Tulane University School of Medicine, Department of Medicine (JG, BS); Tulane University School of Medicine, Office of Community Affairs and Health Policy and Tulane University School of Public Health and Tropical Medicine, Department of Community Health Sciences (AW); RAND Corporation and RAND Health and REACH NOLA (BS) Show
Address correspondence to Benjamin Springgate, MD, MPH; 1430 Tulane Ave SL-16; New Orleans, LA 70112; 504.491. 3459; 504.988.8252 (fax); moc.liamg@etaggnirpsneb Copyright notice The publisher's final edited version of this article is available free at Ethn Dis AbstractBarack Obama’s successful campaign for the presidency has been widely attributed to the use of social networking sites, mobile devices, and interactive websites to engage previously hard-to-reach populations in political activity. Campaign communication strategies may be applicable for youth health promotion efforts, particularly for the highly stigmatized issue of mental health. In this article, we examine elements of the 2008 Obama presidential campaign’s use of social media technologies and content designed to foster effective political participation among youth. We outline how the same social media technologies may be applied to public health efforts focused on reaching and providing services to the 20% of young people who have a diagnosable mental disorder. We discuss the strengths and limitations of the application of these media to date, and raise questions about the future use of these media for engaging hard-to-reach populations in addressing stigmatized public health issues. Keywords: Social Media, Mental Health, Youth, Health Communication, Community Outreach Social media, defined as communication forms that are digital, networked, and interactive,1 facilitate rapid dissemination of public health information. Health departments and universities are among the early adopters of social media for health communication purposes, with many using Twitter (a service which allows users to send their followers 140-character updates via mobile device) and short messaging service (SMS), also known as text messaging, to convey emergency preparedness and disaster response information.2–4 SMS-based efforts have successfully curbed outbreaks of infectious disease.5 The Centers for Disease Control and Prevention (CDC) operates a comprehensive media campaign, which employs Facebook and other social networking sites, online videos, and Twitter to transmit health messages on myriad topics including pandemic flu, other infectious illnesses, and chronic dieasease.6 The public health sector’s adoption of tech-based communication campaigns warrants exploration of the question: What can we learn from previous successful social media communication strategies? Political campaigns provide a relevant parallel in that they must also engage large segments of the populace that may be considered hard-to-reach and then motivate them to action. Barack Obama’s 2008 presidential victory and the highest voter turnout in 40 years7 have been attributed to the campaign’s effective use of social media8–9 to engage historically less politically active groups including young voters. Targeted messaging and interactive communication contributed to the 135% increase in youth votes in the first caucuses10 and the participation of an additional 3.4 million under-30 voters than in the 2004 presidential election.11 Abroms and Lefebvre argue that lessons from the campaign’s successful use of new media are applicable to public health communication broadly,12 but they may be particularly relevant for engaging youth and other hard-to-reach populations around issues such as mental health that are both highly prevalent and stigmatized. In this article, we examine elements of the 2008 Obama presidential campaign’s use of social media technologies and content designed to foster effective political participation among youth. We outline how the same social media technologies may be applied to public health efforts focused on reaching and providing services to the 20% of young people who have a diagnosable mental disorder.13 We discuss the strengths and limitations of the application of these media to date, and raise questions about the future use of these media for engaging hard-to-reach populations in addressing stigmatized public health issues. The Rationale for Using Social Media in Political and Public Health CampaignsSocial media may represent a breakthrough for political and public health campaigns because unlike traditional unidirectional media such as billboards and television advertisements, they engage readily available technology to encourage active communication and participation among the target audiences. They offer the potential first to foster discourse, and subsequently to promote a sense of belonging to a like-minded or similarly-affected group. The ubiquity and familiarity of the media at this juncture make this type of engagement possible for those who may be otherwise difficult to reach such as youth populations and people of color. Fully 65% of people aged 18–29 years report using text messaging.6 At the time of the election, over 17 million Americans aged 18–25 were users of Facebook, the world’s most popular social networking site.14 With these and other social media, such as videos and blogs, the Obama presidential campaign did more than promote voting; it engaged people quickly, discreetly, and cost effectively in political activism through their handheld phones and computers. The campaign transformed these media – until this point used primarily to communicate with families, friends, and for business – to motivate their users and their social networks to involve friends and community members in online or text-based political and social discussion. Once activated, many supporters used these media to create their own politically-focused media content, and enlisted further support by sharing content with their media-capable personal networks. Others were motivated through the promise of a social media-facilitated connection to contribute to traditional campaign activities, such as phone banking, neighborhood canvassing, and hosting campaign house parties. The familiarity, ease of use, and ubiquity of social media technology and content opened new avenues for participation in the campaign and also strengthened traditional forms of participation that had been difficult to establish among similar groups in prior campaigns. The Obama Presidential Campaign’s Application of Public Health-Relevant Social MediaFor this discussion we arrange social media into the following format-based schema: 1. social networking websites and applications; 2. user-generated and distributed digital media; 3. cellular text messaging and Twitter. Social Networking Sites, Other Websites and ApplicationsSocial networking websites lend themselves to campaign and public health work by virtue of their capacity to tap unobtrusively into, and leverage large numbers of, formal and informal relationships. The Obama campaign applied multiple online social networking sites, including Facebook and MySpace, first to reach many youth and minorities and second to keep them engaged with campaign updates. Facebook proved to be the most popular social networking site for the campaign, tallying 2.4 million supporters on the Obama Facebook group by the end of the campaign.15 The campaign’s MyBarackObama.com website integrated social networking technology. Users created personalized accounts and produced their own web-content to share through multiuser online discussion forums. The campaign drew from users’ accounts to enrich the base of traditional campaign workers, sending them regular email and recruiting them to support classic election engagement efforts such as phone banking and neighborhood canvassing. Networked communication between the campaign and users, as well as among users, was focused, efficient, and cost-effective.8 User-generated and Distributed Digital MediaUser-generated and distributed digital media offer several advantages to political and public health campaigns seeking to create and disseminate compelling messages rapidly and inexpensively. These media (frequently film or music) enable decentralized, volunteer, and creative constituent bases to produce their own campaign content. Film, songs, sound, visual art, digital audio, or visual effects can be shared with a personal network of contacts and spread virally to reach a much broader audience. Content can be disseminated easily to other recipients through email, social networking websites, cell phone applications, or digital media-dedicated web sites such as YouTube. Some constituents and media content recipients may perceive this horizontal, or peer-to-peer, communication as more reliable than vertical political or health messages that come from experts.1 Campaigns also can take advantage of this trust and the ubiquity of the technology to disseminate internally-generated media content more cheaply than otherwise would be possible. During the 2008 presidential campaign, 14.5 million hours of Obama campaign-created videos were viewed on YouTube,16 a digital video sharing site popular with youth, in which the average age of a video uploader is 26.17 This advertising venue represented an estimated savings of $47 million over comparable television advertisements.16 Campaign content was easily shared with target audiences, and unlike television and radio spots, merged unobtrusively into potential voters’ usual activities, like checking their email or Facebook page. User-generated videos –made by and for constituents – may be a particularly effective engagement tool for disseminating complex information and soliciting new support through online video sharing sites.18 Constituents may develop a deeper sense of ownership in the outcome of the campaign through their creation of new political content. Such content was included in the nearly 1,800 YouTube videos posted on MyBarackObama.com,19 and may have been more influential in shaping attitudes of likely voters than videos generated by the campaign itself.20 SMS and TwitterIn recent years, text messages and Twitter have become popular means of communication of brief messages. Applications to political and public health campaigns can facilitate rapid and bidirectional communication with target audiences, particularly among youth but increasingly among adults as well. Obama supporters elected to receive text messages including campaign updates, local events, and public appearances, as well as reminders to vote. By sending information directly to mobile phones, the campaign not only utilized a means of communication familiar to the target population, but also overcame limitations in home internet access among target groups. Text messaging represented an innovative way to reach homes without landlines, which disproportionately comprise minorities and those under 30.21 At about $1.56 per vote generated, text messaging represented a cost-effective method for communication, especially as compared to phone calls and door-to-door canvassing, which cost approximately $20 and $30, respectively, per vote generated.22 Twitter is used by one-third of adults under 30 and by over a quarter of African Americans,23 representing another efficient means of communication with traditionally hard-to-reach populations. Over 112,000 people followed Obama’s Twitter updates,19 enabling them to remain connected to political developments and calls for action. DiscussionCampaigns – whether political or public health – face the common challenge of motivating populations to change their attitudes, beliefs, and behaviors to align with campaign goals. The successful application of social media to engage hard-to-reach populations in the context of Barack Obama’s presidential campaign suggests that similar strategies may be applicable for promoting youth mental health. Integration of digital communication forms into education and outreach efforts shows promise for overcoming stigma and motivating help-seeking behaviors among the 70% of youth with mental disorders who do not receive adequate care.13 Social media may also provide social support for young people who feel isolated or stigmatized by a mental disorder. Some examples of recent digital communication efforts to promote youth mental health are in Table 1. Table 1Digital communication efforts to promote youth mental health Social MediumDescriptionEarly Successes and Potential for Engaging Youth and MinoritiesSocial networking sites and interactive websitesSocial networking sitesMental health information, tips, links, and reports are posted on Facebook pages supported by organizations such as National Institute of Mental Health (NIMH) Mental Health America, and Active Minds24–27Wide variety of mental health information available to users Enables limited two-way information exchange between CDC and subscribers Web pages can be viewed without a social networking site accountOnline screening toolsMental Health America and other organizations offer free online screenings for depression, substance abuse, anxiety, and PTSD28–29Users answer screening questions anonymously Those who screen positive for a mental health problem are provided information on local mental health resourcesPatients Like Me30Website and online community users create health profiles (anonymous or public) detailing current health diagnoses, symptoms, and treatmentProvides basic health information Users engage in online discussion with community members affected by similar mental or physical health issues Users can track symptoms and medication use User diagnosis and treatment information is aggregated and displayed in graphical formatPost Secret Community31Online community to share secrets and discuss mental health89,000 registered users Chat room format in which users post secrets, questions, and ideas for discussion Users provide one another with social support, advice, and resourcesUser generated digital mediaIt Gets Better Project’s YouTube channel32Contains videos of adults offering hopeful messages for sexual minority youth Created in response to the suicide of bullied gay high school studentWithin one month: Over 650 videos featuring diverse adults were uploaded to site Videos exceeded the channel’s capacity Nearly 2 million page views33SMS and TwitterMississippi Department of Mental Health’s Helpline34Users communicate with helpline staff via SMS or interactive websiteUsers send text messages or use interactive website to ask for help with mental health concerns Anonymous communication reduces stigma and may facilitate entry into careText messaging pilot project for college student mental health35SMS messages focused on wellness, stress management, and adjustment to college were sent to all students’ mobile devicesStudents reported acceptability of receiving SMS, as long as messaging did not overtly focus on mental health 5% of first-year students responded with requests for helpText messaging pilot projects for mental health treatment adherenceSMS messages were sent to adolescent psychiatry patients between visits36 SMS messages supported treatment for bulimia nervosa37Patients in both pilot projects found receiving SMS messages to be acceptable SMS successfully kept patients engaged in psychiatric treatmentTwitterNIMH, Mental Health America, Active Minds and BringChange2Mind.org provide education and mental health resources through Twitter messages, or tweets38–40NIMH has over 68,000 followers, while Mental Health America, Active Minds, and BringChange2Mind have nearly 2,000, over 1,600, and 1,200 followers, respectively Open in a separate window The use of social media allows public health efforts to creatively engage hard-to-reach populations in symptom recognition, help seeking, and adherence to treatment, all in a manner that reduces barriers to access caused by the stigma attached to mental health issues. The National Institute of Mental Health, Mental Health America and Active Minds, Inc., a non-profit organization focused on eliminating mental health stigma on college campuses, all employ a familiar medium, Facebook,24–26 to educate target populations about mental health symptom recognition and provide treatment resources. As Obama’s campaign demonstrated, disseminating information via social networking sites effectively reaches target populations; in the case of mental health there is an added benefit of de-stigmatizing discussion of mental health issues. Just as potential Obama voters were engaged by the substantial presence of campaign supporters on social networking sites, youth who visit mental health-focused Facebook pages see thousands of profiles associated with these sites, conveying that there is broad support for those affected by mental illness. Youth reliance on the internet as a trusted source of health information -nearly one-quarter have searched online for information about depression or mental illness41 - suggests that web-based, interactive self-screening tools may be perceived as acceptable for discreetly identifying symptoms of mental disorders.28–29 People who would not otherwise seek screening due to concerns about privacy may feel comfortable completing an online questionnaire because it requires no interaction with another person. Likewise, SMS and Twitter, with their ability to reach target populations rapidly and discretely, show promise for increasing awareness of available mental health services and facilitating youth entry into counseling. Messaging may be particularly effective when framed in terms of maintaining wellness or addressing stress, rather than recognizing symptoms of stigmatized mental disorders.35 Obama’s campaign strategy of using social media to elicit consistent assistance from supporters parallels recent mental health treatment adherence efforts. Text messaging has been used to maintain engagement of adolescent psychiatry patients between usual visits and was valued as a follow up-support to inpatient treatment for bulimia nervosa patients.36–37 Social media may even facilitate technology-based mental health service delivery for some populations and conditions. The Mississippi Department of Mental Health operates a youth-oriented helpline via web-based and text messaging to facilitate anonymous communication between users and mental health providers. 34 Therapy delivery via SMS or email on secure websites may be preferable to in-person contact for some tech-savvy populations and those who live in rural areas but have access to cellular phones and internet. The role of SMS in supporting effective delivery of cognitive behavioral therapy for depression for adolescents is being explored.42 Facilitating social support via online communities may represent social media’s greatest implication for improving youth mental health. By creating a space for youth to share thoughts and life experiences, such communities may counteract one of the primary effects of mental health stigma – the loss of social engagement opportunities that can lead to self-harming behaviors.43 Just as youth responded to political messaging provided by peers during the 2008 presidential campaign, they are likely to trust user-generated content presented by peers or people they perceive to be similar to themselves via familiar online websites or YouTube. The community art project PostSecret has become an unlikely source of emotional support for troubled youth.31 Displayed on the PostSecret website are homemade postcards upon which participants anonymously write their secrets about such issues as relationships, family, sexuality, drug use, and history of abuse. The act of creating and sending a postcard may be an outlet for those who would not otherwise discuss their experiences and viewing the postcards may reduce feelings of isolation for those experiencing similar challenges. The site also hosts an online forum in which some 89,000 users discuss myriad topics including mental health concerns and provide support for one another.44 Similarly, for those with a diagnosed mental illness, the for-profit, online community Patients Like Me.com, facilitates discussion among users facing similar ailments.45 Patients Like Me users become credible sources of information, providing one another with emotional support and disease management suggestions. These discussions, along with the statistics on other users’ diagnoses and treatment the site provides, create a sense of belonging to a group and may reduce users’ feelings of detachment and shame. The It Gets Better Project employs user-generated media,46 a tremendously powerful tool in Obama’s social media campaign, as a suicide prevention strategy for a subgroup that experiences disproportionately high rates of unmet mental health needs: sexual minority youth.47 In response to the suicides of teens who experienced bullying due to their perceived sexuality,48 gay, lesbian, bisexual, and transgender adults created and shared videos via the It Gets Better Project’s YouTube channel to offer support to sexual minority youth who are harassed at school. With over 650 user-generated videos uploaded and nearly two million views, the widely popular project exceeded its YouTube capacity in just one month.33 These videos, created by people who are perceived as trustworthy because they have experienced homophobia and discrimination themselves, offer bullied sexual minority youth hope that their lives will indeed improve. ConclusionYouth-oriented mental health campaigns would be wise to continue using social media—preferably in multiple forms—to encourage recognition of mental health symptoms and facilitate access to services when indicated. However, to effectively engage youth, the public health sector must take a lesson from the Obama campaign and from the aforementioned successful informal mental health efforts by allowing users to determine the types of information and services they desire, and to create social community networks that facilitate information sharing and support for health-seeking behaviors. User-generated content was vital to Obama’s election, as it provided a mechanism of feedback to the candidate and his staff, enabling supporters to help set the agenda for the campaign. Through their videos and messages, youth made clear which of the candidate’s views resonated with their own. The campaign could then reiterate messaging that appealed to supporters and scale back others. Similarly, youth have responded well to social media-delivered mental health projects initiated outside of the public health sector because these efforts have been driven by those with a personal understanding of relevant issues. When youth with mental health concerns create their own content via participation in interactive health forums, they are transformed from consumers of health messaging into purveyors. They can be adept at communicating relevant information and may help facilitate peer entry into mental health care. Youth participants’ provision of social support may also counteract the effects of stigma that deter treatment seeking. The greatest strength of social media is not its capacity to simply send information to large segments of the population, but rather to engage previously underserved groups in accessing health information and becoming proactive consumers of health services. There is tremendous potential for its continued application to mental health, but the public health sector must more effectively engage youth in designing relevant messaging and services. As evidenced by their participation in PostSecret, Patients Like Me and the It Gets Better Project, youth are willing to engage in difficult discussions about mental health when they believe they are supported by a social community and they receive information from trusted sources. The public health sector must find creative ways to build on young peoples’ participation in these informal networks and encourage them to take meaningful action on their information they receive. References1. Bernhardt J. [Accessed February 11, 2010.];Public Health 2.0: New media for advancing health and advancing your career. http://www.slideshare.net/jaybernhardt/public-health-20. 2. [Accessed October 20, 2010.];Broward County launches Twitter site –“Ready Broward” - for emergency management information. http://bcegov3.broward.org/newsrelease/AdminDisplayMessages.aspx?intMessageId=2713. 3. [Accessed October 20, 2010.];Indiana University - Purdue University Indianapolis adds Twitter, RSS feed as new tools for emergency communication. http://newscenter.iupui.edu/3937/IUPUI-Adds-Twitter-RSS-Feed-as-New-Tools-for-Emergency-Communication. 4. University Communications. [Accessed October 20, 2010.];UA launches emergency text message system. http://uanews.org/node/16235. 5. Yen MY, Wu TS, et al. Taipei’s use of a multi-channel mass risk communication program to rapidly reverse an epidemic of highly communicable disease. PLoS One. 2009;4(11) [PMC free article] [PubMed] [Google Scholar] 6. Centers for Disease Control and Prevention. [Accessed October 28, 2010.];Social media at CDC. 2010 http://www.cdc.gov/socialmedia/ 7. Associated Press. [Accessed January 29, 2010.];Turnout in presidential elections hit 40-year high. http://www.politico.com/news/stories/1208/16576.html. 8. Swanson B. [Accessed February 11, 2010.];Obama ran a capitalist cam\paign. http://online.wsj.com/article/SB122602757767707787.html. 9. McGirt E. [Accessed March 31, 2010.];How Chris Hughes helped launch Facebook and the Barack Obama campaign. http://origin-www.fastcompany.com/magazine/134/boy-wonder.html. 10. Von Drehle D. [Accessed March 30, 2010.];The year of the youth vote. http://www.time.com/time/politics/article/0,8599,1708570,00.html. 11. The Center for Information and Research on Civic Learning and Engagement (CIRCLE) [Accessed January 29, 2010.];Turnout by education, race and gender and other 2008 youth voting statistics. http://www.civicyouth.org/?p=324. 12. Abroms LC, Lefebvre RC. Obama’s wired campaign: lessons for public health communication. J Health Comm. 2009;14:415–423. [PubMed] [Google Scholar] 13. Kessler RC, Berglund P, Demler O, Jin R, Walters EE. Life-time prevalence and age-of-onset distribution of DSM-IV disorders in the national co-morbidity survey replication. Arch Gen Psychiat. 2005;62:593–602. [PubMed] [Google Scholar] 14. Smith J. [Accessed January 29, 2010.];Latest data on US Facebook age and gender demographics. http://www.insidefacebook.com/2008/09/18/latest-data-on-us-facebook-age-and-gender-demographics/ 15. Personal Democracy Forum. [Accessed March 28, 2010.];Facebook supporters. 2008 http://techpresident.com/scrape_plot/facebook/2008. 16. Miller CM. [Accessed January 29, 2010.];How Obama’s Internet campaign changed politics. http://www.bits.blogs.nytimes.com/2008/11/07/how-obamas-internet-campaign-changed-politics/ 17. Wesch M. [Accessed January 29, 2010.];YouTube statistics. http://www.mediatedcultures.net/ksudigg/?p=163. 18. Burgess JE, Green JB. YouTube: Online Video and Participatory Culture. Cambridge, MA: Polity Press; 2009. [Google Scholar] 19. Owyang J. [Accessed February 5, 2010.];Snapshot of presidential candidate social networking stats. 2008 Nov 3; http://www.web-strategist.com/blog/2008/11/03/snapshot-of-presidential-candidate-social-networking-stats-nov-2-2008/ 20. Heaney CA, Israel BA. Social networks and social support. In: Glantz K, Rimer B, Visnawath K, editors. Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass; 2002. [Google Scholar] 21. Blumberg SJ, Luke JV. [Accessed March 29, 2010.];Wireless substitution: Early release of estimates from the National Health Interview Survey. 2008 Jul-Dec; http://cdc.gov/nchs/data/nhis/earlyrelease/wireless200905.pdf. 22. [Accessed February 11, 2010.];Fact Sheet on Youth Vote and Text Messaging. http://www.studentpirgs.org/new-voters-project/research/youth-vote-and-text-messaging. 23. Fox S, Zickuhr K, Smith A. [Accessed February 11, 2010.];Twitter and status updating. 2009 fall; http://www.pewinternet.org/Reports/2009/17-Twitter-and-Status-Updating-Fall-2009.aspx?r=1. 24. [Accessed October 21, 2010.];National Institute of Mental Health Facebook page. http://www.facebook.com/nimhgov. 25. [Accessed October 27, 2010.];Mental Health America Facebook page. http://www.facebook.com/mentalhealthamerica. 26. [Accessed October 27, 2010.];Active Minds Facebook page. http://www.facebook.com/mentalhealthamerica#!/activemindsinc. 27. [Accessed October 27, 2010.];Active Minds: Changing the conversation about mental health. http://www.activeminds.org/index.php. 28. [Accessed October 21, 2010.];Take a screening. http://www.nmha.org/go/help/finding-help/take-a-screening/take-a-screening. 29. [Accessed October 21, 2010.];Screening for Posttraumatic Stress Disorder (PTSD) http://www.adaa.org/living-with-anxiety/ask-and-learn/screenings/screening-posttraumatic-stress-disorder-ptsd. 30. [Accessed October 22, 2010.];Patients Like Me. http://www.patientslikeme.com/ 31. [Accessed October 22, 2010.];Post Secret Project. http://www.postsecret.com/ 32. [Accessed 2010, October 21.];It Gets Better Project YouTube Channel. http://www.youtube.com/itgetsbetterproject. 33. Winter R. “It Gets Better Project” outgrows its YouTube channel. [Accessed October 27, 2010.]; http://ecolocalizer.com/2010/10/09/it-gets-better-project-outgrows-its-youtube-channel/ 34. [Accessed October 21, 2010.];Welcome to Mississippi Department of Mental Health’s Hotline. https://login.ancomm.com/mshelpline/ 35. Joyce D, Weibelzahl S. [Accessed October 27, 2010.];Student counseling services: Using text messaging to lower barriers to help seeking. http://www.easy-hub.org/stephan/joyceieti.pdf. 36. Mäkelä K, Teemu P, Stenman M. Development of short message service application for patient–provider communication in clinical psychiatry. Telemed J E-Health. 2010;6:827–829. [PubMed] [Google Scholar] 37. Bauer S, Percevic R, Okon E, Meermann R, Kordy H. Use of text messaging in the aftercare of patients with bulimia nervosa. Eur Eat Disord Rev. 2003;11:279–290. [Google Scholar] 38. [Accessed October 27, 2010.];NIMH gov on Twitter. http://twitter.com/nimhgov. 39. [Accessed Oc-tober 27, 2010.];Mental Health America on Twitter. https://twitter.com/MentalHealthAm. 40. [Accessed October 27, 2010.];Active Minds, Inc. on Twitter. http://twitter.com/active_minds. 41. Purcell K, Lenhart A. [Accessed October 22, 2010.];Trends in teen communication: opportunities and challenges for public health campaigns. 2009 http://www.pewinternet.org/Presentations/2010/Sep/ONDCP.aspx. 42. [Accessed October 22, 2010.];Using a text-message system to engage depressed adolescents in cognitive-behavioral therapy homework.
|
