Introduction

The first generation of the Internet required sophisticated computer skills in order to post information to static webpages for viewers to search and digest. This has given way to a new generation of Internet programs, generally referred to as social media, which allow lay members of the public to post information online. Today, the Internet is replete with highly accessible web sites that provide users with an easy and convenient way to communicate, collaborate, and share multimedia. These social media sites include but are not limited to blogs, microblogs (e.g., Twitter), social networking sites (e.g., Facebook), wikis (e.g., PBworks), and video sharing applications (e.g., Youtube).¹

According to the Pew Internet Project, 74% of American adults now use the Internet, and 61% use it to obtain health related information.² As a result of statistics like these, many public health practitioners recognize social media’s promise for public health³ and have begun using these Internet programs for health communication purposes. For example, the Centers for Disease Control and Prevention (CDC) have promoted the use of social media as another channel for health communication⁴ and have implemented several ongoing social media campaigns.⁵ Many public health agencies (e.g., local and state health departments) are following suit and utilizing social media to reach the public with important health information that in some cases has helped influence decision making.⁶ Recognizing its potential for public health practice, CDC launched a new toolkit outlining best practices for creating a local social media strategy.⁴

While social media has provided a new way for Internet users to communicate, share information, and learn, it has also created new avenues that can threaten public health.

Social Media Threats

Emerging and unique health threats exist in the social media landscape and can be realized on social media web sites sponsored by public health agencies if not managed appropriately. Threats may be in the form of cyber-bullying or solicitation where users specifically target other users online. The incidence of cyber-bullying has increased as social media usage has increased and often results in serious health outcomes, with many victims experiencing high levels of depression and low self-esteem.⁷ Studies have revealed that the prevalence rate of adolescents participating in cyber-bullying is as high as 36%.⁸ Other studies linked social media to risks involving exposure to harmful tobacco advertising⁹ and alcohol abuse.¹⁰ Additional research is needed that explores the public health impact of explicit content, suicide endorsements, online gambling and gaming, as well as solicitation and predation.

While threats can be overt attempts to harm another user, they might also be less obvious or identifiable. For example, misinformation about health topics as well as conspiracy theories related to health behaviors have appeared on social media websites. A recent study of Human Papilloma Virus (HPV) vaccine conversations on Myspace showed that men were more likely to hold negative views about and spread negative information concerning the HPV vaccine while blogging.¹¹ In their content analysis of 153 YouTube videos related to immunizations, Kellan et al. found that nearly one-third of the videos emphasized risk, advocated against, promoted distrust, or made allegations of conspiracy regarding immunizations.¹² In addition, more and more users are turning to Wikipedia and other websites where users post health related information. Little research has been done to assess the quality of this information except to show that it may be inferior to what could be found through reputable agencies (e.g., National Cancer Institute).¹³

Threats such as these have important implications for public health agencies that desire to use social media as a way to reach priority populations with important health information. Many public health agencies such as state and local health departments are creating Facebook pages, YouTube channels, and Twitter accounts.¹⁴ Officials can work to avoid the iatrogenic effects of social media programming by carefully crafting policies for development and use. Failure to do so could provide some users with a medium to: (1) post hazardous content, (2) directly target other users with threats and solicitations, and (3) post misinformation related to health topics. In addition, failure to manage social media could provide victims of these threats with the rationale to pursue litigation against a public health agency.

As social media has empowered the lay public to join online conversations, public health practitioners have become more involved in using social media for health promotion purposes. Public health officials are challenged with managing the use of these technologies in at least two ways: a) when their own staff use social media applications on agency computers (internal), and b) their clients post information on agency sponsored social media sites (external). Agency sponsored pages might include a health department Facebook page, Twitter account, or YouTube channel. To avoid the challenges and threats associated with social media, many public health officials simply block access to social media applications on agency computers. However, such broad stroke reactive policies may have deleterious professional repercussions.¹⁵ In light of the growing popularity of social media and its promise for public health promotion, administrators may manage these threats through carefully crafted social media policies. While several good social media policy examples exist, few public health administrators are aware of these options. In addition, public health agencies such as state and local health departments have been less responsive in developing policies compared to healthcare. The purpose of this study was to identify the important elements of social media policies as informed by a content analysis of existing policies in healthcare and governmental/nonprofit agencies.

Methods

The sampling unit included social media policies as identified by the Social Media Governance Policy Database.¹⁶ This database was created in 2009 in order to provide leaders and managers with the tools necessary to implement effective social media efforts within their agencies. The database includes a total of 176 policies from a variety of industries. Within the database, policies are categorized as relating to advertising, public relations and marketing agencies; business products and services; consumer products and services; healthcare; and government or nonprofit.

A total of 21 social media policies from the healthcare category and government or nonprofit category were identified and included in this review. All policies in the healthcare category were included. Because of their closer alignment to public health, only policies from health related agencies in the government or nonprofit category were included for review. For example, social media policies in the government or nonprofit category eliminated from the review included but were not limited to New York City, Harvard Law School, and the US Navy. No policy in the Social Media Governance Policy Database directly related to a state or local health department.

Each policy was reviewed twice in order that thematic categories could be generated and frequencies of common provisions and guidelines determined. The first review used an open coding technique to establish thematic categories by closely examining and comparing elements of the policies for similarities.¹⁷ This review involved careful reading of the text and identification of the common provisions and guidelines of each social media policy. Based on this review, researches then induced nine thematic areas to which provisions and guidelines could be categorized.

Once thematic categories were identified, the text of each policy was read a second time in order that the number of common provisions and guidelines for each category could be determined. These data were captured by using Qualtrics, an online survey tool, and then downloaded to a spreadsheet for analysis. Frequencies of major thematic areas were computed using STATA statistical software.

Results

This content analysis of social media policies clearly revealed two distinct categories of provisions and guidelines. These categories included provisions and guidelines for (1) internal staff use and (2) external client use of social media. Of the policies reviewed, 62% included aspects of an internal social media policy while 52% included aspects of an external social media policy. Only 3 agencies had aspects of both internal and external social media policies.

Several major themes relative to internal (staff) provisions and guidelines were identified and included using social media for agency purposes; proprietary or client information; professional or respectful online behavior; and reference to existing laws, rules and obligations. Over one-half of the internal policies included reference that would preclude the disclosure of privileged agency information or the release of client or patient information through social media applications. Over one- third of the internal policies required staff to be respectful of colleagues, partners, clients/patients, and competitors through their online communications and to obtain permission from management prior to establishing any agency sponsored social media presence on an external social media platform. The complete list of thematic categories and descriptions for internal social media policies are included in Table 1.

Figure 1

Table 1. Internal Policy Provisions and Guidelines (Employees) (N = 21)

External policy provisions and guidelines pertained specifically to external clients and their use of agency sponsored social media applications. Over one-half (55%) of the external policies were available to clients through the actual social media outlet. That is, these external policies were posted most often on the social media outlet site (e.g., Facebook page) and not on the agency homepage. Only two of the external policies imposed minimum age restrictions for commenters.

Several major themes relative to external (client) use of agency sponsored social media were identified, including agency oversight, online behavior, personal privacy, agency right to comments, and commenter responsibilities. Nearly half of the external policies included a statement regarding an agreement to not post unlawful, obscene, defamatory, threatening, harassing, abusive, slanderous, hateful, or embarrassing material on the agency sponsored social media site. In addition, over one-third of the external policies pertained to the agencies’ right to monitor or terminate client access to the agency-sponsored social media site and an agreement to not post “spam” or irrelevant/off-topic material. Thematic categories and descriptions for external social media policies are included in Table 2.

Figure 2

Table 2. External Policy Provisions and Guidelines (Clients) (N = 21)

Discussion

Healthcare and governmental/nonprofit agencies have developed social media policies that can help inform the development of social media policies in public health agencies (e.g., local and state health departments). Using an online database of social media policies,¹⁶ this study identified the common elements of social media policies. These findings build upon results from previous research by expanding research to include a content analysis of external policies.¹⁸ From their research, Hrdinova and colleagues¹⁸ recommended that social media policies include eight elements: employee access, account management, acceptable use, employee conduct, content, security, legal issues, and citizen conduct. Seven of the recommendations from their research address internal staff while only one addresses external clients. Our study, however, revealed a very clear demarcation between internal social media policies that pertain to staff and external social media policies that pertain to clients.

Internal Policy

External Policy

Conclusions

An agency response associated with addressing the public health threats of social media requires that officials recognize online threats as “real” and subsequently exercise managerial responsibilities to mitigate these threats. Awareness has been heightened as agencies face ligation due to improprieties on social media sites.^{23, 24}

This study provides evidence of several key thematic categories that can help provide public health officials with a starting point for establishing internal and external social media policies. Internal policies focus on staff expectations and behavior while external policies focus on client expectations and behavior. While not every policy reviewed in the study had both and internal and external policies, public health officials should discuss the value of both for their agency. As these policies are established, they should be prominently displayed for all users of the social media, especially on a webpage announcing the social media tools.

To initiate the policy making process, an internal policy making board can be created to develop and oversee social media use policies. This board can be responsible for the creation of both internal and external social media use policies for public health agencies as informed by the best practices outlined in this paper.