Like, comment, tag, share: Facebook interactions in health research

Journal Pre-proof Like, comment, tag, share: Facebook interactions in Health Research Kehinde Obamiro

PII:

S1386-5056(19)31300-0

DOI:

https://doi.org/10.1016/j.ijmedinf.2020.104097

Reference:

IJB 104097

To appear in:

International Journal of Medical Informatics

Received Date:

18 November 2019

Revised Date:

2 February 2020

Accepted Date:

6 February 2020

Please cite this article as: Obamiro K, Like, comment, tag, share: Facebook interactions in Health Research, International Journal of Medical Informatics (2020), doi: https://doi.org/10.1016/j.ijmedinf.2020.104097

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.

Like, comment, tag, share: Facebook interactions in Health Research

Kehinde Obamiro

University of Tasmania, Newnham drive, Launceston, [email protected] +61415225361

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Introduction

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Few would argue the extent to which the Internet has revolutionised all forms of communication and information sharing. Under that same revolution comes the way in which research is or can be conducted. So integral has the Internet become to contemporary culture

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that some have suggested that modern ethnographic research should incorporate it in consideration of all communication, behaviour and artefact (Garcia et al. 2009). The same

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could easily be said for other forms of research, such as phenomenology or case studies, with

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the Internet fast becoming the principal way in which we communicate, exchange viewpoints, reflect on experiences and build relationships.

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A key aspect of the Internet that facilitates research is social media, especially the meteoric rise in the use of Facebook as one of the primary applications for social connectivity. Facebook

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can be considered a rich source of data due to the high amounts of demographic information shared by users and stored in the system, as well as the way in which users share their

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thoughts and behaviour in their natural environment (Kosinski et al. 2015). Due to its high usage, Facebook has established itself as an ideal mechanism for recruitment in research studies. Standard recruitment strategies, where human participants are required for data collection, can be expensive and time consuming (Thornton et al. 2016), leading to prolonged wait times before data collection can begin. Such traditional methods of recruitment can

include printed advertisements, media releases and direct approaches via mail or email (Bunge et al. 2019). Yet, Facebook, with its heightened accessibility, instantaneous communication options and targeted advertising prove much more efficient and effective in recruiting participants in the shortest possible timeframe. One such study found recruitment via Facebook was up to 2.5 times faster than traditional methods (Kayrouz et al. 2016) while others have found that Facebook enables access to a larger and more diverse pool of potential participants and reduces the overall costs of the study as a consequence of more direct and

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faster periods of recruitment (Christensen et al. 2017, Lane et al. 2015, Whitaker et al. 2017). Additionally, studies have compared Facebook-sourced participants with those recruited face-to-face and found very few differences (Thornton et al. 2016), verifying that this method

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more reliable, and effective research outcomes.

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of recruitment could produce largely similar representative samples, allowing for high quality,

Facebook has also proven a valuable tool for research beyond ease of recruitment and the

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mining of rich data provided by users. The functionality of Facebook allows it to also maintain a connection between researchers and participants. For example, the ‘Like’ or ‘Follow’

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functions allow interested members of the Facebook community to receive any updates on the research project as and when updates are made, enabling a sense of continued

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connection to the project (Kosinski et al. 2015). This report focuses on one functionality that

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remains under-discussed and perhaps under-utilised as a tool in health research – the ability for participants or interested parties to leave comments directly on Facebook posts relating to research projects. Further, this report provides some considerations for researchers intending to use Facebook in recruiting participants for research. 2.0

Method

The study was a Bowel Cancer Awareness Study conducted by the Centre for Rural Health,

University of Tasmania, to assess bowel cancer risk awareness in Tasmania. Participants were recruited to complete a survey on LimeSurveyTM via a Facebook page used to advertise the study. The Facebook page was established in April 2019 and three paid advertisements targeted Tasmanian residents aged 18 years or older. This was done using the Facebook location settings, which ensures that only people based in Tasmania can view the advertisement. An incentive was added to increase participation rates, in the form of the chance for three individuals to win one iPad mini each. Numerous comments were made on

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the Facebook page over a three-month period, which were categorised into the aim and intent of the comment and then thematically analysed. Specifically, these comments were

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reviewed to determine how valuable Facebook comments can be to research. Ethics and Consent

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The Social Science Human Research Ethics Committee granted ethical approval for the

submission of the survey. 4.0

Result

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research with reference number H0018042. Consent to participate was implied by the

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The Facebook advertisement for the survey reached 136,640 people over the course of a

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three-month period at a cost of $0.04 (4 cents) per person. Of this number, only 2651 was organic reach, that is, the number of people that was reached at no advertisement cost. The

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reach was varied between males (43%) and females (56%), with 1% choosing not to provide information regarding their gender. The advertisement reached more females compared to males across all age groups (Figure 1). The total number of link-clicks was 9627, of which the majority occurred between 18.00 pm and 22.00 pm (Figure 2). A total of 590,757 views were recorded at a cost of 0.9 cents per view. Of note, 92% of advertisement views were via a mobile device (Figure 3). There were a total 246 of comments, 788 ‘likes’ (or ‘loves’), 28 tags

and 250 shares made by participants and interested parties on three separate advertised posts. The terms ‘participants’ and ‘interested parties’ are used as it cannot be determined if all those who left comments participated in the survey. A total of 4975 participants responded to the survey, even from remote and very remote areas of Tasmania. Of this number, 3703 responded to every item on the survey, resulting in a cost of $1.40 per participants. Also, 26% of all respondent reported that they were from areas classified as small rural towns, remote communities or very remote communities, according to the Modified Monash Model

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classification system (Health 2019).

Among respondents, the mean age was 54 years (of which 24% of respondents were 60 years old and above), and 68% were females. Diverse ethnic groups were represented in the survey,

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including Caucasian, Chinese, African, Hispanic and Aboriginal and Torres Strait Islander

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people. Of note, over 12% of respondents reported to be of a different ethnicity outside of being Australian or English.

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The comments left in response to the Bowel Cancer Awareness Study survey were both positive and negative in the language used. Positive language was on a spectrum of a simple

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‘thank you’ or commenting that the survey took no time at all, to statements that the bowel cancer screening kit ‘saved their life’. Some commented on relatively short wait times to

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receive follow-up colonoscopies while others related stories of cancer experiences and the

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hope that increased awareness and prevention brought with them. Negative language tended to centre on extended wait times for follow up colonoscopies (which seemed to depend on which part of the state participants were from), waiting up to 12 months even when categorised as ‘urgent’. Frustration was expressed that money had been allocated to ensure the bowel cancer screening kit was sent out to all people over 50 years old, yet no money had been committed to ensure follow up procedures could be done in a timely manner. Others

expressed disappointment that testing was not always 100% accurate, while a few expressed frustrations that they had completed the survey yet been unable, due to technical reasons, to enter the prize draw. From the thematic analysis of the comments comments received, four separate functions of these comments became apparent upon analysis – 1) the capacity to ask questions; 2) the ability to interact with others; 3) promotion of the survey, and; 4) suggestions for future research (Table 1).

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Across the comments, several questions focusing on the following were asked: technical difficulties entering the prize draw, how to obtain a replacement bowel screening kit, who was conducting the research and clarifying why certain questions had been included in the

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survey. For example, some participants were concerned that they were being asked questions

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about income and were unsure of how this fit with the topic of bowel cancer. The researchers were able to respond directly and comment that income as a social determinant of health

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could be linked to many health risks, including cancer risk. After which, respondents seeking clarification expressed satisfaction with the response provided.

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Comments and peer support also facilitated health research in this instance, by allowing participants to interact. Comments can be viewed by anyone who accesses the post and

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replies can be left to these comments. Two such participants were able to readily interact to

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discuss their experiences of wait times and one was able to provide encouragement and support to the other. Comments left by participants also served in several instances to directly promote the survey and bowel cancer awareness. Two participants disclosed their personal experiences with bowel cancer and expressed encouragement and appreciation to others participating. Others provided general positive comments and urged more people to participate in order to address

the risk of bowel cancer. Of significant note, 28 participants directly ‘tagged’ another person. Tagging involves linking a Facebook friend directly to the post so that they see this in their notifications. They are then able to see something that they might otherwise have missed. The final function of Facebook comments observed was the capacity for respondents to flag possible avenues for future research. For example, several comments were made about possible cancer clusters in certain areas within Tasmania and expressed a desire for future

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research to focus on possible explanations for this.

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Females

Number of people

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Males

14000 12000 10000 8000 6000 4000 2000 0 18-24

25-34

35-44

45-54

55-64

65+

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Age (years)

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Figure 1: Number of people reached by the Facebook advertisement, by age

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900 800

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600 500 400 300 200

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Number of clicks

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100

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Time of day

Figure 2: Time of the day when advertisement link was clicked

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Number of views

500000 400000 300000 200000 100000 0

Desktop device

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Figure 3: Number of advertisement views by device type

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Mobile device

Discussion

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From the experience of the Bowel Cancer Awareness Study using Facebook, the research

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team came to value the insight offered by the comments left on posts about the study, especially with regards to the following: the capacity to ask questions; the ability to interact with others; promotion of the survey; and suggestions for future research.

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The capacity to ask questions ensured that respondents issues regarding survey technicalities

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were resolved promptly. The advantage of considering comments when conducting research or collecting data on social media is that questions and concerns can be addressed, where

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appropriate, directly by the research team. This increases the likelihood that participants will understand the content of the survey, as they have had an opportunity to clarify their uncertainties.

The interactions between participants ensured that respondents were able to encourage, affirm and support each other. The capacity to interact could potentially serve to create a more positive experience for participants and open more honest and interactive lines of

communication. Although no demand was placed on participants to promote the survey, many nonetheless, promoted the survey when they shared their bowel cancer experience and encouraged other people to participate, or by tagging their friends on Facebook and requesting them to complete the survey. Tagging is, in effect, a form of snowball sampling, which is beneficial in certain types of research question. Snowball sampling is often used by researchers via a direct approach to those who meet the inclusion criteria for a research study and having

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them suggest others who might be willing and able to participate (Marshall and Rossman

2006). Our observation aligns well with that of Kosinski et al who reported that Facebook offers an extension to snowball sampling by enabling original participants to tag friends,

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share posts and invite others in a way that can create a positive feedback loop and

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increased sample sizes (Kosinski et al. 2015). Indeed, Facebook has been found to be a social media platform that works very much off promoting information through strong social ties

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(Valenzuela et al., 2018). That is, Facebook promotes stories or facilitates tags or invites from those you interact the most with or select to follow first in your newsfeed, creating

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stronger social pressure on the Facebook user to engage in more time-intensive activities. Also, Facebook and other social media platform provides alternative options for

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communication and interactions, in a manner different from direct solicitation (e.g., email),

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and this is often viewed as less intrusive (Kwon et al., 2014). The researchers did gain valuable information concerning useful research ideas, including perceived higher cancer clusters in certain parts of Tasmania, possible explanations, and the need to improve healthcare delivery services in Tasmania, especially with regards to access to a colonoscopy procedure. Such information, whether first-hand or anecdotal, can raise awareness of possible links between places and cancer incidences. Verification of the

information provided can be useful in helping our research teams prioritise and make informed decisions on areas for future research. The Tasmanian population of people of aged 18 years and older is estimated to be around 354,000 (ID Polpulation Experts 2018), of which, our Facebook advertisement reached over 136,000 people (38%), across Tasmania, including people of diverse ethnic groups and those in remote and very areas according to the Modified Monash Model classification (Department of Health 2019), at an affordable cost of $0.04 (4 cents) per person. This suggests that

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accessibility is enabled using Facebook for recruitment, not just by reaching the largest possible group, but also by being able to access otherwise harder to reach groups. Those groups of low incidences and those groups normally highly stigmatised have been found to

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be more readily accessed through Facebook due to the ability to maintain anonymity and

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confidentiality (Ramo and Prochaska 2012, Fenner et al. 2012).

This research did encounter several limitations. First, of the 136,000 people reached, less than

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2% was organic reach. Regardless of the total number of ‘likes,’ ‘comments,’ ‘tags’ or ‘shares,’ organic reach was still poor. This could be because the competition on user’s newsfeed is on

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the rise due to availability of excessive content online, making it harder for many stories to gain exposure (Hubspot 2018). This suggests that in order to ensure optimal coverage when

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using Facebook for research purposes, budgeting for advertising costs is necessary to ensure

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adequate visibility of research information. Second, despite fairly even reach of the advertisement across both males and females, only 32% of those who eventually participated in the survey were males. To improve the participation of males, other methods, including the use of traditional approaches may be employed to supplement Facebook surveys. The reason for the lower participation rate in males may be because males have been reported to be less likely to engage with online

health-related information (Bidmon and Terlutter, 2015). The research was also limited by its application solely to Facebook. No other forms of social media were used to promote the survey and it was beyond the scope therefore of this research to examine the way in which platforms, such as Twitter, can be used to engage participants and promote health research. However, a systematic review on the use of Twitter for health research suggests that the social media platform is also quite useful for study recruitment, intervention and capturing live data (Sinnenberg et al., 2017).

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The research also did not consider the impact of recent negative media relating the use of personal information by Facebook. The social media giant has been subject of a suite of criticisms relating to misuse of personal data, including the harvesting of data by Cambridge

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Analytica to make targeted political ads, glitches that published private posts and accusations

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of the ‘weaponisation’ of personal data (Ho, 2018). Such negative media can decrease public confidence in the platform, reduce its user base or limit people’s interactions with Facebook,

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and therefore with health research utilising Facebook. As Facebook moves into a new era of government scrutiny and consideration of its role in ethics and privacy, the impacts of this on

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Facebook and other social media platforms as research tools are as yet unknown. A recent article has highlighted the prospect of using block chain technology in social networking

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platforms to minimise privacy infringement associated with the use of Internet technologies

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(Park and Ozel, 2019). Since the Internet technology is heavily dependent on centralized servers, it has been suggested that block chain technology has the capacity to mitigate this limitation and assure data privacy (Park and Ozel, 2019, Al-Saqaf & Seidler, 2017). Therefore, new social media platforms using block chain technology may be beneficial in improving public confidence, as well as increase the utility of the social media space for health research.

The research promoted several strengths or noteworthy findings that can be considered when considering Facebook for research and data collection. Although there have been reports in the past suggesting that Facebook may not be a useful research tool in the older population (Kross et al. 2013, Whitaker et al. 2017), the mean age of respondent who attempted at least one question in our survey was 54 years, of which 25% were 60 years or older, suggesting that Facebook may now be considered a useful research resource even in the older population. This is supported by the assertion by Duggan et al, that while Facebook may still be used at

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high levels among young people, it has also experienced a rise in use by older adults, with approximately 56% of older adults using Facebook, and 31% of those over 65 years (Duggan et al. 2015). This makes recruitment of older participants, previously only accessible through

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traditional means, more reachable as their use of Facebook increases.

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Over 90% of advert views were via a mobile device. This has significant implications for investigators using Facebook for research as mobile devices are often smaller than a desktop

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device and appropriate font size is required to ensure readability. Considering that most people clicked on the advertisement between 18.00 and 22.00 hours (6-10pm), this may

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suggest that evenings are the best time to engage in Facebook advertising. Not much research or information is available regarding appropriate time to schedule Facebook advertisements

Conclusion

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within the context of healthcare research.

From the Bowel Cancer Awareness Study, we found that Facebook comments on our study page allowed for an opportunity for ongoing contact with respondents, opportunity to receive feedback, address concerns and harness future research ideas. The ability to further utilize the potential for Facebook comments to enrich data collection and health research warrants continuous and sustained interest as research methodology progressively utilises the Internet

and social media platforms as an effective and affordable option. Lastly, researchers should fully consider the advantages and limitation of Facebook before using it as a platform for health research. Summary

From the experience of the Bowel Cancer Awareness Study using Facebook, the research team came to value the insight offered by the comments left on posts about the study, especially with regards to the following: the capacity to ask questions; the ability to interact with others; promotion of the survey; and suggestions for future research.

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We found Facebook to be effective and affordable in reaching a wide range or respondents, including people of diverse ethnic groups and those in remote and very areas.

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We also found that Facebook comments on our study page allowed for an opportunity for ongoing contact with respondents, opportunity to receive feedback, address concerns and pursue future research ideas. The ability to further utilize the potential for Facebook comments to enrich data collection and health research warrants continuous and sustained interest as research methodology progressively utilises the Internet and social media platforms as an effective and affordable option.

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statement

Conflict of interest.

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Kehinde Obamiro: Conceptualization, Methodology, Formal analysis, Investigation, Writing - Original Draft, Writing - Review & Editing and supervision. Sancia West: Formal analysis, Investigation, Writing - Original Draft. Simone Lee: Conceptualization, Methodology, Formal analysis, Writing Review & Editing.

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The authors have no conflict of interest.

Acknowledgement: We like to thank the Cancer Council Tasmania for providing the fund for the research.

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Table 1: Theme, description and example quote

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Promotion of the survey

‘Person 1: Done, I have waited 15 months for my colonoscopy I was on the urgent list’ ‘Person 2: I had mine after 30 days and was only semi-urgent, I hope you have yours as soon as possible’ Facebook comments section ‘Please do this I survived a brush provided the opportunity with Bowel Cancer’ for individuals to promote the survey without been requested to. Several individuals ‘Our area has an unprecedented requested the research amount of people who have, or team to consider had, or passed away from bowel researching into specific cancer. Both my in-laws, the man areas of concerns related to next door, the lady down the back bowel cancer. the school gardener and so on. It just seems a lot of people from this one area that grew their own veggies used to catch fish and thought they were living healthy. The one who thing they have in common is they all used a certain weed killer everywhere and on their veggie gardens. Don't know if coincidence but I think it's worth looking into’

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Suggestions for future research

Example Quotes ‘Sorry, but what do one’s income and years of education have to do with Bowel cancer?’

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Ability to interact with

Theme Description The Facebook comment section provided an opportunity for participants to ask the research team questions and have their concerns addressed. Connections were established easily and quickly, leading to meaningful interactions.

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Theme Capacity to ask question