Brief CommunicationTranslating evidence to practice in the

Brief Communication
Translating evidence to practice in the health professions:
a randomized trial of Twitter vs Facebook
Jacqueline Tunnecliff,1 John Weiner,2 James E Gaida,3 Jennifer
L Keating,1
Prue Morgan,1 Dragan Ilic,2 Lyn Clearihan,4 David Davies,5
Sivalal Sadasivan,6
Patitapaban Mohanty,
7
Shankar Ganesh,
7
John Reynolds,
2
and Stephen Maloney
1
1Department of Physiotherapy, Monash University, Frankston,
Australia, 2Department of Epidemiology and Preventive
Medicine,
Monash University, Melbourne, Australia, 3Discipline of
Physiotherapy and University of Canberra Research Institute for
Sport

and Exercise (UCRISE), University of Canberra, Canberra,
Australia, 4School of Primary Health, Monash University,
Melbourne,
Australia, 5Warwick Medical School, University of Warwick,
Coventry, United Kingdom, 6JC School of Medicine & Health
Scien-
ces, Monash University Malaysia and 7Swami Vivekanand
National Institute of Rehabilitation Training and Research,
Odisha,
India
Correspondence to Associate Professor Stephen Maloney,
Department of Physiotherapy, Monash University, PO Box
527, Frankston, 3199, Victoria, Australia; [email protected]
Received 7 October 2015; Revised 21 April 2016; Accepted 30
April 2016
ABSTRACT
Objective: Our objective was to compare the change in research
informed knowledge of health professionals
and their intended practice following exposure to research
information delivered by either Twitter or Facebook.
Methods: This open label comparative design study randomized
health professional clinicians to receive
“practice points” on tendinopathy management via Twitter or
Facebook. Evaluated outcomes included knowl-
edge change and self-reported changes to clinical practice.

Results: Four hundred and ninety-four participants were
randomized to 1 of 2 groups and 317 responders ana-
lyzed. Both groups demonstrated improvements in knowledge
and reported changes to clinical practice. There
was no statistical difference between groups for the outcomes of
knowledge change (P¼ .728), changes to clini-
cal practice (P¼ .11) or the increased use of research
information (P¼ .89). Practice points were shared more by
the Twitter group (P < .001); attrition was lower in the
Facebook group (P < .001).
Conclusion: Research information delivered by either Twitter or
Facebook can improve clinician knowledge and
promote behavior change. No differences in these outcomes
were observed between the Twitter and Facebook
groups. Brief social media posts are as effective as longer posts
for improving knowledge and promoting
behavior change. Twitter may be more useful in publicizing
information and Facebook for encouraging course
completion.
Key words: social media, evidence-based practice,
communication, education, professional, computer-assisted
instruction
INTRODUCTION
A significant gap remains between research generated
healthcare

knowledge and clinical practice.1–3 Social media can rapidly
link
researchers and clinicians from diverse geographical regions,
disciplines, and areas of practice; making it an ideal medium for
knowledge exchange and education. Approximately 25% of
health professionals currently use social media for obtaining
research information.4
Social media has been defined as a “collection of web-based
technologies that share a user-focused approach to design and
func-
tionality, where users can actively participate in content
creation
VC The Author 2016. Published by Oxford University Press on
behalf of the American Medical Informatics Association. All
rights reserved.
For Permissions, please email: [email protected]
403
Journal of the American Medical Informatics Association,
24(2), 2017, 403–408
doi: 10.1093/jamia/ocw085
Advance Access Publication Date: 29 June 2016

Brief Communication
http://www.oxfordjournals.org/
http://www.oxfordjournals.org/
and editing through open collaboration between members of
com-
munities of practice.”5 The use of social media in education
may
lead to positive learning experiences,5,6 increases in knowledge
and
skills,7–10 and changes to the clinical practices of health
professio-
nals.10,11 However, there is a need for studies to evaluate the
relative
effectiveness of different social media based applications.12
Two of the largest social media applications are Facebook (1.49
billion monthly active users) and Twitter (316 million monthly
active users).13,14 Both sites promote user interaction and
allow
posting of text, videos, and weblinks; however, Twitter limits
posts
to 140 characters. Neither site charges access costs. The
popularity

and features of these sites indicate their potential application in
communicating research information and, therefore, were
chosen
for investigation in this study.
OBJECTIVE
The primary objective of this study was to determine if research
information delivered by Twitter or Facebook would result in
greater changes in research informed knowledge and practices
of
health professionals. The secondary aim was to compare
participant
behavior and engagement with the two mediums.
METHODS
Design
An open label randomized comparative design was used, with a
mixed methods approach to data collection and analysis. The
Mon-
ash University Human Research Ethics committee (CF 14/1372
–
2014000640) approved the study.
Participants
Health professional clinicians of any discipline (e.g., medicine,

phys-
iotherapy, podiatry), geographical location, or level of expertise
(including undergraduate students), were eligible to participate.
Recruitment occurred via an email invitation distributed to
clinical
affiliates and departments of Monash University, Faculty of
Medi-
cine, Nursing and Health Sciences, Australia; Monash
University
Malaysia; Swami Vivekanand National Institute of
Rehabilitation
Training and Research, India; and the University of Southern
Cali-
fornia. Professional associations representing professions
registered
with the Australian Health Practitioner Regulation Agency15
were
also invited to distribute the invitation to participate via email
or
their own social media sites.
Intervention
A short course, consisting of the same 8 “practice points” or
key

educational messages of 140 characters or less, on topics related
to
tendon management were delivered to each group via posts on
Twit-
ter16 and Facebook17 web pages. Each practice point was
linked to
supplementary information in the form of peer-reviewed journal
articles or podcasts by clinical experts. The course was
designed by
educational, clinical, and research experts, and was identical
except
that the Facebook posts contained the practice point plus an
addi-
tional 2–6 short written statements (1–2 sentences) that
highlighted
key concepts from the supplementary information. The practice
points were delivered evenly over a 2 week period, to both
groups at
the same time points. The pages were not restricted access.
Procedure
Clinicians consented to participate by providing contact details
through an online survey. Those who provided a valid email
address

were enrolled. Participants were stratified by role (student,
clinician,
or other) and randomized to receive the practice points via
Twitter
or Facebook. Participants received video and written
instructions on
obtaining a social media account and accessing the practice
points
from their allocated site. The instructions also encouraged
interac-
tion on the allocated site. Participants were sent three reminder
emails at each data collection point to minimize attrition. The
study
was conducted between August and October 2014.
Outcomes
Data was obtained via an anonymous online survey completed 1
week before (baseline assessment) and after (post-intervention
assessment) the short course. A password was used to match
pre-
and post-course data. Demographic details, information on
tendon
management experience, and current use of social media were
obtained.

Outcomes were determined based on the Kirkpatrick hierarchi -
cal levels of evaluation 1–3.18 Participation and engagement
data
was also collected. A data collection summary can be found in
Appendix 1.
Kirkpatrick Level 1: Participant Reactions
The Social Media Use and Perception Instrument (SMUPI), a
ques-
tionnaire of 10 items with high internal consistency,19
measured
attitudes towards using social media in continuing professional
development.
Kirkpatrick Level 2: Knowledge
Sixteen multiple choice questions assessed knowledge (A–E
responses) (Appendix 2). One question correlated with each
“practice point” and one correlated with information from each
piece of supplementary information. The questions in both
assess-
ments were identical, but question and response order were
random-
ized to minimize score improvements based on pattern
recognition.

Participants were not given assessment answers until the
conclusion
of the study. Self-rated measures of tendon management
confidence
and knowledge were also obtained.
Kirkpatrick Level 3: Behavior Change
Participants were asked “has the education you have received
via
social media during this trial changed the way you practice, or
intend to practice, with musculoskeletal clients?” and “has the
edu-
cation you have received during this trial increased your use of
research evidence within your clinical practice?”
Participation was evaluated via the number of participants who
connected with the social media pages and completed the
assess-
ments. Data on interaction was obtained through participant
self-
report and from the number of times posts were approved of
(“liked” or “favorite”), shared or commented on.
Analysis
Mixed linear models were used to analyze the repeated measure-

ments (pre- and post-exposure to the intervention) on the
partici-
pants. The restricted maximum likelihood method (REML), as
implemented in the GenStat statistical package,20 was used to
fit the
models, calculate predicted means and test, using F-tests, the
main
effects of group (Twitter vs Facebook) and time (pre vs post) as
well
404 Journal of the American Medical Informatics Association,
2017, Vol. 24, No. 2
as their 2-way interaction. Pairwise least significant difference
tests of
the group-by-time means were based on these analyses and
conducted
at the 5% significance level. Diagnostic plots of residuals were
checked for assumptions on which these methods are based.
Analyses
of the 5-point Likert scale responses also used the restricted
maximum
likelihood method as is customary with large datasets.21 The
analyses

of binary response outcomes, measured post intervention, were
based
on logistic regression models, also fitted using GenStat.
Discrete count
data from Twitter and Facebook sites were analyzed using a
variance-
stabilizing transformation in an analysis of variance.
RESULTS
Five hundred clinicians consented to participate. Five were
excluded
due to an invalid email address, and one participant asked to be
removed. Four hundred and ninety-four participants were
randomized.
The attrition rates from randomization to baseline assessment
were
48.2% for the Twitter group and 41.7% for the Facebook group;
the
difference was not significant [v2 (1, n¼494)¼2.09, P¼ .148].
Attri-
tion from baseline assessment to post intervention assessment
was
32.8% for the Twitter group and 8.3% for the Facebook group;
this

difference was significant [v2 (1, n¼494)¼17.37, P < .001].
Three
hundred and seventeen responses were analyzed (140 Twitter,
177
Facebook). There were 99 baseline assessments, 45 post
intervention
assessments, and 173 matched baseline and post intervention
assess-
ments. A consort flow-chart is available in Figure 1.
Demographics
Demographic data and data on tendon management experience
and
social media use was obtained from the baseline assessment and
is
presented in Table 1.
Kirkpatrick levels 1, 2 and 3
Following the intervention, (the short course consisting of
practice
points) there were statistically significant increases in SMUPI
score,
self-rated confidence, self-rated knowledge and multiple choice
assessment score; but no statistically significant differences
between
the groups in their changes over time. Participants in both
groups

reported a change in practice/intended practice and increased
use of
research in practice/intended practice as a result of the
intervention
but there was no statistically significant difference between the
groups. This is shown in Table 2.
The Twitter page developed 428 “followers” and the Facebook
page received 155 “likes.” An estimated 10.0% (8/80) of the
Twitter
group and 7.8% (9/115) of the Facebook group reported
interacting
online. The difference between groups was not significant [v2
(1,
n¼195)¼0.28, P¼0.597)]. An estimated 42.6% (20/47) of the
Twit-
ter group and 34.8% (24/69) of the Facebook group reported
lack of
time as a reason for lack of interaction on the social media
sites.
Statistically significant differences were found between groups
for number of times information was shared (mean shares per
post
Twitter 10.40, Facebook 0.20, SED 3.030, P < .001) and
approved

of (“liked”/”favourite”) (mean Twitter 14.00, Facebook 8.00,
SED
1.414, P¼ .005).
DISCUSSION
This study has demonstrated that research information delivered
by
either Twitter or Facebook can improve clinician knowledge and
Expressed interest in par�cipa�ng (n=500)
Excluded (n=6)
n=1 complaint about process
n=5 no email address provided
Randomized (n=494)
Allocated to Facebook (n=247)Allocated to Twi�er (n=247)
Comple�on of baseline Assessment
(n=128)
Withdrew (n=1)
Reason unknown
Comple�on of baseline Assessment
(n=144)
Comple�on of post interven�on
assessment (n=86)
Comple�on of post interven�on

assessment (n=132)
Figure 1. Consort flow chart showing attrition of study
participants.
Table 1. Participant demographics and participant
characteristics
Twitter Facebook
N (%)a N (%)a
Baseline demographic data sets 128 144
Area of practice
Physiotherapy/physical therapy 95 (74.2) 98 (68.1)
Medicine 18 (14.1) 19 (13.2)
Osteopathy 2 (1.6) 3 (2.1)
Podiatry 7 (5.5) 11 (7.6)
Other 4 (3.1) 11 (7.6)
Not stated 2 (1.6) 2 (1.4)
Role
Undergraduate Student 33 (25.8) 36 (25.0)
Postgraduate Clinical Trainee 9 (7.0) 13 (9.0)
Clinician 78 (60.9) 78 (54.2)

Other 8 (6.3) 17 (11.8)
Not stated 0 (0.0) 0 (0.0)
Age
Under 18 0 (0.0) 0 (0.0)
18–24 28 (21.9) 39 (27.1)
25–34 59 (46.1) 64 (44.4)
35–44 31 (24.2) 28 (19.4)
45–54 8 (6.3) 8 (5.6)
55–64 2 (1.6) 4 (2.8)
65þ 0 (0.0) 1 (0.7)
Sex
Male 79 (61.7) 71 (49.3)
Female 47 (36.7) 71 (49.3)
Not stated 2 (1.6) 2 (1.4)
Country
Australia 48 (37.5) 59 (41.0)
India 14 (10.9) 14 (9.7)
Malaysia 5 (3.9) 6 (4.2)
UK 29 (22.7) 23 (16.0)

USA 12 (9.4) 17 (11.8)
Other 19 (14.8) 24 (16.7)
Not stated 1 (0.8) 1 (0.7)
Tendon management experience
Provide health care to clients with
tendon disorders once a week or more
61 (47.7) 62 (43.1)
Social Media experience
Use Twitter 75 (58.6) 66 (45.8)
Use Facebook 106 (82.8) 130 (90.3)
aPercent of group (Twitter or Facebook) that provided baseline
data.
Journal of the American Medical Informatics Association, 2017,
Vol. 24, No. 2 405
promote behavior change. No statistical differences in these
out-
comes were observed between the Facebook and Twitter groups.
This research is consistent with previous literature that
indicates

that web based or social media programs are useful as learning
tools,5,7,8,10,11 and can improve clinician knowledge and
promote
behavior change.10
This study has also found that the provision of extra informa-
tion, beyond a 140 character message, did not impact on
knowledge
or behavior change. Short messages may be beneficial to busy
healthcare workers as lack of time is often cited as a barrier to
evi-
dence based practice.1 However, trustworthiness of information
gathered via social media is a key concern of clinicians.4 Our
data
indicates that brief messages, when obtained from a reputable
source and linked to full sources of information may be
acceptable
to clinicians.
There were two interesting differences between the groups.
There was greater overall attrition from the Twitter group. Site
familiarity may be a factor, as more health professionals use
Face-

book than Twitter.4 In this study, over 80% of clinicians in each
group use Facebook; <60% in each group use Twitter. The
prefer-
ence of clinicians to use Facebook over other social media sites
for
obtaining research information may also be a factor.4
Therefore, the
use of Facebook may have encouraged online course
completion.
The Twitter page developed a far greater following than the
Table 2. Kirkpatrick level 1–3 outcomes
Baseline measures
Predicted Mean (n)
Post-Intervention measures
Predicted Mean (n)
Difference (SED)b P-value
Kirkpatrick level 1 outcomes
SMUPIa
Twitter 40.34 (126) 41.85 (86) 1.51 (0.66) .024
Facebook 39.53 (143) 40.86 (127) 1.33 (0.58) .022

Difference (SED)b �0.81 (0.82) �0.99 (0.91)
P-value .326 .277 .841d
Self-rated confidence in tendon managementc
Twitter 3.380 (128) 3.784 (86) 0.404 (0.083) <.001
Facebook 3.216 (143) 3.644 (131) 0.428 (0.072) <.001
Difference (SED)b �0.164 (0.106) �0.141 (0.116)
P-value .124 .227 .830d
Tendon management self-rated knowledgec
Twitter 3.181 (127) 3.727 (86) 0.546 (0.082) <.001
Facebook 3.027 (143) 3.570 (131) 0.543 (0.071) <.001
Difference (SED)b �0.154 (0.102) �0.157 (0.112)
P-value .135 .163 .975d
Multiple choice assessment total score (max score 16)
Twitter 7.649 (123) 10.308 (80) 2.659 (0.381) <.001
Facebook 6.599 (136) 9.435 (118) 2.835 (0.331) <.001
Difference (SED)b �1.050 (0.469) �0.874 (0.521)
P-value .026 .095 .728d
Assessment score for questions that addressed the practice
points (max score 8)

Twitter 4.155 (123) 5.523 (80) 1.368 (0.233) <.001
Facebook 3.789 (136) 5.431 (118) 1.642 (0.203) <.001
Difference (SED)b �0.366 (0.259) �0.093 (0.293)
P-value .159 .752 .378d
Assessment score for questions addressing the supplementary
information (max score 8)
Twitter 3.485 (123) 4.819 (80) 1.333 (0.211) <.001
Facebook 2.848 (136) 4.025 (118) 1.177 (0.184) <.001
Difference (SED)b �0.637 (0.255) �0.793 (0.211)
P-value .013* .006* .578d
Number reporting change (n) % of group (95% CI) P (between
group
differences)
Reported change in practice due to intervention
Twitter 59 (77) 77 (67-86) .11
Facebook 77 (117) 66 (57-74)
Reported increased use of research in practice
Twitter 55 (78) 71 (60-81) .89
Facebook 80 (115) 70 (61-78)

aTotal of ten items, each measured on a 5 point Likert scale,
whereby higher score¼more favorable attitude.
bSED¼Standard Error of the Difference.
cMeasured on a 5 point Likert scale 1¼very poor, 5¼very good.
dP-value is for the F-test of a two-way interaction.
*Statistically significant difference between groups.
406 Journal of the American Medical Informatics Association,
2017, Vol. 24, No. 2
Facebook page, and more participants in the Twitter group
shared
the received information within their own social networks.
Twitter
is particularly useful in publicizing information, and it appears
this
also applies to research information.
Social media promotes online social interactions, which may
enhance learning22 and promote change through social
influence.23
Interaction in this study was encouraged in the course
instructions, and
a tendon expert was available to answer questions. However,
10% or
less of the participants in each group reported interacting

online. Over
30% of participants in each group cited lack of time as a key
barrier to
interacting. Approximately 60% of clinicians are evidence
“pragmatists” – those to whom validity of evidence is secondary
to the
daily demands of practice.2 Therefore, the interaction in this
study may
reflect everyday professional use of social media for accessing
research
evidence. Concerns about professional image may also influence
online
interactions.4 Herein lies the paradox of social media based
learning
communities; the openness and diversity which can enrich
learning
may also negatively impact upon the socio–emotional aspects of
group
formation which may be beneficial for collaborative learning.24
While significant improvements in knowledge occurred, the
improvements were small (an increase in total assessment score
of
<3). A lack of time to read or listen to supplementary

information
may have influenced this result. The practice points may also
have
been lost among the large volumes of information that can
appear
on social media accounts, or may have been filtered out by the
social
media sites themselves.
There are several limitations to this study. Baseline measures
were collected shortly after randomization had occurred,
potentially
resulting in chance bias. However, participant assessments were
anonymous, therefore randomization after completion of
baseline
measures was not possible. There was no control group to assess
the
impact of a learning effect from the assessment or to see if the
course
was equally effective if delivered via email or text message.
How-
ever, this study aimed to compare social media modalities and
the
benefits and limitations of each. Participants from the Twitter

group
had a statistically significant higher baseline assessment score
for
knowledge related to the supplementary information. There are
a
number of health professional information sharing sites on
Twitter,
and participants allocated to Twitter may be more inclined to
partic-
ipate if they had previous exposure to these sites. An error
resulted
in 5 participants from the Twitter group obtaining the course
infor-
mation for both Twitter and Facebook, however due to the small
number of participants affected, this is unlikely to have
impacted the
results. Both Facebook and Twitter sites were publically
available,
and participants were not asked to keep group allocation or
infor-
mation confidential, meaning the groups may not have been
mutu-
ally exclusive. However, participants were not informed of the

alternate group, and the diversity of participants limits the
potential
impact of this confounding factor. The sites were open access;
there-
fore people other than study participants may have interacted on
the
sites. The same assessment was used before and after the
interven-
tion however, question and answer order were randomized to
limit
any potential learning effects. The high attrition rates may have
resulted in attrition bias,25 however, given that online courses
often
have dropout rates of �50%26,27 the attrition level is not
abnormal
for this type of education.
CONCLUSION
Evidence based “practice points” on tendinopathy management
can
increase clinician knowledge and influence changes in practice,
whether delivered by Facebook or Twitter. No differences in
these
outcomes were observed between the Twitter and Facebook
groups.

Messages of 140 characters or less are as effective as longer
posts in
conveying research information.
Future research directions may include investigating social
media
interaction and the subsequent impact on learning and behavior
change, and how perceived e-professionalism influences
clinicians’
willingness to participate in social media based professional
educa-
tion. Social media may provide a low cost method of
widespread
distribution of information and an economic analysis of using
social
media to distribute research information would complement
existing
literature.
CONTRIBUTORS
The authors listed contributed to the research design, data
collec-
tion, analysis, write-up, and critical review of the final
manuscript.

FUNDING
This work was supported by the Monash University Strategic
Project Grant
Scheme 2014, Grant Number: SPG-L 007
COMPETING INTERESTS
None.
ACKNOWLEDGMENTS
The authors of this article have no formal relationship with
either Twitter or
Facebook.
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active-facebook-users-worldwide/
https://about.twitter.com/company
https://about.twitter.com/company
https://http://www.ahpra.gov.au/
https://twitter.com/cetsm
https://twitter.com/cetsm
https://www.facebook.com/Clinical-Excellence-Through-Social-
Media-328092517357004/
https://www.facebook.com/Clinical-Excellence-Through-Social-
Media-328092517357004/ocw085-TF1ocw085-TF3ocw085-
TF4ocw085-TF5ocw085-TF6ocw085-TF7

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