HEALTH ORGANIZATIONS' USE OF FACEBOOK FOR HEALTH ADVERTISING AND PROMOTION

Hyojung Park, Shelly Rodgers, and Jon Stemmle

ABSTRACT: The purpose of this study is to examine how health organizations use interactive features and social media channels on Facebook to manage their brand for advertising purposes. A content analysis of 1,760 wall comments on health organizations' Facebook pages reveals that nonprofit health organizations are more active in posting to Facebook than any other health organization examined. However, nonprofit health organizations do not take full advantage of interactive features or other social media channels. Government agencies and schools/universities exhibit the broadest use of interactive features; health care institutions appear more devoted to integrating social media channels with Facebook than the other types of organizations. Overall, health organizations strategically use branding and advertising techniques to manage their image and promote their brands. Still, there is room for improvement to take better advantage of various social media tools for consumer-generated advertising and viral marketing.

Social media websites such as Facebook, YouTube, and Twitter have become the most popular destinations on the Internet, with two out of three Americans using social media sites, which translates into 63.7% of U.S. Internet users, or about 147.8 million people (eMarketer 2011). Social media sites also serve as a growing source of health care information, and Facebook is the preferred source of health information for those who use social media sites for health purposes (Dolan 2011). The growing popularity of the Internet and the proliferation of social media websites provide opportunities to online health advertisers and marketers. A recent national survey by the Pew Research Center indicates that more than half of U.S. adults (57%) seek health information on the Internet and that onefifth use Facebook or other social media to receive updates about health issues (Fox and Jones 2009). Although the emergence of new media has made information seeking and sharing more convenient and satisfying (Fox and Jones 2009), low health literacy remains a major problem in the United States (Berkman et al. 2011). In these circumstances, it is necessary to analyze how health organizations use social media to promote public health and build their brand identities, as well as to identity strategies for improvement. Social media sites allow health organizations to engage in conversations with consumers through unique interactive features, such as sharing videos and photos, commenting on Facebook, or retweeting on Twitter. Although many studies attempt to understand interactivity as a key concept in Internet advertising (Downes and McMillan 2000), interactivity in the context of social media sites has received scant attention.

Interactive features and applications offered on social media sites, such as feedback mechanisms, news feeds, or quizzes, may enhance an organization's promotional and branding activities by entertaining visitors and encouraging their repeat use of an organization's social media site (Zarrella 2009). This scenario provides an opportunity to add to existing research on interactivity by identifying current uses of social media channels and interactive features by health organizations that aim to create and disseminate promotional messages about a health issue (Kamel Boulos and Wheeler 2007). Therefore, this study examines how health-related organizations make use of interactive features and social media channels on Facebook and identifies how health organizations use Facebook to manage their brand for advertising purposes. Specifically, we examine who, among health organizations, is using Facebook to promote health issues; what interactive features health organizations employ; which social media channels are used in conjunction with Facebook; and how health organizations use Facebook branding techniques to manage their social presence online. In addition, we identify and contrast five types of health organizations to determine whether there are differences in the interactive features used, social media channels selected, or branding techniques used in Facebook. A content analysis of 1,760 wall comments posted on the Facebook pages of health organizations provides a map of social media use for health communication. This descriptive study thereby provides a foundational basis for further investigations of social media marketing in health care and other fields. The results can be used for strategic
Journal of Interactive Advertising, Vol 12 No 1 (Fall 2011), pp. 62-77. 2011 American Academy of Advertising, All rights reserved ISSN 1525-2019

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communication planning and hypothesis generation. Such an understanding also enables an identification of key variables for follow-up studies that want to examine the effects of message features on psychological processes, as well as provide insights into the uses, opportunities, and challenges associated with the adoption of and research on this popular medium in the health care sector. Practically speaking, this study provides a guide for how health organizations can strategically integrate social media elements into their communication planning. The variables identified can also help social media marketing managers compose effective metrics to evaluate their social media efforts and measure the success of their strategies. The remainder of this article is organized as follows: We first define social media and interactivity and provide background information about health organizations' use of social media to fulfill advertising and marketing goals. Next, we provide the rationale and framework for this descriptive study, followed by a review of literature that leads into three research questions. Finally, we provide the method details, results, and a discussion. Social Media and Interactive Features: Definitions and Background Kaplan and Haenlein (2010, p. 61) define social media as "a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of User Generated Content." Social networking sites in particular refer to "web-based services that allow individuals to (1) construct a public or semi-public profile within a bonded system, (2) articulate a list of other users with whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system" (boyd and Ellison 2008, p. 211). Distinguishing features of social media include participation, openness, conversation, community, and connectedness (Mayfield 2008). A common element of social media sites is that content is often created and shared by the users of the sites (Gangadharbatla 2011). For this study, we focus on a specific group of users of social media: health organizations that use social media to promote health issues and build a brand presence in social media. Feedback mechanisms, such as buttons or quizzes, facilitate more participation from users of social media and encourage a discussion among users with relatively few access or content creation barriers (Mayfield 2008).

The emergence of social media platforms also offers increased capabilities for interactive communication and information sharing online (Kaplan and Haenlein 2010). The participatory nature and instant feedback of social media add a degree of interactivity to online advertising and marketing by facilitating consumer control and involvement in content creation and dissemination (Trusov, Bucklin, and Pauwels 2009). With this interactive potential, many corporations and organizations have turned their focus to incorporating social media elements into their marketing and promotion strategies and fostering two-way or multidirectional communication between brands and consumers (Burson-Marsteller 2010; Tuten 2008). Recognizing the power of social media marketing, the health care community has also tapped into social media tactics as part of its communication planning (Chou et al. 2009). Interactivity refers to "the condition of communication in which simultaneous and continuous exchanges occur, and these exchanges carry a social, binding force" (Rafaeli and Sudweeks 1997, p. 4). Interactivity enables social networking sites to facilitate consumers' understanding of health information (Nutbeam 2000), increases word of mouth among interpersonal networks (Kalichman et al. 2002), and improves consumers' self-management behaviors (Guendelman et al. 2002). Of many social networking sites available on the Web, Facebook is the most popular, with more than 750 million users and 30 billion pieces of content (web links, news stories, blog posts, notes, photo albums) shared each month (Facebook 2011). As a virtual social media platform, Facebook offers an easy, cost-effective way for both profit and nonprofit sectors to communicate health information, promote their products and services, and build brand communities. For example, an increasing number of health organizations have come up with Facebook health applications that allow users to keep track of their exercise and diet goals (Donohue 2009) and coordinate their exercise plans (Dugan 2010). Health insurance companies also have begun providing health tips and advice and send marketing messages via Facebook in an effort to interact with customers to enhance the image of the insurance industry (Terry 2011). The interactive capabilities offered on Facebook also make virtual content-sharing activities easy for users and encourage target audiences to engage in viral marketing (Thackeray et al. 2008). This type of personal recommendation is effective in getting the attention of potential consumers and influencing attitudes toward an organization and its brands (Thackeray et

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al. 2008). Thus, Facebook is an ideal platform for facilitating brand awareness and promoting brand engagement, because its core consists of social networking and relationship building (Tuten 2008). LITERATURE REVIEW Rationale and Framework for a Descriptive Study on Social Media To identify opportunities for social media and advertising theory, we examine how health organizations use Facebook and its interactive features, social media channels, and branding techniques to establish and maintain a brand presence. Because this study is descriptive in nature, it is necessary to establish its importance in the broader advertising and interactive advertising literature, because some descriptive studies, especially those that use content analysis as a method, have been criticized for inferring causal relations that result in invalid conclusions or implications (Carlson 2008). Grimes and Schulz (2002, p. 145) recognize that descriptive studies are "concerned with and designed only to describe the existing distribution of variables, without regard to causal or other hypotheses." They often provide a springboard to more rigorous hypotheses about causal relations with comparison groups, and descriptive results can support trend analysis, health care planning, and hypothesis generation (Grimes and Schulz 2002). A common approach to descriptive studies is that of newspaper coverage, which answers five basic "W" questions: who, what, why, when, and where (Grimes and Schulz 2002), along with one "H" question: how. This approach bears similarities to Lasswell's comment on communication, which advertising scholars have used for decades: "Who says What in Which Channel to Whom with What Effects" (see Gangadharbatla 2011). Within this framework, we begin by asking who is using Facebook to promote health issues-that is, health organizations that disseminate health advertising and promotional messages on their Facebook pages. These messages may take the form of promoting an event or directing traffic to view a new product or service on the organization's website. There is a difference between people who post comments on behalf of themselves and those who post comments on behalf of health organizations. Presumably, health organizations have a strategic goal in mind, and their participation in Facebook and other social networking sites is intended to be part of a larger integrated strategic communications plan. Accordingly, we are interested in health

organizations' postings, not the postings of individuals who post comments on their own behalf on their Facebook profiles. As the most popular social networking site, Facebook enables health organizations, such as government agencies, medical centers, and pharmaceutical companies, to communicate effectively with a target audience and widely spread their messages through existing social networks. To begin to understand how health organizations use Facebook, we must understand who is represented among these organizations, which leads to the first research question: RQ1: Who are the health organizations on Facebook? Interactive Features In the next step, we sought to understand what interactive features the health organizations use (RQ2) and which social media channels they select (RQ3). As an interactive medium for health communication, the Internet has changed the way people seek, acquire, and share information to manage their health (Rains 2007). Its rising influence has led health professionals and health organizations to find new ways to communicate health information to the public and promote their health care services (Suggs 2006). The advent of social networking sites has advanced the interactive potential of the Internet by allowing ongoing, multifaceted conversations and introducing a wide array of interactive features (Hawn 2009; Orsini 2010). Such interactive features can also encourage users to pass along health messages and share information about healthcare products, creating viral marketing opportunities for health organizations (Thackeray et al. 2008). Among the broad array of interactive features available on Facebook, we attempted to examine as many as possible to give a nearly comprehensive picture of the interactive features that health organizations use to create and disseminate messages related to health literacy. However, it is possible, and even likely, that different types of health organizations use different interactive features. Do nonprofit corporations employ Facebook for health advertising and promotion more than corporate health organizations, due to their smaller budgets, staff, and resources? Or do business organizations use Facebook and its features to a greater degree, because their bigger budgets and staff help them manage consumer conversations? The orientation of the organization also should affect its social media use: Those that view social media as part of a larger integrated health communications program presumably make greater use of features that pertain to their particular goal and

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target audience. Those that lack such a goal or that visit social media sites simply because it is a fad do not make as much use of the interactive features, social media channels, or branding techniques available on Facebook. To identify the interactive features being used, as well as potential differences among types of health organizations, we consider the following research question: RQ2: What interactive features do health organizations use on Facebook, and what differences are there, if any, in the usage types of these health organizations? Social Media Channels Because Facebook allows third-party developers to create compatible applications, a growing number of social media channels are available to users. With their entertaining and informative value, these social media channels and tools can increase the motivation of Facebook users to return to the site or generate intentions to continue creating and disseminating content (Newson, Houghton, and Patten 2009). The integration of Facebook with other social media, such as YouTube, Flickr, and Twitter, makes it easy not only for health organizations to manage their messages, photos, and audio/video materials but also for their Facebook visitors or fans to find needed information in various formats (Reed 2010). The use of social media channels creates an opportunity to facilitate the flow of health information by virtue of a dynamic and evolving ecology of networks across different social media platforms (Thackeray and Neiger 2009). Effectively implementing various social media outlets may further contribute to increasing consumers' awareness of health-related products and services advertised by health organizations by accelerating the speed of shared information. A recent real-life example illustrates how the integration of social media outlets can drive web traffic to an organization's social networking site. In response to the outbreak of H1N1 in 2009, government health agencies and local health departments used Facebook and Twitter to provide up-to-date information, including flu clinic schedules, availability of vaccines, and mortality reports (National Association of County & City Health Officials 2009). They also posted several videos about flu season safety tips and flu vaccine information on their YouTube sites. With these communication efforts, far more people joined one local health department's social networking pages, and those fans and followers acted as "information ambassadors" who disseminated more

information through their networks (National Association of County & City Health Officials 2009). To disseminate health messages more widely and attract greater viral attention, health organizations presumably integrate various social media platforms into their communication planning and align their social media activities. This task is accomplished by referring back to the various social media channels the health organization utilizes, whether Twitter, YouTube, or Flickr. Again, different types of health organizations should use the social media channels differently, and therefore, RQ3: Which social media channels do health organizations use on Facebook, and what differences are there, if any, in the usage types of these health organizations? Branding and Self-Presentation on Social Media A core component of social networking sites is the public display of personalized user profiles and personal connections, which offers users a range of options for presenting highly selective versions of themselves and managing their images (boyd and Ellison 2008). Organizations and individual users can take advantage of self-presentation tools offered by Facebook to enhance their images and broaden connections with other users (Trusov, Bucklin, and Pauwels 2009). Selfpresentational performances, such as creating user profiles, are strategic activities designed to give good impressions to others (Goffman 1959). Thus, they are closely related to the notion of impression management on social networking sites. Impression management is "the goal-directed conscious or unconscious attempt to influence others' perceptions about a person, object, or event by controlling or managing the exchange of information in social interaction" (Dwyer 2007, p. 2). In the social media environment, users engage in impression management when creating their profiles, which often include personal information and photos or images. People select certain attributes to include in their profiles but exclude others to present themselves in a positive manner (Utz 2010). Users can construct such positive self-presentations using deliberately chosen photos or avatars (Wang et al. 2010). Such deliberative behaviors affect the impressions viewers obtain when viewing personal web pages (Toma, Hancock, and Ellison 2008). Such crafted self-presentations enable users to strategically manage their interactions on social networking sites (Ellison, Heino, and Gibbs 2006). Health organizations similarly can adopt impression management strategies to produce positive organizational self-

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presentations and manage online impressions on Facebook. They may upload unique logos and create appealing profiles to attract more users. In virtual worlds, an organization's brand identity is created through a profile (Scott 2011). For example, biographical information and photos are important components of branding, because they reflect an organization's characteristics and serve as cues that enable visitors to determine if an organizational page fits their personal preferences and needs (Evans 2010; Scott 2011). Thus, health organizations should create a profile that helps users learn about their affiliations by posting specific, descriptive biographical information and using their logo as an avatar. An attractive identity on Facebook may lead visitors to "like" the organization's page and join its community (Tuten 2008). Building brand communities is an important step for an organization to increase brand awareness and enhance customer loyalty (Holland and Baker 2001; Thorbjrnsen et al. 2002), which may also provide an opportunity for the organizations to use viral marketing through word of mouth (Thackeray and Neiger 2009; Trusov, Bucklin, and Pauwels 2009). In this respect, social networking sites such as Facebook can also serve as cost-effective and efficient advertising means. Health organizations could incorporate them as part of their promotional strategies. For example, government health agencies might promote services or benefits and improve their credibility as public-serving organizations; pharmaceutical companies could increase awareness of new products and seek to improve attitudes toward their services. By creating positive self-presentations in the social media environment, health organizations can generate good impressions and gain more users' attention, thereby achieving their promotional goals. Therefore, this study asks, RQ4: How do health organizations use Facebook for impression management/branding purposes, and what differences are there, if any, in the usage types of these health organizations? METHOD Sampling Frame For this content analysis, we sampled health organizations' Facebook pages. There is an abundance of health organizations on Facebook, so we focused on those dealing with health literacy, which logically should be industry leaders in communicating easily understood health messages to other health organizations and the public. The relatively complex

sampling technique consisted of multiple searches of databases and social media sites using the key term "health literacy" or some variation thereof (health and literacy, literacy). Specifically, we searched Facebook and Twitter using the key terms, then separated health organizations from individual people posting messages about health. A previous, similar analysis of Twitter also had identified multiple organizations; if they were on Facebook, they appeared in the current sample. To ensure comprehensiveness, additional searches on Google used the key terms and "Facebook." Comments containing the key terms and posted by health organizations in Facebook were traced back to business profiles. These search results were combined, and any duplicate organizations were deleted. The final sample consisted of 35 organizations (see the Appendix). In the absence of an established sampling technique for social media, an expert who has published extensively on sampling in mass media channels undertook a critique of the sampling technique in advance of the actual sampling. This study used a census sample, meaning that the sampling frame included all wall postings/comments on the identified health organizations' Facebook pages that met the sampling criteria. The sampled comments were posted between May 8, 2008 (first date on which an organization posted a comment), and July 13, 2010. All comments posted by health literacy organizations thus were captured for the analysis (see Rodgers and Chen 2005). Comments unrelated to health literacy were excluded from analysis. A total of 1,760 wall comments were collected for the content analysis. Coding Procedure and Intercoder Reliability The unit of analysis was an individual wall posting, or comment, on health organizations' Facebook pages. To avoid observation bias driven by a researcher's expectations, two trained coders, other than the researchers, carried out the content analysis of the sampled wall comments. The coders received several hours of training on the coding procedures. During the initial training, category definitions and detailed instructions were discussed, and the coders practiced coding a subsample of wall comments until a satisfactory level of consensus was achieved. Before the actual coding was undertaken, another subsample of comments (11.4%, N = 200) was double-coded to determine intercoder reliability. The two coders then coded 75.1% (n = 1,323) and 13.5% (n = 237) of the sample, respectively. Using Holsti's (1969) formula, intercoder reliability was calculated at .91 on average. Values of Holsti's reliability coefficient above .90 indicate a fairly high and acceptable level of agreement among coders (Wimmer

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and Dominick 2006). Thus, the data appeared to be sufficiently reliable for analysis. Coding Scheme The coding categories were developed on the basis of previous literature in health communication and media studies (Rodgers and Chen 2005; Rodgers and Thorson 2009; U.S. Department of Health and Human Services 2009). Corresponding to the research questions, the coding scheme consisted of four parts: (1) basic descriptive information about the wall comments on Facebook and the Facebook user (i.e., health organization), (2) interactive features on Facebook, (3) social media channels used in combination with Facebook, and (4) Facebook features on selfpresentation/branding/advertising by the health organization. Descriptive variables. The following descriptive variables were coded for categorization purposes: (1) date of the comment, (2) type of access, and (3) number of fans on the health organization's page. The date was literally the date on which the comment was posted. The type of access was a categorical level variable, coded to determine the visibility of the Facebook profile and wall posts, according to three levels: open, with a public profile visible to anyone; partially open, with a semi-public profile such that some parts were visible to anyone online, but other parts were visible only to "friends"; and closed, with a private profile visible only to people who belong to that organization's network. Facebook also tracks the number of fans (i.e., users who "like" the Facebook page), so the coders simply recorded the number of fans already indicated on the Facebook page. Type of health organization. Health organization type was defined in terms of the elements that made up the organization and its collective goal (see Rodgers and Thorson 2009). This categorical-level variable had five main categories and an "other" category: Government centers or agencies, such as the CDC or NIH. Health care institutions, such as hospitals and medical centers. Schools or universities. Business/corporations/pharmaceutical companies. Community/advocacy/nonprofit groups. Other.

Although government agencies and educational institutions may fall into the category of nonprofit organizations, they were classified as separate categories in this study because their organizational objectives differed in terms of health promotion (Rodgers and Thorson 2009). Nonprofit groups or organizations included public charitable organizations and private foundations, such as the Literacy Assistance Center and the Missouri Foundation for Health, which receive donations or funds from individual members of the public. Interactive features. Interactive features were defined in terms of their ability to facilitate simultaneous and constant sharing among participants of a given community. The variable was coded at the nominal level, where yes = 1 or no = 0. There were 14 interactive features, plus an "other" category: comments/posts, e-mail, photo- or image-sharing, videosharing, blogging, instant messaging, mobile/text messaging, e-cards, RSS feed, e-games, e-mail updates, widgets, links to bookmark the page, and e-mail newsletters. Social media channels. Social media channels were defined as online platforms that enable members to produce, share, or collaborate on content across social networks (Tuten 2008). This variable was measured as an organization's integration of other social media sites with Facebook. Social media channels was a nominal-level variable, coded yes = 1 or no = 0. Six social media channels were coded: Twitter, MySpace, YouTube, Flickr, blogs, and other. Branding/advertising techniques. Branding or advertising techniques refer to the use of features offered by the social media site that enable an organization to promote its brand, product, or service offerings. Branding/advertising technique was operationally defined as whether an organization used features for self-presentation and promotion, such as photos and biographies (Scott 2010). This variable was measured on a nominal scale, where yes = 1 and no = 0. There were five branding techniques coded to indicate whether the organization included the following features on its page: logo, photo, biographical advertisement, wall post advertisement, and advertising goal. RESULTS Descriptive Statistics Date of comment. Results of descriptive statistics show that March 2010 had the highest number of comments written by health organizations (n = 244), followed by April 2010 (n = 193) and February 2010 (n = 167) (see Figure 1).

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Type of access. All of the wall postings were published in an open format with a public profile visible to anyone online. There was no variation in this variable, so it was dropped from further analysis. Number of fans. The number of fans varied depending on the type of health organization. The government agencies had 40 fans, and health care institutions had 580 fans. The other totals varied, from 45-250 fans for schools and universities, 3-713 for business corporations, and 1-467 for nonprofit organizations.

RESEARCH QUESTIONS In terms of who among health organizations is using Facebook for health literacy promotion, the descriptive results show that nearly half of the comments came from nonprofit organizations (n = 863), followed by schools or universities (n = 292), government centers or agencies (n = 264), health business corporations (n = 178), and health care institutions, such as hospitals (n = 163).

Figure 1. Frequency of Wall Comments Posted per Month on Facebook by Health Organizations

The second research question sought to examine how health organizations use interactive features on Facebook (Table 1). By far, the most common interactive feature was photosharing (98.1%, n = 1,726), followed by blogging (47.2%, n = 831), video-sharing (28.2%, n = 496), RSS feed (27.9%, n = 491), e-mail (9.3%, n = 164), and e-newsletter (1.1%, n = 18). The investigation of RQ2 also reveals differences among the interactive features used, according to the type of health organization. Photo-sharing features were used by nearly all the government agencies (n = 264), health care institutions (n = 163), schools/universities (n = 292), and nonprofit organizations (n = 851). These organizations used photosharing functions more frequently than health business corporations (87.6%, n = 156), and the differences among the 2 (4, N = 1760) = 117.664, p < .05). Blogging was used more frequently in the

comments of Facebook pages of government agencies (100%, n = 264), health care institutions (100%, n = 163), and schools/universities (97.9%, n = 286) than health business corporations (23.0%, n = 41) and nonprofit organizations 2 (4, N = 1760) = 1328.411, p < .05). For RSS feeds, the most frequent use was among government agencies (100%, n = 264) and schools/universities (77.7%, n = 227), whereas none of the health care institutions, health business corporations, or nonprofit organizations used RSS feeds. Health care institutions, such as medical centers and hospitals (100%, n = 163) and schools/universities (80.1%, n = 234), were more inclined to use video-sharing features than were the other health organization types (11.5%, n = 99 for nonprofit organizations; n = 0 for government agencies; n = 0 for health business corporations).

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Table 1. Interactive Applications Used by Health Organizations

Health Organization Application Comments E-mail Photo-sharing Video-sharing Blogging RSS feed e-newsletter Total Government 264 (100.0%) 0 (0.0%) 264 (100.0%) 0 (0.0%) 264 (100.0%) 264 (100.0%) 0 (0.0%) 264 (15.0%) Hospital 163 (100.0%) 0 (0.0%) 163 (100.0%) 163 (100.0%) 163 (100.0%) 0 (0.0%) 0 (0.0%) 163 (9.3%) School 292 (100.0%) 52 (17.8%) 292 (100.0%) 234 (80.1%) 286 (97.9%) 227 (77.7%) 0 (0.0%) 292 (16.6%) Business 178 (100.0%) 0 (0.0%) 156 (87.6%) 0 (0.0%) 41 (23.0%) 0 (0.0%) 0 (0.0%) 178 (10.1%) Nonprofit 863 (100.0%) 112 (13.0%) 851 (98.6%) 99 (11.5%) 77 (8.9%) 0 (0.0%) 18 (2.3%) 863 (49.0%) Total 1760 (100.0%) 164 (9.3%) 1726 (98.1%) 496 (28.2%) 831 (47.2%) 491 (27.9%) 18 (1.1%) 1760 (100.0%) 117.664* 1097.328* 1328.411* 1508.789* 2

Notes: The percentages in the cells are the column totals, so the numbers add up to 100% in each column, but not across the rows. Four degrees of freedom. * p < .05.

In terms of social media channels (RQ3), Table 2 shows that YouTube was used the most frequently by health organizations (78.4%, n = 1379), followed by blogs (47%, n = 827), Twitter (40.6%, n = 715), and Flickr (39.1%, n = 688). A chi-square analysis reveals that social media channels differed among the five types of health organizations. Twitter was used more frequently by health care institutions (100%, n = 163) than by universities or schools (59.9%, n = 175), health business corporations (53.4%, n = 95), or nonprofit 2 (4, N = 1760) = 500.455, p < .05). Government agencies did not use Twitter in any postings. In contrast, YouTube was used more frequently by government agencies (100%, n = 264), health care institutions (100%, n = 163), and schools/universities (97.9%, n = 286)

compared with health business corporations (51.7%, n = 92) 2 (4, N = 1760) = 330.017, p < .05). Flickr was used more frequently by health care institutions (100%, n = 163) and schools/universities (80.1%, n = 234) than by nonprofit organizations (33.7%, n = 2 (4, N = 1760) = 754.724, p < .05). Flickr was not used by government agencies or health business corporations. Blogs were used more frequently by government agencies (100%, n =264) , health care institutions (100%, n = 163), and schools/universities (97.9%, n = 286) than by health business corporations (23.0%, n = 41), and nonprofit organizations (8.5%, n = 73). The sampled health organizations significantly 2 (4, N = 1760) = 1341.450, p < .05).

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Table 2. Social Media Channels Used on Facebook by Health Organizations

Health Organization Application Twitter YouTube Flickr Blog Total Government 0 (0.0%) 264 (100.0%) 0 (0.0%) 264 (100.0%) 264 (15.0%) Hospital 163 (100.0%) 163 (100.0%) 163 (100.0%) 163 (100.0%) 163 (9.3%) School 175 (59.9%) 286 (97.9%) 234 (80.1%) 286 (97.9%) 292 (16.6%) Business 95 (53.4%) 92 (51.7%) 0 (0.0%) 41 (23.0%) 178 (10.1%) Nonprofit 282 (32.7%) 574 (66.5%) 291 (33.7%) 73 (8.5%) 863 (49.0%) Total 715 (40.6%) 1379 (78.4%) 688 (39.1%) 827 (47.0%) 1760 (100.0%)
2

500.455* 330.017* 754.724* 1341.450*

Notes: The percentages in the cells are column totals, so the numbers add up to 100% in each column but not across the rows. Four degrees of freedom. * p < .05

The results for RQ4, related to the number of branding/advertising techniques that health organizations used on Facebook, are in Table 3. An organization's photo (avatar) appeared in nearly all the comments by health organizations (99.5%, n = 1,752), followed by the presence of advertising goals (90.5%, n = 1,592), logos (88.1%, n = 1,550), post ads (53.2%, n = 936), and bio ads (4.0%, n = 70). Logos

were used more frequently by government agencies (100%, n = 264), health care institutions (100%, n = 163), and health business corporations (98.9%, n = 176) than by educational institutions (62.0%, n = 181) or nonprofit organizations (88.8%, n = 766). These differences were statistically 2 (4, N = 1760) = 267.065, p < .05).

Table 3. Branding/Advertising Techniques Used by Health Organizations for Promotional and Advertising Purposes in Facebook
Health Organization Feature Logo Photo Bio ad Post ad Ad goal Total Government 264 (100.0%) 264 (100.0%) 0 (0.0%) 169 (64.0%) 221 (83.7%) 264 (15.0%) Hospital 163 (100.0%) 163 (100.0%) 0 (0.0%) 67 (41.1%) 139 (85.3%) 163 (9.3%) School 181 (62.0%) 292 (100.0%) 0 (0.0%) 106 (36.3%) 268 (91.8%) 292 (16.6%) Business 176 (98.9%) 178 (100.0%) 52 (29.2%) 144 (80.9%) 153 (86.0%) 178 (10.1%) Nonprofit 766 (88.8%) 855 (99.1%) 18 (2.1%) 450 (51.2%) 811 (94.0%) 863 (49.0%) Total 1550 (88.1%) 1752 (99.5%) 70 (4.0%) 936 (53.2%) 1592 (90.5%) 1760 (100.0%)
2

267.065* 8.353 110.705* 36.115*

Notes: Four degrees of freedom. *p < .05.

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Only 70 bio advertisements were identified among business organizations (29.2%, n = 52) and nonprofit organizations (2.1%, n = 18). None were present in the comments posted by health care organizations, government agencies, or schools/universities. As for post advertisements, a chi-square analysis showed that health business corporations (80.9%, n = 144) had a higher proportion of post ads than government agencies (64.0%, n = 169), nonprofit organizations (51.2%, n = 450), health care institutions (41.1%, n = 67), or schools/universities (36.3%, n = 106). Advertising goals (i.e., "purposeful" posts) were least likely to be used among government agencies (83.7%, n = 221), health care institutions (85.3%, n = 139), and health business corporations (86.0%, n = 153) compared with schools/universities (91.8%, n = 268) and nonprofit organizations (94.0%, n = 811). These differences 2 (4, N = 1760) = 36.115, p < .05). DISCUSSION Overview This descriptive study examined health organizations' use of interactive features, social media channels, and branding/advertising techniques on Facebook. Specifically, we examined who among health organizations used Facebook to promote health issues, what interactive features were being used, which social media channels were used in conjunction with Facebook, and how health organizations used Facebook's branding/advertising techniques to manage their selfpresentation and social presence online. We have identified and contrasted five types of health organizations on these primary variables, and the results of chi-square analyses reveal significant differences in the interactive features used, social media channels selected, and branding techniques applied in Facebook, according to health organization type. RESULTS AND IMPLICATIONS Nonprofit organizations were more active in posting to Facebook than any other health organization examined. They had more than double the number of posts compared with schools/universities and government agencies, and approximately five or more times that of business organizations and health care institutions. Yet the nonprofit organizations did not incorporate a wide array of interactive features (e.g., video-sharing, RSS feeds, blogging) into their social media strategies. Nonprofits rarely offered informative videos or links to their social media sites, where visitors of Facebook pages expect to find detailed information about an organization to obtain a better understanding of a health issue.

The photo-sharing function was the only interactive application that nonprofit organizations used for involving the public. The results also indicate that nonprofit health organizations are not taking full advantage of other social media channels available, such as Twitter, YouTube, and blogs, which can be integrated with Facebook. Nonprofit organizations did not use branding techniques as frequently as the other organizations. In contrast, health business organizations used Twitter least frequently and did not use Flickr at all. This pattern of results implies that organizations simply may not be aware of these Facebook features (Harbison 2011). Alternatively, the lack of use may arise because nonprofits, by virtue of having small staffs and budgets, cannot afford to use the interactive features, which would necessitate additional staffing, time, and resources, so they focus only on one aspect of Facebook. Health care institutions used social media channels more frequently than the other organizations, including Twitter, YouTube, and Flickr. The same was true of schools/universities. Medical centers and hospitals appeared to strive to leverage their social media efforts by employing various social media channels in combination with Facebook. Social media need to be part of a larger strategic communication effort and should not be treated as an "addon" to what marketers are already doing online or offline. Because schools/universities and health care institutions often have greater resources than nonprofits, both in personnel (e.g., student labor) and funding, these groups can exploit other social media in combination and on a wider scale. Government agencies and schools/universities appeared to undertake the broadest use of the interactive features of any of the organizations examined, including RSS feeds and videosharing. In contrast, health business corporations used interactive features least. Commercial businesses used photosharing and blogging about health literacy less frequently than the other organizations examined. This finding corresponds to previous research indicating that nonprofit organizations and public institutions give consideration to how to integrate interactive elements into their communication planning (Waters 2007). It is plausible to speculate that social media technology is more appealing to public and nonprofit health sectors, as an inexpensive but effective way to communicate with target audiences, despite their lack of staffing and resources (National Association of County & City Health Officials 2009). Health business corporations appear to approach social media in a more staid, conservative manner,

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whereas nonprofits and schools/universities have more freedom to share information freely and try new approaches. This study also has examined how health organizations made use of branding/advertising techniques, presumably for selfpresentation to manage their image and promote their brands. Business organizations did not take advantage of the interactive features or social media channels offered by Facebook to promote of health literacy, but they relied heavily on the use of logos as a branding technique. All the government agencies and health care institutions examined had their logos on their Facebook pages, whereas schools/universities and nonprofit organizations did not actively employ this branding technique. The implication is that some organizations may have established policies on social media participation, whereas others do not. Those with better established policies presumably would do a better job taking advantage of the interactive features on Facebook. For example, the Centers for Disease Control and Prevention (CDC) has guidelines on social media use among CDC employees, such as the rule that every employee who uses Facebook on behalf of the CDC must use a CDC logo. This distinction may help explain why some organizational types made use of Facebook branding techniques, such as the use of a logo or avatar, whereas other organizational types did not. Almost all organizations examined uploaded a unique image or photo as an avatar. Although the use of organizations' photos was not used to the same extent by nonprofits as it was by the other organizations examined, the differences among organizations were not significant. This result suggests that health organizations put a great deal of effort into making a good impression on visitors and managing their images on social networking sites. These efforts may generate public perceptions that they are attentive and responsive to their Facebook pages and thereby drive more users of social networking sites to their pages through viral marketing (Thackeray and Neiger 2009). Business organizations, government agencies, and health care institutions used post advertisements more frequently and thus were more goal-oriented in nature than nonprofit organizations. Facebook postings by nonprofit organizations and educational institutions rarely included specific brand names but appeared purposeful, which likely relates to the focus of these organizations' social media marketing. Unlike business corporations, nonprofit organizations and schools/universities primarily dedicated their communication

efforts to increasing health literacy and promoting relevant public services, rather than advertising for monetary benefits. Intertwined with this finding, health organizations' use of social media brings benefits to not only themselves but also the public, especially in terms of health literacy. New communication technologies can broaden educational opportunities to help people increase their health knowledge and develop appropriate information-seeking skills (Ratzan 2001). Health literacy awareness is low, and the health literacy gap is a significant topic in health communication (Nutbeam 2000). In these circumstances, Facebook and other social networking sites provide several advantages over other communication channels for achieving organizational goals for health literacy. Their interactive features, such as videos and widgets, may attract more users' attention and help to drive web traffic to organizations' pages, thereby increasing awareness of both the organizations' presence and health literacy issues. The theoretical significance of this study pertains to the application of the principal model of advertising and communication, "Who says What in Which channel to Whom with What effects," to burgeoning social media. As an initial attempt to examine the use of social media for health advertising and promotion, this descriptive study provides a strong, potential basis for further research into the effective use of social media tools. This study also offers insights for social media managers, in that it provides a snapshot of health organizations' current use of social media and offers ways to improve their social media practices. Social media managers working in the health care sector need to utilize more interactive features and platforms and create an attractive social network identity to connect with more users and build their brand. Organizations may not need to invest in a plethora of social media sites. Rather, it is important to know how to provide feelings of comfort and connection and create greater fluidity with existing social media pages (Tuten 2008). The communication and branding objectives of a health organization can be achieved through strategic planning and the constant evaluation of social media use. LIMITATIONS AND FURTHER RESEARCH Despite the great lengths taken to ensure a sound sampling technique, no known techniques currently exist for sampling social media. Inasmuch as we are confident in the sample collected (i.e., cross-checks yielded no additional health

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literacy organizations), additional studies must develop tried and true sampling procedures. Technology is constantly changing, which poses several challenges. At the time of the coding, there was no means by which businesses could leave a comment on their own Facebook page. That has changed in the past few weeks; now businesses can leave their own comments to be voted on, and people can click through to a health organization's business page (Harbison 2011). At the time of the coding, Facebook used the term "fans" to refer those who "liked" the health organization's page and could link to it to receive updates. Since April 2010, Facebook has changed its terminology from "becoming a fan" to "liking" a page. The phrase change should not alter the meaning of what we coded, but additional interactive features enhance "liking," such as voting on "liked" pages, and they need to be examined by further studies. Although we tried to be comprehensive in coding interactive features, social media channels, and branding/advertising techniques, other features remain. Fans might tag themselves in photos, businesses can send automatic updates to fans, and businesses can automatically block certain words or terms to control what content gets posted on the organization's Facebook page. The features we coded were readily apparent and indicated in the postings and organizations' biographical pages. However, these features are not readily apparent by examining a business's Facebook page, because they rely on commands behind the scenes (i.e., the organization uses Facebook settings), making it impossible to know if the organization uses some features. Different methods thus are needed to gain perspective on the types of features that health organizations use behind the scenes to interact with and create relationships with consumers. Online tools such as RSS feeds and blogging presumably should work best when used in combination. However, which combinations work best for which organizations? If a hospital wants to build credibility on its blog, what combination of interactive features must be present? Additional research is needed to determine which combinations work best under which circumstances and for which organizational type. From these results, it seems that the combination of social media and interactive features offered by the channels depends on the type of health organization, the target audience the health organization wants to reach, and the strategic communication goals of the organization. For example, it may be that blogs work better for organizations that want to communicate with

other organizations, because they require a level of knowledge and expertise, unlike an everyday citizen as a member of the target audience. The increasing role of mobile in driving social media suggests that further studies should examine the unique interactive features, social media channels, and branding techniques in mobile channels. The use of mobile phones enables consumers to share more content through social media sites, which has implications not just for social media sites but potential word of mouth and advertising on social media sites. There is also a need to understand these interactive features to develop better social media analytics (e.g., share of voice, resonation, support response) and engagement data (e.g., clicks, fans, followers, views, likes, check-ins). We examined the number of fans for this study, but it was difficult to assess this variable for the range of organizations that emerged as part of this analysis. Studies also should examine "likes" and other forms of engagement to assess the value of the social media site for users. Additional research might look at the effects of specific interactive features on Facebook to gain an understanding of consumers' perceptions of their use health organizations. When a health organization uses a specific interactive feature, do consumers and potential consumers necessarily see it as a benefit? Consumers' perceptions of the interactivity of social networking sites are a key concern for online health organizations. Feedback systems that use real-time chat, for example, can be costly to staff and may limit the types of organizations that can afford such features. Knowing the circumstances in which the use of interactive features, social media channels, and branding techniques improve or enhance an organization's brand presence in social media sites would help inform theory about psychological processing of these features; it also could clarify the practical uses of the many features available in social media sites (Cui, Wang, and Xu 2010). Finally, the organizational types examined ground this research on observations of the features used and not used by these particular organizations. The intent is not to draw causal connections but rather to identify what features actually are used, or not. We assume the features are there to enhance users' experience, but we cannot confirm which features or combinations of features have this effect. Nor can we explain why one organizational type uses one feature over another. Time and resources are likely factors, but further studies would need to conduct a survey or depth interviews with

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organizations to understand their motives, as well as challenges the organizations encounter in establishing a social media presence online. CONCLUSION A core strength of social media pertains to its potentially broad appeal, offering a wide array of features, from profiles to instant messaging to news feeds and quizzes to feedback mechanisms (Tuten 2008). The results of this content analysis indicate that of the health organizations examined, nonprofit organizations or community groups were most inclined to engage actively in posting health information and interacting with the public via Facebook. Government agencies and educational institutions were more likely to take advantage of social networking features, channels, and branding techniques than health business corporations and medical centers. The growing number of interactive features, social media channels, and branding tools and widgets makes it easier for organizations and businesses to bring social media content back to their corporate websites. Although Facebook holds great potential as a communication tool, there is much that remains to be understood in terms of the features offered by social media sites and used by organizations, as well as the benefits to the organizations and users of social media. Anecdotally, organizations are told to diversify their social media efforts by coordinating social networking applications to satisfy audiences' diverse needs and expectations (Waters et al. 2009). This study shows that the manner in which organizations are doing so varies considerably, depending on the social media feature and organizational type examined. REFERENCES Berkman, Nancy D., Stacey L. Sheridan, Katrina E. Donahue, David J. Halpern, and Karen Crotty (2011), "Low Health Literacy and Health Outcomes: An Updated Systematic Review," Annals of Internal Medicine, 155 (2), 97-107. boyd, danah M. and Nicole B. Ellison (2008), "Social Network Sites: Definition, History, and Scholarship," Journal of Computer-Mediated Communication, 13 (1), 210-30. Burson-Marsteller (2010), The Global Social Media Check-up 2010, http://www.burson-marsteller.com (accessed January 8, 2011). Carlson, Les (2008), "Use Misuse, and Abuse of Content Analysis Research on the Consumer Interest," Journal of Consumer Affairs, 42 (1), 100-105.

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Gangadharbatla, Harsha (2011), "Social Media and Advertising Theory," in Advertising Theory, S. Rodgers and E. Thorson, eds. Routledge (in press). Goffman, Erving (1959), The Presentation of Self in Everyday Life. New York: Anchor/Doubleday. Grimes, David A. and Kenneth F. Schulz (2002), "Descriptive Studies: What They Can and Cannot Do," Lancet, 359 (9301), 145-49. Guendelman, Sylvia, Kelley Meade, Mindy Benson, Ying Qing Chen, and Steven Samuels (2002), "Improving Asthma Outcomes and Self-Management Behaviors on Inner-City Children: A Randomized Trial of the Health Buddy Interactive Device and an Asthma Diary," Archives of Pediatrics and Adolescent Medicine, 156 (2), 1114-20. Harbison, Niall (2011, April 18), "Seven Useful Facebook Features Marketers May Not Know," http://www.simplyzesty.com (accessed April 20, 2011). Hawn, Carleen (2009), "Take Two Aspirin and Tweet Me in the Morning: How Twitter, Facebook, and Other Social Media are Reshaping Health Care," Health Affairs, 28 (2), 361-68. Holland, Jonna and Stacey Menzel Baker (2001), "Customer Participation in Creating Site Brand Loyalty," Journal of Interactive Marketing, 15 (4), 34-57. Holsti, Ole R. (1969), Content Analysis for the Social Sciences and Humanities. Reading, MA: Addison-Wesley. Kalichman, Seth C., Lance Weinhardt, Eric Benotsch, Kari DiFonzo, Webster Luke, and James Austin (2002), "Internet Access and Internet Use for Health Information Among People Living with HIV/AIDS," Patient Education and Counseling, 46 (2), 109-16. Kamel Boulos, Maged N. and Steve Wheeler (2007), "The Emerging Web 2.0 Social Software: An Enabling Suite of Sociable Technologies in Health and Health Care Education," Health Information & Libraries Journal, 24 (1), 2-23. Kaplan, Andreas M. and Michael Haenlein (2010), "Users of the World, Unite! The Challenges and Opportunities of Social Media," Business Horizons, 53 (1), 59-68. Mayfield, A. (2008), "What Is Social Media?" Networks, V1.4 UPDAT, 36. iCrossing, http://www.icrossing.co.uk/fileadmin /uploads/eBooks/What_is_Social_Media_iCrossing_ebook.pdf .

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Suggs, L. Suzanne (2006), "A 10-Year Retrospective of Research in New Technologies for Health Communication," Journal of Health Communication, 11 (1), 61-74. Terry, Ken (2011), "Heal Themselves via Facebook, Twitter," fiercehealthit.com (accessed April 6, 2011). http://www.

---, Emily Burnett, Anna Lamm, and Jessica Lucas (2009), "Engaging Stakeholders Through Social Networking: How Nonprofit Organizations are Using Facebook," Public Relations Review, 35 (2), 102-106. Wimmer, Roger D. and Joseph R. Dominick (2006), Mass Media Research: An Introduction, 8th ed. Belmont, CA: Thomson Wadsworth. Zarrella, Dan (2009), The Social Media Marketing Book. Sebastopol, CA: O'Reilly Media, Inc. ABOUT THE AUTHORS Hyojung Park is a doctoral candidate in journalism at the University of Missouri. Her research interests include relationship management in public relations, crisis communication, health communication, and social media marketing. E-mail: hpqk3@mail.missouri.edu Shelly Rodgers is Associate Professor of Strategic Communication at the University of Missouri School of Journalism. Her research is funded by more than $7 million in grants and focuses on advertising, health communication, and new technology. E-mail: srodgers@missouri.edu Jon Stemmle is the associate director of the Health Communication Research Center at the University of Missouri School of Journalism. He spent the past 15 years in public relations and strategic health communication. His specialties include tailored health communication, social marketing practices, and community-based health interventions. E-mail: stemmlej@missouri.edu

Thackeray, Rosemary and Brad L. Neiger (2009), "A Multidirectional Communication Model: Implications for Social Marketing Practice," Health Promotion Practice, 10 (2), 171-75. ---, ---, Carl L. Hanson, and James F. McKenzie (2008), "Enhancing Promotional Strategies Within Social Marketing Programs: Use of Web 2.0 Social Media," Health Promotion Practice, 9 (4), 338-43. Thorbjrnsen, Helge, Magne Supphellen, Herbjrn Nysveen, and Per Egil Pedersen (2002), "Building Brand Relationships Online: A Comparison of Two Interactive Applications," Journal of Interactive Marketing, 16 (3), 17-34. Toma, Catalina L., Jeffrey T. Hancock, and Nicole B. Ellison (2008), "Separating Fact from Fiction: An Examination of Deceptive Self-Presentation in Online Dating Profiles," Personality and Social Psychology Bulletin, 34 (8), 1023-36. Trusov, Michael, Randolph E. Bucklin, and Koen Pauwels (2009), "Effects of Word-of-Mouth Versus Traditional Marketing: Findings from an Internet Social Networking Site," Journal of Marketing, 73 (5), 90-102. Tuten, Tracy L. (2008), Advertising 2.0: Social Media Marketing in a Web 2.0 World. Westport, CT: Greenwood. U.S. Department of Health and Human Services (2009), Health Resources and Services Administration, http://www.hrsa.gov/healthliteracy/ (accessed September 26, 2009). Utz, Sonja (2010), "The (Potential) Benefits of Campaigning via Social Network Sites," Journal of Computer-Mediated Communication, 14 (2), 221-43. Wang, Shaojung Sharon, Shin-Il Moon, Kyounghee Hazel Kwon, Carolyn A. Evans, and Michael A. Stefanone (2010), "Face Off: Implications of Visual Cues on Initiating Friendship on Facebook," Computers in Human Behavior, 26 (2), 226-34. Waters, Richard D. (2007), "Nonprofit Organizations Use of the Internet: A Content Analysis of Communication Trends on the Internet Sites of the Organizations on the Philanthropy 400," Nonprofit Management & Leadership, 18 (1), 59-76.

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APPENDIX. List of Organizations (a) Government centers or agencies National Network of Libraries of medicine

Journal of Participatory Medicine Kansas City Nursing News Literacy Assistance Center Literacy Volunteers of New Jersey Minnesota Health Literacy Partnership Missouri Foundation for Health San Diego County Taxpayers Association Wisconsin Literacy World Education Yellin Center

(b) Health care institutions St. Mary's Hospital

(c) Schools or universities Health Sciences Libraries, University of Michigan Spencer S. Eccles Health Sciences Library, University of Utah Tufts-Emerson Health Communication University of Wisconsin Department of Family Medicine

(d) Business/corporations/pharmaceutical companies Compass Healthcare Communications H is for Hope Books Health Literacy Innovations Minority Nurse Magazine MS&L Worldwide No Time to Teach PharmaLive

(e) Community/advocacy/nonprofit groups American College of Physicians Foundation Cover Missouri D.C. Learns Make Health Care Right e-Patient Connections Global Health Corps Health Literacy Awareness Health Literacy for All Health Literacy Missouri Health Literacy Month Health Literacy Out Loud Health Technica

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