Despite the ubiquity of health-related communications via social media, no consensus has emerged as to whether this medium, on balance, jeopardizes or promotes public health. 
 
During the current COVID-19 outbreak, social media has been described as the source of a toxic ‘infodemic’ (register for the July 21 WHO conference on infodemiology) but also a valuable tool for public health promotion, harnessed by national and local public health departments to convey risk mitigation strategies. 
 
We argue that, like other forms of media, social media are just a tool, neither inherently good nor evil. We present a metaphorical epidemic/response model to illustrate the multiple, often conflicting, functions of social media in public health, incorporating context and multiple levels of outcomes. 
 
The SPHERE Continuum is a framework to guide the investigation and assessment of the effects of social media on public health. We consider the functions of social media across the epidemic/response continuum, ranging from contagion; vector; surveillance; inoculant; disease control; and treatment. 
 
We also describe attributes of the communications, diseases/pathogens, and ‘hosts’ that influence whether certain functions dominate over others. 
 
Finally, we describe a comprehensive set of outcomes relevant to evaluation of the effects of social media on the public’s health.
 
Check out the full article here and let us know what you think about how this model helps you structure research on social media and health outcomes.
 
Full Citation:
Schillinger. D., Chittamuru, D., & A.S. Ramírez. (2020). From “Infodemics” to Health Promotion: A Novel Framework for the Role of Social Media in Public Health. American Journal of Public Health. June 2020:e1-e4. doi:10.2105/AJPH.2020.305746 

I am so excited to showcase preliminary results from a project that has been nearly a year and a half in the making! Tihis collaboration with Buoy Healthcare examines what people do with health information obtained from sources other than a health professional, and extends my previous research in information seeking.

Much has been written about the importance of the internet and other media as sources for medical information. Research based on self-reported media use has established that deliberate information seeking from the media, including the internet, has been associated with increased engagement in preventive behaviors relating to diet and physical activity, more positive patient-clinician interactions, and has also assisted individuals in coping with uncertainty.
On the other hand, another line of research has raised concerns about potentially negative effects of the current information environment – that is, for many people, having access to so much information about health is detrimental and leads to feelings of being overwhelmed and inaction. 

Yet an important limitation of most previous studies in this area is that they rely on self-reports of both information seeking and behavioral or psychosocial outcomes. Further, most studies rely on generalized, non-time bound health information seeking (i.e., “Have you ever looked for information about [a topic] from [a source]”), or ask about information seeking within a specific timeframe but do not examine the content of the information or recommendation. Thus, the next frontier in this line of research is one that links objective measures of information seeking – both sources and content – with clinical and psychosocial outcomes to understand how people use the information they seek and find from nontraditional sources. 

Although Buoy’s primary aim is to contribute to improved patient care, an important contribution of such a tool may be related to reducing the negative effects of the current overwhelming health information environment. A tool like Buoy has the potential to cut through the clutter of too much and contradictory information to provide personalized, science-based recommendations. The overarching aim of this project is to understand how people use information they seek and find from Buoy. 

We surveyed a random sample of Buoy users immediately following the completion of their Buoy session to assess their reason for utilizing Buoy, their experiences with the tool and how it relates to other information they may have found online or through other non-clinical sources, their intentions to comply with Buoy recommendations, their confidence in the Buoy diagnosis, and treatment recommendations. We also assessed intentions to share the information and treatment advice with family members and clinicians, and perceptions of information overload, fatalism, uncertainty management, and satisfaction with patient-clinician interaction. We followed up with respondents 2 weeks after the initial survey to as the same questions as well as new questions to examine what they did following their online consult with Buoy and assess their information-seeking efficacy. 

A benefit of the collaborative approach is the potential to overcome the self-report limitations of prior studies. Thus, we  obtained from Buoy the paths individuals took and Buoy’s final recommendation. Once we finish analyzing the data, we will be able to match the initial reason for the consult to the reason reported in the survey, and also assess the extent to which respondents understood the recommendation and acted upon it. 

Stay tuned for the results and implications of this research! 

For years now, I have been struggling to understand how communication can both contribute to health disparities and also be used to solve disparities. One important aspect has been teasing out dimensions of "culture" that affect the kinds of information people have access to as well as the effects that information has on their attitudes, behaviors, and health outcomes. 

In one recent study, published in Social Science & Medicine, we tackled the construct of "fatalism" we tackled the construct of fatalism. Fatalism refers to a set of beliefs about the causes and controllability of diseases. Specifically, beliefs that individuals are powerless to influence health or illness, since these are controlled by external forces – you’ll get cancer if you’re meant to get cancer, for example. Based on the literature – including embarrassingly enough some of my own prior work – we expected the Mexican-American women we interviewed to exhibit high levels of fatalism. 

We didn’t find that. There was some modest fatalism indicated in the quantitative survey, but it was clear through the interviews that this group largely didn’t hold fatalistic beliefs. They very well understood that poor diet can cause diabetes, obesity, and heart disease. And they knew that diet was within their individual control. 

So they rejected fatalistic beliefs in favor of clear explanation of link between behaviors and disease. However, despite knowing that diet is technically within one’s control, many participants felt that their ability to act on knowledge was constrained by internal and external factors. Internal factors include cooking skills and motivation to prepare healthy foods as well as personal tastes. External factors include physical access to healthy foods (many participants live in food deserts where fresh and healthy foods are not available) or financial access (40% of the sample was food insecure). 

I argue that this finding is consistent with the critique of fatalism as reflecting an accurate appraisal of the structural barriers to health that exist for vulnerable populations, and suggests why in quantitative studies, participants might respond in ways that could be characterized as fatalistic but are rather acknowledgements of the very real constraints.

Another important finding was that Mexican-American women felt overwhelmed by the nutrition information environment. There is too much information about diet, and it is confusing.

The perceived conflict in the public information environment has at least two negative consequences: First, this tells us something about trust in information sources. Perceiving the information environment as consisting of contradictory knowledge engendered mistrust in public information sources for nutrition information. This mistrust can have long-term consequences for interventionists who want to use those sources to disseminate critical health information. The second outcome is directly related to health outcomes and disparities: The contradictions reported in news and other public sources sow confusion about the “right” healthy course of action. This confusion could lead to inaction or a rejection of advice on the grounds that it might change in the future, just as the prior messages have changed. 

These findings are relevant not just for nutrition or health contexts, and also are part of the conversation about what “fake news” and deliberate misinformation campaigns are doing to society. 

Yet despite feeling overwhelmed with too much information, participants described important information gaps. They wanted specific information: How to operationalize the basics. So there is still room for skills-based nutrition education.

So what does this all have to do with health disparities? Well, I find it interesting that fatalism as a construct is usually associated with ethnic minorities and people in structurally vulnerable situations. But I think this is irresponsible because it can lead to rather simplistic solutions such as trying to change fatalistic attitudes that are not really the source of the health issue, or too easy dismissal of structural issues. 

This study thus expands understand of how communication can contribute to health disparities. One of the mechanisms that appears to link fatalism to disease risk is information overload – that is, the exposure to excessive and conflicting information but with little guidance on how to determine the relative value of information from different sources. Information overload – sometimes mischaracterized as fatalism – may lead to confusion that negatively impacts the adoption of preventive behaviors, ultimately contributing to disparities. 

A more indirect route through which information overload may contribute to disparities reflects the nature of the information environment and its perceived relevance for specific subgroups. In this study, Mexican-American women simultaneously describing having TOO much but NOT ENOUGH of the right kind of information. This desire for deeper knowledge & specific skills may be attributable to structural barriers that limit the ability to access appropriate information (this is a form of information inequality). 

But…it’s also possible that the information is there but not perceived as appropriate for this particular audience. Somehow bicultural women are not identifying with the messages, so I still need to work on figuring out how to do that…stay tuned! But to help with the information overload issue, we’ve created a measure of diet information overload that is in press in Patient Education & Counseling, and hopefully, it will be widely adopted and allow for better discrimination of information overload from fatalism and also to assess how people respond to the information environment.

What other "cultural" values do you think have served to hide structural issues that harm the health of vulnerable populations? 

I spend a lot of my time doing research related to understanding how to communicate in a culturally appropriate manner with bicultural audiences. This is increasingly important because bicultural Latinos are a growing segment of the US population and yet epidemiological evidence suggests they are at high risk for poor health. 

In one study published last year in the Journal of the Academy of Nutrition and Dietetics, we found that Mexican-American described food as central to expressing cultural identity. Yet Mexican food traditions were characterized as unhealthy; many preferred American foods, which were seen as healthier. Among the participants who expressed a desire to eat healthfully, to do so meant to reject Mexican ways of eating.

This study raises questions about the nature of the “dietary acculturation paradox.” While food—the eating of Mexican foods—is central to the maintenance of ethnic identity throughout acculturation, negative perceptions about the healthfulness of Mexican foods introduce tension into Mexican-American women’s self-identification. This study suggests a subtle contradiction that may help to explain the dietary acculturation paradox: While previous research has suggested that as Mexicans acculturate to the United States they adopt unhealthy diets, this study finds evidence that they do so at least in part due to perceptions that American diets are healthier than Mexican diets. Implications for interventions to improve Latinos’ diets include an emphasis on the family and use of Spanish linguistic cues. Finally, messages that simply advocate for “traditional” diets should be reconsidered because that message is discordant with perceptions of the healthfulness of such foods.

How would you go about designing effective nutrition education messages for this group? 

Are you interested in health, social justice, policy, or communication? You may want to apply for our research assistant position in immigration policy. Please see attached or here for more information and apply by December 17, 2018.

The Communication, Culture, & Health research team is heading to San Diego for APHA2018! We hope to see you there. (Click on the pictures for downloadable files so you can be sure to catch our work.)

The Communication, Culture, and Health research team has been awarded two Student Success Internship positions for the 2018-19 school year.

If you are a second- or third-year student who is highly motivated, self-directed, and interested in getting hands-on experience with public health research, please consider applying. In addition to earning $15 per hour, Student Success Interns have opportunities for professional and leadership development outside of the research lab. Interns work directly with faculty and graduate students. 

One internship will focus on Nutrition Communication research. The selected student will work on developing and testing empowerment-based messages pertaining to healthy diets for Mexican-American women. Please email your cover letter and CV/resume to Dr. Deepti Chittamuru.

The other internship will focus on Immigration Policy Communication research. The selected student will work on a research project assessing California’s communication environment related to state and local policies, such as health care and enforcement policies, that influence the well-being of immigrants. In addition to the paid intern, we will be looking for 2-3 students interested in working on the project for course credit during the spring semester. Please email your cover letter and CV/resume to Dr. Maria-Elena Young.

Excerpt of my acceptance speech for the 2017 Early Career Award of the American Public Health Association's Public Health Education & Health Promotion Section, delivered November 7, 2017 in Atlanta, GA.

I am humbled when I look at the list of previous winners, leaders that I admire in the field of health promotion. Truly, the Early Career Award is an honor.
 
It is validation that I am doing good work – I especially appreciate this recognition because I have not always felt my work was understood.
 
As writers write what they know, I study what I know. My research aims to understand how to communicate with bicultural Latino audiences to improve the health of this growing and at-risk population.
 
I am myself Mexican-American and my intellectual journey started with my own uncomfortable reckoning with identity. As a young child, I was brought to the United States from Mexico. In that era – the early 80s – and in that place – rural Texas – it was advised that immigrants shed their markers of identification from wherever they came from. So I moved here and was immediately immersed in an English-language world. Within six months my sister and I were fluent in English and Spanish was reserved for summers, when we would get shipped to my abuelita’s house in Mexico. There, my cousins would tease me about my American ways. But at home in Texas and then Arizona, I knew I was not fully American. Despite my parents’ attempts to integrate we would always be outsiders. We looked different and – even if my sister and I managed to escape with no accent, our parents did not. Plus we had funny names.
 
Even though we lived in regions with substantial Latino populations, we always lived where the good schools were. Which is to say, we lived in majority-Caucasian neighborhoods. But of course I was surrounded – in Texas, Arizona, and California – by a broader culture where there were substantial Latino populations. And so when people talked about “diversity,” it was presumed that Latinos were part of that diversity.
 
So when I arrived at the University of Pennsylvania for my doctoral studies, I could not put my finger on why I felt so unmoored. I had heard that Philadelphia was a diverse city, but all I saw was black and white. What I figured out was that people used “diverse” as a code to indicate the presence of African-Americans. What was missing for me – what made me feel unmoored – was the Latino population!
 
At this time I started learning about race in the media and health disparities among African-Americans and the ways in which communication could both contribute to but also help to alleviate health disparities.
 
So based on my own experiences, I got curious. I started asking questions about ethnicity – in media representations, media effects, and health outcomes, and I got blank stares or at best, the response that little was known.
 
And so I started looking into the literature myself, and I found research in health promotion among Latinos. What I found was that almost all of this research was done exclusively with Spanish-speaking populations and was really focused on the challenge of translating appropriately.
 
But this felt incomplete to me, because I knew that Latinos don’t just speak Spanish. And I was learning that population trends support my personal experience: The growth of the Latino population isn’t – and hasn’t been for a while – from new, Spanish-speaking immigrants – it’s from the children of immigrants who will grow up entirely in the United States, and are disproportionately likely to suffer from preventable risk factors and poor health outcomes.
 
And that is how I developed my research agenda.
 
I am gratified that I am no longer the only person talk about the need to move beyond thinking about language as a way to convey health information to Latinos. There is a lot of work to be done, since I still get people telling me about how they translate materials to Spanish as the entirety of their Latino outreach, but I do see more work coming out, not just from me, that is trying to tease out aspects of the Latino experience that affect how we communicate effectively about health with Latinos.
 
So I am grateful for the honor of the Early Career Award in recognition of my contributions to this field.
 
But – the Early Career Award is not just an honor.
 
It is also a challenge. When I look at the list of previous winners, I am humbled by their great accomplishments AFTER their Early Career phase. So, the challenge of the Early Career Award is this: You have done well so far, but you have the potential to do great things.
 
I am thankful for the intellectual home that I have found in the Health Communication Working Group of APHA.
 
To all of you: THANK YOU for having the confidence to grant me this honor and to challenge me to greater achievements.
 
I humbly accept the challenge. 

The Communication, Culture, and Health research team is back from Atlanta with a great report from the American Public Health Association's annual meeting.

​Alex Lemon (BA, 2017) gave a fantastic presentation on the to a standing room only crowd. Erendira Estrada (current Public Health PhD student) delivered a fabulous talk on an ecological approach to communication intervention. In between those talks, I talked about a communication centered approach to engaging communities in research and intervention development.

I also was awarded the 2017 Early Career Award from the Public Health Education and Health Promotion section. The award honors a scholar who has made outstanding contributions to the practice and profession of public health promotion in the first 10 years after the Ph.D. and who shows promise for continued development. I am honored to have been nominated on behalf of the association’s Health Communication Working Group.

Registration is now open for our webinar on Monday, November 13!

Click here to register. Free for members of the Society for Nutrition Education & Behavior; $25 fee if you are not a member.

Click here to read the full paper or email for a copy if you can't access it.