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The Use Of Social Media For Health In Low And Middle-Income Countries : A Scoping Review Hagg, Emily 2016-08

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 i  THE USE OF SOCIAL MEDIA FOR HEALTH IN LOW AND MIDDLE-INCOME COUNTRIES: A SCOPING REVIEW    By    Emily Hagg  B.N., University of Lethbridge, 2005    A SCHOLARLY PRACTICE ADVANCED RESEARCH (SPAR) PROJECT SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF SCIENCE    in    THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES  (Nursing)  THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)     August 2016  © Emily Hagg, 2016  i Abstract Background: Social media allows for instant access to, and dissemination of, information around the globe.  Access to social media in low and middle-income countries has increased exponentially in recent years due to technological advances. In high-income countries such as the United States, social media is used extensively for health-related purposes, and there is a large body of literature on its use. Within low and middle-income countries, however, research has only just begun to emerge on the use of social media for health.   Objective: To identify, explore and summarize the current state of the literature on the use of social media for health in low and middle-income countries.  Methods: A scoping review was conducted on literature available to the end of January 2016. Five databases were searched, and grey literature was identified through the Google and Google Scholar search engines.  Literature was considered for inclusion if it (1) was published in English, (2) was conducted in or in relation to a low or middle-income country, (3) reported on as least one type of social media or social media use generally, and (4) reported on at least one aspect of human health. Results: Twenty-three articles met the inclusion criteria. Fifteen were research articles, and eight were review/discussion/descriptive and evaluative reports. Since 2010, when the first article was published, most of the literature has focused on Asian (n=9) and African (n=6) countries. Twitter (n=6) and Facebook (n=4) were the most frequently discussed individual social media platforms. The identified literature was categorized into four themes: use for health education and influence; use within infectious disease and outbreak situations; use within natural disaster, terrorism, crisis and emergency response situations; and producers and consumers of social media for health. Conclusion: Despite the potential for misinformation, the existing literature suggests that using social media for disease surveillance, mass communication, and education and knowledge translation offers important health-related benefits in low and middle-income countries. However this is a nascent body of literature and future research should investigate the relative effectiveness of various platforms for different users, other potential uses, and pursue a broader geographical focus.  Keywords- social media, social networking sites, health, global health, public health, developing countries, low-income countries, and middle-income countries   ii  Preface This Scholarly Practice Advancement Research (SPAR) project is original, unpublished, independent work by the author, E. Hagg.       iii Table of Contents Abstract ........................................................................................................................................... i Preface ............................................................................................................................................ ii Table of Contents ......................................................................................................................... iii List of Tables ..................................................................................................................................v List of Figures ............................................................................................................................... vi Acknowledgments ....................................................................................................................... vii Dedication ................................................................................................................................... viii Chapter 1: Introduction ................................................................................................................1  Purpose and Research Questions .........................................................................................3 Chapter 2: Methods .......................................................................................................................4  Information Sources .............................................................................................................4  Search Strategy ....................................................................................................................4  Inclusion and Exclusion Criteria  .........................................................................................7  Study Selection, Categorization and Data Extraction  .........................................................7  Analysis ...............................................................................................................................8 Chapter 3: Results..........................................................................................................................9  Search Results and Selection of Literature ..........................................................................9  Summary of Selected Literature  .........................................................................................9  Timeline: Evolution of the Literature  ...............................................................................16  Type of Paper  ....................................................................................................................17  Geographical Focus  ..........................................................................................................19  Type of Social Media  ........................................................................................................19  Themes of the Literature  ...................................................................................................20 Theme 1: Health education and influence .............................................................................21 Theme 2: Infectious disease and outbreak situations  ............................................................21 Theme 3: Natural disaster, terrorism, crisis and emergency response  ..................................21 Theme 4: Producers and Consumers of Social Media  ..........................................................22   iv  Producers of Social Media .................................................................................................22   Organizational producers  ......................................................................................22   Misinformation and challenges of tweets  .............................................................22  Consumers of Social Media  ..............................................................................................23   Young and marginalized populations  ...................................................................23   Expectations and assumptions of consumers  ........................................................23 Chapter 4: Discussion ..................................................................................................................25 Key Findings .............................................................................................................................25 Gaps and Potential for Future Research  ...................................................................................26 Implications  ..............................................................................................................................27 Limitations  ...............................................................................................................................27 Conclusions  ..............................................................................................................................28 References .....................................................................................................................................29 Appendix A ...................................................................................................................................35      v List of Tables Table 1. Search Terms  ....................................................................................................................5 Table 2. Search Strategy and Number of Hits for each Database and Search Engine .....................6 Table 3. Articles Included in Scoping Review ..............................................................................11 Table 4. Analysis of Scoping Review ............................................................................................14 Table 5. Summary of the Evolution of Literature  .........................................................................17       vi List of Figures Figure 1. Flowchart of Article Selection........................................................................................10 Figure 2. Timeline: Evolution of the Amount of Literature ..........................................................16 Figure 3. Types of Literature Found ..............................................................................................18 Figure 4. Type of Literature Found, by Year  ................................................................................18 Figure 5. Geographical Focus ........................................................................................................19 Figure 6. Type of Social Media  ....................................................................................................20 Figure 7. Health Focus of Social Media ........................................................................................24         vii Acknowledgments I would like to sincerely thank my supervisory committee Dr. V. Susan Dahinten and Dr. Leanne M. Currie for all of the guidance, support and encouragement throughout this Scholarly Practice Advancement Research project.  The amount I have learned from the both of you during the past two years of this program cannot be expressed in words and I am extremely grateful to have had the opportunity to work with you.  The enthusiasm and dedication each of you has for your respective fields of expertise in global health and nursing informatics is inspiring and I could not have completed this process without you.  Thank you! I would also like to thank my parents and siblings who have been cheering me on from a distance throughout this graduate program.  The infinite Face Time calls, emails and phone calls have provided me with an invaluable source of strength and determination, and I’m truly grateful to have such support!     viii Dedication To the inspirational nurses who came before me - my mother Mary Lou Giles,  Grandma Helen Giles, and Aunt Sally Giles  1 Chapter 1: Introduction An increasing number of people worldwide use the Internet in their daily lives in various contexts, including for accessing health information (Capurro et al., 2014).  Earlier Internet use for health has been focused on advertising and online marketing (Li et al., 2015) while more recently, the importance of online media use for health education and in times of public health crisis has been highlighted (Basch, Basch, Ruggles & Hammond, 2015).  Recent shifts in trends and availability of technology-based social media services for public health initiatives offer enormous possibilities for health improvement (Bennett & Glasgow, 2009). Social media is a broad concept that encompasses Web-based operations that are used for computer-mediated communication (Grajales III, Sheps, Novak-Lauscher & Eysenbach, 2014).  These websites support functions such as social networking (e.g., Facebook, MySpace, Google Plus), professional networking (e.g., LinkedIn), media sharing (e.g., YouTube, Flickr), content production such as blogs (e.g., Tumblr, Blogger, Twitter), knowledge/information aggregation (e.g., Wikipedia), and virtual reality and gaming environments (e.g., Second Life) (Capurro et al., 2014).  Facebook, which was established in 2004, is the most popular of these; in 2015, 72% of online adults globally were users (Duggan, 2015).  These websites are often called social media platforms and are used to create, debate, modify and share material (Kietzmann, Hermkens, McCarthy & Silvestre, 2011).  Social media allows for instant access to and dissemination of information around the world, and users have the opportunity to play an active part in the reporting and dissemination of online material (Odlum & Yoon, 2015).  The high prevalence of use emphasizes the potential for social media activities to impact people’s knowledge, attitudes and behaviours in both high and low resource settings (Hamill, Turk, Murukutla, Ghamrawy & Mullin, 2015).   For the current 2016 fiscal year, low income countries are defined as those having a gross national income (GNI) per capita of less than $1045 per year; middle income countries have a GNI per capita ranging between $1045 and $12,746 per year (Kruk, Gustavo & Knaul, 2015).  Historically, Internet accessibility has been strongly linked to GNI per-capita, with social media use and popularity being limited in low and middle-income countries (LMICs) (Poushter, 2016).  However, significant technological gains have been increasingly emerging in LMICs (Hamill et al., 2015; Li et al., 2015), and due to recent growth and improvement in Internet access, social networking has become more popular in Latin America and the Middle East than it is in Europe   2 and the United States (Poushter, 2016). The progress of information and communication technologies within low-income settings has been enhanced through the ‘leap frog’ effect, which refers to the adoption of advanced technology in a context where immediate preceding technology has not been implemented (Fong, 2009).  This is made possible due to the increasingly low cost of technology accessibility (Mansell, 2011).  The ‘leap-frog’ effect can be seen in Africa where the earlier stage of installing hard-wired infrastructure has been omitted altogether and people can now use cellular networks for wireless access to the Internet, stemming from the rapid expansion of mobile networks (Pew Research Center, 2016).  In 2015, one third of people across developing nations reported owning a smartphone (Poushter, 2016), a fast-growing trend expected only to intensify in coming years.  The potential for health benefits has been demonstrated through research conducted in high-income nations such as the United States, where social media is currently being used in almost every healthcare domain (Amrita, 2013).  The use of social media for health in high-income countries has increased substantially in recent years with over 80% of Americans seeking health information online in 2013 (Househ, 2013).  Social media has given healthcare professionals effective tools to communicate with populations and promote community engagement activities such as fundraising and advertising, and it has been estimated that 70% of U.S. healthcare organizations utilize social media in at least one form (Ventola, 2014; Househ, 2013).  For example, hospitals in high-income countries are increasingly using social media platforms for promotional purposes and to gauge consumer experiences with their organizations (Nuviun, 2016). Interactions on social media platforms also occur around various healthcare topics including health promotion and patient education, and have been credited with enabling more effective and responsive healthcare services in high-income countries (Househ, 2013; Horter, Stringer, Venis & du Cros, 2014).  Patients in the United Kingdom have reported using the services rendered through social media supported shared-decision making, facilitated communication, and resulted in a more positive interaction and a shift towards treating the whole patient rather than just the disease (Horter, Stringer, Venis & du Cros, 2014). Purpose and Research Questions The purpose of this study was to identify, explore and summarize the state of the literature on the use of social media in LMICs in regards to health.  A scoping review was   3 conducted on available literature as scoping reviews are commonly used to better understand a phenomenon and to evaluate where research on a topic has or has not been completed (HLWIKI International, 2015). The general research questions that guided this review were: (1) What is the current state of literature that addresses the use of social media for health in LMICs?   (2) For what purposes are social media being used in LMICs?  (3) Who is using social media for health purposes in LMICs?  (4) What are the key implications of social media use in LMICs on health?   It is anticipated that the findings of this report will be helpful for other researchers on the topic, healthcare professionals, health organizations, and governments working in the context of low and middle-income settings.      4 Chapter 2: Methods A systematic scoping review was identified as the best method for evaluating the literature in this project.  This type of review has become an increasingly popular approach for synthesizing research evidence (Pham et al., 2014). Scoping reviews are often the first step in completing a systematic review or large study (HLWIKI International, 2015), and aim to map the current evidence as opposed to trying to answer a specific question by looking for only the best available information (The Joanna Briggs Institute, 2015).  This is a key difference when compared to other reviews.  Second, scoping reviews can incorporate a range of literature from both published and grey literature, and emerging and established fields (Levac, Colquhoun & O’Brien, 2010; Colquhoun et al., 2015), whereas other forms of reviews analyze empirical evidence from a more narrow body of literature on a specific and focused research question and a particular research design (Pham et al., 2014).  As the subject of social media use for health is a new topic within the literature, is varied and widespread in nature, and is lacking a formal systematic appraisal, a scoping review was chosen to systematically examine the current state of this field. Information Sources Considering the multidisciplinary nature of this subject, a variety of information sources were examined.  Articles were identified through a comprehensive search of five databases comprising literature from nursing, medicine, allied health, global health, social, behavioral, computer, and engineering sciences: the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline/PubMed, Web of Science, CAB Direct (CAB Abstracts and Global Health), and Compendex Engineering Village 2.  Grey literature was identified through searches conducted utilizing the Google and Google Scholar search engines. Hand searching was done of the ‘Journal of Health Informatics in Developing Countries’ as a specific source that was directly related to the topic, reference lists of direct hit articles, and identified other relevant literature by referring to the “similar articles” tool in the PubMed database. Search Strategy  A comprehensive search strategy was undertaken to identify as much literature as possible.  In order to identify both published and grey literature, five databases and two search engines were searched. A comprehensive list of search terms is identified in Table 1. Table 2 identifies the specific search strategies used for each database and search engine.  All searches   5 were conducted during the month of January 2016, and a professional librarian from the University of British Columbia was consulted throughout the search strategy to ensure comprehensiveness.  Table 1. Search Terms Developing countries  Middle-income countries Global health  Public health Health Social media Low-income countries Social networking sites       6 Table 2. Search Strategy and Number of Hits for each Database and Search Engine  Source N Strategy CINAHL n=29 ((MH "Social Media") OR (MH "Social Networking") OR facebook or twitter or instagram or myspace or blogs or tumblr) AND ((MH "Public Health+") OR (MH "Health+") OR health) AND ((MH "Developing Countries") OR (MH "Africa+") OR (MH "Asia+") OR (MH "Indian Ocean Islands+") OR (MH "Pacific Islands)) AND (promot* OR disease outbreak* OR monitor* OR surveill* OR aware* OR map*)  Medline n=31 ((blogging/ OR social media/OR social networking/) OR (facebook or twitter or instagram or myspace or blog* or tumblr)) AND ((Health Education/ or Health/ or Health Equity/ or Global Health/ or Health Communication/ or Public Health/) OR (health promot* or disease outbreak* or health monitor* or health surveill* or health aware* or health map* )) AND (Developing Countries/ OR (Africa* or Asia* or "Indian Ocean Island*" or "Pacific Island*")) Web of Science n=22 (("social network*" OR "social media") AND health AND developing countr*) (Limited to Health Care Sciences Services and Medical Informatics only option) CAB Direct n=64 "social media" AND "health" AND "developing countries" Compendex Engineering Village 2 n=12 ({Social networking (online)} WN CV) AND ((({Condition monitoring} WN CV) OR ({Hazards} WN CV) OR ({Health} WN CV) OR ({Health care} WN CV) OR ({Health care--Nursing*} WN CV) OR ({Medicine} WN CV) OR ({Medical problems} WN CV) OR ({Nursing} WN CV) OR ({Nutrition} WN CV) OR ({Public health} WN CV) OR ({Telemedicine} WN CV))) AND ({Developing countries} WN CV) Google n=17 (intitle:facebook OR intitle:twitter OR intitle:instagram OR intitle:myspace OR intitle:blogs OR intitle:tumblr OR intitle:"social network*" OR intitle:"social media") AND ("Africa" OR "Asia" OR "Indian Ocean Islands" OR "Pacific Islands" OR "developing country" OR "developing countries") AND (health site:edu OR health site:ac.uk filetype:pdf OR health site:.gov OR health site:.gc.ca OR health filetype:pdf) Google Scholar n=3 (("social network*" OR "social media") AND health AND developing countr*)  Total N=178    7 Inclusion and Exclusion Criteria Any literature describing the use of social media in relation to health in any low or middle-income country, including any type of literature whether or not it involved research, among any population group, regardless of date of publication was considered.  Therefore, literature was considered for inclusion if the article (1) was published in English, (2) was conducted in or in relation to a low or middle-income country, (3) reported on as least one type of social media or social media use generally, and (4) reported on at least one aspect of human health. Social media was defined as a collection of Internet-based applications that allow the creation and exchange of user-produced context (Kaplan & Haenlein, 2009).  Literature that focused on the use of mobile phones and cellular capabilities, and articles that focused only on mHealth, which is defined as medical or public health practice supported by mobile devices (World Health Organization, 2011), were excluded. Literature that addressed or focused on low-income or low-resourced settings within high-income countries, and literature where social media was used solely as a method for data collection with no discussion of its use was also excluded. Study Selection, Categorization and Data Extraction  A two-step process was applied when selecting the literature for this review. First, all articles found using only the title and abstract of each piece were screened; then the full text of each article using the inclusion/exclusion criteria was screened.  After this second screening, general and specific information about the literature was extracted.  Data that were extracted from the identified articles included the following: title of the article, author’s name, source of publication (e.g., journal, book, website, conference proceedings), publication year, objectives/purpose of the piece as stated by the author, population being discussed (e.g., gender, ethnicity, occupation, health status/condition), country/geographical region of focus, type of literature (e.g., descriptive, mixed methods, qualitative, review, quantitative), methodology used (if applicable) (e.g., surveys, questionnaires, content analysis, thematic analysis), health focus (e.g., infectious disease, disaster relief, prevention, chronic disease management, behaviour change campaigns), type of social media (e.g., Facebook, Twitter, YouTube, social media used generally), reported findings (if applicable), and authors’ recommendations (e.g., future potential and research opportunities).   8 Data extracted from each article were recorded in an Excel worksheet in order to categorize and compare characteristics.  This was a scoping review and, as the focus was not on the best available evidence, risk of bias or overall quality was not assessed. Analysis  Synthesis of the articles was undertaken in order to answer the research questions that guided this study.  The literature characteristics were categorized based on emerging research themes that presented from the selected literature.  Characteristics of each article were analyzed through several readings of each piece and coded into groupings of similar thematic categories.  The findings are reported through a series of tables and figures that were created from the summarized data that were coded in the Excel worksheet.       9 Chapter 3: Results Search Results and Selection of Literature Searching the five selected databases and two search engines yielded 178 individual articles for possible inclusion in this scoping review.  After removal of duplicates (n=10), titles and abstracts were reviewed for appropriateness; this process led to the removal of another 122 pieces.  Five citations were added from hand searching the ‘Journal of Health Informatics in Developing Countries’, the reference lists of direct hit articles, and other literature identified through the “Similar Articles” tool in the PubMed database.  This left 51 articles for full-text assessment.  Twenty-eight other papers were excluded following a full-text reading of each piece, yielding 23 citations in the final sample.  Published, peer-reviewed literature constituted 22 of the articles while one was grey literature.  Figure 1 outlines the systematic process followed for identifying and selecting literature. Summary of the Selected Literature Twenty-three articles were identified for this scoping review after utilizing the inclusion and exclusion criteria.  A majority of the literature was research-based.  Publication dates ranged from 2010 to 2016, with the majority of literature published in 2014 and 2015.  Infectious disease surveillance and global emergency response were the most common contexts of papers that were published during this period of increased activity in 2014-2015.  Subsequently, the geographical focus of the literature was centered on Asian and African nations, with little to no emphasis on other low and middle-income areas of the world.  Tables 3, 4 and Appendix A provide an overview of the articles included in this scoping review.  The following sections discuss these findings in greater detail.       10  Figure 1. Flowchart of Article Selection       11 Table 3. Articles Included in Scoping Review # Author Year Journal Title of Paper 1 Ahmed, et al. 2015 Proceeding of: 17th International Symposium on Health Information Management Research, York, United Kingdom The Ebola epidemic on Twitter: challenges for health informatics 2 Alexander 2014 Science and Engineering Ethics Social media in disaster risk reduction and crisis management 3 Amrita, et al.  2013 Medicine 2.0 Health care social media: expectations of users in a developing country 4 Basch, et al. 2015 Disaster Medicine and Public Health Preparedness Coverage of the Ebola virus disease epidemic on Youtube  5 Fung, et al. 2013 Infectious Diseases of Poverty  Chinese social media reaction to the MERS-CoV and avian influenza A(H7N9) outbreaks 6 Gu, et al. 2014 Journal of Medical Internet Research  Importance of Internet Surveillance in Public Health Emergency Control and Prevention: Evidence From a Digital Epidemiologic Study During Avian Influenza A H7N9 Outbreaks 7 Gurman, et al. 2015 Journal of Health Communication  Reaching the global community during disasters: findings from a content analysis of the organizational use of Twitter after the 2010 Haiti earthquake 8 Hamill, et al. 2015 Tobacco Control I 'like' MPOWER: using Facebook, online ads and new media to mobilise tobacco control communities in low-income and middle-income countries    12 Table 3. Articles Included in Scoping Review (con’t) # Author Year Journal Title of Paper 9 Horter, et al. 2014 PLoS-ONE  “I can also serve as an inspiration”: a qualitative study of the TB&Me blogging experience and its role in MDR-TB treatment 10 International Federation of Red Cross and Red Crescent Societies 2014 N/A Case Study: Malaria prevention through social media  11 Kituyi, et al. 2014 Conference Precedings of research-in-progress Towards a Framework for the adoption of social media in health in sub-Saharan Africa 12 Kwaak, et al. 2010 Chapter in “HIV and culture confluence: Cross-cultural experiences on HIV, gender and education from Johannesburg conference” (pp. 63-68). Sexual and reproductive desires and practices of Kenyan young positives: opportunities for skills building through social media  13 Lwin, et al. 2014 Acta Tropica  A 21st century approach to tackling dengue: crowd sourced surveillance, predictive mapping and tailored communication 14 Lwin, et al. 2016 Health Education Research  Social media-based civic engagement solutions for dengue prevention in Sri Lanka: results of receptivity assessment 15 Maity, et al. 2015 Clinical Microbiology Newsletter An online survey to assess awareness of Ebola virus disease 16 McCool, et al. 2014 BMC Public Health  Perceived social and media influences on tobacco use among Samoan youth   13 Table 3. Articles Included in Scoping Review (con’t) # Author Year Journal Title of Paper 17 Nduka, et al. 2014 International Journal of Medicine  The use of social media in combating the Ebola virus in Nigeria - a review 18 Odlum, et al. 2015 American Journal of Infection Control What can we learn about the Ebola outbreak from tweets? 19 Oyeyemi, et al. 2014 British Medical Journal (Clinical research ed.) Ebola, Twitter, and misinformation: a dangerous combination? 20 Piroska 2015 American Journal of Public Health  Using a Mobile Photo Booth and Facebook to Promote Positive Health Messages Among Men Who Have Sex With Men in Cambodia 21 Purdy 2011 Reproductive Health Matters  Using the Internet and social media to promote condom use in Turkey 22 Simon, et al. 2014 PLoS-ONE  Twitter in the cross fire - the use of social media in the Westgate mall terror attack in Kenya 23 Thomas, et al. 2013 Developing Country Studies  Health personnel's perception on the use of social media in healthcare delivery system in rural and urban communities of Oyo State, Nigeria  14 Table 4.  Analysis of Scoping Review # Year Type of Paper Geographical Focus Theme 1: Health Education and Influence Theme 2: Infectious Disease and Outbreak Situations Theme 3: Natural Disaster, Terrorism, Crisis, and Emergency Response Theme 4: Producers and Users of Social Media 1 2015 Descriptive Abstract Not Geographic Specific    X 2 2014 Review Short examples from Nigeria and Haiti   X  3 2013 Quantitative India    X 4 2015 Quantitative Not Geographic Specific  X   5 2013 Quantitative China  X   6 2014 Quantitative China  X   7 2015 Quantitative Haiti   X X 8 2015 Descriptive Case Studies Egypt and India X   X 9 2014 Qualitative Not Geographic Specific X   X 10 2014 Case Study Discussion Cambodia, Laos and Vietnam X   X 11 2014 Mixed Methods- Research in progress Sub-Saharan Africa     12 2010 Quantitative  Kenya X   X   15 Table 4.  Analysis of Scoping Review (con’t) # Year Type of Paper Geographical Focus Theme 1: Health Education and Influence Theme 2: Infectious Disease and Outbreak Situations Theme 3: Natural Disaster, Terrorism, Crisis, and Emergency Response Theme 4: Producers and Users of Social Media 13 2014 Descriptive Sri Lanka X X   14 2016 Quantitative Sri Lanka  X   15 2015 Quantitative  India  X   16 2014 Qualitative Samoa X   X 17 2014 Review Ebola-stricken West Africa with an emphasis on Nigeria  X   18 2015 Quantitative Not Geographic Specific  X  X 19 2014 Quantitative Guinea, Liberia, and Nigeria  X  X 20 2015 Descriptive Cambodia X   X 21 2011 Descriptive Turkey X    22 2014 Quantitative Kenya   X  23 2013 Mixed Methods Nigeria    X  16 Timeline: Evolution of the Literature Early literature on this topic began to show its presence in 2010 with a descriptive book chapter aimed at promoting skill building for HIV-positive youth in Kenya; this chapter analyzed the findings of a small quantitative study that was conducted by a separate research group, and focused on identifying opportunities for social media use (Kwaak, Obare & Ormel, 2010).  The number of articles has slowly increased since then, with 2014 and 2015 having the highest numbers yet (see Figure 2).  Using social media for health behavior change campaigns emerged in the literature in 2011 (Purdy, 2011), and has been a regular topic since then.  Research studies including mixed methods studies, theory incorporation, and framework utilization within the literature began being present in 2013, the year growth on the topic started to intensify (Amrita & Biswas, 2013; Fung et al., 2013; Thomas & Adeniyi, 2013) (see Table 4).  This highlights a certain level of maturation of the state of literature even at this early point, three years since the beginning of publication on the topic.  At the time our literature search ended, in January 2016, there was already one quantitative research study present in on the topic (Lwin et al., 2016).  Figure 2. Timeline: Evolution of the Amount of Literature  * Up to January 30, 2016     0246810122010 2011 2012 2013 2014 2015 2016*Number of Articles (Total =23) Publication Year n=10 n=7 n=1 n=3 n=1 n=1   17 Table 5. Summary of the Evolution of Literature Year Number of articles per year Literature Description 2010 1 Descriptive book chapter utilizing Kenyan quantitative study 2011 1 Descriptive health behavior advertising campaign by a private company for sexual health 2012 0  2013 3 Mixed methods, framework use, and theory development began 2014 13 Predominantly crisis management, infectious disease control and surveillance 2015 7 Quantitative infectious disease studies 2016 1 Theory-based quantitative study on a specific application for fore-warning and global communication purposes  Type of Paper  Fifteen of the 23 articles (65%) were research-based, employing various methodologies.  Eleven of these depicted quantitative studies using non-experimental and descriptive research methods such as content analysis, surveys, and questionnaires.  Two qualitative and two mixed- method study designs comprised the smallest groups with 8.5% each of the total number of citations. Non-research articles were combined together into one category to indicate the considerable presence within this review.  These were articles such as reviews, discussions, descriptive and evaluative reports, and held the second largest category with eight citations in total (35%).  Conference proceedings, descriptions of specific social media interventions, and evaluations of case studies and public health campaigns all were included in the non-research category.  Figure 3 displays the number of articles found for each category.  This figure indicates areas where emphasis has been placed to date, and highlights where gaps in the methodologies are becoming evident.  Figure 4 displays the types of methods used each year since publication began.   18 Figure 3. Types of Literature Found    Figure 4. Type of Literature Found, by Year      02468101214QuantitativeResearchNon-ResearchArticlesQualitative Research Mixed MethodsResearchNumber of Papers (N=23) Type of Paper n=11 n=8 n=2 n=2 0246810122010 2011 2012 2013 2014 2015 2016Number of Papers (N=23) Publication Year Non-Research ArticlesMixed Methods ResearchQualitative ResearchQuantitative Researchn=1 n=1 n=3 n=10 n=7 n=1   19 Geographical Focus Most of the literature focused on Asian (n=9, 39%) and African (n=6, 26%) countries, with countries such as India, China, Kenya and Nigeria being a reoccurring focus in several of the articles.  The other two articles (9%) with a specific geographical focus addressed social media use in Haiti and the Samoan Islands, and were categorized in the ‘Other’ category (Gurman & Ellenberger, 2015; McCool, Freeman & Tanielu, 2014). Four of the articles (17%) discussed the use of social media in developing countries more generally, without a specific geographical focus.  Finally, two articles (9%) included results from more than one geographical group; Alexander (2014) included examples from Nigeria and Haiti, while Hamill, Turk, Murukutla, Ghamrawy & Mullin (2015) examined case studies from Egypt and India.  Figure 5 highlights the number of articles found in each geographical region.   Figure 5. Geographical Focus   Type of Social Media The specific type of social media addressed most frequently in the literature to date has been Twitter with six citations out of the total 23 (26%) (see Figure 6).  Most of these have been published since 2013 and correspond with the literature on the Ebola outbreak of 2013-2014 or the surveillance of other infectious diseases. Literature that did not specify a particular platform or addressed social media in general also accounted for six citations (26%).  Five pieces of literature (22%) were classified as ‘Other Forms’ and focused on platforms such as YouTube, blogs, and specific social media applications for surveillance methods.  Facebook was discussed 012345678910Asia Africa Not GeographicSpecificOther More than OneGeographicalAreaNumber of articles  (Total N=23) Geographical Region n=9 n=6 n=4 n=2 n=2   20 in the literature in four citations (17%).  DeMers (2015) noted that Facebook, which was established in 2004, has dominated the social media arena since the early 2000’s both for health and non-health related use, but the findings from this review shows the importance of Twitter, which was established in 2006, for communications regarding infectious disease control and surveillance.  Two articles (9%) specifically addressed more than one social media platform; Nduka, Igwe-Omoke & Ogugua (2014) discussed both the use of Twitter and Facebook during infectious disease information dissemination, and Purdy (2011) examined together Facebook and blogs within an advertising campaign.  Figure 6. Type of Social Media    Themes of the Literature The literature found in this review can be further classified into four distinct themes of social media use for health: its use for health education and influence, use within infectious disease and outbreak situations, use within natural disaster, terrorism, crisis and emergency response contexts, and producers and consumers of social media for health.  All four themes have demonstrated a significant presence, with many of the papers overlapping two or more groups. Figure 7 summarizes the thematic focus of the social media literature included in this scoping review. Seventeen papers overlapped into more than one thematic category, therefore the total sample size for Figure 7 is 40. 01234567Twitter Social Media inGeneral orUnspecifiedOther Facebook More than OneSpecific SocialMedia PlatformIdentifiedNumber of Articles (Total N=23) Type of Social Media n=6 n=6 n=5 n=4 n=2   21 Theme 1: Health education and influence. Fourteen articles (61%) focused on the use of social media for health educational purposes and influence.  Areas of emphasis included health promotion, risk reduction, and support adherence for treatment regimes.  Education campaigns using social media described in the literature included campaigns to influence tobacco uptake and use (McCool, Freeman & Tanielu, 2014; Hamill et al., 2015), support patients undergoing HIV treatment (Kwaak, Obare & Ormel, 2010), influence sexual health behaviors (Piroska, 2015; Purdy, 2011), and influence behaviour related to malaria and dengue fever transmission (International Federation of Red Cross and Red Crescent Societies, 2014; Lwin et al., 2014).  Theme 2: Infectious disease and outbreak situations. The use of social media pertaining to infectious disease and outbreak situations was another common thread within this theme, and was addressed by nine (39%) of the papers.  Five of these articles focused on the use of social media within the recent Ebola outbreak of 2013-2014 (Basch et al., 2015; Maity et al., 2015; Nduka, Igwe-Omoke & Ogugua, 2014; Odlum & Yoon, 2015; Oyeyemi, Gabarron & Wynn, 2014); the four others highlighted social media use in recent influenza, and dengue fever outbreaks (Fung et al., 2013; Gu et al., 2014; Lwin et al., 2014; Lwin et al., 2016).  One sub-category that emerged from analysis of this theme was the focus of three articles on the online public response to outbreak and infectious disease threats on social media platforms (Basch et al., 2015, Fung et al., 2013 & Gu et al., 2014).  The authors of these papers highlighted the importance of early surveillance of public reaction and response for preparation, clarification, and the control of rumors and misinformation. Theme 3: Natural disaster, terrorism, crisis and emergency response. A small number of the papers (n=3, 13%) addressed the use of social media within such contexts as natural disasters, terrorism, and the response to crisis and emergency situations.   These papers reported on positive and negative patterns of social media use in global emergency and crisis situations.  Specific lessons that were highlighted in the literature included what was learned about crisis management practices from the Nigerian famine of the 1960’s (Alexander, 2014), the effectiveness of the Twitter response of organizations following the 2010 Haitian earthquake (Gu et al., 2014), and how social media was used during the 2013 Westgate Mall terror attack in Kenya (Simon et al, 2014).  Natural disaster, terrorism, crisis and emergency response was separated from infectious disease and outbreak situations described above in order   22 to highlight more specifically the different conditions and environments in which social media use has been shown to be influential.  Although literature on natural disasters, terrorism and emergency response occurred less frequently than those of infectious disease and outbreaks, it is important to recognize the distinction between the two while highlighting the similarities in process and platform use (i.e., Twitter remains the most common platform method used in the literature of both threads).  Theme 4: Producers and consumers of social media. Producers of social media. A focus on the producers and consumers of social media was identified as a prominent category through the analysis of the literature on this topic.  Pertaining to producers, several papers discussed how the production of social media by various types of organizations has changed in recent years, along with unique barriers they experience.  Others explored the specific challenges of information production with the use of Twitter.  As Twitter is the most popular form of social media for health in LMICs today, description of the findings from these articles will be included in this section. i) Organizational producers. Three (13%) of the papers focused on health organizations as producers of social media messages.  These health organizations include governmental groups, and non-government organizations.  These articles discussed changes in organizations’ use of social media that have occurred as a result of the evolution of technology and shifting trends of social media use, in a bid to strengthen their engagement with vulnerable populations.  Challenges that have been highlighted in these contexts include capacity building and training within organizations (International Federation of Red Cross and Red Crescent Societies, 2014), working in tandem with traditional communication approaches (Hamill et al., 2015), maximizing trends and the use of strategies to disseminate information quickly (Gurman & Ellenberger, 2015), and appropriate selection of new media tools for successful campaigns (Gurman & Ellenberger, 2015; Hamill et al., 2015).  ii) Misinformation and challenges of tweets. Key challenges that have consistently been identified within the literature of this review are related to the quality of information available, and ethical and privacy issues (Ahmed & Bath, 2015; Maity et al., 2015; Gurman & Ellenberger, 2015; Oyeyemi et al., 2014; Odlum &   23 Yoon, 2015).  This formed an important sub-category related to the producers of social media.  This was the focus of five papers (22%) that highlighted the unique challenges and the potential for misinformation. For example, Oyeyemi et al. (2014) found 59% of retweets on Ebola-related information in West Africa contained inaccurate information. Non-government organizations, public health and government agencies have been highlighted as pivotal in the quick response required to spread correct information and amend misinformation (Oyeyemi et al., 2014; Odlum & Yoon, 2015; Gurman & Ellenberger, 2015).  All five of these papers were published since 2014, and four of the five pieces are focused on the use of Twitter during the Ebola outbreak. Consumers of social media. In conjunction with producers, the category of consumers of social media for health has also been predominant in the literature.  Two sub-categories were found to be present in several articles: young and marginalized populations’ consumer experiences with social media for health in LMICs, and the expectations and assumptions of consumers of social media use in these contexts.  These two sub-categories are discussed separately under this classification of ‘consumers’ as both depict the opportunity and potential available for the users of social media for health. (i) Young and marginalized populations. Four articles (17%) highlighted the unique barriers and potential faced by young and marginalized consumers of social media in LMICs.  Populations such as LGBT individuals (Piroska, 2015), adolescents (McCool, Freeman & Tanielu, 2014), and people with diagnoses such as tuberculosis (Horter, Stringer, Venis & Cros, 2014) and HIV (Kwaak, Obare, & Ormel, 2010) were highlighted in these papers.  Health educational campaigns, and support and empowerment for treatment adherence and prevention were the more specific uses of social media within and for these patient groups; all of the articles described healthcare providers using social media to reach these otherwise hard to access populations.  As all four of these citations were published early in the topic’s lifetime (2010-2014), vulnerable groups were an early target and one of the first populations targeted by healthcare researchers, agencies and providers in the context of LMICs.   (ii) Expectations and assumptions of consumers. Two articles (9%) focused on the expectations and assumptions of consumers of social media.  One paper focused on the general public in India as their sample of social media   24 consumers (Amrita, 2013); the other sampled a stakeholder group of healthcare professionals in Nigeria for their perceptions on the use of social media for healthcare delivery in their state (Thomas & Adeniyi, 2013).  The expectations of the general public as consumers of social media for health were highlighted in the Indian article, while the Nigerian article found feasibility issues for implementation and sustainability of use of social media for health as major findings from their sample.  Figure 7. Thematic Focus of the Literature     0246810121416Health Education andInfluenceProducers andConsumers of SM forHealthInfectious Disease &Outbreak SituationsNatural Disaster,Terrorism &Emergency ResponseNumber of Articles Thematic Focus n=14 n=14 n=9 n=3   25 Chapter 4: Discussion Key Findings Analysis of the literature in this scoping review suggests that social media is being used on a frequent basis for health in low and middle-income countries by a variety of stakeholders including patients, healthcare professionals, the general public, governments, and non-governmental organizations.  The date range of the literature found was from 2010 to 2016, with an increase in volume of literature in 2014 and 2015.  The increase in volume of literature in 2014 and 2015 is concurrent with the Ebola outbreak, as much of the literature in these two years is related to this epidemic and other crisis situations happening around the world.  Sixty-five percent of the literature was research-based, in the form of non-experimental and descriptive research; the non-research-based literature focused on descriptive case studies and evaluative reports.  Asian and African countries were the most common geographical focus of the literature.  With its recent employment in outbreak, crisis, and disaster management and control, Twitter is the most popular platform used in the literature on health in LMICs.  Governmental and non-governmental organizations are key producers of social media for health in LMICs, while consumers are typically young and marginalized populations. The use of social media is forecast to increase and it is likely there will continue to be changes in user trends (Poushter, 2016).  Each use of social media for health comes with its own benefits and challenges that must be considered by decision-makers when choosing a platform or design for different projects.  Positive effects that have been attributed to the use of social media for health in low-resourced settings are those related to infectious disease surveillance (Odlum & Yoon, 2015; Basch et al., 2015), mass communication capacity (Alexander, 2015; Gurman & Ellenberger, 2015), and education and knowledge translation (Hamill, 2015; International Federation of Red Cross and Red Crescent Societies, 2015).  Despite a relatively young field of research, development and maturation of the body of literature can already be seen at this early stage.   Regardless of the progress that has been made, there is an array of negative effects and barriers that require analysis by researchers in future, high-quality primary studies and literature pieces.  Information quality and the misinformation potential of social media are at the forefront of these concerns (Ahmed & Bath, 2015; Alexander, 2014; Oyeyemi et al., 2014; Maity et al., 2015).    26 Gaps and Potential for Future Research There is a paucity of research literature on the use of social media for health in LMICs; therefore, there is a need to conduct experimental and well-designed quasi-experimental studies to test aspects of social media use for health in low and middle-income countries.  This would assist in providing evidence for implementation strategies addressing the different barriers that have been recognized.  Future research should include prevalence studies to identify who is and who is not using social media, and well-designed survey studies to identify acceptance, preferences and barriers to use of social media for health in the context of LMICs.  On-going sustainability is an important consideration for future research of experimental and non-experimental nature. The narrow geographical focus of the literature presents a further opportunity for future research.  A majority of the literature was centered on Asian and African countries, with little attention given to other areas. We found no literature that focused on geographical areas such as South America, Eastern Europe, or the Middle East; thus we have no information on the prevalence of social media use for health in those areas, types of use, or barriers to use. Feasibility issues when researching social media use such as physical access for the researchers, and local government censorship may provide barriers in these areas, as well as a possible lack of Internet access relating to the use of social media in general. The population benefits and supportive research results that could be ascertained in these under-accessed regions is not to be overlooked however, and the decision to proceed must be carefully considered by upcoming researchers.  Future research should explore the impact on population groups that have not yet been addressed.  One such group in which surprisingly, no research exists on this topic is that of maternal and child populations.  Although there is considerable mHealth research focused on maternal-child health (Higgs et al., 2014), our scoping review did not identify maternal-child health as a focal topic or user group for social media use in LMICs.  Social media may be a useful adjunct to the use of mHealth applications concerning maternal-child health, and its use for these populations should be studied, with special consideration given to the misinformation potential.  Utilizing social media for maternal-child health education and behaviour change campaigns could be a viable way for research in this specific context to begin.     27 Implications These findings offer beginning lessons for health care organizations, health care professionals, researchers, and the general public who are concerned with optimizing the use of social media in LMICs for health related purposes.  In addition to being aware of research gaps in the literature on social media use, researchers should also be familiar with the potential use of social media as a data collection method as its use may influence study design and extend the potential reach of the study.  Conducting multiple trials followed by a formal systematic review would be beneficial in providing evidence for policy and practice recommendations. Despite the limited volume of the literature on this topic, there is evidence that the influence of social media on health in LMICs is far-reaching, especially for public health issues.  Despite the need for future research relating to different geographical contexts and certain high-risk populations, social media has the ability to facilitate knowledge translation, communication, collaboration, and education.  Patients and consumers of health-related social media often encounter barriers in both high and low-income settings related to misinformation potential.  Organizations utilizing social media need to proceed with due diligence in terms of the accuracy of their information to avoid translating misinformation.  Also, attention to the readability of an organization’s social media pages and platforms is important in order to build credibility and enhance user friendliness.  The general public as well as healthcare professionals must be wary of the quality of information accessible on the Internet and social media, using only credible and reliable sources for health-related usage. Limitations A limitation to this review is the exclusion of articles not published in English.  This is common in scoping reviews, as most only include English language articles (Bardus, Smith, Samaha & Abraham, 2015).  Despite most of the articles found in the process of this review being published from English-speaking countries, it may have been beneficial to include other languages as this topic is centered on LMICs. Some papers may have been missed that were published in the native languages of these geographical areas. Secondly, although an effort was made to minimize publication bias by searching systematically for grey literature in the databases Google and Google Scholar, publication bias cannot be entirely excluded.  For example, each search in the Google database yielded several hundred thousand results, but for time and resource reasons, the search was limited to the first   28 four pages of each search result.  This may have led to some relevant results being unintentionally excluded.  However, as both Google and Google Scholar search results are generally sorted by relevance, with the most applicable information listed first (Badia, 2009), this may have limited the degree of publication bias.  In addition, literature published since January 30, 2016 (the date of our final search) is not included.  Conclusions This scoping review provides a descriptive map of the literature on the use of social media for health in LMICs.  Social media is used for a variety of purposes, and its use is on the rise.  The positive and negative effects of social media use for health in LMICs have been highlighted through this review.  Social media facilitates mass communication and offers potential for surveillance; thus the potential benefits are vast.  However, there are also challenges to the effective use of social media related to information quality and the potential for misinformation.  The Internet is an unregulated public and global entity; thus, there is the possibility for the spread of rumours contributing to public hysteria.  More research is needed to address gaps in the social media literature related to its limited geographical focus, the paucity of research-based literature, which stakeholders and populations benefit the most and through what methods, and which social media platforms and uses are most effective for knowledge translation. 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Retrieved from http://www.who.int/goe/publications/goe_mhealth_web.pdf   35 Appendix A  # Author Year Findings 1 Ahmed, et al. 2015 Key challenges exist with large sample Twitter data related to information quality, ethical and privacy issues, validity and reliability of information, and feasibility. 2 Alexander 2014 Ways in which social media (SM) can be used positively in a disaster risk reduction and crisis response: As a listening function for monitoring a situation, for crowd-sourcing and collaborative development, for creating social cohesion and promoting therapeutic initiatives, and for the furtherance of causes and research.  Negative side of SM use: Misinformation, exaggerations and inaccurate information (increasing the sense of chaos and insecurity), sheer volume of information (considerable ambiguity about whether SM exert a benign or a malignant influence on public safety and security), and ethical dilemmas.  Ethics an important issue for privacy and misrepresentation.  Some recent successes with social media use in crisis situations. 3 Amrita, et al.  2013 Majority of people responded they expect that health care becomes more accessible and available. Negative influence was highlighted in the openness of privacy.  Users are very skeptical towards keeping their identity and friend’s list open. The less disclosure of health care interests is very prominent. Respondents wish to get advice from experienced people and not only from health experts. Hence immediacy has a positive influence in terms of intermediary communications supported. Usability shows a positive influence where people want to be in directory listings. The users of SM in India expect that they can best utilize social media through emergency service information. They want to be able to learn the operations of the SM site quickly and expect to know about health camps and insurance collaborations. However, people like to become friends with people with similar interests based on their interests identified. 4 Basch, et al. 2015 Over one-third of the videos mentioned how Ebola Virus Disease (EVD) was generally transmitted (39%), with 30% mentioning bodily fluids; 17% mentioning infected fruit bats, monkeys, or handling infected bush meat; 15% mentioning transmission through other avenues such as a deceased body; and 4% mentioning transmission through objects. The death toll in West Africa was mentioned in 32% of the videos. Cases in the United States (21%), fear (19%), and anxiety (20%) were highlighted in about one-fifth of the videos, whereas 19% were comedy skits, and a smaller percentage were about a conspiracy theory (12%) or hoax (5%).  There was little mention of treatment (4%) and no mention of the need for US funding of disaster preparedness; coordination between local, state, and federal governments; or beds ready for containment. 5 Fung, et al. 2013 Reaction to the H7N9 (bird flu) outbreak in 2013 was about two orders of magnitude stronger than the one to the MERS-CoV outbreak in 2012. The results confirmed the hypothesis that the Chinese online community reacted more strongly to an outbreak that was in China than one outside China. 6 Gu, et al. 2014 Internet surveillance was used to investigate the public reaction to the H7N9 outbreaks over time during the first 25 days of the H7N9 epidemic in China in the spring of 2013. The indexes of public reaction, daily posted and forwarded number and BAI, to H7N9 outbreaks were significantly higher in 7 provinces/cities with human H7N9 cases than those in 2 provinces without cases. Both daily posted and forwarded number and BAI were positively associated with the cumulative case fatality rate of human H7N9 infection.    36 Appendix A (con’t)  # Author Year Findings 7 Gurman, et al. 2015 Study findings indicate that the ways in which organizations used Twitter changed over time. Chi-square analyses demonstrated that organizations decreased in their use of certain strategies to disseminate information through Twitter, such as the use of links. Organizations did not change in their use of techniques to involve users (e.g., retweet, call to action), with the exception of using tweets as a fundraising mechanism.  8 Hamill, et al. 2015 Case Study #1-‘Packhead’- Findings: Online application that allowed users to take pictures from their online photo galleries to build custom graphic pack warnings. Failure was deemed due to users were found to be uncomfortable sharing ‘ugly’ photos, and the application was not novel enough to attract mainstream media attention.    Case Study #2-‘Smoke Free Alexandria’- Findings: Facebook page and ads. Positively framed messages and active page management seemed to work well.  Case Study #3-‘Chewonthis.In”- Findings: used a blend of online advertising, community engagement, and social media sharing to obtain reach. Most successful campaign with the largest reach. 9 Horter, et al. 2014 The TB&Me blog was associated with identified health benefits, with no reported instances of harm.  Three key themes emerged from data analysis: participants found that blogging was useful for adherence to multidrug-resistant tuberculosis (MDR-TB) treatment, provided alternative support to patients and gave patients strength and voice, and provided a tool for patient expression and empowerment. Triangulation of results showed that the predominant ideas and majority themes found in the blogger participant group were echoed in the project staff group. The responses of the stakeholder group supported some of the blogger and project staff responses, as well as providing insight into blog exposure and access.   10 International Federation of Red Cross and Red Crescent Societies 2014 By targeting communications and operational staff, the projects were able to combine on-the ground knowledge of programmes with communications expertise. While technology continues to transform humanitarian communications at a rapid rate, it is essential to consider the different starting point of each National Society in relation to the specific country context, the internet accessibility and the internal resources and capacities. The workshop and trainings have played a vital role in helping to develop a skilled set of social media representatives from each National Society, as well as providing a forum by which colleagues from within the region can share their learning and examples of best practice.  11 Kituyi, et al. 2014 No findings yet as this is just the proposal.         37 Appendix A (con’t)  # Author Year Findings 12 Kwaak, et al. 2010 This chapter highlights some of the findings and recommendations of a diagnostic study and related life-skills workshop that assessed the sexual and reproductive health (SRH) information and service needs of young people living with HIV in Kenya with a view to identifying opportunities for the use of social media to address some of these needs. The findings of the diagnostic study show that the SRH needs of HIV-positive young people require social programmes that address their aspirations and rights in the context of chronic illness and vulnerability. Coupled with the challenges of dealing with adolescent SRH issues in general, there is a need for innovative strategies such as the use of social media to address issues of SRH, empowerment, self-esteem, desires and professional aspirations of HIV-positive adolescents within HIV and AIDS programmes. 13 Lwin, et al. 2014 The system integrates three concepts of public health prevention that have thus far been implemented only in silos. First, the predictive surveillance component uses a computer simulation to forewarn health authorities and the general public about impending disease outbreaks. The civic engagement component allows the general public to use social media tools to interact and engage with health authorities by aiding them in surveillance efforts by reporting symptoms, mosquito bites and breeding sites using smart phone technologies. The health communication component utilizes citizen data gathered from the first two components to disseminate customized health awareness messages to enhance knowledge and increase preventive behaviours among citizens. The system, known as “Mo-Buzz,” will be made available on a host of digital platforms like simple mobile phones, smart phones and a website. The authors present challenges and lessons learnt including content validation, stakeholder collaborations and applied trans-disciplinary research. 14 Lwin, et al. 2016 The overall receptivity assessment offered positive, above average scores (>4.00) for reach of the three aspects of potential adoption of Mo-Buzz (response efficacy, self efficacy and intention-to-use), suggesting a definitive need for such a system.  The strong feedback on response efficacy alludes to a prevailing public sentiment about the value of a pro-active, interactive system that can protect people from dengue by forewarning them about dengue outbreaks, and enables real-time communication with health authorities. The positive response on self-efficacy is testament to the latent power of mobile phones as tools of public health intervention delivery in Sri Lanka.  Finally, the strong intention-to-use scores provide evidence-based encouragement for consideration of launching a public version of the Mo-Buzz system.         38 Appendix A (con’t)  # Author Year Findings 15 Maity, et al. 2015 Misconceptions about Ebola Virus Disease (EVD) focused mainly on the transmission and symptoms of the disease. There was a gap in the understanding of the haemorrhagic nature of the disease. About 35% of the participants failed to realize that bleeding is one of the characteristic symptoms of EVD. Moving on to the responses about the sexual mode of transmission of EV, almost 40% of the study participants were not aware of a sexual mode of transmission. The results also showed that half of the study group had no idea that semen from a recovered patient harbours the virus for at least 7 weeks. Awareness regarding the preventive measures, modes of transmission, and symptoms of EVD is required to fill the existing gaps in knowledge. One of the most important ways in which EVD can be prevented is by strict adherence to hand washing. This fact was known by more than half of the study participants but, at the same time, draws our attention to the 40% who were unaware of this basic practice of hygiene for preventing disease transmission. 16 McCool, et al. 2014 Family is critically important for representing normative tobacco use in Samoa. The use of media, in particular digital media, was found to be determined by parental views in the home. Media access remains highly regulated within more traditional households. Loyalty to traditional cultural practices (Fa’a Samoa) underpinned views on the limited influence of media on social norms around tobacco use. Parents were thought to have the greatest influence on youth smoking. Tobacco use was viewed as a personal, or family issue, and not a problem that was amendable to change at a societal level. Strikingly, there was a general lack of understanding about the influence media has on tobacco use opinions, attitudes and behaviour. 17 Nduka, et al. 2014 The cross-country recent epidemic of Ebola Virus Disease (EVD) and the Nigeria success story has been variously commended. This paper reviews the Nigerian Strategy, which led to successful containment of the epidemic in the Country. Evidence shows that a concerted effort involving several epidemiologic steps and mass awareness interventions taken by different groups and healthcare organizations and governments were deployed. The positive role of SM in containing the epidemic is very commendable and is highlighted. This article is important because the Nigerian strategy can be deployed in managing any case of epidemic in developing and developed countries, and provides evidence that developing Countries can provide direction for major global health challenges. 18 Odlum, et al. 2015 A total of 42,236 tweets (16,499 unique and 25,737 retweets) mentioning Ebola were posted and disseminated to 9,362,267,048 people, 63 times higher than the initial number. Tweets started to rise in Nigeria 3-7 days prior to the official announcement of the first probable Ebola case. The topics discussed in tweets include risk factors, prevention education, disease trends, and compassion. Findings demonstrate the usefulness of Twitter mining to inform public health education.     39 Appendix A (con’t) # Author Year Findings 19 Oyeyemi, et al. 2014 The most common misinformation was that Ebola might be cured by the plant ewedu or by blood transfusion. Drinking and washing in salty water were also mentioned. Among these tweets, 248 (44%) were retweeted at least once; 95 of these contained scientifically correct information (38.3%), whereas 146 contained medical misinformation (58.9%; P<0.001).  While most erroneous tweets were left undisputed, in some cases they were corrected by a Nigerian government agency and this correction spread on Twitter three days later. 20 Piroska 2015 Reaching all segments of the men who have sex with men (MSM) and transgender population with sexual health services is difficult. The MStyle campaign successfully reached 90% of visible MSM in target areas via clubs, special events, social marketing, and referrals. As part of this campaign, the MStyle photo booth showed how social media photographs can be used to promote public health messages for safer sexual intercourse. 21 Purdy 2011 By utilising a wide range of digital platforms – a new website, Facebook page, Google Adwords, an e-newsletter, viral marketing, banner ads and involving bloggers – Fiesta achieved strong recognition among the target audience of sexually active young people, though far more men than women. Retail audits, Internet analysis and sales performance suggest that using the Internet was instrumental in establishing Fiesta. Sales reached 4.3 million condoms (of which 8% were sold online) in the first 18 months. In contrast, Kiss, a far more inexpensive condom, launched at the same time but with no digital campaign, sold 2.6 million.  22 Simon, et al. 2014 Four main categories of hash tags were identified: geographical locations, terror attack, social support, and organizations. The abundance of Twitter accounts providing official information made it difficult to synchronize and follow the flow of information. Many organizations posted simultaneously, by their manager and by the organization itself. Creating situational awareness was facilitated by information tweeted by the public. Threat assessment was updated through the information posted on social media. Security breaches led to the relay of sensitive data. At times, misinformation was only corrected after two days. 23 Thomas, et al. 2013 Respondents had a high knowledge of social media, favourably disposed to the use of social media in healthcare delivery. There exist a significant relationship between respondents’ knowledge (r = 0.267; p<0.05) and the perception of health personnel on the use of social media for health care delivery, while there is no significant difference (F=0.956; p>0.05) in respondents’ perception of health personnel on the use of social media for health care delivery across the medical personnel interviewed. Although, a lot of medical personnel in Oyo state have a robust knowledge of social media and think it can be very useful for healthcare delivery, they still do not use it or even see the feasibility of its implementation in Nigeria.  This is largely due to the fact that they do not think their patients will accept the idea, a large percentage that is illiterate and ignorant of social media.    

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