Social Media For Youth Substance Use & Health Promotion by Cense

2012

SOCIAL MEDIA FOR HEALTH PROMOTION WITH YOUTH AND YOUNG ADULT SUBSTANCE USE A resource and evidence review Prepared by Cameron D. Norman CENSE Research + Design

SOCIAL MEDIA FOR HEALTH PROMOTION WITH YOUTH AND YOUNG ADULT SUBSTANCE USE A Resource and Evidence Review April 25, 2012 Prepared by: Cameron D. Norman PhD, Principal CENSE Research + Design Toronto, ON Canada For Health Canada, Tobacco and Drugs Initiative

CENSE Research + Design

Acknowledgements The author wishes to acknowledge the contributions of Bruce Baskerville, Jack Boomer, Rebecca Haines-Saah, Tyler Janzen, Jessica Patterson, Lisa Campbell Salazar, Andrea Yip and a community of Twitter users and online contributors for providing expert opinion, key resource referrals, feedback and commentary on this topic in support of this reportâ&#x20AC;&#x2122;s development. Special thanks to The Public Health Studio for producing the graphical design elements for this report and formatting it for production. For more information about the contents of this report contact: Cameron Norman PhD Principal CENSE Research + Design info@cense.ca www.cense.ca Please cite as: Norman, C.D. (2012). Social Media for Health Promotion with Youth and Young Adult Substance Use: A Resource and Evidence Review. Report submitted to Health Canada (Tobacco and Drugs Initiative). Toronto, ON: CENSE Research + Design.

The views expressed herein do not necessarily represent the views of Health Canada.

TABLE OF CONTENTS

01 02 03 04 05

Executive Summary

Introduction

Context

Methods of Investigation

Review of the Scholarly Literature

06 07 08 09 10 11

Social Media Content Review

Practitioner Perspectives

Conclusions & Limitations

Recommendations

References

Appendix 1

EXECUTIVE SUMMARY Social media has changed the way that youth and young adults communicate

with themselves and the world, and has opened up significant new opportunities for health promotion on issues of substance use.

A multi-method review was undertaken to look at the application of social media to youth and young adult substance use with emphasis on Canadian examples. This included: 1) a search of applied health sciences databases; 2) a literature review; 3) a search of the open web and specific social media networks (e.g., Facebook, Twitter, and YouTube) for examples of social media interventions; and 4) informal interviews conducted with practitioners and researchers working in the field of social media and youth substance use to gain insight into issues not captured elsewhere. The review of the scholarly literature found few examples to illustrate effective interventions using social media and offered little guidance on appropriate evaluation methods. Text messaging was the only intervention format that had enough evidence to assess effectiveness, showing modest impact on tobacco and alcohol use. Examination of examples of social media applications to youth and young adult substance use found a broad field with varying levels of informational depth, opportunities for youth engagement, and quality. The design features of these resources was also varied as some were visibly part of a larger integrated strategy, while others were single pages or videos with limited to no connection to other resources or even the organization or program responsible. Practice and research experts were consulted to provide additional contextual information about the challenges, opportunities and lessons learned from using social media for youth substance use prevention and treatment. Experts emphasized the need to engage youth early on in the design process and keep them engaged in the deployment of the social media strategy, to pay attention to equity issues and recognize the glocalized and mobile nature of social media. Recommendations include: 1) support health professionals in developing a social media strategy for substance use issues using a â&#x20AC;&#x2DC;youth firstâ&#x20AC;&#x2122; approach that emphasizes health equity, person-centred design methodologies and systems thinking, 2) creating a culture of innovation supported by appropriate research methods, and 3) consideration of global and local networks in developing and evaluating interventions. Social media presents a new opportunities and challenges for health promotion including a shift in mindset and model for engagement. Systems and design thinking can facilitate this shift and when used with developmental evaluation methods can produce innovative and responsive ways to address substance use with young people.

INTRODUCTION How is social media

reducing the health burdens created by substance use among youth and young adults?

What are the most

effective ways to engage youth and young adults in health promotion using social media?

What are the most

appropriate social media tools to effectively reduce unhealthy use of drugs, tobacco and alcohol with youth and young adults?

The answer to these questions is the same: We donâ&#x20AC;&#x2122;t know. Facebook. Twitter. YouTube. These are the tools of youth and young adults and represent examples of their most power vehicle for information gathering and social engagement: social media.

Social media is an emergent set of tools and technologies that have transformed the way that people interact with each other through the Internet, enabling active conversation about topics rather than serving as simply another means of broadcasting. It facilitates real-time interactions between people from diverse contexts to connect around common issues and develop novel solutions to problems. This peer-to-peer model of communication is deeply personal and familiar while contributing to a global agora of dialogue and health knowledge. Through social media anyone with Internet access can create, distribute and re-mix content for the same audience as anyone else. For youth and young adults seeking health information, treatment choices, or social support about substance use, social media offers a panoply of options of which few are evidence-based or delivered as part of professional public health services. It is that professional-focused part of the spectrum that this report seeks to illuminate by reviewing the current state of evidence, provide examples of current practice, and suggest possible options for future work. Social media levels the playing field in a game that is open to everyone and is still defining its rules. As this report will illustrate, these new rules are posing challenges for the way that evidence is generated, interventions delivered, and communication strategies implemented. What this means for the prevention and treatment of substance use for youth and young adults is unclear. However, by looking closely at what is being currently in practice, health practitioners can better shape a future that best uses the opportunities that social media creates to address substance use issues with youth and young adults in ways never before possible.

CONTEXT Substance use among youth and young adults remains widespread and continues to challenge public health. Although behaviours such as cigarette smoking have shown signs of decrease in recent years, the rates of use among young people are still higher than any non-clinical population (Health Canada, 2010). Alcohol and drug use among students remains a public health concern as substance use behaviours affect young peopleâ&#x20AC;&#x2122;s current wellbeing and can be precursors to serious health problems later in life (Young et al., 2011). The legal and potential social implications of substance use with youth has often been concealed from the eyes of adults, making it a challenge for public health to deal with directly. It is for this reason that Internet-enabled interventions for health promotion have found purchase among public health professionals as a means of addressing substance use in a manner that is responsive to the needs of youth, protective of their privacy, and attractive at the same time (Norman, Maley, Li, & Skinner, 2008; Norman & Skinner, 2007). Social media represents an evolutionary step towards providing interventions at a distance for youth that requires not only new networked tools, but new ways of thinking about how youth engage with those tools (Norman & Yip, 2011). This report outlines the current state of evidence to support the use of social media for substance use prevention and treatment with youth and young adults, reviews examples of social media applications currently in use, and provides insight from researchers and practitioners engaged in social media use with this population. Included in this report is a review of social media, web applications, and websites in youth health promotion, prevention, and cessation/treatment interventions with a focus on substance use; a scan of the recent literature (past 5 years) related to evaluating social media initiatives that show health impact/ cost-effectiveness; a profile of some of the current Canadian substance use-focused initiatives that use social media; and an identification of specific challenges and recommendations based on demonstrated effective approaches associated with the evaluation of eHealth promotion, prevention and treatment initiatives. For this report websites promoting a product or providing static information content were not considered unless the users of the site also produce and share content (with some exceptions to illustrate current examples of traditional Internet media applications as a reference point). For the purposes of this review, tools like Facebook, Twitter, and YouTube will be the principal technologies of interest as they are the most widely used and popular social media platforms in Canada.

3.1 Defining Social Media

The term Web 2.0 (http://en.wikipedia.org/wiki/Web_2.0), describes a set of tools and technologies that reflect the terms illustrated in Figure 1. These terms reflect an active, interactive, and dynamic set of conditions that shape the way content is generated, distributed, and redesigned.

04 Figure 1: Web 2.0 Word Map

Source: http://en.wikipedia.org/wiki/File:Web_2.0_Map.svg

Social media falls within this realm of Web 2.0. For this review, social media is defined as any networked tool or information technology that derives its principal value from user-generated content and engagement. Social media represents a significant shift in the social and physical locations for interventions. Youth seek engagement, dialogue, participation, immediacy and operate with a temporal flexibility to their lives that is distinctive from older generations where messaging to people was acceptable and messaging with them was rare. The peer-to-peer, many-to-many form of communication used in social media places those using the technologies on a similar footing with each other, which is different from traditional forms of communication where the message was generated and transmitted solely by one party. This shift in power requires different styles of communication. From Facebook Pages to Tweet-ups to video broadcasts and interactive websites, social media provides youth with ways to connect with public health professionals and each other immediately and wherever they are when combined with mobile handsets or tablets. The mobility of social media provides opportunities for engagement with youth anywhere they are and anytime they need services and support.

3.2 Social Media and Youth

Youth and young adults are using social media more than ever before. Although there is limited Canadian data, research from United States suggest that over 70 per cent of youth and young adults are active on social network sites and engage with them on a daily or weekly basis (Lenhart, Purcell, Smith, & Zickuhr, 2010). Tools such as Facebook, Twitter and YouTube are everyday parts of the lives of youth and young adults and serve as a source both healthy and unhealthy substance use information and resources (International Narcotics Control Board, 2012; Reifman, 2009; Seidenberg, Rodgers, Rees, & Connolly, 2011).

05 This shift in the way that users interact with this new class of technologies has had fundamental implications for the range and scope of opportunities for young people to create, share and engage content on health topics. No longer is content creation restricted to those with the resources to develop a website or relegated to a comment section of a web page, now young people can generate content from scratch and distribute it to their peers without having knowledge of computer programming. For health professionals, this is a shift from broadcasting information from a place of authority to co-creating knowledge and forming conversations around health topics. It is as much about a mind-shift as it is a change in technology or media.

3.3 Terms

Youth is categorized as a person between the ages of 12 and 24 years, following the World Health Organizationâ&#x20AC;&#x2122;s operating definition (WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health, 1999). A young adult is defined as a person who is between the ages of 18 and 29 years drawing partly on the debate in the academic literature on age classification in adolescent and youth health (Geiger & Castellino, 2011). This shift translates into having professionals talk to youth to talking with youth and doing it in real-time, potentially at any time and, with mobile devices, any location, has implications for the way that health promoters design and think about their interventions.

â&#x20AC;&#x153;Social media is defined as any networked tool or information technology that derives its principal value from user-generated content and engagement.â&#x20AC;?

For the purposes of this review, substance use was considered within the broadly defined areas of tobacco, alcohol, and drugs and referring to a psychoactive or performance-enhancing compound for a non-therapeutic or non-medicinal effect. Social media is defined as any electronic, networked resource that derives its principal value from user participation. Thus, stand-alone websites without an explicit social component were reviewed as separate entities or not included.

Although social media encompasses a variety of different tools and technologies, for the purposes of this project emphasis will be placed on three specific technologies: Facebook (http://www.facebook.com), YouTube (http://www.youtube.com) and Twitter (http://twitter.com). Social media websites and tools represent more than half of the top ten most visited websites in Canada according to site ranking company Alexa.com (http://www.alexa.com/topsites/countries/CA, search March 16, 2012). Within the top ten, Facebook is the #3 website in Canada, Youtube is #4 and Twitter is #8. Wikipedia (#7), LinkedIn (#9), and Blogspot (#10) were excluded as potential sources because of a lack of deep interactivity (Wikipedia and Blogspot) and a focus on solely professional networking (LinkedIn). The term intervention will be used in the context of this report to describe any social media resource that is focused toward youth that serves a public health interest. Any feed, page, or content source will be considered part of an intervention if it falls within this set of bounds.

METHODS OF

INVESTIGATION This four-pronged review was executed using multiple, overlapping strategies in a phased approach:

A search of the scholarly literature was performed using multiple methods. An initial search of academic applied health sciences databases was performed using the Scholars Portal / Web of Science databases, which capture research from medical, allied health, behavioural science, education, and social science literature. These are the fields where literature on social media, substance use is likely to reside. Keywords derived from the current U.S. National Library of Medicine index of terms coupled with those found in known articles in this area of work. The scholarly search strategy is listed in Appendix 1. A modified version of the search was performed using Google Scholar and through a general Google web search. Peer-reviewed, edited and grey literature resources were all considered. Referrals from health practitioners, review of reference lists were also considered. Virtual â&#x20AC;&#x2DC;hand searchesâ&#x20AC;&#x2122; of the Cochrane and Campbell Collaboration databases and the leading journal specializing in social media and eHealth: Journal of Medical Internet Research (JMIR). Database searches were restricted to the years 2005 - 2012.

2 3

The literature was reviewed for content appropriateness, descriptive completeness (i.e., the intervention was described in sufficient depth), audience, health topic(s) covered, evaluations (if information is present or known), selected features, and overall medium of engagement. Particular attention was paid to the methods of evaluation and assessment of behaviour change or preventive actions taken. A similar search strategy was undertaken of the open web using Google to search for existing examples of social media interventions including references drawn from the scholarly and grey literature. Interventions were identified through the search, through referrals from practitioners and researchers working in public health and health promotion, links provided from found resources and from the snowball strategy performed of those links and referring pages. Resources were reviewed based on relevance, appropriateness, country or province of origin (with emphasis on Canadian examples when possible), scope of service, health topic, and medium of engagement. The breadth, depth and poor indexing of social media in major search tools, has limited what resources could be reviewed. Resource quality was considered by looking at issues of eHealth literacy and related eHealth promotion recommended practices (Norman, 2011; Norman & Skinner, 2006). Resources were compiled and reviewed for commonalities, exceptions and notable features. Emphasis was placed on noting qualities and limitations that could be used to form the basis for actionable recommendations to health promotion professionals and the public health and health sciences research community.

Informal interviews were conducted with practitioners and researchers working in the field of social media and youth substance use. The aim of these interviews was to gain insight into details of service delivery, recruitment, data collection, perceived intervention effectiveness and general operational issues that were not captured in the literature or service profiles. Professionals were identified based on their relationship with existing funded social media and health projects and through referrals from known professionals working in this area. Due to the contextual nature of the funding and service delivery demands for these services, interviews were limited to Canadian-based professionals and youth. Conversations with service providers working in public health developing or delivering social media applications for health promotion were also used to supplement this data to provide contextual practice information.

REVIEW OF THE SCHOLARLY

LITERATURE

What does the scholarly literature say about the effect of social media on youth and young adult substance use?

Both academic (published) and relevant grey literature databases were searched for examples of social media evaluations using keywords drawn from the NLM database, reviews of known published literature, and the incorporation of colloquial terms used in social media (e.g., tweets) (see Appendix 1 for the search strategy). Execution of the search strategy found little evidence for the application of social media to any of the three topic areas: tobacco, drugs or alcohol. The sole exception was limited to a single medium and two issues: text messaging for tobacco or alcohol use. Although multiple articles discussed the challenges and opportunities associated with social media and young people (e.g., Elkin, Thomson, & Wilson, 2010), few explicit intervention evaluations were published in either the grey or peer-reviewed academic literature.

5.1 Seach Results

Of the articles found, only three explicitly used the term â&#x20AC;&#x153;social mediaâ&#x20AC;? (Anderson & Speed, 2010; Seidenberg et al., 2011; Thomson & Wilson, 2012) and just one had an explicit focus on youth-oriented interventions (Seidenberg et al., 2011). The term social Internet was used in one article (Pujazon-Zazik & Park, 2010). Explicit referral to a specific platform or technology was also rare, with one study citing Facebook (Mart, Mergendoller, & Simon, 2009), one (indirectly) focused on Twitter (Pujazon-Zazik & Park, 2010), and four youthoriented studies that identified YouTube as a focus (Backinger et al., 2011; Elkin et al., 2010; Freeman & Chapman, 2007b; Kim, Paek, & Lynn, 2010) in the title or abstract. Text messaging was the most clearly identified form of social media intervention with five cited studies or reviews that were relevant to youth substance use (Free et al., 2009; Suffoletto, Callaway, Kristan, Kraemer, & Clark, 2012; Thurlow & McKay, 2003; Whittaker et al., 2009; Whittaker, Maddison, McRobbie, & Bullen, 2008). Upon executing the review, the principal challenge was determining whether an intervention was indeed a social media intervention or something else from the descriptions provided in the abstract and article. Many interventions that used highly interactive components appeared in the search (e.g., Norman et al., 2008), but were not examples of social media. Absence of detail about interventions is common in the academic eHealth literature, which typically favours research description over intervention description or related theoretical components powering them (Webb, Joseph, Yardley, & Michie, 2010). For example, a 2010 systematic review of online alcohol interventions, of which most were focused on youth or young adults, did not feature a single social mediabased intervention (White et al., 2010) even though the article came up in the search of the literature.

09 The only formal literature review of social media applications for public health (broadly) located was conducted by Schein et al. in 2010 as a non-published white paper prepared for the Peel Public Health Unit in Ontario (Schein, Wilson, & Keelan, 2010). This review included academic content such as conference papers and peerreviewed journal articles and grey literature reports focused on any aspect of public health practice, including commentaries on feasibility and implementation of social media as interventions. Despite broadly defined inclusion criteria, not a single youth-focused intervention study looking at substance use was located and included in the Schein, Wilson and Keelan (2010) review. Analyses of social marketing approaches to tobacco promotion through social media were the only topical areas that looked at substance use and young people (Freeman & Chapman, 2007, 2008, 2010). A second review of ‘social internet’ applications was published in 2010 and focused on potential health outcomes and gender differences (Pujazon-Zazik & Park, 2010), however the breadth of scope of the literature and its different health and non-health-related studies yielded no transferrable insights on effectiveness or efficacy for this review on substance use and youth. The only area where there was reasonable evidence of efficacy was on the use of text messaging for support of tobacco use cessation and alcohol.

5.2 Text Messaging

Text messaging was the only social media technology that did have some explicit evidence behind it, that included peer-reviewed studies (Free et al., 2009; Riley, Obermayer, & Jersino, 2008; Rodgers et al., 2005; Suffoletto et al., 2012; Whittaker et al., 2008), a cross-disciplinary review of text messaging and youth (Porath, 2011) and a systematic review focused on tobacco use cessation for population health in general (Whittaker et al., 2009). However, within even the published systematic review only one relevant article that had an explicit intervention focus was found (Whittaker et al., 2008). A recently published study of text messaging demonstrated potential impact using a brief intervention added to a hospital discharge with young adults admitted for heavy drinking-related problems (Suffoletto et al., 2012). The study found that the text-message intervention helped assess problem drinking levels in young adults exposed to the intervention, helped them set goals for alcohol reduction, and led to fewer heavy drinking days compared to a group that did not receive the intervention. The systematic review on tobacco-related interventions with text-messaging found four trials that all yielded significant positive changes in smoking behaviour attributed to the intervention (Whittaker et al., 2009). Both short and long-term outcomes were positively affected, however the heterogeneity in long-term outcomes limits what can be expected of such interventions. One of the principal challenges with this review – and that of other eHealth interventions overall – is the thin description of the interventions themselves reported in the academic papers. Interventions relied on automated text message systems that delivered personalized messages developed from databases. Two trials (Rodgers, 2005 and Free, 2009) involved daily delivery of 5-6 messages up to a planned quit day followed by a single message every two weeks. Suffaletto and colleagues studied 45 young adults (aged 18-24 year) who were screened as hazardous drinkers after presenting to one of three emergency departments (Suffaletto et al., 2012). Participants were randomly assigned to receive weekly text message (TM) based feedback with goal setting, weekly TM-based assessments without feedback, or a control for a period of three months. Measurements were taken at baseline and three months post-intervention. The results showed that those with the text-message based interventions – with or without a goal – led to fewer heavy drinking days post-admission to the emergency room than the control group. The relatively small sample size limits the generalizations that can be made from this review, however it does demonstrate the feasibility and potential efficacy of text messaging for alcohol use. Both the authors and others suggest that more robust randomized trials are needed.

10 Text messaging is a form of social media, however its absence of wider-scale participation opportunities relative to other social media forms and the inability to adequately share content from text messages to others with ease limits the lessons learned from it relative to tools such as Facebook, Twitter or YouTube. These other social media forms also have features that enable them to easily link to other resources (e.g., webpages, other social media) and embed rich media such as video, text and audio in a manner that text messaging largely is unable to do well. These differences make some of the lessons from text messaging more challenging to transmit to other social media forms. Another missing component of the data was research on mobile applications beyond text-messaging such as smart phone applications or apps.

5.3 Concluding Message

The concluding message from the review of the literature is that there is not enough research to provide sufficient information to serve as evidence to support (or challenge) social media use for youth substance use beyond text messaging. With the exception of text messaging, which has shown some promise as a means of supporting substance use reduction, no body of work has provided evidence to support or reasonably challenge the use of social media as a resource for substance use prevention and cessation. The absence of sufficient research has further limited the ability to identify suitable evaluation challenges arising from social media and substance use work with youth and young adults emerging from the literature. No cost-effectiveness data was presented or found in any of the reviews or original articles.

â&#x20AC;&#x153;The concluding message from the review of the literature is that there is not enough research to provide sufficient information to serve as evidence to support (or challenge) social media use for youth substance use beyond text messaging.â&#x20AC;?

SOCIAL MEDIA

CONTENT REVIEW

What does the youth and young-adult focused social media landscape for

substance use intervention look like?

An online search of social media applications used to support substance use prevention, cessation and change was undertaken using the Google search engine, referrals from health professionals, and linked references obtained from resources located during the review. Additional searches within each social media environment were undertaken to locate appropriate resources. Social media exists in a largely dynamic and decentralized environment in the manner by which tools are indexed. This limits the reach and scope of search engines such as Google and Bing to in locating and cataloguing social media resources. The practical limitations imposed by the way social media resources are indexed, generated and distributed prevented an exhaustive review of the field. Further, initial searches revealed an incomplete, inconsistent and fragmented collection of resources that challenged efforts to conduct systematic, yet practical comparisons. Working with these limitations, a corpus of resources was located using the strategy above, selected and reviewed to provide an illustrative example of social media interventions presently available. The choice to profile different social media interventions was framed based on the various types of content and forms reviewed. For example, some Facebook pages or YouTube sites had no ability to facilitate comments or sharing, which limited their potential to engage their audience. In certain cases, the Facebook page was used as a portal for other Internet sites connected to the program or campaign, while in others a Facebook wall was used more like a bulletin board. A profile the resources reviewed is in Table 1. The table includes Canadian examples except for particularly notable non-Canadian examples. Reviewing these resources finds a broad diversity in the manner by which public health and health promotion services seek to engage youth and young adults and little consistency in the manner by which information is presented. This diversity reflects varying levels of engagement and content types. Facebook was the most popular vehicle for health promotion among the various social media types reviewed. Twitter was the next most popular tool (by number of resources), with YouTube being the third most popular social media tool.

6.1 Profiling Social Media Interventions

One of the primary challenges with reviewing social media applications is the lack of consistent standards across the interventions for identification and contact. Best practices for determining eHealth ownership and markers for quality content (c.f., Charnock & Shepperd, 2004) were not typically followed. Although every social media resource has some marker that indicates when content was posted, the date of content creation date is not always clear given that material can be remixed multiple times. Another feature absent from nearly every single resource reviewed was some form of identifiable contact consistent with better practice guidelines. To illustrate, What’s With Weed (http;//www.whatswithweed.ca) had no identifiers listed, only a reference to a funding sponsor. The only descriptor with contact information provided was: “WhatsWithWeed.ca is a Canadian educational resource developed with young people in Ontario who are both marijuana users and non-users, in partnership with drug education specialists, drug treatment counsellors and researchers with funding from Health Canada. It is not meant to replace advice from a health care professional. Comments or questions can be sent to info@whatswithweed.ca” No names, organizational affiliations or alternative contact points are listed on the website. This pattern was common among the resources reviewed. Of the different media forms, websites were the most likely to provide some form of contact information other than something self-referential (e.g., Facebook page referring to a Facebook page for contact information). More than half of the Facebook resources included in this review were devoid of contact information. One of the best positive examples was the Drugs Not 4 Me page (http://www.facebook.com/drugsnot4me) that offered multiple forms of contact for visitors to the page. A more typical example was Live, Play, Be Tobacco Free, that has a hard to navigate collection of information about sponsorship and contact information, due in part to way in which Facebook pages are designed, and partly due to a reliance on a secondary resource (a web page) as the primary means of conveying information about the resource. The page features an About section that has no discernible contact information, with a website link available on the Info tab. A sample of Twitter profiles are listed drawing on examples from the review that use multiple platforms to provide a base for comparison across social media platforms. Thus, stand-alone Twitter accounts were not included.

6.2 Population of Focus

The population of interest was not evident in many social media interventions. While some were identified by their name (e.g., YATI, Youth Voices Research Group), others did not have an explicit statement of focus on youth even if there were identifiable youth resources (e.g., Quit Exchange).

6.3 Budget

Although the cost of social media platforms are (mostly) free. In discussion with public health and health promotion professionals doing social media work, much of the costs are unknown, particularly because social media is often seen as an ‘add-on’ to complement other forms of health communications. Tools like Facebook, Twitter, and YouTube are all free to use with costs resting on the content development, distribution and time spent monitoring these sites.

13 For the development, deployment and sustainability of a social media platform based around a mobile applications, costs can be far higher. For example, the Crush the Crave Android app and related campaign (University of Waterloo/Canadian Cancer Society) was developed from a budget of close to $300,000. The project, funded by Health Canada, included costs for professional developers, graphic designers, marketing leaders, evaluation and research expertise and data from the Propel Centre for Population Health, and soliciting feedback from young adults. Another example of social media use in youth substance use for tobacco control was the Access Project by The Youth Voices Research Group at the University of Toronto. This short-term research project used participatory video development and blogging to support youth discussions of tobacco treatment access and contraband cigarettes. The project, which was funded by the Ontario Ministry of Health Promotion, ran for three months and estimates for the social media portion of the project suggest it would cost $65,000 to operate at the same level year round. This is based on having one staff member working at .6 full-time equivalent and costs for local youth engagement activities and materials development. The Youth Voices Research Group has conducted multiple health promotion projects using social media, including one that had a comprehensive strategy involving Facebook, Twitter, Flickr, YouTube, a website and blogs focused on youth health navigation run in 2010. Estimates from that project suggest that a fully-implemented, multi-method social media strategy would cost $95,000 to create from scratch to run for a year with a full-time social media staff person assigned to administer the strategy and work with youth and young adults to produce and distribute content. The Youth Voices Research Groupsâ&#x20AC;&#x2122; Youth4Health project model represents the largest known application of social media to youth health promotion.

http://www.facebook.com/ drugsnot4me

http://www.facebook.com/ OntarioLungAssociation

http://www.facebook.com/ InTheNicotime

http://www.facebook.com/ hookedbyhollywood

http://www.facebook. com/pages/Be-Your-BestSelf/213777151982426

http://www.facebook.com/ pages/Quit-Exchange/3 07157932632220chan ge/307157932632220

http://www.facebook.com/ LeaveThePackBehind

Ontario Lung Association

In the Nic-o-time

Hooked by Hollywood

Be Your Best Self

Quit Exchange

Leave the Pack Behind

Resource Locator

Not4Me

FACEBOOK PAGES

Resource Name

Table 1: Resource review

Tobacco use cessation

Health Promotion

Tobacco use advocacy

Tobacco use cessation

Drug use

Focus

Many user updates on the website filled with tips for quitting and other self-help resources. Some debate on the merits of different methods (e.g., Champix vs. mind-over-matter) Post-your-tip contest was run in March. 482 likes.

No clear sense of what the website is about, where it is based and what kind of outcomes it seeks.

Information on a variety of topics and posts using different media forms such as YouTube videos, news articles, and general interest wellness resources. Most post likes are from Be Your Best Self. The page has 192 likes.

1845 likes. Opens like a website with content focusing on new movies (constantly updated every Thursday) that illustrate warnings based on tobacco use in file.

Regular updates, including links to others site on other issues facing youth such as the Pink Shirt Day 2012 campaign.

Custom page with videos embedded in the site, looks like it was designed to serve as a conduit to other web resources, not as a forum for discussion. No threads or posts visible on front page. Embedded link to Twitter feed 2963 likes

Regular updates, links to other websites and YouTube videos. Nearly all self-referencing materials. Some critical discussion on the site, a lot of supportive comments. 62518 likes

Description

http://www.facebook.com/ maddcanada.ca

MADD Canada

6198 likes. Regular updates and news stories from diverse media sources on the problems associated with drinking and driving. Some post likes and a few comments. Little direct-to-youth engagement visible.

780 likes. Consistent, regular posts and updates with links to external sites from around the world. Many of the updates are focused on news articles on the science of cancers

56870 likes. Highly active page with links to videos, magazine articles, user comments and diversity of participants on the website

Links to advocacy resources worldwide with most posts showing some “likes”, yet relatively few comments, some debate. 1533 likes

Many updates and links to different tobacco use related resources for health promotion. Comments are varied in focus and depth from supportive quit messages through to cross-promotions from partner organizations. QU team responds to comments and engages audience. 1050 likes

Description

http://www.facebook.com/ Tobacco use cessation exposeottawa

Expose’

Tobacco use cessation

http://www.facebook.com/ QuitNowBC

Quit Now BC

285 likes. Posts in French and English. Serious news stories mixed with some humourous youth-oriented media shares (e.g., link to GlobalTV episode of American Dad that features ‘big tobacco’ angle)

Major focus is on the quit now contest, virtually no conversation on the site, rather visitors are encouraged to visit QuitNow website. 2269 likes.

Picture Me Smoke http://www.facebook.com/ Tobacco use prevention Little content on the Facebook page, although a well-designed landing. 306 Free Project (Van- PictureMeSmokefreeProject likes. Most information is delivered to users using the feed generated from couver, BC) Likes.

Alcohol awareness

Cancer awareness

http://www.facebook.com/ controlcancer

Campaign to Control Cancer (Toronto, ON / Canada)

Drug use - harm reduction Cancer awareness

http://www.facebook.com/ YouthRISE

YouthRISE

Tobacco use cessation

Focus

Fuck Cancer (Van- http://www.facebook.com/ couver, BC) letsfcancer

http://www.facebook.com/ QuittersUnite

Resource Locator

Quitters Unite

FACEBOOK PAGES

Resource Name

Table 1: Resource review, Continued

http://www.facebook.com/ YATIYouthAdvocacy

http://www.facebook.com/ CrushTheCrave

http://www.facebook.com/ drugsnot4me

YATI

Crush the Crave

Drugs Not 4 Me

http://www.youtube.com/ watch?v=Ho6iDSaq-CQ

http://www.youtube.com/ user/SSDP?ob=0&feature =results_main

http://www.youtube.com/ Tobacco use cessation watch?v=cfHdwSKrL3g& feature=youtu.be

Leave The Pack Behind

Students for Sensible Drug Policy

Nic O Time Challenge 2012

Drug use

Tobacco use cessation

http://www.youtube.com/ user/healthcanada

Drug use

Drug use prevention

Tobacco use cessation

Tobacco use cessation & prevention

Substance use

Focus

Health Canada

YOU TUBE

http://www.facebook.com/ CCSAcommunications

Resource Locator

Canadian Centre on Substance Abuse (Ottawa)

FACEBOOK PAGES

Resource Name

Table 1: Resource review, Continued

Channel was developed and produced by Rocketship Productions, which does interactive marketing on different topics. Multiple videos were produced for this campaign with more than 1100 views for the most popular videos.

This video is not part of a channel, but rather a single post from a single user. This user (nikionthego) who has 6 uploaded videos on completely different topics. An example of a U.S.-based organization using YouTube. The channel has 201 videos and more than 1.3 Million views. Videos focus mostly on public events and speeches by drug policy leaders with some advertisements and humourous clips included.

Health Canadaâ&#x20AC;&#x2122;s YouTube Channel features videos on a variety of health topics including many of the top videos found in a YouTube search of youth, drugs, alcohol and tobacco. The channel has 834 subscribers and 480,881 views.

A Health Canada-sponsored information site on drug-related harms and risks.

To-be-launched mobile app for smoking cessation. Already has 2380 likes. Many photos and comments on the posts from a diverse group of page followers.

362 friends (organization page), no other content.

Not updated regularly. One post in 2012 with little detail. Largely used for promotion of events. 78 likes.

Description

http://www.youtube.com/ user/PreventionInstitute1

http://www.youtube.com/ user/playlivebe

http://www.youtube.com/ user/maddcanada

http://www.youtube.com/ user/PortageCanada

http://www.youtube.com/ user/NAHOnews

http://www.youtube.com/ user/YouthVoicesResearch

http://www.smokingzine. org

Play Live Be Tobacco Free

MADD Canada

Portage Canada

National Aboriginal Health Organization

Youth Voices Research Group

WEBSITES The Smoking Zine

Resource Locator

Saskatchewan Prevention Institute

YOU TUBE

Resource Name

Table 1: Resource review, Continued

NAHO has videos on a variety of health topics that include youth and young adult substance use issues. Emphasis on aboriginal-focused treatment and prevention messages is the focus.

Stories about addiction and treatment are shared in French and English in 17 videos that have more than 6500 views.

MADD has more than 85 videos from public service announcements to short films that feature messages warning of the negative consequences of drinking and driving in French and English.

A tobacco-free contest page featuring youth-created videos promoting a tobacco free lifestyle. The channel has 45 subscribers and 1552 video views.

Three videos are part of this channels (1390 views) that focus on the potential harms of alcohol. This is an example of a prevention-oriented application of using video to connect to an audience.

Description

Tobacco use cessation and prevention

A recently retired intervention that features customizable personal assessments, decision support tools, and interactive games to aid youth in smoking cessation or supporting preventive efforts. The Smoking Zine evaluated as part of a randomized controlled trial published in 2007.

Tobacco use advocacy, The former U of T research unit has a youth-developed series on access to awareness and cessation cigarettes and access to treatment as part of a wider set of videos designed for youth and youth-serving professionals. The channel has 29 videos and more than 27,500 views.

Alcohol, drug and tobacco awareness

Drugs and addiction

Alcohol awareness

Tobacco prevention

Alcohol awareness

Focus

http://www.naho.ca/firstnations/youth-substanceabuse/

http://youthrise.org/

http://www.tripproject.ca/ trip/

http://www.whatswithweed. Drug Use (Marijuana) ca/weed/ Prevention and Cessation

http://www.xperiment.ca/ index_en.html

http://www.hc-sc.gc.ca/ hc-ps/tobac-tabac/youthjeunes/life-vie/index-eng. php

http://www.nationalantidrugstrategy.gc.ca/prevention/youth-jeunes/index. html

NAHO Youth Substance Use Information Page

YouthRise

Trip Project

What’s With Weed

XPeriment.ca

Quit4Life

Health Canada National Drug Strategy / Drugs Not 4 Me

Drug Use prevention

Tobacco Use Cessation

Drug Use prevention and cessation

Drug use education

Drug use prevention and education

Youth substance use

Drug prevention

http://www.not4me.org/

Not4Me

Tobacco use cessation

Focus

http://www.quittersunite. com/

Resource Locator

Quitters Unite

WEBSITES

Resource Name

Table 1: Resource review, Continued

Health Canada’s youth-directed drug prevention resource focuses on the harmful effects of drug use by presenting information, testimonials, and multi-media tools to connect youth to prevention messages.

A multi-media interactive website that enables youth to explore the potential harms associated with drug use. Videos, interactive assessment tools and information on drug-related harms are featured. Quit4Life was once an interactive website for tobacco use cessation and is now a static resource featuring a downloadable handbook. Quit4Life has been extensively evaluated over many years since its inception in the early 2000’s.

A web resource focused on marijuana use including information, self-assessments, and links to other resources.

A Toronto-based youth-focused drug information and safe partying page and related network for youth to connect to each other around issues of safe drug use, treatment and prevention.

A harm-reduction focused website featuring news, briefing papers, and links to training resources.

This aboriginal-focused page includes static content on the risks and harms associated with substance abuse and provides links to other sites that can help a youth interested in further information about prevention and treatment options.

This intervention developed by Canadian Students for Sensible Drug Policy seeks to provide information on the health, social and legal risks associated with drug use through a harm reduction and prevention lens.

An interactive website that provides assessments and supports for young adults in quitting smoking. Links to contests and healthy lifestyle resources are provided along with a blog, discussion forum and social media feeds.

Description

Resource Locator

@hookedhollywood

@quittersunitebc

@youthrise

@letsfcancer

Hooked By Hollywood

Quitters Unite

YouthRISE

Fuck Cancer (Vancouver, BC)

Picture Me @smokefreepx Smoke Free Project (Vancouver, BC) YATI @youth_advocacy

@maddcanada

@crushthecrave

Crush the Crave

MADD Canada

@tripproject

Trip Project

TWITTER FEEDS (SAMPLE)

Resource Name

Table 1: Resource review, Continued

Regular posts, dissemination of information plus highly conversational with twitter users. 234 tweets, 264 following, 118 followers. Regular daily tweets on tobacco prevention news, youth advocacy stories, and health promotion information. 998 tweets, 1998 following, 859 followers

Tobacco use prevention & cessation

Provides regular reports of alcohol-related or suspected traffic accidents with some additional dissemination of resources; daily or multiple posts per day. 2533 tweets, 6 following, 1290 followers.

Announcements, tips and resource sharing as the focus. 3592 tweets, 1311 following, 14697 followers.

Regular daily updates. Focus on dissemination of resources, provocative stories, and conversation with followers. 1159 tweets, 506 following, 1292 followers

Consistent tweeting with dialogue with others. Uses questions to provoke responses and takes a tone of conversationalist, rather than broadcaster. 1296 tweets, 423 following, 338 followers

Resource dissemination, provocations for discussions on current movies, with lots of mentions of other Twitter users. 1672 tweets, 657 following, 487 followers

Resource dissemination for quit smoking including tips and news articles. 367 tweets, 177 following, 610 followers

Highly active posting focused on provoking questions, disseminating drug harm reduction information and sexual health resources. 3278 tweets, 1751 following, 1648 followers

Description

Tobacco use prevention

Alcohol awareness

Cancer awareness

Drug use - harm reduction

Tobacco use cessation

Tobacco use advocacy

Tobacco use cessation

Drug use & sexual health

Focus

PRACTITIONER

PERSPECTIVES

What do professionals working with youth and young adults think about

the opportunities and challenges that social media brings to substance use prevention, treatment and advocacy?

Considering the absence of solid evidence emerging from the literature or content review, expert opinion was sought from practitioners and researchers working with youth, young adults and social media on issues of substance use. This informal review was conducted to generate practice-based evidence to assist in guiding the overall recommendations for public health. As this review was designed to reflect the state of evidence and situate that in Canada, Canadian-based expert practitioners with experience in social media, substance and public health were sought to provide contextual knowledge of the challenges, opportunities, outcomes and processes associated with these forms of intervention. These conversations were intended to contextualize some of the findings and provide additional insight into social media and substance use practice. Reflections, resources and comments on the state of practice was obtained from two PhD-level principal investigators (researchers), two Masters level health promoters who have served as project managers on social media-related projects with youth, and a frontline community health project worker who has direct experience with youth substance use. In keeping with the focus on social media, advice from a global network of health promoters and youth working within this area was also sought and this report reflects those contributions. Commentary was provided through face-to-face or telephone conversations in March 2012 after the literature and content reviews were completed. The purpose of these discussions was to gain additional practice-based experience to provide context to the review given that no clear findings emerged. The author of this report also brings experience as a researcher and practitioner working with youth and eHealth for more than 15 years provided an additional set of insights to complement and compare with those from the others,

7.1 Text Messaging

Of the various areas of social media in use, only text-messaging has enough evidence to evaluate thoroughly. While text messaging has shown promise as a medium for reaching young people, its popularity was questioned given the emergence of new rapid-response methods of communication (e.g., Twitter). One expert pointed out that text messaging in North America didnâ&#x20AC;&#x2122;t take off until used as a voting method on popular teen-oriented talent shows, such as American Idol. Although universally available on any mobile phone, the proliferation of â&#x20AC;&#x2DC;smartâ&#x20AC;&#x2122; phone handsets such as the iPhone, Android and Blackberry now offers options that are typically included with a data plan. Shows like American Idol continue to use text messaging as a voting method while including alternative communication options such as Twitter (e.g., @americanidol) to support voting and fan engagement. Indeed, American Idol now issues a special Twitter account to all of its top finalists who are encouraged to engage with fans during the series. There was speculation that the popularity of text messaging might wane as data costs come down and the means to engage in rapid communication quickly expands. The investment in text messaging as a medium for future health promotion should be considered with caution given these changing trends.

7.2 Youth Engagement

A consistent observation among the expert group is that the world of youth and their social media landscape evolves quickly and that approaches to working with youth must keep pace in to order to maintain relevance. Public health and health promotion professionals need to keep current and prepare to adapt their strategy to these changes and experts mentioned the disconnection between adults and youth in the way that they approach social media. Youth are far more flexible and connected to the media and each other and use it in ways that are not consistent with the intervention approaches that many adult professionals envision. Multiple experts asserted that youth cultural norms clash with the expectations of organizations seeking to develop and deploy interventions aimed at youth that can be managed and controlled and feature messages that warn youth of the dangers of drugs, tobacco or alcohol. This thinking produces interventions that youth “laugh at” or ignore or attracts youth that are already adhering to the message of sobriety or abstinence. These adult-generated interventions also avoid topics like harm reduction that are often seen as more relevant to youth, particularly on issues of drug use. Adults are not always the best or appropriate people to be delivering interventions directed to youth through social media. Adult language, experience, and culture are not always conducive to the rhythms of social media. These barriers to communication limit the accessibility and reach of certain interventions to young people.

7.3 Accessibility and Reach “Adult language, experience, and culture are not always conducive to the rhythms of social media. These barriers to communication limit the accessibility and reach of certain interventions to young people.”

Experts spoke to the challenges in making social media interventions sustainable and attractive to low-income and socially disadvantaged young people as an important challenge for health promotion. One researcher commented on the missed opportunities for health promotion that emerge because many youth who could benefit from social media do not have the tools to take full advantage of it (e.g., reliable wi-fi, multi-purpose mobile handset, digital cameras). This exacerbates or creates health inequities.

Age and gender issues play a large role in shaping the expression of young people through social media interventions and it was repeatedly noted that youth and young adults should not be viewed as a homogenous group, but a multi-layered set of sub-populations. Experts pointed out distinct differences in preferences even among youth of similar ages and sex on issues of design, content, and medium for engagement. Thus, younger girls may like things that younger boys do not like, while these girls may also have quite different perspectives from ones just slightly older in age. This ‘thin-slicing’ of the youth demographic was something remarked on by the experts who had done formative research in developing interventions.

7.4 Mobility and Non-localized networks of support

Access is also tied to the physical space where youth and young adults engage social media material. The proliferation of cloud-based services (that nearly all social media tools employ) means that youth can use Facebook, Twitter and other tools anywhere without dependence on specific devices.

22 The devices that youth are using are increasingly mobile in nature. IPhones, Blackberry and Android handsets are favoured means of youth to communicate. The privacy and portability afforded by these devices allows youth to have ‘live’, real-time access to their peers and to information from anywhere. Mobile devices are shaping the relationship that youth and young adults have with social media content and its context. Youth are attracted to spaces where their peers are trust recommendations from this community about where to go and what information to trust. This community is both local and global in scope. When recalling the spaces that youth frequently cited as helpful and even the resources that professionals recommend to youth and young adults, only some of them are Canadian. In a globalized Internet web, the physical home of a certain resource is becoming less relevant except for material that is of a specific local nature (e.g., face-to-face counseling resources, local advocacy events). Youth regularly engage with a peer network that includes young people who they have met online and may be physically located anywhere on the global, yet also virtually close by.

7.5 Overcoming Stereotypes

There is much stigma to using substances and requiring help. One expert commented on how this stigma is shaping the way that youth use social media and sometimes challenges the idea that youth continually want to share their experiences with others. Indeed, youth may want to share their experiences with other youth who are experiencing the same issues as them, but not with their family and larger social network. The stereotype of the ‘oversharing’ youth is something that creates a misperception about how social media can work to support substance use prevention and treatment.

“There was wide agreement that traditional means of evaluation and assessment were not likely to reveal the true impact of social media on youth substance use.”

Encompassing a strategy for design that enables developers to explore the context of social engagement with youth and shape social media messaging to that specific context. Some youth will want to have their substance use and related support needs known within their more intimate personal networks, but many will not and these preferences cannot be assumed. Ethical as well as design considerations must be taken to ensure that young people are not made more vulnerable through engaging social media than before.

7.6 Effectiveness

There was wide agreement that traditional means of evaluation and assessment were not likely to reveal the true impact of social media on youth substance use. The non-standardized nature of social media tools (as illustrated in the content review) inhibits the level of comparison between services at a level that would satisfy most researchers. Researchers and practitioners spoke of the need to use multiple method designs to study and evaluate social media interventions. A strong emphasis on both quantitative and qualitative data collection methods was made. The highly contextualized nature of social media interactions suggested methods of observation would be useful along with quantitative outcomes-oriented methods.

23 Focus is another problem. One expert spoke of how rapid communication tools like Twitter and Facebook were used by youth to communicate about drug safety concerns in real-time. This enabled youth drug users to co-create and deploy an emergent harm reduction strategy based on experience and data gained from other users. This rapid-response system works because youth are connected directly to the problem and each other and are free to use whatever language and terms they like to communicate. Traditional adult-delivered services are not set-up to respond quickly to emergent problems like ‘bad batches’ of drugs, may be reluctant to consider harm reduction as an option, and use language that doesn’t connect to youth. Thus, ‘success’ in these terms might be the number of youth who take up and share a prevention message that adults might find less attractive. While social media tools themselves may not produce change directly, their indirect effect could be significant. It was suggested that social media’s benefit may be as a conduit to other interventions. One expert suggested that social media tools like smartphone apps might do little on their own even when guided by evidence, but that their true impact could be in how they highlight existing resources and drive traffic to them. For example, a quit smoking app might draw attention to tools like a phone line or counseling by having a link embedded in the app. The attraction to youth may initially be to the app, but the service’s effectiveness would come from connecting youth to face-to-face counseling and phone helplines.

CONCLUSIONS &

LIMITATIONS What is the state of our knowledge about social media and its role in substance use-related health promotion with youth and young adults?

Social media presents challenges and opportunities for public health that are novel and offer a tremendous space for innovation in dealing with substance use issues for youth and young adults. Within this space exist fundament constraints on the way in which evidence is generated and the potential for drawing usable conclusions based on such evidence. This review sought to make a definitive statement on the effect of social media on youth substance use and comment on the evaluative strategies used to assess interventions delivered by these new media forms. The statements that emerge are based on what is not present in the evidence, rather than what is missing. There is not enough evidence to inform action based on the current knowledge base for any of the topic areas -- tobacco, alcohol or drug use â&#x20AC;&#x201C; unless practice-based evidence is considered. Only with respect to text messaging can any evidence-based statement be made and that is simply that the medium is promising and only for tobacco cessation and potentially reducing alcohol intake.

8.1 Limitations

The rapidly evolving nature of the social media landscape poses specific challenges for a review of this nature. The boundaries that befit social media are indeterminable and dynamic, thus completeness is not an achievable goal. The social media sphere is still poorly indexed, limiting some of the utility of tools like Google and Bing to locate specific resources. Within applications such as Facebook, the available search options provide a limited perspective on the true size, shape and depth of a particular network and most pages found during this review were located through snowball sampling or reputation, not the Facebook search feature. Twitter was better, but the short-message nature of tweets introduced different limitations in determining a message focus and conducting a content review. The content of social media itself is highly diverse in its structure and method of deployment even within the same platform. For example, Facebook interventions included pages that were fully integrated with other web resources (e.g., Quitters Unite), while other groups have different accounts for Facebook and other social media resources, relying on their wall as the intervention (e.g., YATI Youth Advocacy). YouTube presents similar challenges in that there are organizations who have channels and develop a roster of videos distributed through that from an organizational account (e.g., Health Canada), while others use individual accounts to distribute content (e.g., Leave the Pack Behind).

25 For the reasons mentioned in previous sections, the diffusion of resources, the methods and indexes required to search for such tools are not highly developed, nor is there a universal standard for even similar platform interventions. The rapid cycle of change that takes place with social media also places constraints on the data. Twitter, for example, is a real-time source of communication and thus, changes in the way conversations are structured, the individual sending the tweets on behalf of an organization, and the style of communication may change rapidly. Thus, the descriptions provided of the resources listed in this report require confirmation by the reader.

“There is not enough evidence to inform action based on the current knowledge base for any of the topic areas -- tobacco, alcohol or drug use – unless practice-based evidence is considered.”

After the initial search strategy was implemented with the scholarly literature and refined, it was decided that additional search terms for tobacco, alcohol or drug to provide a finer-grained analysis would not yield additional actionable information. Further refined scoping of the search if run on all possible and relevant queries is highly unlikely to yield research findings that would change the overall recommendations. Virtual hand searches of leading eHealth journals such as the Journal of Medical Internet Research and the International Journal of Medical Informatics yielded little additional information beyond the initial review. Practitioners provided an important contextual grounding for the data, however the recruitment and data generated was done informally, drawing on recommendations from Health Canada, health practitioners, and the authors’ knowledge of the field. Detailed consultations with experts resulted from the data itself and was not originally part of the project, thus the sample was not representative. The anecdotal nature of the experts’ comments and that of the other public health practitioners’ experience using social media may unintentionally exclude other relevant perspectives. Some of the feedback came from Twitter users and the web community without attribution or expressed interest in being cited. Social media messages exist in real-time and thus the findings from this review are highly bound by temporal constraints. Examples from the resource review are likely to change over time and the very structure of the platforms themselves will evolve. Lessons learned must be considered within this context.

8.2 Issues

Is this absence of social media evidence an artifact of its ‘newness’, a lack of fit between social media and substance use issues with youth or is it due to something inherent in the technologies and the way they are used? Although there is little evidence for use of social media with substance use issues, there is a growing, emergent body of evidence to support the use of these tools and approaches with sexual health promotion. Considerably more research has been done attempting to connect youth with health information and services in the sexual health area than substance use.

26 Tools like Facebook are poorly indexed both within and outside of the site and are difficult to search. Other tools like Twitter are much easier to search through, however only in a quantitative sense. Twitter can determine how many times a particular content point (e.g., word, phrase or hashtag) has been mentioned, but it does not illustrate the context of how that content is used. The popularity of ‘retweeting’ and modifying tweets before sharing them means that this missing contextual element is not trivial. Due to the challenges with relying on conventional search strategies by themselves, snowballing and finding reputation-based links to resources was used to complement the findings from the searches. This was effective at locating resources that did not show up in conventional searches, however this method is both time consuming and yields incomplete findings as it favours established, connected resources over newer or less connected ones.

8.3 Lessons from other areas of health promotion

Neiger et al (2012) reviewed the literature on social media use and general health promotion and found little on social media interventions with even less on related evaluations. In outlining the possibilities for evaluation, the authors recommend metrics that focus on four key performance indicators: insights, exposure, reach and engagement. Examples of how these have been applied were not forthcoming. Another possible framing for social media and Internet-related behaviour interventions was proposed by Lefebvre (2009), who suggests applying a social marketing perspective and the four P’s (Products and Services, Price, Place and Promotion) to the design and evaluation. The Spiral Technology Action Research (STAR) model proposed by Skinner, Maley and Norman (2006) has been applied to youth-focused Internet interventions and their evaluation on issues such as tobacco control, gambling, and sexual health promotion (see: Norman & Skinner, 2007). The latter area of sexual health promotion is another area that has some emergent evidence supporting its use with youth and other populations (Alamagno & Kenne, 2011). Rice and colleagues (2010) looked at social networking, Internet use and HIV/AIDS risk for homeless adolescents. This cross-sectional study found networks exacerbated harm and help depending on the type of connection made through the Internet. When connected to home-based peers, social networks supported higher HIV testing rates, while greater connections to street-based peers correlated with a higher rate of risky sexual exchanges. Gold et al (2011) undertook a systematic examination of online social networking sites for sexual health promotion and found 178 interventions (with one scholarly publication). Similar to this review, the authors found social networking sites “are being used to deliver health promotion, although these activities have not been described in the published scientific literature or evaluated for their effectiveness in improving health outcomes” (p. e7). Along with calls for more research to be undertaken in this area, the authors proposed the following recommendations for what should be considered in that research: “process and impact evaluations of individual health promotion activities using SNSs should consider inclusion of measures such as: • Characteristics of end-users: demographics, health knowledge, attitudes and behaviours; • Quantity of interactions: number of interactions with end-users; • Quality of interactions - content analysis of interactions to assess relevance and utility; • Message spread: number of ‘shares’ and ‘retweets’ of site content (and characteristics of secondary recipients of site content, if possible); • Impact of activity on health knowledge, attitudes and behaviour; and • Cost-effectiveness of activities, particularly in comparison to the cost and effectiveness of delivering health promotion interventions via more traditional channels.” (p. e7)

27 Like youth substance use, much has been published on the process of developing and implementing Internetbased or social media-focused interventions for sexual health promotion (e.g., Flicker et al., 2004; HightowWeidman et al., 2011), but little on its impact. Nonetheless, examining these other fields of practice and study can provide some further guidance on how to proceed within the field of youth substance use.

8.4 Conclusions

Given the relative youth of social media, it is perhaps premature to expect that there would be considerable evidence to support its use for substance use prevention and treatment. Even areas like tobacco use cessation (all methods) for youth have little high-quality evidence to guide them (e.g., Gervais et al., 2007). Areas such as online alcohol interventions and tobacco cessation interventions have shown promise (White et al., 2010; Hutton et al, 2011), however the absence of any solid empirical research and evaluation on social media has left a gap in the evidence. This review parallels the 2011 findings of Gold and colleagues looking at sexual health promotion who found most activity in the area was unreported with only a single published intervention (Moreno et al. 2009) that looked at a social network (MySpace) that is no longer popular with youth. Sexual health promotion is a field that has experience using social media to engage youth. Unlike with substance use, there are multiple examples of social media and web-based interventions for use with youth sexual health that can provide guidance to health promotion professionals looking to bring these tools to alcohol, tobacco and drug use prevention and treatment (e.g., Flicker et al, 2004, 2008a,b; Ralph, Berglas, Schwartz & Brindis, 2011, Rice, Monro, Barman-Adhikari, & Young, 2011). Tobacco and drug use had the most substantial variety of resources available across the different social media platforms. Alcohol was comparatively less covered with few websites or social media interventions available for youth and young adults. Of those that are available, most were prevention focused (e.g., MADD, Saskatchewan Prevention Institute). There are few solid evaluations and little consistent practice of social media for health promotion related to youth and young adult substance use. The absence of standards in research and practice poses significant challenges for a comparative review of social media, limiting the potential to generate or identify best practice indicators. In discussion with the experts and other health promotion professionals, there is little observable dialogue between those working within substance use and between it and other public health areas. Not only would taking a systems approach produce more effective interventions on their own, it would create more effective knowledge translation on social media â&#x20AC;&#x201C;based health promotion more broadly.

RECOMMENDATIONS What steps could public health and health promotion take to effectively

employ social media as a means of addressing substance use among youth and young adults?

Based on the content reviewed, current practice and feedback from experts, the following recommendations are suggested for advancing work in social media and substance use treatment and prevention.

Encourage and support the development of a social media strategy for organizations working on substance use prevention and treatment with youth and young adults.

A survey of the current social media landscape for substance use health promotion finds a non-coherent set of resources and approaches to dealing with youth and young adults. This results in certain social media representations that are transplanted versions of a regular website (e.g., static information provision) while others actively use these forms to engage visitors in dialogue, rapidly update the content, and treat material in a more dynamic manner. With a clearer sense of what social media is expected to do and deliver for organizations, it will be easier in the future to assess when social media is being used as an intervention or as simply an extension of more traditional unidirectional health communications. Although there were notable examples of organizations integrating their social media into a strategy, conversations with practitioners and examples reviewed suggest that this is an exception, rather than standard practice. The dynamic, evolving nature of social media tools coupled with a fundamental shift from a broadcasting model to a peer-to-peer conversation model of communication poses difficulties for public health professionals seeking to craft ways to connect to youth and young adults. Practitioners are using social media out of a perceived need to â&#x20AC;&#x153;go where youth areâ&#x20AC;?, yet without a full grasp of the methods and implications associated with this new paradigm of communication, public health is struggling to connect to youth. Supporting health practitioners in developing a social media strategy that is consistent with their organizationâ&#x20AC;&#x2122;s goals and in the needs and interests of youth will contribute greatly to the development of relevant, high quality and responsive social media resources for young people. By encouraging innovation and the necessary research or evaluation models that can support strategic learning, such as Developmental Evaluation, this evolution of programming will be guided by data rather than speculation.

Develop a ‘youth first’ approach to social media programming

In creation of strategy and development of specific interventions, youth and young adults need to play central role. Simple consultation with youth and young adults is not sufficient, young people need to play tactical and strategic roles in social media projects to ensure relevance and appropriateness. This approach further requires a re-thinking of the language and types of messages that health promotion uses in delivering information. Youth and young adults engage with social media using methods and at times and locations that differ greatly from adult health professionals. This shift includes the role of mobile applications and use of social media from handset devices and tablets. For example, on issues such as drug safety, youth respond quickly and in real-time to threats, and social media provides the means to do this. By developing resources and strategies that fit these behavioural patterns, public health will be better able to produce the most appropriate and timely tools for substance use health promotion.

Expand focus beyond the media technology to include equity

Engaging youth in health promotion has unique challenges and social media adds to these by introducing a layer of technology, which can create or amplify social inequities. Concerns were raised about the types of youth that social media engages and how thought needs to be given to ways in which social media interventions can reach those without the technologies best suited to using these tools effectively. University and college students were most often cited as the demographic involved in the development of social media tools (when youth were consulted) and apps and related campaigns, leaving potential gaps in access or knowledge. Youth from communities of disadvantage and represent a diversity of perspectives – including emphasis on current and past substance use users – are critical to engage and support in maintaining engagement using social media.

Create connections within and between public health initiatives working with social media to look beyond substance use to other domains for knowledge and support

Substance use prevention and treatment with youth and young adults is not a unified field of public health, yet there is much in common between the way social media is being used to address the issues connected to it. Little connection between the work in tobacco, alcohol, or drug use prevention and treatment was made in discussion with practitioners or as part of the social media interventions themselves. With some exception, professionaldirected social media interventions were focused on a single topic. Public health issues like youth sexual health have more established bodies of evidence on the use of eHealth promotion and substance use prevention and treatment professionals could learn much from this area of public health. With such little solid evidence and a rapidly changing field of research and practice, health promotion could gain much from building better links between areas.

Foster a culture of innovation within the substance use practice community on issues of social media to guide evaluation and program improvement.

Social media tools and the content delivered through them changes rapidly and traditional planning and evaluation approaches to understanding their impact and creating program improvements are ill-fitted to this model. To be effective in engaging youth, interventions must be designed in a manner that fits the dynamic youth lifestyle that is accustomed to adopting and adapting to new technologies and ways of communicating. This is an environment of complexity and innovation, thus the methods and tools to support social media development needs to be considered as part of a larger effort to create a culture of innovation. A single method or tool will not likely suffice given the rapid pace of change. For example, within the last 12 months Facebook has unveiled its Timeline format to organize content in a linear manner, Skype integration (to enable video chat within the site), and is allowing thousands of new apps to join its ecosystem; YouTube has completely restructured its look and feel and the manner by which its channels are formatted; while Twitter has gone from being a niche tool to a mainstream form of communication for many young people. An organization seeking to develop for one version of a particular tool without the capacity to adapt to that toolâ&#x20AC;&#x2122;s changes will find itself out of touch. Doing this requires developmental thinking and evaluation (Gamble, 2006; Patton, 2011) and adaptive capabilities that come from developing a culture of innovation (c.f., Christensen & Raynor, 2003) not single-shot attempts at creating new products or services. Use of traditional, linear planning models are unlikely to support the innovation culture necessary to create adaptive strategies that allows organizations to respond to youth needs and demands in a timely manner. Without changing the way plans are developed and executed there is a risk that health promotion will create tools that are always a step behind where youth want to be and where they seek their information from. To make this adaptation and to understand the implications of developing strategies to engage youth in this dynamic context, systems and design thinking are recommended skills that public health professionals need to develop or enlist in creating programs and evaluation plans (c.f., Brown & Wyatt, 2010; Norman, 2009; Patton, 2011). This approach also means paying attention to social networks and expanding the scope of attention for evaluation and program design beyond the individuals that are reached directly, but also towards people within those individualsâ&#x20AC;&#x2122; networks (e.g., Weber & Monge, 2011). This may have implications for the type of success indicators that organizations use to assess program impact and the way in which evaluation data is gathered and used to support innovation, development and improvement. Engagement with youth cannot be done piecemeal, but must be built into the fundamental design process used in creating social media messages and strategies by having young people involved in program development at the outset. Thinking in systems and applying participatory design methods appropriately will best enable public health and health promotion to better support the foundation for a culture of innovation. Doing so will generate more responsive designs of social media interventions that have greater impact on the knowledge, skills and attitudes of youth on matters of substance use. Supporting organizations in developing or enhancing their systems thinking and design thinking skills along with expanding their knowledge of youth engagement strategies is key to implementing this recommendation.

Place social media within a â&#x20AC;&#x2DC;glocalizedâ&#x20AC;&#x2122; context

Youth and young adults function online as part of a global network of connections. Young people are motivated to go where their peers are and use resources that are endorsed by that peer group and are seen as credible, fits with their values and effective. They are less motivated by where these resources are produced. At the same time, this attention to peers means that certain local activities will remain important to them as part of their social networks. Not every local health unit or substance use-related health promotion needs to have an in-depth social media engagement plan. At the same time, there is an opportunity for health professionals to provide specific, targeted interventions and to link these with other ones. It is worth considering how public health can direct youth to existing interventions that are not their own where appropriate rather than seeking to (re)create social media spaces locally. To do this, more substantial, robust practice networks and communication between professionals working in social media and substance use (or public health more broadly) is needed within Canada and internationally. Systems thinking about the problem and designing strategies that fit these environments will enable greater attention to local and global opportunities for health promotion.

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APPENDIX 1 Social media literature review search strategy Host: Scholars Portal / Web of Science 2005 - Current English Only All publication types

Databases: • Communication & Mass Media Index @ Scholars Portal • Communication Abstracts Indexes and Limits • PsycARTICLES • PsycCRITIQUES • PsychINFO • ASSIA: Applies Social Sciences – Index and Abstracts Indexes and Limits • BHI: British Humanities Indexes and Limits • LISA: Library and Information Science Abstract Indexes and Limits Search Strategy: 1. (Teen* or youth or young people) and (social media and social networks) 2. (Teen* or youth or young people) and (internet or web or world wide web or online) 3. (Teen* or youth or young people) and 2 and 1 4. 3 and (innovation or new media) 5. (Teen* or youth or young people) and (social space or social community) 6. (Teen* or youth or young people) and (information technology) 7. (Teen* or youth or young people) and (web 2.0) 8. (Teen* or youth or young people) and (myspace or youtube or facebook or secondlife or gaming or twitter 9. (Teen* or youth or young people) and (health) and (drug*) and (internet) or (web) or (world wide web) or (online) 10. (Teen* or youth or young people) and (health) and (alcohol) and (internet) or (web) or (world wide web) or (online) 11. (Teen* or youth or young people) and (health) and (tobacco or smoking or cigarette*) and (internet) or (web) or (world wide web) or (online) 12. (Teen* or youth or young people) and (health) and (web2.0 or blog* or weblog or youtube or facebook or twitter or myspace or second life) 13. (Teen* or youth or young people) and (health) and (tobacco) and (social media) 14. (Teen* or youth or young people) and (health) and (drug*) and (social media) 15. (Teen* or youth or young people) and (health) and (alcohol) and (social media)