Social media use for public health promotion in the Gulf Cooperation Council
============================================================================

* Sana A. AlSadrah

## An overview

## Abstract

Social media platforms (SMPs) have emerged as powerful tools for public health promotion. As the 6 countries of the Gulf Cooperation Council (GCC) have the highest internet and social media usage rates in the world, and according to the initiatives for the introduction of a new health system and strategies based on non-traditional methods according to the Saudi Vision 2030, this review aimed to investigate different SMPs use and impact on public health promotion in the GCC countries. Accumulating evidence indicated that diabetes knowledge, women’s health, breast-feeding practices, oral health, appropriate antibiotic use, physical activity, road safety awareness, quitting smoking, and breast cancer awareness, were the most common specified topics. Future research should focus on populations that are medically underserved and who have no or limited access to health-care facilities. Also, future research, in particular, the intervention type, is required to cover more countries in the GCC.

*   social media
*   health promotion
*   Gulf Cooperation Council
*   Saudi Arabia
*   Facebook
*   Twitter
*   WhatsApp

In 2019, it was estimated that there were 2.7 billion social media users worldwide, and this figure is speculated to increase to 3 billion by 2021.1 In light of these figures, it is becoming difficult to ignore the potential role that various online social media platforms (SMPs) could play as powerful channels for public health promotion.2 As public media campaigns can be expensive with inconsistent and difficult-to-assess outcomes,3 different online SMPs, including Twitter, Facebook, YouTube, Snapchat, and Instagram, have emerged as frequently utilized platforms addressing health-related issues.4-7 In several geographic places, such as the “Gulf Cooperation Council (GCC)” countries, namely, “Saudi Arabia, United Arab Emirates, Kuwait, Oman, Qatar, and Bahrain”, where over 54 million people live according to population estimates,8 these platforms have become increasingly common. The present online data show that the most used SMPs in the GCC are “Facebook, Twitter, and YouTube” ([http://gs.statcounter.com](http://gs.statcounter.com)). The high socioeconomic status of these countries and the efficient networking and communication infrastructure have enabled the spread of such platforms in the specified area.4

Consistent with the steady growth displayed in several sectors, including the health-care sector, several GCC countries have committed to the Saudi Vision 2030, which aims to enhance the efficiency and quality of the preventive and therapeutic health-care services by streamlining processes and diversifying communication channels.9 In this sense, a growing focus on patient engagement by reducing the barriers to effective communication through online SMPs is required.10

The literature on SMPs’ role as a tool for public health communication is still lacking. Accumulating evidence shows that targeted users prefer to engage in interactive multidirectional conversations about health information rather than one-way communication.11,12 Social media could be valuable in documenting the range of health-related behaviors, promoting awareness of health-protective strategies, and providing interventions for public health issues.3,4,7 However, the quality of health information provided via diverse social media tools can vary, raising some concerns about the putative hazards to social media users who might be exposed to unopposed viewpoints that contradict medical science and public health recommendations.13-15

Although previous publications have evaluated the usage of different SMPs in public health, the information collected about the use of different SMPs for health promotion among the GCC countries as a review article is insufficient. In this sense, this study aimed to explore the online peer-reviewed literature to discern the different SMPs use for health promotion among the GCC populations and also to recognize some concerns that need improvement for future health promotion-related research.

The author consulted a software specialist to determine the common terms used to describe SMPs, and then performed a computerized search of Google Scholar, Scopus, Medline (via PubMed), and Web of Science databases up to June 2019, using the following keywords: “Social media OR Social web OR Social software OR Social network OR Web2 OR Web 2.0 OR telemedicine 2 OR SMP OR Facebook OR Twitter OR Snapchat OR WhatsApp” AND “Health OR Health promotion” AND “Gulf region OR GCC” OR “Saudi Arabia” OR “United Arab Emirates” OR “Kuwait” OR “Oman” OR “Qatar” OR “Bahrain”. The reference list of relevant studies was examined, and some related studies were included.16,17 The findings of the retrieved studies were used to synthesize recommendations concerning the use of SMP for health promotion in the Gulf region.

### Retrieved articles

The initial search after removal of the duplicates retrieved 1960 unique citations. After title/abstract screening, 85 citations were entered into the full-text screening phase. Fifty-five articles were excluded: 35 articles due to irrelevant content, 18 related articles, but not matching one or more of the eligibility criteria as well as 2 review articles. Finally, 30 studies were enrolled in the current work.4,16-44 **Figure 1** summarizes the flow of the included literature during the searching strategy.

![Figure 1](http://smj.org.sa/https://smj.org.sa/content/smj/42/1/9/F1.medium.gif)

[Figure 1](http://smj.org.sa/content/42/1/9/F1)

Figure 1 
Flow shart of the included literature during the search stategy.

### Publication dates and study locations

As noted in **Table 1**, the earliest item is from 2013,18 with more frequent publications in the subsequent years. The “country of origin” revealed that the SMP uses for public health promotion in the GCC countries originated remarkably in Saudi Arabia (23/30; 76.7%).18-26,28,29,31-36,38-40,42-44

View this table:
[Table 1](http://smj.org.sa/content/42/1/9/T1)

Table 1 
Summary of the survey studies on social media use in the GCC countries.

Almost all the included studies were published as original research (26/30; 86.7%),4,19-36,38-44 and only 2 studies were conference proceedings (2/30; 6.7%).16,18 A qualitative (descriptive in nature) cross-sectional study design of the reviewed items using questionnaires or focus groups was predominant (23/30; 76.7%),4,16,18,19-34,36,38,39,44 with few interventional studies (3/30; 10%).35,40,42 The specified outcomes of each included study are summarized in **Table 1**.

### Social media platforms

Of the SMPs used, Twitter was the most commonly used SMP; applied in 11 of the 30 articles (36.7%),4,20-22,25,26,29,32,34,36,38 followed by WhatsApp which included in 7 of the 30 articles (23.3%).29,33-35,37,38,40 Other popular SMPs included Facebook (n=5; 20%),17,27,29,32,34 Instagram (n=7; 23.3%),16,17,29,31-33,37 and Snapchat (n=3; 10%).29,32,42 Interestingly, many studies applied multiple SMPs in the work methodology (**Table 1**).4,17,18,26,29,32-34,37,38,44

### Target populations

Most studies (n=14; 46.7%) focused on the general population within the GCC countries.4,16,17,20,23,26,28,29,33,34,36,40-42 On the other hand, others enrolled participants with specified medical entities/risk factors such as smokers,38 patients with diabetes,18,24,27,30,43 and obese children.37 Few studies (n=3; 10%) focused on healthcare professionals,25,32,44 and other studies (n=6; 20%)4,16,20,27,29,36 focused on the analysis of public health promotion posts and tweets (**Table 1**).

### Health issues

Of the health issues targeted in the enrolled studies, diabetes-related issues were by far the most highly outlined (6/30; 20.0%).18,24,27,30,40,43 Other health issues were women’s health (2/30; 6.7%)20,22 and oral health promotion (2/30; 6.7%)23,26 healthcare delivery and healthcare professional promotion (5/30; 16.6%),25,32-34,44 physical activity adherence (3/30; 10.0%),17,31,37 and breast-feeding (2/30; 6.7%).21,42 Less frequently mentioned areas (namely, each represents 1/30; 3.3%), included antibiotic awareness,4 online medication seeking behavior,29 smoking relapse prevention,38 resuscitations,39 road safety,36 breast cancer awareness,42 and organ donation and brain death awareness.28

## Efficacy of SMPs in public health promotion

### Awareness to the general population

Overall, the patients/participants expressed a high acceptance of receiving public health promotion messages through SMPs. Mainly, over two-thirds of the study participants were seeking online information about health-related issues. Followers of social media accounts that spread related messages showed better awareness of a range of conditions such as women’s health and breast-feeding. These followers expressed more interest in receiving more similar content and in using organized systems to convey such information, namely, “Saudi Arabia Networking for Aiding Diabetes (SANAD)” system. Some factors were associated with more intense online “health-related information-seeking behavior”, including the female gender, younger people, the marital state, higher revenue, higher level of education, and more prolonged time spent for internet navigation.

### Healthcare professional promotion

Authors of 3 studies have successfully used SMPs, “Twitter and YouTube”, as cost-efficient and “mass education” platforms to increase the awareness of convenient antibiotic usage in the general population and the medical-related staff of the Gulf countries. Almaiman et al25 revealed that 79% of the surveyed physicians were seeking online health-related information, and “Twitter” was significantly implicated in improving their medical knowledge and some clinical practice-related issues. Alsobayel et al32 also reported similar findings; as they found SMPs were perceived as being most influential for the development of several competencies as knowledge and problem-solving skill; however, they were perceived as being least helpful in enhancing clinical skills. In a study by Alshakhs et al,44 20% of the participants expressed some concerns related to the risk associated with the use of different SMPs, like ethical- or legal-related issues, a risk to the patient’s health status, or breach of patient’s privacy and confidentiality. However, these participants were willing to use different SMPs for their professional development.

### Public health promotion content and SMPs

Several studies analyzed the characteristics and content of some SMPs to define goals for success. Bahkali et al,22 reported that the favorable outcome that Twitter achieved brought about by several factors summarized as “defining clear goals, being passionate about the health promotion campaign, being motivated and creative, being knowledgeable about the health promotion area, and developing trust between Twitter users and health-care providers”. On the other hand, Mejova et al’s16 analysis of Instagram posts related to the dietary and health activity of the Qatar expats revealed that this population was drastically underrepresented, highlighting the limitation of social media in representing the expat population accurately. Another study by Alhuwail et al41 analyzed the websites of 9 Kuwaiti hospitals. It revealed that these hospitals had a rudimentary online presence which focused mainly on reinforcing services supplied by the hospitals as a type of advertisement rather than engaging the patients or supplying evidence-based-related information. These results highlight gaps in SMP performance that can be addressed to optimize SMPs’ use in public health promotion.

### Studies providing evidence of better efficacy of health promotion versus standard communication/health promotion

The ability of different SMP to promote engagement and interaction can complement traditional programs, increasing their ability to promote awareness and change behavior, as evidenced in some reviewed articles.24,31,35,36 Additionally, integrating social media networks into other communication programs outside the SMPs will influence the impact of the health promotion activities.45

The included studies revealed that different SMPs could enhance women’s health promotion level,20,22 breast-feeding practices and adherence knowledge,21 oral health self-perception and promotion,23,26 appropriate antibiotic use,4 adherence to physical activity,31 road safety awareness,36 smoking cessation,38 diabetes knowledge, self-efficacy,30,40,43 and breast cancer awareness.41

Although the predominant study design is a qualitative “cross-sectional” type (76.7%) using questionnaires or focus groups, with few interventional studies,31,35,40,42,43 which proved to be more effective in health promotion than the standard ones, these qualitative studies are still required to provide the basis of fundamental knowledge on which other future studies could be carried out .

### Remarks

Public health promotion is a field that can benefit from social media, through web-based and mobile communication social networks.45 Different SMPs were widely used to promote health and endorse online health promotion campaigns. These platforms have unique features for exchanging and taking part in open-access information, supplying a channel for dynamic conversations, and allowing users to follow issues of their interest.4 Social media platforms have been employed to increase awareness of DM,3 obesity,46 non-communicable diseases,47 sexual health,6 and cancers48 among others. Besides, they can provide support for “community-based” lifestyle interventions for some people with special conditions like those with mental disorders.49

The present review highlights the literature about the current use of different SMPs in public health-related issues within the GCC countries. The findings support that the SMPs application in public health-related research and practice is still in the maturation stage; no articles were found before 2013, and 30 related articles were published in the last 6 years in the GCC countries. Most included articles used descriptive approaches rather than utilization of the SMPs’ overall potential in terms of multidirectional communication and networking. Of the 30 articles, most were descriptive research articles, whereas only 5 studies included an interventional approach.31,35,40,42,43 This indicates that using different SMPs for health interventions in the GCC countries is not yet a popular approach in public health practice and remains mostly in the descriptive phase of research. More research attempts to specify whether SMPs have an effect on their own or whether the observed outcomes are due to the “non-social media” components or the overall intervention would be important as highlighted by Hamm et al.50 Furthermore, a more in-depth analysis of the way the interventions are conducted through different SMPs and the extent to which these interventions are implemented will take part in better understanding of social media use.

Analysis of the country of origin of the studies indicated that the majority of research on the use of SMPs for public health promotion in the GCC countries originated in KSA. The latter country is a fertile one for this sort of research because 75% of the total Saudi population are “active social media users” in 2017. Approximately 52% were reported to be active on “Twitter”, and 66% were active on “Facebook”.51 These figures reflect the widespread use of SMPs and their potential use in future social media-based public health promotion interventions. Additionally, from a research point of view, the mass population is easily accessible as stated by AlShahrani et al.23

By screening the SMPs used in the included studies, “Twitter” was the most common SMP applied in 14 of the 30 articles (46.7%), and followed by “WhatsApp”, which appeared in 7 of the 30 articles (23.3%). Interestingly, this finding is in line with Reyaee and Ahmed’s analysis of the growth pattern of SMPs use in the Gulf countries.52 They reported that “Twitter” was becoming popular among social media users after “Facebook” in almost all GCC countries.

Although few studies included multiple SMPs or highlighted the importance of combining SMPs with other relatively unprecedented kinds of communication, such as messaging or email,4,33,34,38 most of the included studies relied on a single SMP. This trend accords with the earlier observations reported by some review articles and meta-analyses that assess the social media use for public health promotion.53-55

This work is the first to summarize the role of different SMP in public health promotion in the GCC region. The findings observed in the current study are in agreement with those reported by other studies. For example, Sinnenberg et al55 showed that “Twitter” is supported by multiple organizations that participate in its growth and may have several public health implications. Moorhead et al12 concluded that although SMP is a powerful tool for public health promotion, shared data need to be monitored, and users’ privacy should be maintained. Similar concerns were raised by Taggart et al.56

### Study limitations

Given the relatively new emerging concept of social media with a constantly changing nature, there is no “universal definition,” adding difficulty to the strategy of establishing study eligibility and keeping the work updated since new reports are in a steady state of influx. Subjective bias could be unintended and included. The lack of quality, rigor, or validity analyses of the studies was evident. No quantitative statistical analysis could be executed due to the limited number of eligible articles all over the GCC region except for Saudi Arabia and the reported study-design heterogeneity in the retrieved literature. Evaluation of effectiveness in the short and long run using a variety of methodologies, as suggested by Moorhead et al12 is needed, and further evidence synthesis on specific issues, clinical areas, and GCC populations can provide more details.

In conclusion, SMPs have been used for public health promotion for a range of purposes and medical conditions. Moreover, they could improve the professional development of health-care personnel, and their large-scale deployment is highly supported. However, health-care personnel expressed concerns about the quality of disseminated data on these platforms and recommended monitoring data quality.

Social media research has markedly improved in the past decade due to better empirical research and publication of higher quality studies. However, special attention should be directed to populations who are medically underserved and have no or limited access to health-care facilities as potential SMP-targeted groups, among others.

Future SMP-related research is required to cover more countries in the GCC, to carry out more intervention studies, and to include more systematic analysis of the feeds shared between social media users and health-care practitioners.

## Acknowledgment

*The author would like to thank Editage ([www.editage.com](http://www.editage.com)) for English language editing for the present article*.

## Footnotes

*   **Disclosure.** Authors have no conflict of interests, and the work was not supported or funded by any drug company.

*   Copyright: © Saudi Medical Journal

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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