Health organizations (hereinafter, HOs) have witnessed the consolidation of social media as a tool for institutional communication [1
]. There is no doubt that health communication is especially sensitive due to its importance and implications, so HOs must respond to the needs of citizens, which demand more participation and information in health [2
]. In fact, Health 2.0 is grounded on the idea that medical care must move away from hospital-based attention and focus on promoting health, providing domestic health care and instructing consumers and patients to take responsibility for their own health [3
]. All this has generated a new paradigm in health communication in which the HOs, continually exposed to public scrutiny due to the social importance of their services [4
], have found in social media a vehicle through which to involve society in the organization.
Social media have become a popular tool for health communication [5
], contributing considerably to the value created by HOs and reshaping health information management in a variety of ways, ranging from providing cost-effective ways to improve organization-patient communication and exchange health-related information and experience to enabling the discovery of new medical knowledge and information [6
]. From the user’s standpoint, social media are not only a new way of accessing and sharing information [7
], but they also encourage the collaboration and participation of stakeholders, increase the connectivity of individuals and allow the direct participation of users in the HOs [8
]. In addition, and from an organizational perspective, social media is a valid instrument to: (1) reach and interact with stakeholders, (2) aggregate relevant information from many sources, (3) leverage collaboration, (4) strengthen HOs’ efforts in the field of sustainability [9
], promote corporate social responsibility [10
] and in delivering important messages to their audience [11
Among all social media, Facebook (FB) is one of the most used platforms in the health industry, not only because of the large number of users [12
], but for being considered a valid tool for the dissemination of messages about health [13
], including reaching minority groups that otherwise would be very difficult to involve in public health issues [15
]. In addition, its use for disease surveillance is notorious, encouraging and broadening the field of health studies, being especially used by researchers to address specific health concerns [11
The inclusion of HOs’ main actors (i.e., patients, professionals and organizations) into their communication strategy via social networks [17
] has provided researchers a novel research path. First, previous literature has dealt with the motivations, uses, advantages and disadvantages of this communication channel for health communication [8
]. Given the consensus reached on the potential value of social networks [21
], a new line of research focused on online engagement has emerged. Social media engagement can be defined as a multi-way interaction between and among an organization and digital communities. Using social media channels facilitates interaction, and health messaging is shared in a way that creates opportunities for information to be acted on by the audience [21
]. Its analysis and understanding could lead to better practices that could enhance interactive behaviors, encouraging user engagement with the organization and thus improving the effectiveness of health information dissemination [14
]. In addition, it opens a dialogue between society and the organization, which allows both parties to work collaboratively to address issues that affect health and well-being in general. The importance of this concept in the health sector leads to it being considered a tool at the service of the “common good” [22
In this context, the importance of stimulating interactive behaviors that promote user engagement with the organization through social media, specifically Facebook, is framed. Previous literature has emphasized technical aspects related to the type of publication, the publication schedule, the content disclosed, and other factors related to sociodemographic characteristics, Internet penetration rates or education level, which could influence the user’s online participation through Facebook [23
This set of studies, as shown by [25
], has mainly focused on the country of origin of the largest social media, such as the United States and China, as well as developed countries from Europe and the Oceania region. Developed countries represent an interesting environment to analyze online practices regarding health communication since they are generally characterized by having a quality health system and are more likely to have a population in good health. Thus, their health communication management could serve as a reference for other less developed health systems.
Authors such as [1
] recognize the progress achieved in relation to the adoption and use of social media by health systems in developed countries. The case of Spain is of particular interest. Its health system is ranked seventh out of 190 countries (according to the ranking of the World Health Organization for 2019), and it is considered an essential pillar of social welfare in Spanish society. The good reputation enjoyed by the Spanish healthcare system at an international level makes it an interesting reference to analyze, particularly regarding how Spanish HOs promote new forms of social communication by using innovative channels to reach a bigger and more engaged audience.
This research analyzes which factors, related to the structural characteristics of HOs and their online communication policy, exert an influence on their users’ online commitment, contributing to expand the literature on social networks and health communication. Furthermore, this study aims to help HOs improve decision-making in communication strategies via social media, in order to achieve a greater social commitment. Following the introduction, the rest of the article is organized as follows: Section 2
encompasses the theoretical background and the development of hypotheses, Section 3
details the research design, in Section 4
results are presented and discussed, and Section 5
details the conclusions and final remarks.
2. Literature Review and Hypotheses Development
The literature shows that social media have tremendous potential value in the field of health, primarily because of their ability to allow new forms of access and information exchange, social support and also enhance the collaboration and participation of the stakeholders [8
]. Recent research has explored the motivations that lead HOs to integrate social media into their communication strategy, as well as the use of social media by patients, on one side, and health professionals and health organizations on the other [8
In this sense, patients use social networks based on different motivations which can be summarized in the following categories: emotional, information, esteem, network support, social comparison and emotional expression [9
]. In general, social media have the potential to empower people to develop healthy lifestyles, make better and more informed medical decisions and improve personal health management [6
]. In addition, the use of social networks by patients affects their relationship with healthcare professionals, leading to more equitable communication, thus allowing harmonious relationships and greater interaction [9
Social networks have allowed HOs to adopt strategies to improve their market share, in addition to contributing to the achievement of their organizational mission and the development of medical care [27
]. Previous literature has made it clear that HOs primarily use social media platforms to disseminate health information, advice and suggestions, thus promoting health care, as well as different services and products [23
]. Moreover, social networks are also useful for disseminating organizational efforts on sustainability [9
] or corporate social responsibility [10
Despite the benefits derived from the use of social networks in health communication, there are some drawbacks, such as the possible loss of privacy or security in the shared information [28
] and the lack of specialized training in both health issues and management of social networks by those involved in managing social media communication [29
]. Both HOs and users could lose control of the information disclosed in social media and harmful or inappropriate material may be published in the social network, an event that could affect their reputation and that is difficult to rectify [1
Be that as it may, social media enhance the interaction between supply and demand in the health sector, and could exert a positive effect, for which HOs must strengthen and properly manage user participation in social networks. Previous studies have analyzed the effect that different technical aspects have on the online participation of users, such as the type of publication, the publication schedule, the content disclosed, as well as other factors related to sociodemographic characteristics, internet penetration rates or level of education. For instance, [24
] analyze the features of Facebook posts on Australian public health organizations’ Facebook pages, [14
] by performing an analysis about how to improve the level of engagement with US Federal health agencies on Facebook, [23
] study the types of content US hospitals post on their Facebook pages and, more recently, [25
] explore the factors that facilitate health information diffusion in South East Asia, especially Malaysia.
In summary, and to the best of our knowledge, traditionally, the studies carried out in the context of health communication through social media (basically Facebook) have been descriptive in nature, showing the motivations for their implementation in the health sector, their use, advantages and disadvantages. Under the same descriptive approach, the literature includes aspects related to the type of formats used to publish the information, the frequency of emission according to the days of the week and the publication schedule, as well as the type of content that the HOs disclose. The importance of these studies is notable, since they define the management model that HOs are currently carrying out in their online communication strategy. However, a new set of explanatory studies related to users’ commitment have emerged in the field of health communication. In particular, there is growing interest community research community in understanding which factors (economic and organizational attributes, type of content published in social media, format of posts, among others) explain the user’s commitment to the organization and, therefore, which aspects HOs should emphasize in order to maximize the user’s online participation.
Finally, it should be highlighted that previous literature frame the research mainly from the perspective of several theories: (1) Dialogic Communication Theory [30
], which explains how these organizations use social media as a channel to achieve user commitment; (2) Resource Dependence Theory [31
], which helps to understand why HOs carry out strategies to improve their relationships with stakeholders, thus reducing uncertainty and resource dependence; (3) Media Richness Theory [32
] seeks to explain what type of format should be used by HOs in order to communicate effectively and improve commitment; and, (4) Uses and Gratifications Theory [33
] which aims to explain how individuals select particular types of social media and content in order to satisfy their specific needs or desires.
Given this conceptual framework, it is important for HOs to maintain an ongoing dialogue with their stakeholders, working collaboratively to improve the online management of health communication and, thus, redounding in an improvement of the well-being of society [21
]. Therefore, it is important to continue studying which factors influence the stakeholder engagement with the organization through social networks. To this end, a set of organizational and social media variables are proposed to be analyzed in order to expand this knowledge (Table 1
Regarding their final objective, public HOs manage their communications differently than their private counterparts [1
]. However, public HOs admit that they can also make use of social networks, such as Facebook, to attract their target market [34
] it is important to examine which strategies are the most effective in achieving user engagement with these types of organizations since, as also concluded by [1
], private hospitals achieve better metrics in social networks than public hospitals. This could mean that private hospital marketing campaigns, and the greater investment aimed at generating a more attractive multimedia content, both have a positive impact on users.
Based on these approaches, the following hypothesis is proposed:
Hypothesis 1 (H1).
HOs’ ownership affects the level of users’ online commitment to HOs via social media.
2.2. Economic Capacity
According to [35
], the relationship between the size of a country´s gross domestic product (GDP) and the density of the installed technology is directly proportional. Consequently, there is a strong relationship between the economic level of the population and its access to internet and new technologies [36
]. Furthermore, studies suggest that people living in a more affluent city are more likely to use social networks, with the city’s online activity determined by factors such as individual wealth [37
However, the increase in the cost of health services seems to be one of the main reasons why people with fewer resources turn to websites, online platforms and other online health-related resources [38
]. In addition, both public and private organizations are taking advantage of Medicine 2.0 technological advances to offer health services, due to the significant cost reduction and the resulting impact on national health spending [39
Therefore, the following hypothesis is posed:
Hypothesis 2 (H2).
The economic capacity of the population affects the level of users’ online commitment to HOs via social media.
2.3. Size of the Organization
In general, large organizations present a greater ability for survival and growth, due to their better access to the resources needed. In this sense, [40
] argue that larger organizations have greater ability to incorporate technology into their communication channel and to use it efficiently to build close relationships with their main stakeholders. These results are supported by [41
], concluding that larger organizations attain a higher stakeholder commitment.
Despite this, [42
] state that smaller organizations are most likely to adopt social networks and are more interested in implementing social media as a one or two-way communication strategy [43
]. Similarly, [44
] point out that organizations with a limited budget have found in social media an affordable way to communicate with their members, since one of the motivations for Internet use is to improve the quality of health care but also for cost reduction [8
]. In addition, smaller organizations are an example of how social media can be used strategically to involve and engage stakeholders with their goals [45
Nevertheless, while the only cost in the use of social media is the time involved (in contrast with traditional marketing and communication methods, which also involve costly printing and mailing), larger HOs are more likely to implement official social media accounts [46
Thus, the following hypothesis states:
Hypothesis 3 (H3).
The size of the organization affects the level of users’ online commitment to HOs via social media.
2.4. Online Community Size
Organizations seek to establish partnerships or alliances with key stakeholders, and online communities of social networks represent an optimal tool to achieve it [47
]. HOs with fewer fans operate differently from those with a greater number of followers [24
], missing the potential of social media to reach a larger audience [1
]. HOs that want to enhance the growth of their online community must be willing to develop content and dialogues that encourage interaction [48
] since, if they do not, the online community may be weakened [49
Likewise, the size of the online community encourages the development of social media content [50
]. In an environment characterized by a growing consumer distrust towards corporate messages, sharing information through these platforms (when the user understands that this information is beneficial) is a powerful way to increase consumer confidence, thus maintaining and strengthening the online community and maximizing user participation in order to generate word of mouth marketing [24
Based on the above, the following hypothesis is proposed:
Hypothesis 4 (H4).
The size of the online community affects the level of users’ online commitment to HOs via social media.
The type of format through which content can be disseminated on social networks (photo, video, link, etc.) is a key aspect to assessing the quality of the communication [51
]. In addition, the different types of formats exhibit different levels of interactivity, expressed through the degree to which users can influence the form and content of the media environment [52
]. Multimedia has proven to be the format that has the potential to be engaging for users because of its direct impact on various senses [53
]. The photo format, according to [54
], is especially appropriate for health communication, due to its impact on people’s knowledge, attitudes and perceptions regarding health issues.
The authors of [24
] analyze the relationship between the use of different types of formats and the level of user engagement, concluding that although the video format is the most attractive for users, its presence is scarce in the social networks of the sampled HOs. On the contrary, the link format and the publications made through text only are always present in social networks, but in general, they are not considered attractive [14
]. The authors of [25
] identify that posts with a good engagement rate are significantly associated with a video format, although the most common format in posts are the link and the photo format.
Considering previous literature, the following hypothesis is posed:
Hypothesis 5 (H5).
The message format affects the level of users’ online commitment to HOs via social media.
The ability of the message’s content to capture the user’s attention directly influences the scope of the information disclosed [24
]. Social media users mainly share information on these platforms when they believe that the information is beneficial to others [56
]. Thus, the shared information can contribute to maintaining and strengthening the online community, being an incentive to maximize the user’s commitment to the organization by generating “word of mouth marketing” [24
Although the content of the message disclosed is a factor that has been recently incorporated into the analysis of health communication through social media, its contribution to the generation of engagement in the context of HOs would require further study. Previous research is heterogeneous with respect to the criteria used to classify message content and which is the most appropriate methodology to analyze the information but agrees in that the most recurrent content does not necessarily generates greater engagement.
In this sense, [57
] show that organization promotion was the dominant content type across posts, using the social network as a unidirectional communication channel, rather than encouraging participation and engagement for users. The authors of [14
] use the National Library of Medicine’s Medical Text Indexer to perform semantic groups, discovering that posts about ”activities and behaviors” and “phenomenon” are positively associated with the level of engagement, despite the fact that the content “concepts and ideas” is the most recurring among posts. For [11
], the categories that generated the greatest engagement were “testimonies”, “solidarity” and “anniversaries”, despite not being the most frequent topics. The authors of [25
] state that posts with a good engagement rate were significantly associated with a health education post and a risk communication post. Finally, literature shows that controversial issues such as vaccination, or sensitive topics as cancer, attract the attention of users and generate debate [55
] and that the audience is willing to commit when the organization provides relevant educational and news content [59
Thus, the following hypothesis is posited:
Hypothesis 6 (H6).
The content of posts affects the level of users’ online commitment to HOs via social media.
Social networks provide health communication with multiple benefits for users/patients and health organizations alike. Social media allow HOs to create an innovative and bidirectional communication channel between doctors, patients and the researchers, through which users’ increasing demand for information and participation on health-related issues can be met. From an organizational standpoint, embedding social media into the HO´s communication strategies can help these organizations to increase their visibility in the market, strengthen their corporate image and strategic position and reach their target audience. Therefore, and in line with previous literature, improving the effectiveness of health communication should involve encouraging user participation in HOs’ social networks. Thus, the main aim of this study is to identify the main factors that could influence the level of online users’ commitment.
The relevance of the health-related information contrasts with the (sometimes) difficult understanding of its implications. Our findings show that HOs could improve their users’ engagement by encouraging them to express their feelings, opinions or concerns through “comments” and posting information through attractive, visually rich and interactive formats (such as videos). Furthermore, users show great interest in content related to scientific knowledge, especially regarding controversial topics (such as vaccinations or new drugs) or topics in which there is a particular social awareness (i.e., cancer), urgency or lack of knowledge (such as the Ebola epidemic in 2014–2016 or the recent COVID-19 pandemic thread in 2020). HOs may also be missing opportunities to connect with their audience, since the hours and days of posting are not optimally exploited. HOs should reschedule both the posting day and the time of the day beyond business days or hours. In this regard, technological advances could help in this task, programming the content publication at a time that is more likely to generate user interaction, such as evening hours and during the weekend. This combined strategy could allow HOs to reach a wider audience and to achieve higher levels of engagement, disseminating health related information in a simple but effective way, and meeting the user’s needs for knowledge and the establishment of bidirectional communication with health experts.
Although the topic, format and timing variables behave similarly throughout the whole sample, some organizational differences arise. The results show that public entities are more efficient in managing their online communication strategy than their private counterparts and that the largest HOs exhibit better results in terms of engagement. These results point out that public and larger HOs are much more aware of the resources they have at their disposal to disseminate information and engage their users, generating value without increasing their costs. Furthermore, users living in poorer regions are more involved with HOs, so it is possible that they may be missing an opportunity by not connecting with large audiences in more affluent regions, which are critically important for private HOs.
Our findings contribute to the existing theories mentioned in the literature review. According to the Dialogic Communication Theory, social media are a valuable channel for health communication, especially in less favored areas in view of the greater commitment they exhibit with HOs. Regarding Resource Dependence Theory, smaller HOs should take advantage of the interactive potential offered by social media to reduce uncertainty and resource dependence, due to the optimal relationship between assuming lower costs of implementation and maintenance and reaching a wider audience. Pertaining to Media Richness Theory, our findings support the view that not all formats present the same level of engagement, with video and photos having a greater impact on users’ engagement. Finally, it is also worth noting the relevance of the Uses and Gratifications Theory, since the findings of our research confirm that, in order to be effective, HOs should ensure that posts are relevant and in line with users’ interests. This is particularly true in the case of information about scientific knowledge and medical studies which have shown to enhance users’ commitment to an HO.
This study expands the existing literature on health communication through social media, with the added value of focusing on the HOs belonging to one of the most reputable health systems worldwide, the Spanish health system. Therefore, knowing what is being done at the level of dissemination of health information, this may be relevant for other areas to improve the commitment of users with the organization, constituting a benchmark for environments where the health system suffers from low levels of commitment. For those involved in the management of HOs, the benefits offered by social media to improve relations with their users are highlighted, and concrete actions and recommendations that HOs can follow at the organizational level and with respect to their communication policy are included.
Despite its findings, this work has some limitations, such as the selection of hospital, clinic and healthcare organizations and the limited study period of one year. Furthermore, the treatment of photo-based posts has represented an added difficulty, and data downloaded with the Facebook API depends on the organization’s privacy settings and some explicative factors that have not been considered. These limitations could be overcome in future research and lead to new studies. It would be interesting to carry out research in areas where the health system is not as well considered, as in the case of underdeveloped countries, in order to establish a comparison that would help to address possible deficiencies in health communication in the latter. In addition, new research delimiting the medical specialty of the organization and the organization´s reputation, as well as analyzing other actors involved in health communication, would help to understand the social media phenomenon. Similarly, other factors in addition to those considered in this study would be interesting to explore, such as the sentiment of messages or a specific analysis of the audiovisual content posted by the organization. Likewise, with the aim of contributing to an expansion and enrichment of the current literature on this topic, a more in-depth content analysis could be performed by applying different emotion lexicon or by establishing a classification criterion of topics based on the preferences of Facebook users identified through a previous survey.