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Adoption and use of social media among public health departments
© Thackeray et al; licensee BioMed Central Ltd. 2012
Received: 29 October 2011
Accepted: 26 March 2012
Published: 26 March 2012
Effective communication is a critical function within any public health system. Social media has enhanced communication between individuals and organizations and has the potential to augment public health communication. However, there is a lack of reported data on social media adoption within public health settings. The purposes of this study were to assess: 1) the extent to which state public health departments (SHDs) are using social media; 2) which social media applications are used most often; and 3) how often social media is used interactively to engage audiences.
This was a non-experimental, cross sectional study of SHD social media sites. Screen capture software Snag-It® was used to obtain screenshots of SHD social media sites across five applications. These sites were coded for social media presence, interactivity, reach, and topic.
Sixty percent of SHDs reported using at least one social media application. Of these, 86.7% had a Twitter account, 56% a Facebook account, and 43% a YouTube channel. There was a statistically significant difference between average population density and use of social media (p = .01). On average, SHDs made one post per day on social media sites, and this was primarily to distribute information; there was very little interaction with audiences. SHDs have few followers or friends on their social media sites. The most common topics for posts and tweets related to staying healthy and diseases and conditions. Limitations include the absence of a standard by which social media metrics measure presence, reach, or interactivity; SHDs were only included if they had an institutionally maintained account; and the study was cross sectional.
Social media use by public health agencies is in the early adoption stage. However, the reach of social media is limited. SHDs are using social media as a channel to distribute information rather than capitalizing on the interactivity available to create conversations and engage with the audience. If public health agencies are to effectively use social media then they must develop a strategic communication plan that incorporates best practices for expanding reach and fostering interactivity and engagement.
Social media has enhanced communication between individuals and organizations and it has the potential to augment public health communication. Social media refers to "activities, practices, and behaviors among communities of people who gather online to share information, knowledge, and opinions using conversational media" . Social media applications are broadly categorized as forums and message boards, review and opinion sites, social networks, blogging and microblogging, bookmarking, and media sharing . In particular, social media allows organizations to talk to their customers, for customers to talk to each other, and for customers to talk to the organization . In public health, social media can be used to inform, educate, and empower people about health issues , to enhance the speed at which communication is sent and received during public health emergencies or outbreaks , to mobilize community partnerships and action , to facilitate behavior change , to collect surveillance data , and to understand public perceptions of issues .
Individual, corporate and organizational use of social media is increasing. It is estimated that by 2015, the number of individuals and corporations who have social networking accounts will reach over three billion . Sixty-five percent of adult internet users in the U.S. use social networking sites . Technorati currently registers over 1.2 million blogs . Thirteen percent of internet users have a Twitter account . A study among Fortune 500 companies reported that 60% of corporations had Twitter accounts and 56% had Facebook profiles . Among Forbes 200 largest charities, use of at least one form of social media increased from 75% in 2007 to 97% in 2009 . In public health, the Centers for Disease Control and Prevention is actively using social media . However, there is a lack of data on social media adoption within broader public health settings, particularly state public health departments (SHDs).
A SHD baseline measure of social media adoption can serve as a benchmark for how public health agencies are doing at increasing access to health information through technology, an objective identified in Healthy People 2020 . These data may act as a catalyst to accelerate social media use and encourage more research on the effectiveness of social media in public health. Therefore, the purposes of this study were threefold: 1) to assess the extent to which SHDs are using social media; 2) to determine which social media tools are used most often; and 3) to assess the extent to which social media is being used interactively to engage audiences.
Fields included on the coding sheet
Facebook (FB) page URL
Number of people who like the FB page
Number of tweets in one month & total all-time tweets
Date YouTube channel was established/joined
Date joined Flickr
FB Photos (yes/no) & number of photos
Number of Twitter followers
Number of YouTube upload views
Number of photos in photo stream
Date of first/last FB wall post
Number of Twitter users the state is following
Number of YouTube subscribers
Number of photo sets/photos in each set
FB discussions (yes/no) & number of discussions
Date of the first/last tweet
Number of YouTube channel views
Number of photo set views
FB events (yes/no) & number of events
Number of YouTube videos posted
Number of comments on each photo set
FB videos (yes/no) & number of videos
Total @ symbols (replies or responses)
Name of YouTube video
Date of photo set
Date of the individual FB wall post
Total hash-tag symbols
Date YouTube video was posted
Internal or external post (yes/no)
Post tweet via third-party API
Number of YouTube video views
Post an auto feed (yes/no)
Number of YouTube video likes/dislikes
FB post original (yes/no)
Number of YouTube video comments
Total number of comments on FB individual post
Total number of likes on FB individual post
Metrics for coding state health department use of social media*
number of tweets
number of photos
posting content, comments, or likes
tweets, replies to tweets
to posts, comments
number of people
the SHD connected
with through the
social media application
number of followers
number of subscribers
number of views
number of page likes
Facebook metrics associated with state health departments
# of Page Likes
Total Posts in one Month
Posts with Likesno (%)
Posts with Commentsno. (%)
Total Comments on Posts
Ratio of Posts to Comments
Twitter metrics associated with state health departments
All-time total tweets
Tweets in one month
@ Replies one month
Re-tweets in one month
YouTube metrics associated with state health departments
Number of subscribers
Number of comments
Posting on social media sites averaged once per day (Table 3, Table 4). Twitter re-tweets constituted 22.5% of all tweets; only 1.5% of tweets were in response to a tweet made by a follower. The SHD was the primary author of nearly all Facebook posts (89.5%). Just over a quarter (26.9%) of Facebook posts were an auto-feed, meaning that the content was originally posted on a third-party API (e.g., HootSweet). The majority (86%) of Facebook posts received no comments and 45.1% of Facebook posts had no likes (Table 3).
The majority of Twitter tweets (79.7%) were health related, 14.1% were non-health related, and for 6.2%, the information was not adequate to determine the topic area. The health-related tweets focused on general areas of staying healthy (39.7%), diseases and conditions (26.2%), environmental health (8%), injury, violence, and safety (5.4%), emergency preparedness and response (4.6%), other diverse areas (16.1%). Specifically, the most common topics were nutrition (11.4%), heart disease (7.3%), cancer (7.3%), environmental health (6.5%), tobacco use (6.5%), flu, (5.4%) and emergency preparedness and response (3.8%).
The majority of Facebook posts (88.3%) were health-related. Non-health posts had no common threads and included topics such as deaths of prominent officials, business awards, office hours, and job openings. Of the health-related posts, 77.8% were factual health-related information, 6.8% were about services offered, and 15.7% were event announcements. The most common topics were flu (9.5%), environmental health (6.0%), heart disease (5.5%), nutrition (4.5%), tobacco (4.3%), emergency preparation (4.3%), and cancer (3.6%).
Views of photos and videos were limited. The total number of photos posted on Flickr was 167 (mean = 41.75). The ratio of views to photos ranged from 1.55 to 47.65. The mean number of You Tube videos was 30. The mean number of video views was 687 (median = 144), not including an outlier CPR-related video receiving four million views. Over three-fourths of videos (78.3%) received no likes and 70.7% of videos received no comments (Table 5).
Social media use differed between rural states and urban states. There was a statistically significant association between a SHD use of any social media and the U.S. Census Bureau's measure of the state's average population density per square mile (r = .346; p = .01). There were no significant differences between U.S. census region and use of social media (chi square = 2.279, p = .517).
The purpose of this study was to assess the degree to which SHDs were using social media and how they used it. The majority of SHDs are using at least one social media application with rates similar to large companies , charities , and nonprofit organizations . However, compared to these organizations, a greater percentage of SHDs used Twitter. The overwhelming preference for Twitter may be associated with keeping the public up-to-date with SHD-related news. Yet Twitter is used by less than 13% of internet users , indicating a mismatch with audience preference for receiving information.
SHD's social media use varied by population density. These findings are in contrast to previous research that found no difference in individual use of social networking sites by urban or rural location . The results are similar to a study that showed rural hospitals used social media less frequently than urban hospitals . Additionally, on a typical day, people living in rural areas are less likely than urban residents to visit a video sharing site  and only 9% of Twitter users live in rural areas .
Audience reach with social media was limited. Relative to a state's population, the proportion of people who comprised followers, friends, and subscribers was small. An audience member's demographic characteristics, including occupation or professional affiliations, are unknown on social media applications. It is possible that the audience is the general population, or other public health professionals, including SHD employees.
Social media is more than another communication channel. As mentioned previously, there are several ways SHDs can use social media. If utilized effectively, social media has the potential to improve the way public health agencies engage, interact and communicate with its various audiences. Specifically, social media are technologies that facilitate opportunities for engaging with the audience  and for creating and maintaining relationships . If public health agencies can use social media to engage their audiences and create relationships, something that has previously been hindered by time and distance restrictions, then they are one step closer to establishing true community-based partnerships to address public health problems.
This study showed that, SHDs are not capitalizing on social media's interactive potential. Their one-way social media communication pattern is similar to the results of an analysis of politicians and government agency Twitter posts that revealed the most common purpose was a one-way sharing of public information . Very few of the audience members were viewing the videos or photos. Using comments and likes as a proxy measure for reading posts, relatively few engaged in reading. A like indicates that a person has at least read a post or watched a video, and while there was a greater proportion of likes than comments received, it is only part of the engagement process. Research shows that if a person likes a product page, they are more likely to buy the brand, recommend the brand to others and share branded content . However, liking the page does not result in purchasing the product. This may be true for public health as well. Liking a page or a post may not equal following behavioral recommendations or participation in public health programs.
There may be a few reasons why SHDs have limited social media interaction. The first may be that there is a mismatch between the content that is posted and audience preferences. SHDs are posting and tweeting about health topics and not about the agency. The health topics may be a reflection of the national health observances that were occurring during February and March, including American Heart Month, National Nutrition month, National School Breakfast Week, and Colorectal Cancer Awareness Month. If the audience is primarily other health professionals, general health content may generate fewer comments. If the audience is the general public, the content may be poorly developed or the topics may be of little interest. The majority of Facebook posts were auto feeds, meaning there was little thought given to matching the content with audience preferences for information. SHDs cannot assume that because they post content on a social media application that people will respond. It is important to communicate information in a way that reflects the audience preferences, stimulates response or discussion, and is tailored to the social media application.
Public health agencies use of social media is in the early adoption stages. Because social media use is becoming so pervasive, it seems prudent for SHDs to strategically consider how to use it to their advantage. To maximize social media's potential, public health agencies should develop a plan for incorporating it within their overall communication strategy. We recommend a framework posted by Bernoff and Li as a starting point . The agency must identify what audience they are trying to reach, how that audience uses social media, what goals and objectives are most appropriate, and which social media applications fit best with the identified goals and objectives.
Some study limitations should be noted. First, there is not a universally accepted standard for which social media metrics measure presence, reach, or interactivity. Second, we identified the SHD as using social media if there was an institutional account as identified on the health department website home page. It is possible that individual programs or organizational units within a health department are using social media independent of a department-wide coordinated effort. Lastly, this was a cross-sectional study to establish a baseline of social media use by SHDs.
Most SHDs have recently begun to use at least one social media application. The most popular social media is Twitter despite the fact that only 13% of internet users have a Twitter account. The reach of social media is limited as evidenced by the low number of followers, page likes, and subscribers. Additionally, SHDs appear to be using social media as another channel to distribute information rather than creating conversations and engaging with the audience. If public health agencies are to use social media effectively they must develop a strategic communication plan that incorporates best practices for expanding reach and fostering interactivity and engagement.
This study was funded by a grant from the sponsoring university.
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