Media Will Change Public Health Mark Dredze, Johns Hopkins University in-the-moment updates, they’re fi lled with use- ful observations and information about the larger world. Researchers have examined a range of ap- plications based on tweets, ranging from politi- cal polling1 to earthquake monitoring,2 that have demonstrated Twitter’s ability to deliver fast, cheap, and reliable tools for monitoring real-world events. These successes have drawn interest from the public-health community, whose goal is to study the health of a population and develop policies that improve health outcomes. Traditionally, this requires expensive, time-consuming monitoring mechanisms, primarily surveys and data collec- tion from clinical encounters. Even high-priority projects, such as the US Centers for Disease Con- trol and Prevention’s (CDC’s) FluView program that tracks the weekly US infl uenza rate, are still slow because they require clinical data aggrega- tion. Twitter and other social media could reduce cost and provide real-time statistics about public health. Recent work in machine learning and natural language processing has studied the health con- tent of tweets and demonstrated the potential for extracting useful public-health information from their aggregation. This article examines the types of health topics discussed on Twitter, and how tweets can both augment existing public-health ca- pabilities and enable new ones. I also discuss key challenges that researchers must address to deliver high-quality tools to the public-health community. Discovering Health Topics on Twitter Twitter’s size and breadth make it diffi cult to de- termine exactly which types of public-health work it can support. Initial work in my research group3,4 explored health-related tweets and topics on Twitter through the development of new com- putational models. Because many public-health ac- tivities are disease-oriented, we developed a model that discovered diseases (ailments) from raw tweets for guided exploration, rather than relying on pre- defi ned illnesses. We used supervised learning to filter tweets and find health-related messages, yielding 1.6 million English health tweets from March 2009 to October 2010. To explore these tweets, we developed the Ail- ment Topic Aspect Model (ATAM), a probabilistic graphical model for uncovering ailments.3 ATAM assumes that each message discusses a single ail- ment, manifested through the message’s words, and associates three types of words (general dis- ease words, symptoms, and treatments) with ail- ments. For example, the message “fever + head- ache = fl u, home sick with Tylenol” discusses influenza, where “fever” and “headache” are symptoms, “Tylenol” a treatment, and “fl u” a gen- eral word associated with the ailment. Human annotators labeled 15 ailments discov- ered by ATAM, including headaches, infl uenza, insomnia, obesity, dental problems, and seasonal allergies. Examining the words, symptoms, and treatments most associated with each ailment, and the groups of messages that discuss each ailment, can support a variety of public-health initiatives. Augmenting Existing Public-Health Capabilities A core capability of public-health programs, bio- surveillance monitors a population for adverse health events, which include expected seasonal events, such as infl uenza or environmental aller- gies, disease outbreaks, such as the H1N1 virus, and other health threats, such as food poisoning or a biochemical contaminant. Surveillance is the Social media such as Twitter have created platforms for people to broadcast informa- tion, thoughts, and feelings about their daily lives. Since Twitter messages (called tweets) often refl ect IS-27-04-Health.indd 81 7/25/12 12:37 PM 82 www.computer.org/intelligent IEEE INTELLIGENT SYSTEMS key first step in any comprehensive response strategy. Consider the exam- ple of the H1N1 virus, which struck the US in 2009. Public-health offi- cials had to direct vaccine supplies to the areas and populations where they were most needed, requiring accurate information about where H1N1 infec- tions were occurring and which de- mographic groups were most affected. Traditional biosurveillance relies on information collected from clin- ical encounters, a time-consuming process. For example, in the case of influenza tracking, the CDC requires two weeks to collect and release sta- tistics about the US flu rate. Web- based approaches can produce faster results, such as Google Flu Trends,5 which analyzes real-time search que- ries to produce a daily flu rate. When users search for flu-related queries, such as “flu medicine” or “flu symp- toms,” Google aggregates these sta- tistics to measure rises in flu traffic. These have been shown to correlate with the CDC’s official estimates, providing more timely influenza surveillance.5 Analyzing Twitter messages could provide a similar surveillance capa- bility. Studies4,6 have shown corre- lations between influenza tweets and CDC data, using supervised learning and unsupervised learning. This idea has been extended to low- resource settings in developing coun- tries, such as surveillance of cholera in Haiti.7 Because Twitter provides location information for some tweets, biosur- veillance can be geographically local- ized. For example, we visualized the per capita tweeting rate about sea- sonal allergies for the month of June 2010 (in Figure 1, where the darker colors indicate more tweets4). As ex- pected, the Midwest and Northeast have substantial Twitter traffic as compared to other regions of the US, which follows the expected start of allergy season. By contrast, the win- ter months have few allergy messages. Beyond surveillance, Twitter can support other public-health tasks, such as health risk assessments. For example, the annual CDC Behav- ioral Risk Factors Study surveys more than 300,000 people nation- wide for several risk factors, such as asthma, smoking, and exercise. The study is both expensive and time- consuming, making it inappropriate for rapid hypothesis generation and testing. Twitter could augment this survey by investigating additional questions or providing faster results. We compared4 each of the survey ques- tions that had corresponding ail- ments discovered by ATAM across the 50 states, uncovering interesting correlations, such as a positive corre- lation between states with high smok- ing rates and those with high Twit- ter message rates about cancer (r = 0.648), a negative correlation between exercise and obesity messages (r = −0.201), and a negative correlation between good healthcare coverage and messages about ailments in gen- eral (r = −0.253). Creating New Public- Health Capabilities The monitoring of Twitter data can also enable the creation of entirely new public-health capabilities, sup- ported by both the expressiveness of tweets and the coverage of topics not normally included in public-health data, particularly those that people are reluctant to discuss with health- care workers. The public forum of social media encourages messages that express a range of details, yielding health infor- mation such as the illness, symptoms, and treatment strategy—for example, “took some Tylenol for my flu” or “stuck home with flu and 102 fever.” Consider Figure 2, which shows the word cloud for insomnia generated via ATAM output, in which word size corresponds to influenza likeli- hood, and color indicates word type (red are symptoms, green are treat- ments, and blue are general words). Although search engine users might Figure 1. The rate of Twitter messages about seasonal allergies for June 2010. Messages were automatically coded using a machine-learning method and geo- located based on user-provided location. Overall shading indicates significant allergy messages, showing the heart of allergy season. States in the Northeast and Midwest are particularly active. Dashed states had insufficient data. IS-27-04-Health.indd 82 7/25/12 12:37 PM JuLY/AuGuST 2012 www.computer.org/intelligent 83 turn to Google to look for insomnia remedies, Twitter users provide a va- riety of details about their sleepless nights. Additionally, Twitter covers differ- ent topics than those covered by tra- ditional public-health data sources such as clinical encounters and phone surveys. Behaviors that people might be reluctant to share with physicians are on full display on Twitter, includ- ing behaviors, opinions, and sub- populations that are otherwise dif- ficult to track through traditional mechanisms, suggesting a whole new area of large-scale public-health research. Disease self-management can be hard to study, as it doesn’t involve a physician and patients might be re- luctant to share unapproved prac- tices with health officials. We stud- ied medication usage from tweets by creating medication usage pro- files based on ailment groupings.4 For pain relievers, for example, we found that Tylenol and Advil have broad profiles (headache, cold relief, and so on) while Vicodin is targeted at dental problems and injuries. For allerg y medication, Claritin and Zyrtec were almost exclusively used to treat allergies, while off-label uses of Benadryl included insomnia. Mon- itoring medication usage on Twit- ter can discover new trends in self- medication otherwise unreported by patients. The information gap in traditional public health is especially prevalent in patient-directed programs such as weight loss and smoking cessation. These depend on a sustained effort from patients outside the clinical set- ting, making it difficult to track and measure patient efforts. For exam- ple, a recent study of 15,000 tweets found that Twitter is commonly used to manage and share information about health-promoting physical activities.8 Tweets focused on exer- cise included muscle-strengthening, aerobic, and flexibility-enhancing activities. An analysis of the content revealed that most tweets reported evidence of or plans for exercising. The frequency of such messages sug- gests that the social supports provided by Twitter could be used as a plat- form for encouraging exercise and health-promoting behavior. Addi- tionally, roughly 10 percent of the messages posed exercise questions to other users, and many contained ad- vertisements for a product or service. Mining this information could reveal trends of physical activity, as well as new ways of promoting healthy behaviors. Although dental pain is a com- mon proble m , on ly a fe w c om - plaints result in seeing a dentist, and thus clinical evidence covers only a small part of the population. A re- cent study considered reports of den- tal pain on Twitter as a means of surveying a larger spectrum of pa- tients.9 A survey of 772 messages re- vealed a variety of topics, including reporting dental pain, action taken in response, impact on daily life, and advice sought from the Twitter community. More than 80 percent of messages discussed general pain, 22 percent discussed taking some re- sponsive action, and 15 percent dis- cussed impact on daily activities. While actions included seeing a den- tist (44 percent), just as many self- medicated (43 percent). These find- ings show that Twitter can broaden the study population and indicate that effective treatment of dental problems relies on providing accurate information about self-management. The prevalence of dental communi- cations suggests that Twitter can be an effective medium for dental profes- sionals to disseminate self-management information. Twitter is of special interest in stud- ies of patient health behaviors, such as drug and alcohol use. Kyle Prier and colleagues explored tweets about smoking to learn more about tobacco use.10 They used an unsupervised clustering algorithm to group smok- ing tweets, discovering themes that Figure 2. A word cloud visualization showing the words most associated with the ailment “insomnia” as discovered by a machine-learning model that examined 1.6 million tweets related to health. Larger fonts indicate more related terms, blue indicates general terms, red highlights symptoms, and green represents treatments. General words such as “hours,” “awake,” and “tired” characterize insomnia messages, with symptoms such as “nightmares” and “yawning” and treatments of “Benadryl” and “sleeping pills.” IS-27-04-Health.indd 83 7/25/12 12:37 PM 84 www.computer.org/intelligent IEEE INTELLIGENT SYSTEMS reflected general substance abuse, ad- diction recovery, tobacco promotion (bars and clubs), and antismoking ad- vertising campaigns. These themes suggest Twitter as a promising data source for tobacco use behaviors and trends. Each of these studies— on self- medication, exercise, dental pain, and smoking—demonstrates the po- tential for new areas of public-health research based on Twitter data. The next few years promise detailed clini- cal studies using data in each of these areas as well as whole new types of questions. How will Twitter data im- pact the study of community health behaviors, mental health, and biosur- veillance customized to specific de- mographic groups? The development of new technologies coupled with the exploration of these questions has great potential to expand the scope of public-health practice. Automatically extracting mean- ing from text with computational tools is difficult, particularly when the text is multilingual and infor- mal. Yet computational algorithms will be required for practical public health applications of Twitter data. Preliminary research suggests that aggregating millions of messages can resolve difficulties in understanding individual messages: the tweet “head- ache” is ambiguous, but a corre- sponding increase in messages of the form “bad headache, home sick with flu” suggests a common cause. How- ever, a deeper analysis of individual tweets, which might be required for some tasks, remains a challenging problem. In addition, bias pervades all stages of social media analysis: social media users aren’t representative of the en- tire population, user groups may be more or less inclined to tweet infor- mation, and users might report inac- curate or imprecise diagnoses (for ex- ample, influenza instead of H1N1). Controlling for bias is a hallmark of clinical research, yet social media bi- ases are little understood. Large-scale aggregation could help obviate bi- ases for common illnesses. However, smaller populations will require bias correction, which may rely on auto- matically inferring user demograph- ics for sampling adjustments. Finally, social media research must consider user privacy. Even when data are publicly available, users have privacy expectations, such as concern over algorithms that infer unstated user demographics or diagnoses from public data. Although studies have posed little concern so far, an increase in research complexity could cause a commensurate rise in legal and ethi- cal issues. Social media researchers must remain vigilant regarding pri- vacy issues. Regardless, with the development of new technologies addressing these challenges, we can expect to see en- tirely new capabilities for public-health research, policy, and practice. References 1. B. O’Connor et al., “From Tweets to Polls: Linking Text Sentiment to Public Opinion Time Series,” Proc. Int’l Conf. Weblogs and Social Media (ICWSM), AAAI, 2010, pp. 122–129. 2. T. Sakaki, M. Okazaki, and Y. Matsuo, “Earthquake Shakes Twitter Users: Real-Time Event Detection by Social Sensors,” Proc. World Wide Web Conf. (W W W 10), ACM, 2010, pp. 851–860. 3. M.J. Paul and M. Dredze, “A Model for Mining Public Health Topics from Twitter,” tech. report, Johns Hopkins Univ., 2011. 4. M.J. Paul and M. Dredze, “You Are What You Tweet: Analyzing Twitter for Public Health,” Proc. Int’l Conf. Weblogs and Social Media (ICWSM), AAAI, 2011, pp. 265–272. 5. J. Ginsberg et al., “Detecting Influenza Epidemics Using Search Engine Query Data,” Nature, vol. 457, no. 7232, 2008, pp. 1012–1014. 6. A. Culotta, “Lightweight Methods to Estimate Influenza Rates and Alcohol Sales Volume from Twitter Messages,” Language Resources and Evaluation, 2012; www.springerlink.com/content/ x738116375268725/. 7. R. Chunara, J.R. Andrews, and J.S. Brownstein, “Social and News Media Enable Estimation of Epidemiologi- cal Patterns Early in the 2010 Haitian Cholera Outbreak,” Am. J. Tropical Medicine and Hygiene, vol. 86, no. 1, 2012, pp. 39–45. 8. L. Kendall et al., “Descriptive Analysis of Physical Activity Conversations on Twitter,” Proc. Extended Abstracts on Human Factors in Computing Systems (CHI), ACM, 2011, pp. 1555–1560. 9. N. Heaivilin et al., “Public Health Sur- veillance of Dental Pain via Twitter,” J. Dental Research, vol. 90, no. 9, 2011, pp. 1047–1051. 10. K.W. Prier et al., “Identifying Health- Related Topics on Twitter: An Explora- tion of Tobacco-Related Tweets as a Test Topic,” Social Computing, Behavioral-Cultural Modeling, and Prediction, LNCS 6589, Springer, 2011, pp. 18–25. Mark Dredze is an assistant research pro- fessor in computer science and a research scientist at the Human Language Technol- ogy Center of Excellence at Johns Hopkins University. Dredze has a PhD in computer science from the University of Pennsylvania. Contact him at [email protected] Selected CS articles and columns are also available for free at http://ComputingNow.computer.org. IS-27-04-Health.indd 84 7/25/12 12:37 PM 1� Public�Health�Reviews,�Vol.�35,�No�1 Social Media Engagement and Public Health Communication: Implications for Public Health Organizations Being Truly “Social” Amy Burnett Heldman, MPH,1 Jessica Schindelar, MPH,1 James B. Weaver III, PhD, MPH2 ABSTRACT Social media are designed to be engaging, but often are used as a mechanism by public health organizations and practitioners for mass information dissemination rather than engaging audiences in true multi-way conversations and interactions. In this article we define and discuss social media engagement for public health communication. We examine different levels of engagement for public health communication and consider the potential risks, benefits, and challenges of truly embracing the social component in public health practice. Some implications of engagement for public health communication via social media are addressed, and recommendations for future work and research are proposed. Key Words: Social media, engagement, public health communication, public health Recommended Citation: Heldman AB, Schindelar J, Weaver JB III. Social media engagement and public health communication: implications for public health organizations being truly “social”. Public�Health�Reviews. 2013;35: epub ahead of print. INTRODUCTION Inarguably, social media have become an integral part of the public health conversation. The number of users and the voracity with which these users 1 Centers for Disease Control and Prevention, Office of the Associate Director for Communication, Division of Public Affairs, Atlanta, GA, USA. 2 Centers for Disease Control and Prevention, Office of the Associate Director for Communication, Office of the Director, Atlanta, GA, USA. Corresponding Author Contact Information: Amy Burnett Heldman at [email protected]; Centers for Disease Control and Prevention, 1600 E. Clifton Road, MS-E21, Atlanta, GA 30033, USA. 2� Public�Health�Reviews,�Vol.�35,�No�1 consume information on social media sites continues to grow. Data1 show that 67 percent of internet users participate in social networking sites, and Facebook, the most popular social media platform, reported 1.1 billion monthly active users earlier this year.2 How social media can be harnessed to best achieve public health outcomes is a topic of much discussion and study in the public health community. Recent studies3-6 have examined the effectiveness of and implications for using social media and other digital media in health promotion and disease prevention endeavors, finding mixed and, in some cases, less than compelling evidence of efficacy in impacting public health. Others have issued calls to action for increased study and focus on social media and other emerging technologies as part of a comprehensive public health communication strategy.6-8 Unfortunately, as Neiger et al.9 have noted, there is very little evidence to indicate that social media are being adequately used by public health organizations in ways that leverage the ability to have meaningful conversations with our audiences. Similarly, Chou et al.,4 following a review of public health interventions using Web 2.0 and social media, concluded there is a “need to harness the participatory nature of social media.” Public health practitioners, it would seem, must embrace the unique characteristics and functionality of social media to engage members of digital communities in interactive conversations about health; a communication approach that we have labeled social�media�engagement. In this discussion, we define social media as the collection of digital channels and tools (e.g., Facebook, Twitter, and YouTube) used for public health communication. One defining characteristic of all social media is their potential to facilitate engagement—the interactive, synchronous communication and collaboration among numerous participants via tech- nology. There is a multi-way communication, at�the�same�time�but�in�different� places, functionality available through social media, enabling public health organizations to move from basic information dissemination typical of traditional mass media to a fully interactive information sharing dialogue. While many public health organizations, such as the United States Centers for Disease Control and Prevention (CDC), the US Food and Drug Administration (FDA), the World Health Organization (WHO), the American Public Health Association (APHA), and others10-13 have established a social media presence, the role of social media engagement in advancing public health communication work at the organizational level is infrequently discussed. In this article, we look at social media engagement through a public health lens to develop a definition of social media Social�Media�Engagement� 3 engagement for public health endeavors, to discuss the importance of such engagement, and to make practical recommendations for implementing social media engagement in public health communication. SOCIAL MEDIA ENGAGEMENT: IMPORTANCE FOR PUBLIC HEALTH Before we discuss the opportunities presented by social media engagement, it is important to better understand the unique characteristics of social media that make these important channels for public health communication work. The CDC14 has identified the following characteristics that make social media viable channels for public health communication efforts: • Social media can work best when integrated with traditional public health communication channels. While some think social media can be used as independent, stand-alone channels disparate from “traditional” health communication tactics, many of the strategies that work for social media are those that work for and have been proven to be effective for traditional health promotion or other mass communication efforts.3,15,16 Just because social media channels are “new” does not mean that the established body of evidence from years of health communication and promotion research is null and void. Social media work best when integrated into a health communication strategy to support overarching communication goals and objectives. • Through social media, we can target and reach diverse audiences. Just as some audiences may prefer to receive health information via print materials, or from their peers, some audiences prefer to receive health information and communicate with public health organizations online. Indeed, 59 percent of US adults who use the internet reported that they have looked online for health information in the past year,17,18 with 35 percent indicating they had gone online specifically to understand an emerging health condition. With the number of social media users steadily growing,1 social media present an opportunity to reach audiences who may prefer to receive health information through these channels. • Social media allow us to share public health information in new spaces. Social media allow us to share relevant content in new and emerging channels, test how our messages resonate in different spaces, and provide opportunities for multiple exposures to messages. Through the use of social media channels, public health organizations can share relevant content where users are already spending their time. As public 4� Public�Health�Reviews,�Vol.�35,�No�1 health communicators, we can connect “starting where the people are”19 by using social media.20,21 Sharing health content in new spaces allows public health communicators to potentially tap into the large audiences of social media channels. For example, explosive growth in the use of Instagram, a photo-sharing social media site, among African American and Hispanic audiences1 affords a great opportunity to determine the best ways within the channel to target public health messaging for these demographic groups. • We can listen and collect feedback in real-time. A unique characteristic of social media is that we can learn more about our audiences by paying attention to social media conversations at the aggregate level as they are unfolding in real-time. Just as social media have been used to inform and support public health surveillance and epidemiology,22-24 so too can social media be used to scan publicly-available social media content to inform communication activities. Social media monitoring tools allow public health organizations to learn more about what diverse audiences are saying regarding public health topics, identify information gaps, and adjust messaging accordingly. Social media give us insights into what health information may be important and interesting to users, in the moment. This real-time aspect of social media is a key component to ensuring that our communication efforts are relevant, meaningful, and useful to our audiences. • Social media permit us to increase direct engagement. Finally, due to the multi-way, interactive functionality that is inherent to these platforms, social media can allow us to increase direct engagement to maintain and increase trust and credibility, among other engagement benefits that are the subject of further discussion in this paper. We acknowledge the dual nature of social media as a tool both for mass message dissemination to audiences and for multi-way interactions with sizable audience segments. It is this interactive potential that defines social media engagement: lack of interaction is simply broadcasting. As public health communication practitioners, we often focus our efforts on using social media for dissemination. It is not clear, however, if we are using social media to engage with our audiences, and considering what engagement means for the field of public health. What exactly does social media engagement mean for public health communications? Social�Media�Engagement� 5 DEFINING SOCIAL MEDIA ENGAGEMENT FOR PUBLIC HEALTH In the simplest of terms, social media engagement is social—it is par- ticipatory and reciprocal, lending itself to conversations and interactions between and among a public health organization and its diverse audiences via social media channels. Social media has been characterized as mutually beneficial for public health organizations and their audiences to connect to each other in ways that promote a “common good”.9 Drawing from these characteristics, we arrive at a social media engagement definition that frames engagement as a multi-way interaction between and among an organization and digital communities that could take many forms, using social media channels to facilitate that interaction; health messaging is shared in a way that creates opportunities for information to be acted on by the audience, thereby opening a dialogue with the organization that allows both parties to work collaboratively to address issues affecting the health and well-being of the audience. Though new social media channels and terminology have emerged relatively recently in the public health communication area, engagement is not a new concept. Discussions on ways to interact with target audiences and communities for the benefit of public health pre-date social media25,26 and are worth noting due to characteristics shared with social media. Public health defines community� engagement as “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people.”27 Similarly, community� building, as described by Minkler and Wallerstein,26 is “an orientation to the ways in which people who identify as members of a shared community engage together in the process of community change.” Social media engagement is fast emerging as a way to complement and support the existing evidence and best practices from the community engagement and community building perspectives. The Clinical and Translational Science Awards Consortium25 has discussed the potential of “community-mediated forms of communication,” including social media, in engaging the public, because social media provide opportunities for interaction and discussion, build and sustain networks, build trust, mobilize communities, and support engagement, among other benefits. Social media are ideally suited for online community building by facilitating broad and deep� interaction and engagement with target audiences. Public health community engagement, when moved online to social media channels, is characterized by interaction with multiple, self-selected communities. 6� Public�Health�Reviews,�Vol.�35,�No�1 These online communities are non-traditional in that they are not defined by space, time, or geography. Rather, online communities are formed by individuals who organize themselves around a given issue. A large, active online community has formed, for example, around global efforts to improve access to clean water. Advocates have successfully used social media to raise awareness of water issues around the world and improve access to clean water.28 PRINCIPLES OF SOCIAL MEDIA ENGAGEMENT FOR PUBLIC HEALTH Social media strategists have proposed several multi-stage models and levels of social media engagement.9,29-31 Drawing from these examples as well as our own experiences as public health practitioners implementing social media engagement strategies in a large organization, we propose seven principles that should be part of an organization’s public health communication social media strategy. Each item represents a different level of agency and public interaction, with each requiring different degrees of organizational commitment (e.g., staffing, financial resources, and infra structure development). Of these principles, no single way of engaging the public is right or wrong or better than another. Detailed below are the seven principles of social media engagement that public health organizations should strive to incorporate into their communication goals and management strategies. • Listening to social media conversations. One of the most basic forms of engagement is to use social media to identify the health information needs of users. This can be accomplished through the use of social media monitoring tools.32 Public health organizations should use social listening to identify what people are saying on social media channels about priority public health topics, find gaps in messaging, and under- stand what people care about to inform a cohesive, comprehensive communication strategy. This will help to ensure that messages align with the needs of our audiences. The ability to listen and respond with relevant messaging demonstrates that public health organizations are paying attention and developing messaging accordingly. As they listen, organizations should follow established best practices for social media to ensure that privacy is protected.33 • Engaging with influencers and their conversations. By monitoring social media, public health organizations can also identify key partners and public health influencers driving online conversations on health topics of interest and develop mutually beneficial relationships with Social�Media�Engagement� 7 them. Influencers can include both organizations and individuals34 and exhibit the characteristics of credibility, persistence in convincing others, and ability to drive conversations so that others take notice of the topic or idea and show support.35 For example, conducting outreach to bloggers who discuss public health topics that align with an organization’s priorities could be an effective way to engage on Twitter.36,37 Once identified, organizations can engage with influencers to discuss ways to promote messaging on shared communication goals to increase the reach of public health communications. Identifying and determining appropriate ways to engage with social media influencers and establish a reciprocal social media relationship can be a simple and powerful way to increase the reach of messaging and align with other public health influencers. Caution is advised, however, when reaching out to and/or partnering with social media influencers as they often achieve such a status because they are perceived as independent and trustworthy. Public health organizations must be sensitive to the possible risk of influencers becoming or being seen as “spokespersons” for their organizations.38,39 • Responding to questions or comments received via social media channels. Social media channels are a powerful tool for customer service and can demonstrate that organizations are paying attention to the conversations. At the public health organization level, this should include responding to health-related questions and comments—both negative and positive—received through organizational social media channels. Organizations should fully embrace this aspect of social media engagement and encourage quick replies. Establishing a nimble, responsive infrastructure allows an organization to thoughtfully and efficiently provide feedback to such social media inquiries. • Create opportunities for users to engage with your organization, and for your users to engage with each other. Organizations should identify opportunities to connect directly with users, and to facilitate discussions between users. These “small acts of support”15 may have a “ripple effect” across social media sites, leading to increased engagement among other users. For example, many public health organizations have hosted Facebook and Twitter chats, which are scheduled social media events that allow direct, real-time interaction between social media followers and organization experts and leaders. These events allow users to connect directly with an organization, share resources and information on a public health topic, and talk to each other during the event. Simple content approaches, such as asking users to comment on social media material, can also demonstrate a commitment to engaging with social media users. 8� Public�Health�Reviews,�Vol.�35,�No�1 • Welcome and solicit user-generated content. Encourage users to share their stories, participate in message creation, and collaborate on ideas or strategies that can be shared on an organization’s social media channels to increase users’ engagement and reaction to public health messages. Challenge.gov, the US federal government’s contest- and challenge- hosting site, shares challenges that encourage public participation.40 For organizations that do not have the capacity to host a large-scale user- generated content program, soliciting user-generated content can be as simple as asking users to submit photos related to a health campaign, or share their personal stories through an organization’s social media channels. For example, the federal “Facing AIDS”41 social media initiative supports the National HIV/AIDS Strategy’s efforts to combat stigma associated with HIV and promote HIV testing. Social media users are encouraged to take pictures of themselves holding signs with personalized messages about why they are “Facing AIDS.” Users can then upload and share the photos on social media with their communities. • Create opportunities to integrate online and offline engagement. Integrating social media engagement with in-person experiences allows engagement in both the virtual and real world, and gives committed social media users the opportunity to gain exclusive access to events and opportunities. Examples of online/offline engagement include NASA Social,42 which provides in-person opportunities for users who currently engage on NASA social media accounts, such as meet and greet sessions and behind the scenes events to connect with NASA scientists. The American Red Cross also offers training to individuals on using social media on behalf of the Red Cross. During disasters, these Digital Disaster Volunteers report back to the Red Cross social media team and “monitor, engage, and report on activity surrounding specific disasters.”43 • Leveraging social media for community engagement. As discussed above, using social media to enhance community engagement activities could be useful to public health, though more work in this area is needed to determine how best to seek input and feedback from the public and stakeholders on public health issues through social media. Organizations could consider implementing simple engagement activities in lieu of a comprehensive social media community engagement strategy. For example, the Substance Abuse and Mental Health Services Administration’s online discussion forum, designed “as part of the agency’s continuing efforts to increase opportunities for public engagement, collaboration and participation,” could be used and adapted as a model mechanism to solicit input.44 Social�Media�Engagement� 9 A recent study illustrates how a mix of engagement activities can result in a quantifiable outcome, and shows promise for leveraging social media engagement for public health impact.45 In May 2012, the social networking platform, Facebook, allowed users to share organ donation status on their Facebook timelines; that status was shared with the users’ Facebook friends. Taking engagement a step further, users could then officially register online as an organ donor with their state’s Department of Motor Vehicles. Engaging with Facebook as a partner, capitalizing on the platform’s ability to allow users to post and share information with their Facebook friends, and providing a simple way to make the organ donor pledge “real” resulted in a 21.2-fold increase in new online donor registrations on the day the initiative began. While the number of online donor registrations decreased throughout the 12 day campaign, registration rates remained elevated. As the authors note, this model holds great potential for determining the best ways to apply social media engagement efforts to other public health communication work. CONSIDERATIONS FOR SOCIAL MEDIA ENGAGEMENT FOR PUBLIC HEALTH Social media engagement, in whatever form it takes, is an important area of study and further discussion for public health communication—how do we “put social in social media?”6 Existing and emerging social media channels and tools that allow users to connect with public health organizations, and to connect with one another, should not be dismissed as a passing fad or trend—social media have become ubiquitous. As Mays et al.45 note, “One point that is very clear is that…channels that enable extensive networks of consumers to actively engage one another…are not disappearing any time soon.” Fox46 echoes this sentiment: “The social life of health information is robust. The online conversation about health is being driven forward by two forces: 1) the availability of social tools and 2) the motivation, especially among people living with chronic conditions, to connect with each other.” Social media are not going away, nor are the expectations that if an organization has a social media presence, the organization will be engaging on it. Public health communicators should work to determine how best to harness the unique characteristics of social media to advance communication. There is also an expectation of direct relationships with organizations and individuals through social media. Social media allow users unprecedented access to public health organizations and leaders. A growing number of public health leaders are establishing an official spokesperson presence in social media. The directors of the CDC, the National Institutes 10� Public�Health�Reviews,�Vol.�35,�No�1 of Health, and other public health leaders have all built robust Twitter audiences. Social media users expect individuals on social media to listen, respond, and interact in a personal way that reflects both the leader’s and the organization’s personality and priorities. Seeing the person behind the public health organization improves trust and credibility over time, by allowing users to talk to and with the person versus interacting with an impersonal organization. Another reason, perhaps the most important, that engagement needs to be embraced is the potential impact on health behavior change. At its very core, engagement requires that users do� something with information— listen, share, create, act, respond, ask. As public health communicators, we ultimately want our audiences to take action to improve their health by practicing healthy behaviors. Evidence that engaging in online communications positively impacts people’s health is limited4,9,47; this does not mean that the potential for impact is not there, just that more inquiry is needed.48,49 The effects of engagement need to be better studied to determine how we can foster and encourage healthy behaviors through these channels. CHALLENGES IN SOCIAL MEDIA ENGAGEMENT FOR PUBLIC HEALTH Just as there are many benefits to using social media for engagement purposes, there are risks and challenges that must be discussed, analyzed, and addressed in the public health community. • Loss of Message Control. Potential risks of and fears related to social media engagement include loss of control of the message, giving credence and credibility to “junk science,” and reputational concerns.6 Concerns about negative comments misdirecting and reshaping the message and conversation, or “online incivility,”50 are valid. These concerns should be factored into the management of an organization’s social media engage- ment strategy and also speak to the need to proactively engage with social media influencers to encourage a thoughtful dialogue on public health topics where common ground can be found. • Shift to “Direct-to-Consumer Engagement”. An additional challenge is our default public health perspective; in public health we are trained to look at populations in the aggregate. We are not always comfortable in thinking about one-on-one interaction on the individual level. How to mitigate these risks and concerns, while also leveraging social media engagement, is an important area of inquiry for the field to move forward. While there are certain risks inherent in social media engagement, there could be more risk in not engaging. Establishing clear, responsive Social�Media�Engagement� 11 approval processes for social media engagement will help public health organizations manage risk and ensure the accuracy and quality of information. Risks can be recognized and assuaged to truly unlock the potential of social media engagement. • Resource Allocation (Monetary and Personnel). Public health organizations interested in developing a social media engagement strategy should be mindful of the level of effort needed. In general, our experience shows that the higher the level of engagement, the more effort needed51 to adequately and effectively maintain a consistent, coordinated engagement approach. Organizations must be willing to commit the time to provide appropriate oversight of the effort, routinely monitor and respond to feedback and questions received, identify engagement opportunities, review data from engagement efforts, and adjust strategies accordingly. While there are tools and systems available to help manage an organization’s social media presence, they cannot replace the human element required to make decisions and judge appropriateness. Planning documents and guidelines51,52 are available to aid public health organizations in assessing whether integrating social media into existing communication strategies is feasible and determining if the outcomes justify the financial and work allocations. • Assessing Impact on Public Health Outcomes. A further challenge is quantifying the impact and demonstrating the value of social media engagement. Responding to a question on Facebook or asking users for feedback on public health issues results in what public health outcome? Korda and Itani3 point out that evaluation and measurement of social media engagement need to be better studied to determine if meaningful engagement is actually occurring. Jürgens53 notes the many opportunities and methodological challenges of evaluating and studying social media, as does Moorhead,47 whose systematic review found that many social media studies have limited methods and are exploratory and descriptive in nature, reporting eight gaps in the literature that need to be addressed, including studies with larger sample sizes and more robust method- ologies. 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