Zhang, Campo, Janz, et. al. took a long, hard, and well designed look at Twitter in promoting health behaviors. Their study published in JMIR is important to those of us who advocate for SM and Health Communications and using social media to improve patient engagement. The paper addresses physical activity an important surrogate marker for healthcare and Twitter because it opens our thinking about how to identify communications strategies for not just physical activity but all healthcare. The authors also present how we can use Twitter on how people talk about physical activity.
Objective: In order to provide insights into designing health marketing interventions to promote physical activity on Twitter, this exploratory infodemiology study applied both social cognitive theory and the path model of online word of mouth to examine the distribution of different electronic word of mouth (eWOM) characteristics among personal tweets about physical activity in the United States.
Results: Tweets about physical activity were dominated by neutral sentiments (1270/1500, 84.67%). Providing opinions or information regarding physical activity (1464/1500, 97.60%) and chatting about physical activity (1354/1500, 90.27%) were found to be popular on Twitter. Approximately 60% (905/1500, 60.33%) of the tweets demonstrated users’ past or current participation in physical activity or intentions to participate in physical activity. However, social support about physical activity was provided in less than 10% of the tweets (135/1500, 9.00%). Users with fewer people following their tweets (followers) (P=.02) and with fewer accounts that they followed (followings) (P=.04) were more likely to talk positively about physical activity on Twitter. People with more followers were more likely to post neutral tweets about physical activity (P=.04). People with more followings were more likely to forward tweets (P=.04). People with larger differences between number of followers and followings were more likely to mention companionship support for physical activity on Twitter (P=.04).
In their section on Principle Findings the authors point out that physical activity is different from other commercial activity which shows 60% of tweets positive, 12% neutral, and 25% negative. In their study 85% of tweets were neutral. They attribute this finding to the fact buying something is a transaction that people can easily and quickly identify likes, dislikes, pluses, and minuses. While it takes longer to identify tangible results with physical activities. The authors offer an alternative explanation
… people might be less willing to comment or have more difficulty commenting on their own behaviors than on commercial products. When people comment on a product or service, they evaluate third-party providers, which is a relatively easy task. When discussing physical activity, however, they have to evaluate their own behaviors and their own selves, which may be more difficult cognitively
This is important as we move forward in SM and HC. how do we help or identify patients willingness to self identify their own health behaviors. More importantly how do we understand what and how patients are doing with data gathered on the internet or via social media?
Changing or learning about healthcare is not like buying a car though it is moving in that direction through price transparency and the publishing of outcomes by hospitals. And consider the reality where a huge percent of adults use the internet to seek health related data and knowledge. Inquiring minds want to know. This melding of healthcare into a consumer driven decision with four parties exerting pressure on the system patient, HCP, hospital, and insurance provider is not going to go away soon. In some regards the power is moving to the patient. (I would like to see the true power couple being the patient and the HCP.) Where Twitter and other social media comes in is through the consumer seeking information and knowledge in order to make the decision regarding treatment, provider, HCP, etc. Therefore, those in the business of or providing healthcare would want to consider how does the consumer find, use, and share knowledge on their health. The authors addressed that this way:
People with more followers were more likely to post neutral tweets about physical activity. People with more followings were more likely to forward tweets. These findings suggest that people with different number of followers and followings may have different motivations for using Twitter regarding physical activity. People with fewer followers and followings might be more likely to connect with a close social network on Twitter and talk about physical activity positively for fun, whereas people with more followers and followings might be more likely to use Twitter primarily for information sharing about physical activity. However, future research is needed to further examine the reasons and confirm these suggestions.
The authors noted that the gap between following and followers is important because people with the widest the gaps were more likely to mention companionship support on Twitter. This was counter to the idea that a narrower gap may demonstrate “higher reciprocity between actual friends”. It is thought that the wider gap may mean more actual friends. Taking this outside of physical activity it could point to a way to look at caregivers seeking information and their support network where they are following many who have knowledge to share but only share with a small group of friends.
In the section on Practical Implications the authors make the following observation:
Findings about how eWOM characteristics differed among Twitter users with different networking characteristics can provide insights into segmentation of audiences in future physical activity marketing interventions on Twitter. The association between the number of followers and followings and the valence of eWOM about physical activity indicates that interventions encouraging positive discussion of physical activity could start by enrolling individuals with fewer followers and followings and observing and learning how they talk positively about physical activity.
Because people with more followings tended to forward opinions or information about physical activity on Twitter suggests that public health practitioners could target people with more followings in future physical activity marketing interventions. Public health practitioners could develop Twitter accounts to promote physical activity and encourage Twitter users to follow the accounts and retweet tweets about physical activity to their followers.
Taken out of exercise and considered for healthcare in general. These finding speak directly to ways and audiences to address specific to healthcare delivery either from the HCP or the provider. Finding the right audience who will expand the message with authority and who will help improve care is key. The authors have given us not just an analysis of Twitter and exercise but how to look at Twitter as part of a strategy to determine who, what, where, when, and how changes in healthcare can be made.
Making Medical Decisions for Patients without Surrogates
NEJM has a perspective written by Thaddeus Mason Pope, J.D., Ph.D. which continues an article from last months New York Times “Hiring an End-of-Life Enforcer”
In the NY Times article addresses the need to fill the gap identified in 2006 study that reported 16% of those in intensive care have no designated decision-maker and family to fill that roll. Paula Span author of the Times article talks about health fiduciaries who could guide the patient in these decisions. Pope in the NEJM addresses how the healthcare professional and the state are addressing this gap of the ‘unbefriended’ or “unrepresented’ since any decision made for this group of patients may not meet even minimally sufficient safeguards. “Consequently, health care decisions made on their behalf are at risk of being biased, arbitrary, corrupt, or careless.”
None of these decision-making mechanisms, however, can help the unrepresented. They have no POLST forms, no advance directives, no agents, and no default surrogates. And the unrepresented are a big group — including some elderly and mentally disabled patients, as well as many who are homeless or socially isolated. In many states, lesbian, gay, bisexual, or transgendered patients may have same-sex partners who could serve as decision makers but are not legally recognized as surrogates. Experts estimate that 3 to 4% of the 1.3 million people living in U.S. nursing homes and 5% of the 500,000 per year who die in intensive care units are unrepresented.
Pope notes that Georgia enacted a medical-guardian statue to help the unrepresented. A survey of Georgia probate judges show the law in ineffective because there are not enough people who want to do this work.
One policy Pope presents is prevention. Keep patients from becoming unrepresented from the get go by supporting their ability to make their own healthcare decisions, complete advanced directives based on choices and decisions, help them find and agent, finally identify a surrogate.
Physicians can make decisions for these patients since they are trained to but are not good surrogates and most states specifically prohibit patients from selecting their physician as surrogates. Pope sees the ethics committee who can work hard and quickly to identify the patients wishes and offer different perspectives. Here is the bad news on this, only five state have empowered multidisciplinary committees to make treatment decisions. The rest of the states can do better and should.
So long as legally sanctioned mechanisms are nonexistent or inadequate, I believe that providers have both the duty and the discretion to design these policies.
I agree and more importantly this is the ultimate in social networking, embracing those who can’t or don’t have the ability to make end-of-life decisions. We will not find them on Twitter. They are residents in hospitals and nursing homes. How can we reach out to these institutions and offer our knowledge, capacity, and friendship to support and help those in need? Instead of having followers on Twitter perhaps we need to follow someone who is alone and dying so they do not suffer needlessly.